Long-term risk factors for suicide in suicide attempters examined at a medical emergency in patient unit: results from a 32-year follow-up study

Assessing the risk of intentional self-harm in montelukast users: an updated Sentinel System analysis using ICD-10 coding

BACKGROUND

Montelukast prescribing information includes a Boxed Warning issued in March 2020 regarding neuropsychiatric adverse events. A previous Sentinel System study of asthma patients from 2000 to 2015 did not demonstrate an increased risk of intentional self-harm measured using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, with montelukast compared to inhaled corticosteroids (ICS).

METHODS

Using a new user cohort study design, we examined intentional self-harm events in patients aged 10 years and older who were incident users of either montelukast or ICS as monotherapy, with a diagnosis of asthma, between October 1, 2015, to June 30, 2022, in the Sentinel System. We measured intentional self-harm using ICD-10-CM codes, which may have better accuracy for capturing suicide attempts than ICD-9-CM codes. We used inverse probability of treatment weighting to balance baseline covariates. We performed subgroup analyses by age group, sex, psychiatric history, and pre/post Boxed Warning era and conducted sensitivity analyses varying type of care setting of the outcome and exposure episode gaps.

RESULTS

Among 752,230 and 724,855 patients in the montelukast and ICS exposure groups respectively, we found no association between montelukast use and self-harm compared to ICS use [Hazard Ratio (95% Confidence Interval): 0.96 (0.85, 1.08)]. This finding was consistent across all subgroups, and sensitivity analyses.

CONCLUSION

Our results cannot exclude other neuropsychiatric idiosyncratic reactions to montelukast. Compared to the previous Sentinel study, this study identified about double the rate of self-harm events, suggesting a greater sensitivity of ICD-10 codes for measuring self-harm than ICD-9.

The University Chaplain: An Often Unrecognised Resource in Suicide Prevention-Initial Qualitative Results from Exploratory Research into the Roles of University Chaplains at One Australian University

University chaplains are often unrecognised as resources in suicide prevention. This exploratory article highlights the valuable contributions university chaplains at one Australian university make to suicide prevention. Three overarching themes related to the contributions of university chaplains to suicide prevention were generated: (1) person-centred care; (2) the role of university chaplains in suicide prevention; and (3) professional development. Of particular note is that university chaplains actively contribute to all three phases of the suicide prevention framework: prevention, intervention, and postvention.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predicting Suicide Among US Veterans Using Natural Language Processing-enriched Social and Behavioral Determinants of Health

Despite recognizing the critical association between social and behavioral determinants of health (SBDH) and suicide risk, SBDHs from unstructured electronic health record (EHR) notes for suicide predictive modeling remain underutilized. This study investigates the impact of SBDH, identified from both structured and unstructured data utilizing a natural language processing (NLP) system, on suicide prediction within 7, 30, 90, and 180 days of discharge. Using EHR data of 2,987,006 Veterans between October 1, 2009, and September 30, 2015, from the US Veterans Health Administration (VHA), we designed a case-control study that demonstrates that incorporating structured and NLP-extracted SBDH significantly enhances the performance of three architecturally distinct suicide predictive models - elastic-net logistic regression, random forest (RF), and multilayer perceptron. For example, RF achieved notable improvements in suicide prediction within 180 days of discharge, with an increase in the area under the receiver operating characteristic curve from 83.57-84.25% (95% CI = 0.63%-0.98%, p-val < 0.001) and the area under the precision recall curve from 57.38-59.87% (95% CI = 3.86%-4.82%, p-val < 0.001) after integrating NLP-extracted SBDH. These findings underscore the potential of NLP-extracted SBDH in enhancing suicide prediction across various prediction timeframes, offering valuable insights for healthcare practitioners and policymakers.

Detection of Personal and Family History of Suicidal Thoughts and Behaviors using Deep Learning and Natural Language Processing: A Multi-Site Study

Objective

Personal and family history of suicidal thoughts and behaviors (PSH and FSH, respectively) are significant risk factors associated with future suicide events. These are often captured in narrative clinical notes in electronic health records (EHRs). Collaboratively, Weill Cornell Medicine (WCM), Northwestern Medicine (NM), and the University of Florida (UF) developed and validated deep learning (DL)-based natural language processing (NLP) tools to detect PSH and FSH from such notes. The tool's performance was further benchmarked against a method relying exclusively on ICD-9/10 diagnosis codes.

Materials and Methods

We developed DL-based NLP tools utilizing pre-trained transformer models Bio_ClinicalBERT and GatorTron, and compared them with expert-informed, rule-based methods. The tools were initially developed and validated using manually annotated clinical notes at WCM. Their portability and performance were further evaluated using clinical notes at NM and UF.

Results

The DL tools outperformed the rule-based NLP tool in identifying PSH and FHS. For detecting PSH, the rule-based system obtained an F1-score of 0.75 ± 0.07, while the Bio_ClinicalBERT and GatorTron DL tools scored 0.83 ± 0.09 and 0.84 ± 0.07, respectively. For detecting FSH, the rule-based NLP tool's F1-score was 0.69 ± 0.11, compared to 0.89 ± 0.10 for Bio_ClinicalBERT and 0.92 ± 0.07 for GatorTron. For the gold standard corpora across the three sites, only 2.2% (WCM), 9.3% (NM), and 7.8% (UF) of patients reported to have an ICD-9/10 diagnosis code for suicidal thoughts and behaviors prior to the clinical notes report date. The best performing GatorTron DL tool identified 93.0% (WCM), 80.4% (NM), and 89.0% (UF) of patients with documented PSH, and 85.0%(WCM), 89.5%(NM), and 100%(UF) of patients with documented FSH in their notes.

Discussion

While PSH and FSH are significant risk factors for future suicide events, little effort has been made previously to identify individuals with these history. To address this, we developed a transformer based DL method and compared with conventional rule-based NLP approach. The varying effectiveness of the rule-based tools across sites suggests a need for improvement in its dictionary-based approach. In contrast, the performances of the DL tools were higher and comparable across sites. Furthermore, DL tools were fine-tuned using only small number of annotated notes at each site, underscores its greater adaptability to local documentation practices and lexical variations.

Conclusion

Variations in local documentation practices across health care systems pose challenges to rule-based NLP tools. In contrast, the developed DL tools can effectively extract PSH and FSH information from unstructured clinical notes. These tools will provide clinicians with crucial information for assessing and treating patients at elevated risk for suicide who are rarely been diagnosed.

Characteristics of suicide attempts in Northwestern Iran: a five-year population-based survey

BACKGROUND

Suicide is a serious public health problem in the world. This study aims to describe the characteristics of suicide attempters in North-Western Iran and identify latent classes of suicide attempts.

METHODS

This cross-sectional study was conducted in Ardabil Province (Northwest Iran) during 2017-2021 based on a registration system for suicide attempts. We performed latent class analysis (LCA) using a procedure for LCA (PROC LCA) in SAS to investigate the subgroups of suicide attempters based on their characteristics and method, history, and outcome of suicide.

RESULTS

Three latent classes were identified for males and females; the first class (non-lethal attempters with lower educational levels) comprised 41.3% of males and 55.4% of females. The second class (non-lethal attempters with higher educational levels) described 52.4% of males and 42.7% of females. Finally, the third class (lethal attempters) included 6.4% of males and 1.9% of females. The main method of suicide attempts was poisoning with medications (87.3%). The results show that only 2.8% of people have a history of suicide attempts. Also, the suicide rate reached 8.26 per 100,000 population in 2021.

CONCLUSION

The present study showed an increasing trend of suicide attempt incidence rate in Ardabil Province from 2017 (99.49 per 100,000 population) to 2021 (247.41 per 100,000 population). This means that the rate of change was 147.92 per 100,000 population during the study period. The findings of LCA, stress the necessity of identification and prioritization of unmet needs of people who had an incomplete suicide in Ardabil.

ASSIP vs. Crisis Counseling for Preventing Suicide Re-attempts: Outcome Predictor Analysis of a Randomized Clinical Trial Data

OBJECTIVE

Knowledge of the effectiveness and limits of the suitability of brief interventions in suicide prevention is greatly needed. We investigated subgroup differences and predictors for suicide re-attempts within a clinical trial population recruited for a brief intervention to prevent re-attempts.

METHODS

Consenting adult patients receiving treatment for a suicide attempt in Helsinki City general hospital emergency rooms in 2016-2017 (n = 239) were randomly allocated to (a) the Attempted Suicide Short Intervention Program (ASSIP) or (b) Crisis Counseling (CC). Participants also received their usual treatment. Information on primary outcome repeat attempts and secondary outcomes was collected via telephone and from medical and psychiatric records for 2 years. As proportions of re-attempts did not differ significantly between ASSIP and CC (29.2 vs. 35.2%), patients were pooled and predictors for suicide re-attempts were analyzed using Kaplan-Meier and logistic regression analyses.

RESULTS

Re-attempts were predicted by participants' younger age (OR 0.965 [0.933-0.998]), previous suicide attempts (OR 2.437 [1.106-5.370]), psychiatric hospitalization in the year preceding baseline (OR 3.256 [1.422-7.458]), and clinical diagnosis of a personality disorder (OR 4.244 [1.923-9.370]), especially borderline personality disorder (OR 5.922 [2.558-13.709]).

CONCLUSIONS

Within a population of suicide attempters consenting to a brief intervention trial, the risk of re-attempt was strongly predicted by subjects' young age, history of previous attempts, psychiatric hospitalizations, and personality disorder, particularly borderline personality disorder. The composition of treated populations with regard to these characteristics may strongly influence the observed success of brief interventions. Their potential as moderators of treatment effectiveness and as indicators of the utility of brief interventions warrants further investigation.HIGHLIGHTSDuring the 2-year follow-up, 32% of trial participants reattempted suicide.Rates of reattempts varied and were strongly predicted by clinical subgroup.Subgroup composition may strongly influence brief interventions' observed outcome.

Meta-analysis of clinical risk factors for suicide among people presenting to emergency departments and general hospitals with suicidal thoughts and behaviours

BACKGROUND

Suicidal thoughts and behaviours (STB) are a common reason for presentation to emergency departments and general hospitals. A meta-analysis of the strength of clinical risk factors for subsequent suicide might aid understanding of suicidal behaviour and help suicide prevention.

METHODS

We conducted a meta-analysis of cohort and controlled studies on clinical risk factors and later suicide among people presenting to emergency departments and general hospitals with STB. Data were extracted from papers meeting inclusion criteria, published in Medline, PsycINFO, and Embase between 1 January 1960 and 10 October 2022 using papers located with the search terms ((suicide*).m_titl AND (emergency* OR accident and emergency OR casualty OR general hospital OR toxicology service).mp) or were indexed in PubMed and had titles located with the search terms (suicide* OR self-harm OR self-harm OR self-injury OR self-injury OR self-poisoning OR self-poisoning OR overdose OR para-suicide OR parasuicide [title/abstract]) AND (Emergency department OR emergency room OR Casualty OR general hospital OR toxicology OR accident and emergency [all fields]). Data about the association between clinical risk factors and suicide extracted from three or more studies were included in a random-effects meta-analysis of the odds of later death by suicide. The study was registered in PROSPERO and conducted according to MOOSE and PRISMA guidelines.

RESULTS

Seventy-five studies reported on 741,624 people, of which 19,649 died by suicide (2.65%). Male sex (odds ratio (OR) = 1.99) and age (OR = 2.01) were the most consistently reported risk factors. The strongest associations with subsequent death by suicide related to violent self-harm methods at the hospital presentation, including: unspecified violent method (OR = 4.97), any violent method (OR = 4.57) and the specific violent methods of drowning (OR = 4.32), hanging (OR = 4.26), and use of firearms (OR = 10.08). Patients categorised as higher risk using suicide prediction scales or any other method that combined risk factors had moderately increased odds of suicide (OR = 2.58). Younger age, Black and Hispanic ethnicity, overdose, a diagnosis of adjustment disorder, and the absence of any psychiatric diagnosis were protective against suicide.

CONCLUSIONS

Most risk factors for suicide among people who have presented with STB are not strongly associated with later suicide. The strongest risk factors relate to self-harm methods. In the absence of clear indicators of future suicide, all people presenting with suicidality warrant a thorough assessment of their needs, and further research is needed before we can meaningfully categorise people with STB according to suicide risk.

The Recovery from Attempting Suicide

A positive trajectory of life after an attempted suicide is extremely limited in research despite its advantage of aiding salutary outcomes. A systematic review of the qualitative research was conducted to explore the impact the attempt of taking your own life has had on your life and your work, to discover what changes participants have made to move toward a life worth living, and to understand how people can help better support individuals from attempted suicide attempts. A comprehensive search of online articles identified thirteen eligible studies. Three themes emerged: (1) rediscovering a life of meaning (2) contextual factors that facilitate a life worth living (3) internal changes. Limitations were discussed along with recommendations for future research.

Multiphasic Personality Assessment in a Case Series of Adolescent Patients with Suicidal Ideation and/or Attempts

Suicide is an important public health issue. To examine the differences in personality characteristics between a group of adolescents with suicidal ideation (SI) and a group with a history of suicidal attempts (SA), we conducted a cross-sectional study. We enrolled 55 adolescents (51 females; 12-18 y.o.) who presented SI and/or SA. Using the Columbia Suicide Severity Rating Scale, we divided the sample into two groups: adolescents with SI and adolescents with SA. All participants filled in the Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A). Adolescents in the SA group had greater difficulties in social relations, risky behaviors, and more intense suicidal ideation compared to those in the SI group. Adolescents in the SA group scored higher in Omission, in the Lie Scale, the Conduct Problem Scale, the Less Aspirations Scale, the Repression Scale in the MMPI-A, and item 283 of the MAST compared to the other group. The results suggest that using the MMPI-A to assess certain features (e.g., tendency to lie, repression) may be helpful in identifying young people who are at high risk of suicide. However, further research is required to determine the effectiveness of using this instrument.

Levels of IL-6 are Associated with Lifetime Attempted Suicide in Alcohol Use Disorder Patients

Background

Patients with alcohol use disorder (AUD) have an increased risk of suicide. Neuroimmunological measures, such as cytokines, are shown to deviate in people with attempted suicide. Few studies have investigated this among AUD patients.

Patients and Methods

One-hundred and fourteen patients undergoing residential treatment for AUD were interviewed on lifetime suicide attempts (SA) along with several other background variables and clinical characteristics. Serum blood samples were drawn for analysis of cytokines.

Results

Thirty-one patients (27%) reported at least one SA. These patients had more symptoms of current affective disorders and more severe dependence. In bivariate analysis only IL-6 and IL-10 appeared to be associated with lifetime SA but without reaching statistical significance. In multivariate linear regression, adjusting for sex, nicotine use, somatic illness, and the use of anti-inflammatory drugs, IL-6 was associated to SA (p = 0.033).

Conclusion

The cytokine IL-6 has repeatedly been found to be associated with suicidality. The present study concurs with this role of IL-6 in a naturalistic observational study of AUD patients.

The Influence of Treatment Latency on Suicide-Specific Treatment Outcomes

INTRODUCTION

The Attempted Suicude Short Intervention Program (ASSIP) provides an effective and cost-effective treatment option for people who have attempted suicide. Studies suggest that longer treatment latency is associated with poorer response to therapy, more severe symptomatology, and more suicide attempts This study examined the influence of treatment latency (time between suicide attempt and initiation of therapy) on the number of suicide attempts over the long-term course of ASSIP and the influence of treatment relationship on the extent of suicidal ideation.

METHOD

Survival and regression analyses were performed on 60 participants who had recently attempted suicide and received ASSIP at an outpatient psychiatric clinic. 60% were women and 40% were men.

RESULTS

The results found no significant association between treatment outcome in ASSIP and treatment latency (HR = 1.06; 95% CI: 0.92- 1.21, p = .44). Treatment relationship significantly influenced suicidal ideation at time t4 (B = - .35, t(55) = -3.21, p = .002), but treatment latency was not significantly associated with suicidal ideation (B = .02, t(55) = 0.87, p = .39).

CONCLUSION

No relationship between treatment latency and treatment outcome could be found, suggesting that ASSIP can be implemented at any time after the last suicide attempt. In contrast, the treatment relationship plays a central role in ASSIP.

An exploration of suicidal ideation and attempts, and care use and unmet need among suicide-ideators in a Belgian population study

BACKGROUND

Suicidal ideation, or thinking about death and suicide, is common across all layers of society. The aim of this paper is to add to the understanding of suicidal ideation in the general population, as well as help-seeking behaviors and perceived unmet mental health needs among those who report suicidal thoughts.

METHODS

The research is part of a representative population-based survey study of mental wellbeing in Antwerp (Flanders, Belgium) carried out in 2021. A total of 1202 participants between 15 and 80 years old answered the Ask Suicide-Screening Questions (ASQ), and an additional question about suicide plans. Participation was by invitation only and possible online or via a postal paper questionnaire. Univariate and multivariate logistic regression analyses were used to explore the association between both current suicidal ideation and self-reported lifetime suicide attempt with the sociodemographic factors age, gender, educational level, origin and financial distress. Moreover, formal care use for mental health was examined among those experiencing suicidal ideation, and logistic regression analyses were used to assess associated sociodemographic factors. Finally, perceived unmet mental health needs were assessed among suicide ideators.

RESULTS

The point-prevalence of suicidal ideation was 8.6% and was higher among younger age groups and individuals reporting financial distress. The lifetime-prevalence of suicide attempts is 6.5% and was higher in younger people and individuals with a primary educational level and with financial distress. About half (45.6%) of those with suicidal ideation consulted a professional for mental health problems in the past twelve months. Men and those with a primary educational level were less likely to seek help. Half of suicide ideators without care use perceived some need for mental health care, and a third of suicide ideators who used care perceived the obtained help as insufficient, resulting in a population prevalence of 3.6% suicide ideators with a fully or partially perceived unmet need.

CONCLUSIONS

The prevalence of suicide attempts, suicidal ideation and unmet needs among suicide-ideators is high in this Belgian sample. Mental health care need perception in suicide ideators needs further investigation.

A narrative inquiry into caregivers' experiences and management after a relative's suicide attempt in a rural community in Northeast Thailand

Suicide attempts have long-term negative consequences for families. This study reports a narrative inquiry using a social constructionist perspective to investigate how caregivers in rural northeast Thailand describe their experiences and management strategies following a family member's suicide attempt. From thematic analysis, three themes emerged: (1) distress and embarrassment, (2) managing to prevent re-attempts, and (3) letting go and moving on with my life. The implications discussed for mental health professionals include recognizing caregivers' experiences and developing more effective ways to manage the risk of future attempts.

The Importance of Timing, Fundamental Attitudes, and Appropriate Interventions as Key Aspects of Chaplain Suicide Prevention: A European Expert Panel of Mental Health Chaplains

An expert panel consisting of six mental health chaplains from several European countries was convened to ascertain the specific contribution of mental health chaplains to suicide prevention, and to generate good practices for suicide prevention. Three themes emerged: (1) the importance of timing; (2) fundamental attitudes of the chaplain towards the patient, and (3) appropriate interventions.

Validation of the Occupational Depression Inventory in Brazil: A study of 1612 civil servants

OBJECTIVE

The Occupational Depression Inventory (ODI) assesses work-attributed depressive symptoms. The ODI has demonstrated robust psychometric and structural properties. To date, the instrument has been validated in English, French, and Spanish. This study examined the psychometric and structural properties of the ODI's Brazilian-Portuguese version.

METHODS

The study involved 1612 civil servants employed in Brazil (M_AGE = 44, SD_AGE = 9; 60% female). The study was conducted online across all Brazilian states.

RESULTS

Exploratory structural equation modeling (ESEM) bifactor analysis indicated that the ODI meets the requirements for essential unidimensionality. The general factor accounted for 91% of the common variance extracted. We found measurement invariance to hold across sexes and age groups. Consistent with these findings, the ODI showed strong scalability (H = 0.67). The instrument's total score accurately ranked respondents on the latent dimension underlying the measure. Furthermore, the ODI exhibited excellent total-score reliability (e.g., McDonald's ω = 0.93). Occupational depression correlated negatively with work engagement and each of its components (vigor, dedication, and absorption), speaking to the ODI's criterion validity. Finally, the ODI helped clarify the issue of burnout-depression overlap. Relying on ESEM confirmatory factor analysis (CFA), we found burnout's components to correlate more strongly with occupational depression than with each other. Using a higher-order ESEM-within-CFA framework, we found a correlation of 0.95 between burnout and occupational depression.

CONCLUSION

The ODI displays robust psychometric and structural properties within the Brazilian context. The ODI constitutes a valuable resource for occupational health specialists and may help advance research on job-related distress.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Determinants of suicidal history before assisted versus self-initiated suicide late in life: an observational study

BACKGROUND

Older adults are at risk of assisted and self-initiated suicide. The links between prior attempts and assisted suicide in the elderly have not been investigated. Hence, we aimed to investigate and describe the occurrence, timing and determinants of suicide attempts prior to assisted and self-initiated suicide.

METHODS

We developed a retrospective study of all assisted and self-initiated suicides among people over 65 years in the canton of Geneva, Switzerland, for a 10-year period (2010-2019). Cases were identified by cross-referencing hospitals' routinely collected electronic data and a forensic report database. Cases were characterised in terms of sociodemographic factors, mental health disorders, main comorbidities, temporal sequence, methods of injury, medical complications and disclosure rates of previous attempts. The study used descriptive statistics.

RESULTS

A total of 26 of 497 (5.2%) and 20 of 149 (13.4%) older adults had made previous attempts before assisted and self-initiated suicide, respectively. More than half of them had made a single attempt, mostly by medication poisoning, sometimes more than 10 years before dying. Individuals who made two attempts were significantly more represented among the assisted suicide decedents. One self-initiated suicide decedent and half of the assisted suicide cases had disclosed that they had considered suicide. Individual characteristics were similar, except for assisted suicide decedents, who were eight years older than self-initiated suicide decedents. Almost all the individuals had mental disorders. Depression, anxiety and chronic pain were particularly prevalent among decedents of assisted suicide. The substantial representation of women in both groups may be an indication of their vulnerability, possibly related to chronic pain and life stressors.

CONCLUSIONS

Our results show commonalities between older assisted and self-initiated suicide decedents who made an attempt (s) before suicide. Further research is needed to demonstrate the overlap between the determinants of assisted suicide and other forms of suicidality and to support a suicide prevention strategy applicable to both types of suicide.

A comprehensive study of medically serious suicide attempts in France: incidence and associated factors

AIMS

People who make medically serious suicide attempts (MSSAs) share a number of features with those who die by suicide, and are at a high risk of suicide themselves. Studies to date have mostly focused on clinical samples of MSSAs. An epidemiological examination at a national level can help to identify risk profiles and pathways of care in this population.

METHODS

We explored the French nationwide hospital discharge database (Programme de Médicalisation des Systèmes d'Information, PMSI) to identify any MSSA taking place between 2012 and 2019. Relevant demographic and medical information was collected about the first MSSA of each attempter. Data from 2010 and 2011 were used to verify the absence of prior attempts.

RESULTS

First occurrences of MSSAs amounted to 81 959 cases over 8 years, with a mean age of 45.8 years, and 53.6% women. Incidence was higher in women (18.1 v. 17.3 per 1 00 000). The most common suicide method was deliberate self-poisoning (64.9% of cases). In comparison, violent methods associated higher mortality and comorbidity and were more frequent in men. The most common mental disorders were mood disorders (55.6%) and substance use disorders (46.2%). A minority of MSSA survivors were hospitalised in psychiatry (32.5%), mostly women.

CONCLUSIONS

MSSAs are frequent and easy to identify. There is a need to reinforce the continuity of psychiatric care for this population given the high risk of subsequent suicide, and the low rates of psychiatric hospitalisation after an MSSA even if violent methods are used. Specific care targeting this population could reduce treatment gaps.

Combined effects of nitric oxide synthase 3 genetic variant and childhood emotional abuse on earlier onset of suicidal behaviours

Marked heterogeneity in suicide attempters has been observed, with earlier onset being linked to stronger heritability, more childhood maltreatment. Nitric oxide signalling system might be implicated in this relationship through its role in the stress response/adaptation. This study examined how NOS genetic variants and childhood maltreatment were associated with age at first suicide attempt (SA). Adult patients with SA history (N = 414) filled in the Childhood Trauma Questionnaire, and six functionally relevant NOS2 and NOS3 polymorphisms were genotyped. Analyses included χ², Mann-Whitney U tests, Kendall's regression, multivariate linear and Cox survival regressions, and a moderation analysis. The NOS3 promotor 27-bp variable number tandem repeat (VNTR) bb homozygous state and childhood emotional abuse were independently associated with earlier age at first SA, which was robust after controlling for confounders [regression coefficient - 3.975, 95% CI -6.980 - (-0.970), p = 0.010, and - 1.088, 95% CI -2.172 - (-0.004), p = 0.049]. No interaction was observed. In the Cox proportional hazards model for age at first SA, the hazard ratio for patients with childhood emotional abuse and NOS3 27-bp VNTR bb was 0.533 (95% CI 0.394-0.720, p < 0.001) compared to patients without. Intermediate scores were observed with either only the risk genotype or only childhood emotional abuse. A graded relationship was also observed for repeated SA, family history of SA, and severe SA history. These results are preliminary due to a low statistical power and call for replication and further characterization of the role of nitric oxide system in the susceptibility to early-onset SB.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predictors of future suicide attempts in individuals with high suicide risk admitted to an acute psychiatry suicide intervention unit in India. A survival analysis study

OBJECTIVE

Determination of suicide vulnerability remains challenging in mental illness. Variability in risk factors identified compound its poor predictability. Longitudinal studies, offering more reliable indices of risk, from developing countries are conspicuously limited. Furthermore, research advances allude to inherent vulnerability. This study, the first of its kind from India, consequently aimed to delineate factors influencing subsequent attempts in mental illness and acute suicidality.

METHOD

Baseline and follow-up information (up to five years) was obtained from medical records of individuals (n = 130) with acute suicidality [recent attempt (first attempt/ reattempt) and high-risk ideators]. Variables were compared between individuals with, and without subsequent suicide attempts. Time to attempt and factors influencing the same was determined using survival analysis, and Cox proportional hazard for estimating the likelihood of a subsequent suicide attempt.

RESULTS

Median duration of follow up of the sample (n = 130) was 23 months. The sample comprised of individuals with a recent attempt (first-time attempt), recent reattempt and recent high-risk ideators. Subsequent suicide attempts were noted in 30 (23.1 %) patients. Baseline sociodemographic and clinical variables, including suicidality, could not differentiate individuals with a subsequent suicide attempt. Survival analysis indicated that 65 % of subsequent attempts occurred within 9 months of discharge. Family history of suicide and the presence of impulsive-aggressive traits were associated with both, reduced survival time and overall increased risk of a subsequent suicide attempt.

CONCLUSION

This study delineates both, the time frame associated with greatest risk, as well as individuals most likely to reattempt suicide. It thereby offers insights into potential windows of opportunity to mitigate prospective suicide risk. Strategies such as enhanced after-care and integrating specific interventions to attenuate impulsive-aggressive behaviors could be a focus to prevent future attempts, thereby decreasing rates of suicide amongst those with mental illness. Furthermore, the findings of this study reaffirm the role of factors that independently confer vulnerability to suicide. Traversing noted regional variations, the findings importantly reinforce the distinct pathophysiological underpinnings of suicide in mental illness.

Tools to Detect Risk of Death by Suicide: A Systematic Review and Meta-Analysis

Objective: There is limited knowledge about the ability of instruments to detect risk of suicide in a range of settings. Prior reviews have not considered whether the utility of instruments depends on prior probability of risk. We performed a systematic review to determine the diagnostic accuracy of instruments to detect risk of suicide in adults using likelihood ratio analysis. This method aids evaluation of prior probabilities of risk.

Data Sources: We searched MEDLINE, Cochrane Database of Systematic Reviews, PsycINFO, EMBASE, and Scopus from inception through January 19, 2021.

Study Selection: We included clinical trials, observational studies, and quasi-experimental studies assessing the diagnostic accuracy of instruments to detect risk of suicide in adults. There were no language restrictions.

Data Extraction: Three reviewers in duplicate assessed full texts to determine eligibility and extracted data from included studies. Positive (LR+) and negative likelihood ratio (LR-) and 95% CIs were calculated for each instrument.

Results: Thirty studies met inclusion criteria. Most instruments showed minimal utility to detect or rule out risk of suicide, with LR+ ≤ 2.0 and LR- ≥ 0.5. A few instruments had a high utility for improving risk detection in emergency department, inpatient mental health, and prison settings when patients scored above the cutoff (LR+ > 10). For example, among patients discharged from an emergency department, the Columbia Suicide Severity Rating Scale-Clinical Practice Screener had a LR+ of 10.3 (95% CI, 6.3-16.8) at 3-month follow-up. The clinical utility of the instruments depends on the pretest probability of suicide in the setting. Because studies spanned over 6 decades, the findings are at risk for secular trends.

Discussion: We identified several instruments that may hold promise for detecting risk of suicide in emergency department, inpatient mental health, or prison settings. The utility of the instrument hinges, in part, on baseline suicide risk.

Registration: PROSPERO: CRD42021285528.

Common and differential risk factors behind suicidal behavior in patients with impulsivity-related disorders: The case of bulimic spectrum eating disorders and gambling disorder

BACKGROUND AND AIMS

Mental disorders with high levels of impulsivity such as bulimic spectrum eating disorders (BSED) and gambling disorder (GD) are associated with high risk of suicidal behavior. The aim of the present study was to identify the common and differential vulnerability factors behind suicide attempts in a sample of patients with BSED compared to patients with GD.

METHODS

A total of 6,077 adults who sought treatment and met criteria either for BSED (n = 2,391) or GD (n = 3,686) were assessed at a specialized hospital unit. Personality traits, psychopathological symptomatology, lifetime history of suicide attempts and socio-demographic variables were evaluated.

RESULTS

The prevalence of suicide attempts was higher for BSED patients (26.2%) compared to GD patients (7.1%) being anorexia nervosa (Binge/Purge type) and bulimia nervosa the most affected subtypes. In the predictive model, the transdiagnostic vulnerability factors with the highest contribution to the risk of suicidal behavior both in BSED and GD were unemployment, early age of onset of the disorder, worse psychopathological state, and self-transcendence personality trait. However, specific risk factors for suicidal acts were identified in each disorder: longer duration of the disorder, lower education levels and reward dependence were exclusively associated with BSED while female gender, older age, and higher harm avoidance were associated with GD.

DISCUSSION

Patients with GD and BSED share certain vulnerability factors although certain factors are exclusive to each disorder.

CONCLUSIONS

Interventions need to pay special attention to both common and specific vulnerability factors to mitigate the risk of suicidal acts in these disorders.

Sex-specific factors associated with lifetime suicide attempt among patients with alcohol use disorders

BACKGROUND

Patients with alcohol use disorder (AUD) are at high risk for suicide attempts. Mental health problems along with AUD-related factors may contribute to this increased risk. Studies have shown sex differences in rates and correlates of suicide attempts.

AIMS

The purpose of the study was to examine mental-health-related and AUD-related factors associated with suicide attempt separately in female and male AUD patients.

METHOD

We collected information about lifetime suicide attempt and mental-health- and AUD-related factors for AUD in-patients (n = 114; 32 females) receiving rehabilitative treatment.

RESULTS

The prevalence of lifetime suicide attempt was 27%, and the rate was similar in both sexes. Among females, current depressive symptoms and current post-traumatic stress disorder diagnosis were associated with suicide attempt. In male AUD patients, among the mental-health-related factors, lifetime major depression, panic disorder, social phobia, childhood sexual abuse and antisocial personality disorder were associated with suicide attempt. In addition, AUD-related factors including longer duration of drinking, history of delirium tremens, greater severity of AUD and lower levels of prolactin were associated with suicide attempt in males.

CONCLUSIONS

Our results indicate that suicide attempts in female AUD patients were more mental-health-related, whereas those in males were also related to the severity of AUD. This suggests that a suicide prevention programme for AUD patients would benefit from a sex-based understanding of the risk factors.

Suicide mortality after a nonfatal suicide attempt: A systematic review and meta-analysis

INTRODUCTION

Deliberate self-harm and suicide attempts share common risk factors but are associated with different epidemiological features. While the rate of suicide after deliberate self-harm has been evaluated in meta-analyses, the specific rate of death by suicide after a previous suicide attempt has never been assessed. The aim of our study was to estimate the incidence of death by suicide after a nonfatal suicide attempt.

METHOD

We developed and followed a standard meta-analysis protocol (systematic review registration-PROSPERO 2021: CRD42021221111). Randomized controlled trials and cohort studies published between 1970 and 2020 focusing on the rate of suicide after suicide attempt were identified in PubMed, PsycInfo and Scopus and qualitatively described. The rates of deaths by suicide at 1, 5 and 10 years after a nonfatal suicide attempt were pooled in a meta-analysis using a random-effects model. Subgroup analysis and meta-regressions were also performed.

RESULTS

Our meta-analysis is based on 41 studies. The suicide rate after a nonfatal suicide attempt was 2.8% (2.2-3.5) at 1 year, 5.6% (3.9-7.9) at 5 years and 7.4% (5.2-10.4) at 10 years. Estimates of the suicide rate vary widely depending on the psychiatric diagnosis, the method used for the suicide attempt, the type of study and the age group considered.

CONCLUSION

The evidence of a high rate of suicide deaths in the year following nonfatal suicide attempts should prompt prevention systems to be particularly vigilant during this period.

Excess mortality by suicide in high-risk subgroups of suicide attempters: a prospective study of standardised mortality rates in suicide attempters examined at a medical emergency inpatient unit

OBJECTIVES

The primary aim of the present study was to investigate the putative excess mortality by suicide in suicide attempters. As a secondary aim, we investigate excess mortality in specific, clinically relevant subgroups: individuals with repeated suicide attempts (RA); individuals who used violent method at the attempt (VA); and those who scored high on the Suicide Intent Scale (HS) at the time of the baseline attempt. Finally, we investigate excess mortality in men and women separately and within 5 years and over 5 years after hospital admission for attempted suicide.

DESIGN

Prospective register-based follow-up for 21-32 years. Standardised mortality ratio (SMR) was calculated for suicide using national census data. Clinically relevant subgroups were investigated separately.

SETTING

Medical emergency inpatient unit in the south of Sweden.

PARTICIPANTS

1039 individuals who were psychiatrically assessed at admission to medical inpatient care for attempted suicide between 1987 and 1998.

OUTCOME MEASURE

Suicide.

RESULTS

The overall SMR for suicide was 23.50 (95% CI 18.68 to 29.56); significantly higher (p<0.001) among women (30.49 (95% CI 22.27 to 41.72)) than men (18.61 (95% CI 13.30 to 26.05)). Mortality was highest within the first 5 years after the index suicide attempt (48.79 (95% CI 35.64 to 66.77)) compared with those who died after 5 years (p<0.001) (14.74 (10.53 to 20.63)). The highest independent SMR was found for VA (70.22 (95% CI 38.89 to 126.80)). In a regression model including RA, VA and HS all contributed significantly to excess suicide mortality.

CONCLUSIONS

An elevated risk of premature death by suicide was found in suicide attempters compared with the general population. Assessment of previous suicide attempts is important, even though the attempt/s may have occurred decades ago. When assessing suicide risk, clinicians should consider repeated attempts and whether the attempts involved high suicidal intent and violent method. Healthcare interventions may benefit from targeting identified subgroups of attempters.

A Randomized Clinical Trial of Attempted Suicide Short Intervention Program versus Crisis Counseling in Preventing Repeat Suicide Attempts: A Two-Year Follow-Up Study

INTRODUCTION

The Attempted Suicide Short Intervention Program (ASSIP) is a brief psychotherapeutic intervention, and a pivotal study found it to be remarkably effective in reducing repeat suicide attempts.

OBJECTIVE

To compare the effectiveness of ASSIP to crisis counseling (CC) in a randomized clinical trial (ISRCTN13464512).

METHODS

Adult patients receiving treatment for a suicide attempt in a Helsinki City general hospital emergency room in 2016-2017 were eligible to participate. We excluded psychotic or likely non-adherent substance-abusing or substance-dependent patients. Eligible patients (n = 239) were randomly allocated to one of two interventions. (a) ASSIP comprised three visits, including a videotaped first visit, a case formulation, and an individualized safety plan, plus letters from the therapist every 3 months for 1 year, and then, every 6 months for the next year. (b) CC typically involved 2-5 (median 3) face-to-face individual sessions. In addition, all participants received their usual treatment. One and 2 years after baseline, information related to participants' suicidal thoughts and attempts, and psychiatric treatment received was collected via telephone and from medical and psychiatric records.

RESULTS

Among randomized patients, two-thirds initiated either ASSIP (n = 89) or CC (n = 72), with 73 (82%) completing ASSIP and 58 (81%) CC. The proportion of patients who attempted suicide during the 2-year follow-up did not differ significantly between ASSIP and CC (29.2% [26/89] vs. 35.2% [25/71], OR 0.755 [95% Cl 0.379-1.504]).

CONCLUSIONS

We found no difference in the effectiveness of the two brief interventions to prevent repeat suicide attempts.

How Did the COVID-19 Pandemic Affect the Use of Emergency Medical Services by Patients Experiencing Mental Health Crises?

The COVID-19 pandemic and its resulting social restrictions have significant implications for mental health. The objective of this study was to determine the monthly trends and types of patients experiencing a mental health crisis (MHC) who used emergency medical services (EMSs) before and during the COVID-19 pandemic. A retrospective observational study was conducted using EMS data. During the study period, 8577 patients used EMSs for MHCs. EMS dispatches for MHCs and suicide completion after the COVID-19 pandemic were decreased by 12.4% and 12.7%, respectively, compared to those before the COVID-19 pandemic. Segmented regression analysis found that the number of patients per month was 6.79 before the COVID-19 pandemic. The number decreased to 4.52 patients per month during the COVID-19 pandemic, although the decrease was not statistically significant. The monthly number of patients experiencing an MHC decreased during strict social distancing measures but increased during relaxed social distancing measures. The percentage of hanging increased from 14.20% before the COVID-19 pandemic to 14.30% (p = 0.03) during the COVID-19 pandemic, whereas the percentages of jumping (from 15.55% to 15.28%, p = 0.01) and self-harm by smoke (from 4.59% to 3.84%, p < 0.001) during the COVID-19 pandemic were decreased compared to those before COVID-19. However, the effect size for the above findings was small (below 0.20). More than 25% of the patients experiencing an MHC who used EMSs refused to transfer to the ED over both study periods (26.49% in the pre-COVID-19 period and 28.53% in the COVID-19 period). The COVID-19 pandemic and social restrictions seemed to have some effects on the use of EMSs by MHC patients. Hanging is mainly performed indoors and is not found easily if social distancing persists, and a patient experiencing an MHC who refuses to be transferred could potentially attempt suicide. Subsequent studies should be performed to determine whether these findings are temporary during the COVID-19 pandemic or whether they will show different aspects after the COVID-19 pandemic.

Prediction of suicidal behavior using self-reported suicidal ideation among patients with bipolar disorder

BACKGROUND

People with bipolar disorder have elevated suicide risk. We estimated the ability of the Patient Health Questionnaire (PHQ9) to predict suicide outcomes for outpatients with bipolar disorder.

METHODS

Visits by adults with bipolar disorder who completed a PHQ9 were identified using electronic health record (EHR) data. Bipolar diagnoses and suicide attempts were ascertained from EHR and claims data, and suicide deaths from state and federal records. Depression severity was assessed via the first eight items of the PHQ9, while suicidal ideation was assessed by the ninth item.

RESULTS

37,243 patients made 126,483 visits. Patients reported at least moderate symptoms of depression in 49% and suicidal ideation in 30% of visits. Risk of suicide attempt was 4.21% in the subsequent 90 days for those reporting nearly daily suicidal ideation compared to 0.74% in those reporting none. Patients with nearly daily suicidal ideation were 3.85 (95% CI 3.32-4.47) times more likely to attempt suicide and 13.78 (95% CI 6.56-28.94) times more likely to die by suicide in the subsequent 90 days than patients reporting none. Patients with self-harm in the last year were 8.86 (95% 7.84-10.02) times more likely to attempt suicide in the subsequent 90 days than those without.

LIMITATIONS

Our sample was limited to patients completing the PHQ9 and did not include data on some important social risk or protective factors.

CONCLUSIONS

The PHQ9 was a robust predictor of suicide. Suicidal ideation reported on the PHQ9 should be considered a strong indicator of suicide risk and prompt further evaluation.

Identifying and Managing Suicidality in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

Adult patients affected by myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) are at an increased risk of death by suicide. Based on the scientific literature and our clinical/research experiences, we identify risk and protective factors and provide a guide to assessing and managing suicidality in an outpatient medical setting. A clinical case is used to illustrate how information from this article can be applied. Characteristics of ME/CFS that make addressing suicidality challenging include absence of any disease-modifying treatments, severe functional limitations, and symptoms which limit therapies. Decades-long misattribution of ME/CFS to physical deconditioning or psychiatric disorders have resulted in undereducated healthcare professionals, public stigma, and unsupportive social interactions. Consequently, some patients may be reluctant to engage with mental health care. Outpatient medical professionals play a vital role in mitigating these effects. By combining evidence-based interventions aimed at all suicidal patients with those adapted to individual patients' circumstances, suffering and suicidality can be alleviated in ME/CFS. Increased access to newer virtual or asynchronous modalities of psychiatric/psychological care, especially for severely ill patients, may be a silver lining of the COVID-19 pandemic.

Suicide Thoughts and Attempts in the Norwegian General Population during the Early Stage of the COVID-19 Outbreak

The aim of the study was to examine the prevalence of suicide thoughts and attempts during the early stage of the COVID-19 outbreak and examine pandemic-related factors associated with suicide thoughts in the general Norwegian population. A sample of 4527 adults living in Norway were recruited via social media. Data related to suicide thoughts and attempts, alcohol use, pandemic-related concerns, and sociodemographic variables were collected. Associations with suicide thoughts were analyzed with logistic regression analysis. In the sample, 3.6% reported suicide thoughts during the last month, while 0.2% had attempted suicide during the same period. Previous suicide attempts (OR: 11.93, p < 0.001), lower age (OR: 0.69, p < 0.001), daily alcohol use (OR: 3.31, p < 0.001), being in the risk group for COVID-19 complications (OR: 2.15, p < 0.001), and having economic concerns related to the pandemic (OR: 2.28, p < 0.001) were associated with having current suicide thoughts. In addition to known risk factors, the study suggests that aspects specific to COVID-19 may be important for suicidal behaviors during the pandemic.

Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective

OBJECTIVES

To explore how mandatory reporting to the supervisory authority of suicides among recipients of healthcare services has influenced associated investigations conducted by the healthcare services, the lessons obtained and whether any suicide-prevention-related improvements in terms of patient safety had followed.

DESIGN AND SETTINGS

Retrospective study of reports from Swedish primary and secondary healthcare to the supervisory authority after suicide.

PARTICIPANTS

Cohort 1: the cases reported to the supervisory authority in 2006, from the time the reporting of suicides became mandatory, to 2007 (n=279). Cohort 2: the cases reported in 2015, a period of well-established reporting (n=436). Cohort 3: the cases reported from September 2017, which was the time the law regarding reporting was removed, to November 2019 (n=316).

PRIMARY AND SECONDARY OUTCOME MEASURES

Demographic data and received treatment in the months preceding suicide were registered. Reported deficiencies in healthcare and actions were categorised by using a coding scheme, analysed per individual and aggregated per cohort. Separate notes were made when a deficiency or action was related to a healthcare-service routine.

RESULTS

The investigations largely adopted a microsystem perspective, focusing on final patient contact, throughout the overall study period. Updating existing or developing new routines as well as educational actions were increasingly proposed over time, while sharing conclusions across departments rarely was recommended.

CONCLUSIONS

The mandatory reporting of suicides as potential cases of patient harm was shown to be restricted to information transfer between healthcare providers and the supervisory authority, rather than fostering participative improvement of patient safety for suicidal patients.The similarity in outcomes across the cohorts, regardless of changes in legislation, suggests that the investigations were adapted to suit the structure of the authority's reports rather than the specific incident type, and that no new service improvements or lessons are being identified.