Suicide in the absence of mental disorder? A review of psychological autopsy studies across countries

Machine learning based identification of suicidal ideation using non-suicidal predictors in a university mental health clinic

Suicide causes over 700,000 deaths annually worldwide. Mental disorders are closely linked to suicidal ideation, but predicting suicide remains complex due to the multifaceted nature of contributing factors. Traditional assessment tools often fail to capture the interactions that drive suicidal thoughts, underscoring the need for more sophisticated predictive approaches. This study aimed to predict suicidal and self-harm ideation among university students using machine learning models without relying on suicidal behavior related predictors. The goal was to uncover less obvious risk factors and provide deeper insights into the complex relationships between psychiatric symptoms and suicidal ideation. Data from 924 university students seeking mental health services were analyzed using seven machine learning algorithms. Suicidal ideation was assessed through the 9th item of the Patient Health Questionnaire-9. Three predictive models were developed, with the final model utilizing only subdomains from the DSM-5 Level 1 Self Rated Cross-Cutting Symptom Measure. Feature importance was assessed using SHAP and Integrated Gradients techniques. To ensure model generalizability, the best-performing model was externally validated on a separate dataset of 361 individuals. Machine learning models achieved strong predictive accuracy, with logistic regression and neural networks reaching AUC values of 0.80. The final model achieved an AUC of 0.80 on the training data and 0.79 on external validation data. Key predictors of suicidal ideation included personality functioning and depressed mood (both increasing the likelihood), while anxiety and repetitive thoughts were associated with a decreased likelihood. The use of non-suicidal predictors across datasets highlighted psychiatric dimensions relevant to early intervention. This study demonstrates the effectiveness of machine learning in predicting suicidal ideation without relying on suicide-specific inputs. The findings emphasize the critical roles of personality functioning, mood, and anxiety in shaping suicidal ideation. These insights can enhance early detection and personalized interventions, especially in individuals reluctant to disclose suicidal thoughts.

The Insight Study: A Case-Control Psychological Autopsy Study Examining Factors Associated With Suicide in Middle-Aged People

INTRODUCTION

Despite current suicide prevention strategies, suicide rates are increasing in many Western countries in the 45-60 age group. To comprehend the high risk of suicide in this group, it is essential to gain insight into its risk factors.

METHODS

A case-control psychological autopsy study examined the differences between individuals who died by suicide (i.e., suicide cases) and those with psychological problems (i.e., living controls) between the ages of 45 and 60 years.

RESULTS

Eighty-two informants were interviewed regarding 48 suicide cases and 23 controls. Controls were significantly more likely than suicide cases to have discussed the subject of euthanasia (45.5% vs.15.2%), to experience physical problems (95.7% vs. 70.8%), and to undergo treatment for these problems (73.9% vs. 39.6%). Suicide cases were more likely to be diagnosed with a depressive episode, depressive disorder (87.5% vs. 60.9%), but less likely to have current treatment for psychiatric disorders (70.8% vs. 95.7%). Suicide cases were more likely than controls to experience problems at work (85.4% vs. 60.9%), future financial problems (59.0% vs. 22.2%), and concerns about these problems (56.8% vs. 22.2).

CONCLUSION

The results suggest possibilities for suicide prevention among middle-aged individuals through targeted interventions addressing mental healthcare, occupational settings, and financial distress.

Geography and risk of suicidal ideation and attempts post outpatient psychiatric visit in commercially insured US adults

OBJECTIVE

This study sought to determine whether demographic and clinical factors for suicidal ideation (SI) and suicide attempts (SA) in adults vary across different census divisions in the US.

METHODS

A nationwide cohort was constructed using commercial health insurance claims data of adults aged 25-64 years with at least one mental health or substance use disorder-related outpatient visit between 2014 and 2015. Survival analysis was used to study how the association of demographic and clinical factors on SI and SA vary by geographic divisions.

RESULTS

The Mountain Division had the highest rates of SI and SA in almost all observed time intervals after the index visit. The Northeast region and the West coast had the lowest rates. For both SI and SA, we observed strong interaction effects between geographic division and urbanicity (χ2(152) = 188.14, p = 0.02; χ2(152) = 196.20, p = 0.01, respectively). In particular, urbanicity was a risk factor for SI in the West North Central (HR = 0.71, 95% CI: [0.50, 0.99]) and the Pacific (HR = 0.54, 95% CI: [0.40, 0.74]) Divisions. Urbanicity was also a risk factor for SA in the West North Central Division (HR = 0.39, 95% CI: [0.16, 0.95]), but a protective factor for SA in the Mountain Division (HR = 1.71, 95% CI: [1.11, 2.63]).

CONCLUSIONS

The association between urbanicity and SI and SA varied by US geography. Future suicide prevention efforts should include a focus on urban adults in the West North Central and the Pacific Divisions, and rural adults in the Mountain Division.

Are we Using the Right Evidence to Inform Suicide Prevention in Low- and Middle-Income Countries? An Umbrella Review

OBJECTIVE

Suicide disproportionately affects low- and middle-income countries and evidence regarding prevention approaches developed in high income countries may not be applicable in these settings. We conducted an umbrella review to assess whether the conclusions of suicide prevention systematic reviews accurately reflect the studies contained within those reviews in terms of setting generalizability.

METHODS

We conducted database searches in PubMed/Medline, Embase, PsycInfo, PsychExtra, OVID global health, and LILACS/BECS. We included systematic reviews with the outcome of suicide, including bereavement studies where suicide death was also the exposure.

RESULTS

Out of the 147 reviews assessed, we found that over 80% of systematic reviews on suicide deaths do not provide an accurate summary of review findings with relation to geographic relevance and ultimately generalizability.

CONCLUSION

Systematic reviews are often the resource used by practitioners and policymakers to guide services. Misleading reviews can detrimentally impact suicide prevention efforts in LMICs. We call for systematic reviewers to be responsible when generalizing the findings of their reviews particularly in the abstracts.

Occurrence and characteristics of suicidal ideation in psychiatrically healthy individuals based on ecological momentary assessment

Decedents with no known mental disorder comprise 5-40% of suicides, suggesting that suicide ideation (SI) and behavior may occur in the psychiatrically healthy with important implications for suicide risk screening. Healthy Volunteers (HV) and patients with Major Depressive Disorder (MDD) provided 7 days of Ecological Momentary Assessment (EMA) data about SI and stressors. Longitudinal mixed effects logistic regression models compared HV and patient SI and stressors. Mixed effects linear regression models compared HVs' and patients' SI score change from the previous epoch's SI score when each stressor occurred. HVs (n = 42) reported less frequent (p < 0.001) and less intense SI (p < 0.003) than patients (n = 80), yet did endorse SI and/or SI-related items in 44% of EMA epochs, endorsing SI items in 25% of epochs with non-zero SI scores. For 7 of 8 stressors, patients reported stressors more often than HVs (all p < 0.001) responding to them with increased SI (0.0001 < p < 0.0472). HVs were relatively resilient to stressors, reporting SI increases only in response to neglect (p < 0.0147). Although SI and SAs are documented among psychiatrically healthy individuals, scientific attention to these observations has been scant. Real-time SI measurement showed that HVs' SI was less pronounced than MDD patients', but was endorsed, nonetheless. Patients were more likely to report stressors than HVs, perhaps due to greater sensitivity to the environment, and reported SI in response to stressors, which was less common in HVs. Both MDD patients and HVs most often manifested passive SI (viz, "decreased wish to live"). However, passive SI (viz, "desire for death"), may predict suicide, even absent SI per se (thinking about killing yourself). This study validates the utility of real-time SI assessment, showing that HVs endorse SI items in 11% of epochs, which implies that suicide risk screening focused on those with mental disorders may be too narrow an approach.

Rational suicide? Interviews with Swedish psychiatrists

Semi-structured interviews were performed with 12 psychiatrists regarding their perceptions of the Swedish Vision Zero for Suicide. Focusing on the topic of rational suicide, we re-analyzed these interviews using descriptive content analysis. The informants generally acknowledged the existence of rational suicide and its occurrence also among severely ill psychiatric patients, but expressed varying perceptions of the relevance of the concept in clinical practice. The difficulty of identifying rational suicide was considered to be a major problem. Another experience was a potential conflict between promoting a patient's rationality and preventing suicide. While the normative aspects of rational suicide have been addressed in the literature, our results highlight a need for further attention to the epistemological and practical aspects of rational suicide.

Suicidal behaviour is pathological: implications for psychiatric euthanasia

Some have challenged the validity of labelling suicidal thoughts and behaviours (STB) as pathological. In this paper, we argue that STB is indeed pathological, thereby, situating suicide prevention within the realm of medicine, complicating calls for the legalisation of medical assistance in dying for individuals whose sole condition is psychiatric (psychiatric medical assistance in dying (MAID)). Evidence shows STB predicts the risk of suicide; moreover, several mental illnesses are associated with STB, and 70%-90% of suicide deaths are linked to psychiatric illness. Treating psychiatric illnesses can prevent suicide. We contend that this clinical evidence not only warrants the classification of STB as pathological but also necessitates its treatment and prevention. This perspective poses a challenge to legislation that would legalise psychiatric MAID.

The synergy of depression and flourishing/languishing on suicidal thoughts and behaviors: Findings from a national sample of emerging adult students in higher education in the United States

BACKGROUND

Suicide is a leading cause of death among students in higher education, driven in large part by mental illness, but also mental wellness. Relatively few studies have examined the extent to which depression and flourishing/languishing interact in relation to suicidal thoughts and behaviors.

METHODS

We analyzed data from the Healthy Minds Study (2020-2021; emerging adult students aged 18-29; N = 101,435), and calculated interaction contrast ratios to estimate the interaction between depression and flourishing/languishing on suicidal thoughts and behaviors, using an additive scale, adjusting for age, gender, race/ethnicity, and food insecurity.

RESULTS

When compared with students who were flourishing without depression, the students who were languishing without depression, and the students who were depressed but still flourishing had significantly greater odds of suicidal thoughts and behaviors. However, students who were depressed and languishing had the greatest odds, exceeding the sum of the individual effects.

CONCLUSION

The interaction of depression and flourishing/languishing produced a synergy that increased odds of suicidal thoughts and behaviors. Flourishing interventions may prove to be an effective strategy for universal suicide prevention.

A Secondary Analysis of the Complex Interplay between Psychopathology, Cognitive Functions, Brain Derived Neurotrophic Factor Levels, and Suicide in Psychotic Disorders: Data from a 2-Year Longitudinal Study

Identifying phenotypes at high risk of suicidal behaviour is a relevant objective of clinical and translational research and can facilitate the identification of possible candidate biomarkers. We probed the potential association and eventual stability of neuropsychological profiles and serum BDNF concentrations with lifetime suicide ideation and attempts (LSI and LSA, respectively) in individuals with schizophrenia (SCZ) and schizoaffective disorder (SCA) in a 2-year follow-up study. A secondary analysis was conducted on a convenience sample of previously recruited subjects from a single outpatient clinic. Retrospectively assessed LSI and LSA were recorded by analysing the available longitudinal clinical health records. LSI + LSA subjects consistently exhibited lower PANSS-defined negative symptoms and better performance in the BACS-letter fluency subtask. There was no significant association between BDNF levels and either LSI or LSA. We found a relatively stable pattern of lower negative symptoms over two years among patients with LSI and LSA. No significant difference in serum BDNF concentrations was detected. The translational viability of using neuropsychological profiles as a possible avenue for the identification of populations at risk for suicide behaviours rather than the categorical diagnosis represents a promising option but requires further confirmation.

Suicide in individuals with no psychiatric disorders: what makes you vulnerable?

Globally, hundreds of thousands of people die by suicide every year. Suicides are usually associated with psychiatric illness. However, considerable evidence suggests that a significant number of individuals who die by suicide do not have diagnosable psychiatric disorders. The goal of this article is to attract attention to an overlooked issue of suicide in persons with no psychiatric disorders and to discuss some aspects of this issue. Research on identification and prevention of suicidal behavior in people with no psychiatric disorders is very limited. The available data indicate that suicides in individuals without psychiatric disorders are related to life stressors, lack of social support, and certain personality traits such as impulsivity. Suicide risk may be increased in military veterans with no psychiatric disorders. Many physical disorders, especially conditions associated with pain increase suicide risk in individuals with no diagnosable psychiatric disorders. Developmental, genetic and physical factors may play a role in the psychobiology of suicide in people with no psychiatric conditions. Promoting resilience may reduce suicide risk in the general population. Clinicians who work with medical or surgical patients need to have sufficient training in suicide prevention. Possibly, shifting some suicide prevention resources from individuals who are regarded as high-risk suicide patients to the general population may reduce suicide rates. Public education and better awareness about suicide may reduce suicide deaths among people with no psychiatric disorders.

Lifetime Suicide Attempts in Otherwise Psychiatrically Healthy Individuals

Importance

Not all people who die by suicide have a psychiatric diagnosis; yet, little is known about the percentage and demographics of individuals with lifetime suicide attempts who are apparently psychiatrically healthy. If such suicide attempts are common, there are implications for suicide risk screening, research, policy, and nosology.

Objective

To estimate the percentage of people with lifetime suicide attempts whose first attempt occurred prior to onset of any psychiatric disorder.

Design, Setting, and Participants

This cross-sectional study used data from the US National Epidemiologic Study of Addictions and Related Conditions III (NESARC-III), a cross-sectional face-to-face survey conducted with a nationally representative sample of the US civilian noninstitutionalized population, and included persons with lifetime suicide attempts who were aged 20 to 65 years at survey administration (April 2012 to June 2013). Data from the NESARC, Wave 2 survey from August 2004 to September 2005 were used for replication. Analyses were performed from April to August 2023.

Exposure

Lifetime suicide attempts.

Main Outcomes and Measures

The main outcome was presence or absence of a psychiatric disorder before the first lifetime suicide attempt. Among persons with lifetime suicide attempts, the percentage and 95% CI of those whose first suicide attempt occurred before the onset of any apparent psychiatric disorders was calculated, weighted by NESARC sampling and nonresponse weights. Separate analyses were performed for males, females, and 3 age groups (20 to <35, 35-50, and >50 to 65 years).

Results

In the total sample of 36 309 respondents, 1948 persons had lifetime suicide attempts; 66.8% (95% CI, 64.1%-69.4%) were female, and 6.2% (95% CI, 4.9%-7.4%) had no apparent lifetime psychiatric diagnoses when surveyed. In addition, 13.4% (95% CI, 11.6%-15.2%) made their first suicide attempt prior to psychiatric disorder onset. Thus, an estimated 19.6% of respondents first attempted suicide without an antecedent psychiatric disorder. No significant age or sex differences were detected in the percentage of those with lifetime suicide attempts absent psychiatric disorders, although females were more likely than males to attempt suicide in the year of psychiatric disorder onset (14.9% [95% CI, 12.5%-17.3%] vs 8.6% [95% CI, 6.0%-11.2%]; P < .001), and attempts were less frequent among those older than 50 to 65 years (3.9% [95% CI, 3.5%-4.4%] vs 6.1% [95% CI, 5.4%-6.8%] for 35-50 years and 6.2% [95% CI, 5.6%-6.9%] for 20 to <35 years; P < .001).

Conclusions and Relevance

In this study, an estimated 19.6% of individuals who attempted suicide did so despite not meeting criteria for an antecedent psychiatric disorder. This finding challenges clinical notions of who is at risk for suicidal behavior and raises questions about the safety of limiting suicide risk screening to psychiatric populations.

Advancing early detection of suicide? A national study examining socio-demographic factors, antecedent stressors and long-term history of self-harm

BACKGROUND

A range of factors including mental disorders, adverse events and history of self-harm are associated with suicide risk. Further examination is needed of the characteristics of suicides which occur without established risk factors, using national surveillance systems.

METHODS

Data on all suicides in Ireland from 2015 to 2017 were drawn from the Irish Probable Suicide Deaths Study (IPSDS). Variables examined included socio-demographics, psychiatric history and precipitant stressors. Suicide data were linked with data on prior self-harm from the National Self-Harm Registry Ireland (NSHRI). Latent Class Analysis (LCA) was used to identify sub-groups of suicide cases.

RESULTS

Of the 1809 individuals who died by suicide, 401 (22.2 %) had a history of hospital-treated self-harm. Four distinct profiles of suicides were identified. One group was marked by high levels of prior self-harm and mental health conditions. Two of the groups included few individuals with a history of self-harm but had notably high levels of mental health conditions. These two groups had relatively high levels of reported chronic pain or illness but differed in terms of socio-demographics. The final group, predominantly male, had markedly low levels of mental health conditions or self-harm but high levels of personal stressors and substance use.

LIMITATIONS

The use of coronial data may be limited by bias in the collecting of information from the deceased's family members.

CONCLUSIONS

A sub-group of suicide cases exists without any psychiatric or self-harm history but with salient occupational or health-related proximal stressors. Suicide prevention interventions should include occupational settings and should promote mental health literacy.

From suicide to accident - Case report - The significance of the medico-legal autopsies

INTRODUCTION

Suicide is the intentional and voluntary act of destroying one's own life, while an accident is an unintended event that involuntarily causes injury to one's health or destruction of life.

CASE PRESENTATION

We report a case of a 54-year-old male who was found in a forest in late November, approximately 500 m away from his car. He was positioned bent over a trunk of a tree with his head beneath the rest of his body. His pants were down to his knees, and there were soiled blades of grass and leaves on his body. Investigation of the case circumstances revealed that he had attempted suicide by carbon monoxide poisoning, using a hose connected to the exhaust pipe and running it through the window into the cabin. Window on the driver's side was broken with glass particles on the driver's seat. Wrappers from "Rivotril" tablets, a generic benzodiazepine, were also found in the car. Autopsy revealed the following: postmortem hypostasis was of a cherry red color and well pronounced on the upper part of the front of the body and face. Numerous bruises, contusions, and erosions were present all over the body. Frostbites were especially pronounced in the knees and elbows area. The synovial membranes were partially bloodstained and reddish in color. Opening the stomach revealed erosions of the gastric mucosa (Wischnewsky sign). Chemical toxicological analysis detected presence of benzodiazepines and carboxyhemoglobin (25%).

CONCLUSION

Based on the autopsy findings, chemical toxicological analyses, and investigation of the case circumstances, it has been concluded that the death occurred due to the combined effects of hypothermia, postural asphyxia and carboxyhemoglobin and benzodiazepine intoxication. The manner of death in this case is a combination of accidental and suicidal, as the victim attempted suicide but ultimately died due to exposure to low external temperature.

Characteristics of deaths by suicide in postmortem studies in Brazil: A systematic review and meta-analysis

INTRODUCTION

Suicide is one of the leading causes of death, with a trend for its increase in Brazil in past decades. This study aimed to review the characteristics of suicides in Brazilian postmortem studies.

METHODS

Studies investigating suicide deaths in Brazil, and based on autopsy or psychological autopsy were included. Proportions were pooled across studies with the use of random and fixed effects models.

RESULTS

6777 references were retrieved from six databases (searches up to January, 2023), and 45 studies included. In autopsy studies (k = 37, n = 16,231), substance use at toxicological analysis was found in 36.42% of cases (95% CI: 30.05-43.32), previous suicide attempts in 23.92% (95% CI: 6.73-57.78). In psychological autopsy studies (k = 8, n = 139), previous suicide attempts were reported in 28.09% (95% CI: 19.74-38.28), psychiatric conditions/symptoms in 90.67% (95% CI: 67.79-97.82), family history of suicidality in 21.33% (95% CI: 13.5-32.03). Most suicide deaths were reported in males and took place at the victim's home, hanging was the most frequent suicide method. Included studies presented significant limitations in quality assessment.

CONCLUSION

Future studies should present more robust methodology, including bigger samples, the use of controls, and validated methodology.

A Statewide Analysis of Self-Inflicted Injuries During COVID-19 Pandemic: Is There Adequate Access to Mental Health?

INTRODUCTION

Many social and behavioral changes occurred during the COVID-19 pandemic. Our objective was to identify changes in incidence of self-inflicted injuries during COVID-19 compared to prepandemic years. Further, we aimed to identify risk factors associated with self-inflicted injuries before and during the pandemic.

METHODS

A retrospective cohort study of patients aged ≥18 y with self-inflicted injuries from 2018 to 2021 was performed using the Pennsylvania Trauma Outcome Study registry. Patients were grouped into pre-COVID Era (pre-CE, 2018-2019) and COVID Era (CE, 2020-2021). Statistical comparisons were accomplished using Wilcoxon rank-sum tests and chi-square or Fisher's exact tests.

RESULTS

There were a total of 1075 self-inflicted injuries in the pre-CE cohort and 482 during the CE. There were no differences in age, gender, race or ethnicity between the two cohorts. Among preexisting conditions, those within the pre-CE cohort had a higher incidence of mental/personality disorder (59.2% versus 52.3%, P = 0.01). There were no significant differences in the mechanism of self-inflicted injuries or place of injury between the two periods. Additionally, there were no differences in discharge destinations or mortality between the two cohorts.

CONCLUSIONS

During the height of social isolation in Pennsylvania, there were no associated increases in self-inflicted injuries. However, there were increased incidences of self-inflicted injuries among those with a prior diagnosis of mental or personality disorder in the pre-CE group. Further investigations are required to study the access to mental health services in future pandemics or public health disasters.

Health Service Protection vis-à-vis the Detection of Psychosocial Risks of Suicide during the Years 2019-2021

Health services are especially relevant in suicide prevention and intervention, representing a favourable environment in which to implement specific strategies to detect and address suicidal behaviours. Indeed, a significant proportion of people who die by suicide (DBS) present at primary care and mental health services during the last year, month, or even days before committing suicide. The objective of this descriptive and cross-sectional study of all registered cases of death by suicide (N = 265) in Extremadura (Spain) was to determine which of those people who died by suicide had mental health problems (MHP) and what type of assistance they had requested. Diagnoses, previous suicide attempts, type of health service, and last visit before death were explored with univariate analyses and logistic regressions. The proportion of people without MHP was found to be high, and these people had hardly visited the health services at all in their last year. People with MHP, between the ages of 40 and 69, and with previous suicide attempts were more likely to have visited the mental health service in the three months prior to their death. It is, thus, necessary to provide health professionals with tools and training in the prevention of and approach to suicide. Efforts must be directed towards effectively assessing mental health and the risk of suicide since a large proportion of people who die by suicide may go unnoticed.

Existing and Novel Biological Therapeutics in Suicide Prevention

We summarize outcomes for several pharmacologic and neurostimulatory approaches that have been considered potential treatments to reduce suicide risk, namely, by reducing suicide deaths, attempts, and ideation in various clinical populations. Available treatments include clozapine, lithium, antidepressants, antipsychotics, electroconvulsive therapy, and transcranial magnetic stimulation. The novel repurposing of ketamine as a potential suicide risk-mitigating agent in the acute setting is also discussed. Research pathways to better understand and treat suicidal ideation and behavior from a neurobiological perspective are proposed in light of this foundation of information and the limitations and challenges inherent in suicide research. Such pathways include trials of fast-acting medications, registry approaches to identify appropriate patients for trials, identification of biomarkers, neuropsychological vulnerabilities, and endophenotypes through the study of known suicide risk-mitigating agents in hope of determining mechanisms of pathophysiology and the action of protective biological interventions. Reprinted from Am J Prev Med 2014; 47:S195-S203, with permission from Elsevier. Copyright © 2014.

Characteristics of suicide decedents with no federally funded mental health service contact in the 12 months before death in a population-based sample of Australians 45 years of age and over

INTRODUCTION

More than half of suicide decedents have no contact with mental health services 12 months before death. It is uncertain if they have different characteristics than decedents who use mental health services.

METHODS

A case-series design. Participants 45 years and older, who died by suicide (2006-2018). Comparisons were made between those who did and did not have contact with mental health services, using individually linked data from federal services in the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS).

RESULTS

Of 186 cases, 71% had no contact with mental health services. Physical health services were used equally by 75%. Psychiatric medication use was uncommon, except for antidepressants, 50% with mental health service contact and 20% with no contact. Older age, lower income, involuntarily unemployed, firearms as suicide method, greater physical disability, less functional impairment due to emotional problems and lesser proportions with mental illness, were associated with no contact with mental health services.

CONCLUSIONS

For suicide prevention, middle-older aged adults may have less requirement for mental health intervention, and greater requirement for the development of complementary interventions focused on physical health and social issues, which are not necessarily best delivered by clinical mental health services.

Implementing a Suicide Audit in Montreal: Taking Suicide Review Further to Make Concrete Recommendations for Suicide Prevention

OBJECTIVE

A suicide audit was pilot implemented in order to generate recommendations on how to improve suicide prevention.

METHODS

Thirty-nine consecutive suicides that occurred in Montreal, Canada from January to October 2016 were audited. A retrospective analysis of their life trajectory and service utilization was conducted using the psychological autopsy method, which included interviewing suicide-bereaved survivors and examining health and social services records and the coroner's investigation file. A psychosocial and service utilization profile was drawn for each decedent. A multidisciplinary panel reviewed each case summary to identify gaps in terms of individual intervention, provincial public health and social services, and regional programs.

RESULTS

Five main suicide prevention recommendations were made to prevent similar suicides: (1) deploy mobile crisis intervention teams (short-term, high-intensity, home-based treatment) in hospital emergency departments; (2) train primary and specialized mental health care professionals to screen for and manage substance use disorders; and (3) implement public awareness campaigns to encourage help seeking for depression and substance use disorders; (4) access for all, regardless of age, to an effective psychosis treatment program; and (5) provide universal access to a general practitioner, especially for men.

CONCLUSIONS

The suicide audit procedure was implemented effectively and targeted recommendations were generated to prevent similar suicides. However, resistance from medical and hospital quality boards arose during the process, though these could be allayed if regional and provincial authorities actively endorsed the multidisciplinary and multi stakeholders suicide audit process. HighlightsA bottom-up approach to generate recommendations for suicide prevention.Implementation was challenging with resistance to our interdisciplinary approach.The audit needs the support of the regional health department to lift barriers.

Psychosocial and psychiatric factors preceding death by suicide: A case-control psychological autopsy study involving multiple data sources

BACKGROUND

A range of factors including mental disorders and adverse life events can increase the risk of suicide. The objectives of this study were to examine psychosocial and psychiatric factors and service engagement among suicide decedents compared with living controls.

METHODS

A case-control study using multiple sources was conducted. Information on 132 consecutive cases of suicide was drawn from coronial files, and interviews were carried out with 35 family informants and 53 living controls. GPs completed questionnaires for 60 suicide cases and 27 controls.

RESULTS

The majority (83.3%) of suicide decedents had contacted a GP in the year prior to death, while 23.3% had 10 or more consultations during the year prior to death. Half of suicide decedents had a history of self-harm. Suicide cases were significantly more likely than controls to have a psychiatric diagnosis (60% vs. 18.5%) and a depressive illness (36.7% vs. 14.8%). Over one-quarter of suicide decedents had been treated as a psychiatric inpatient.

DISCUSSION

Primary care providers should be supported to deliver multidisciplinary interventions to engage, assess, and treat patients at risk of suicide, targeting those who present very frequently, those with a history of self-harm or substance misuse, and those with psychological presentations.

Factors of suicidal behavior among inpatients with major depressive disorder: A retrospective case series

OBJECTIVE

Previous studies indicate that more than half of those who died by suicide had a depressive disorder. When discussing the factors associated to suicidal behavior (SB) among patients with major depressive disorder (MDD), sociocultural contexts should also be carefully considered. This case series study explored the factors correlated to SB among MDD patients in Beijing, China.

METHODS

The patient information sheets were retrieved from an electronic database that comprised patient medical information. Three forms of binary logistic regression equations were conducted to explore the factors associated to SB among patients with MDD. For the inconsistent variables produced by the three regression models, the propensity score matching (PSM) analysis was done for further verification.

RESULTS

In this retrospective study, 1,091 depressed cases were enrolled. The difference between the SB group and non-SB group in gender, impulsivity, the severity of depression, history of major mental trauma, and family history of suicide were statistically significant in univariate comparisons (P < 0.05); the binary logistic regression analysis and the PSM analysis showed that female gender, history of major mental trauma, impulsivity, family history of suicide and severity of depression were factors correlated to SB among patients with MDD (odds ratios >1).

CONCLUSIONS

Female gender, the history of major mental trauma, impulsivity, the severity of depression, and family history of suicide were independently associated with the appearance of SB among MDD patients in Beijing, China. Inevitably, these findings should be viewed with particular caution due to the inherent drawbacks of a retrospective nature. More prospective longitudinal research should be conducted to examine those dynamic alterations in the corresponding confounders.

The Malay Literacy of Suicide Scale: A Rasch Model Validation and Its Correlation with Mental Health Literacy among Malaysian Parents, Caregivers and Teachers

The 27-item Literacy of Suicide Scale (LOSS) is a test designed to measure the respondent’s suicide knowledge. The purpose of this study is to examine the psychometric properties of the Malay-translated version of the LOSS (M-LOSS) and its association to sociodemographic factors and mental health literacy. The 27-item LOSS was forward–backward translated into Malay, and the content and face validities were assessed. The version was distributed to 750 respondents across West Malaysia. Rasch model analysis was then conducted to assess the scale’s psychometric properties. The validated M-LOSS and the Malay version of the Mental Health Knowledge Schedule (MAKS-M) were then distributed to 867 respondents to evaluate their level of suicide literacy, mental health literacy, and their correlation. Upon Rasch analysis, 26 items were retained. The scale was found to be unidimensional, with generally satisfying separation and reliability indexes. Sex, socio-economic status, and experience in mental health were found to significantly impact the mean score for mental health literacy. This study also found a significant mean difference for suicide literacy across school types. Furthermore, while this study observed a weak but significant negative correlation between age and suicide literacy, no correlation was found between mental health and suicide literacy.

Association between Suicide Rate and Human Development Index, Income, and the Political System in 46 Muslim-Majority Countries: An Ecological Study

Very little has been researched assessing the relationship between the suicide rate and the ecological perspectives of the country, especially in the Muslim majority countries. We aimed to determine the association between suicide rate and the ecological parameters of 46 Muslim majority countries. We extracted the Muslim majority countries and their suicide rate, income distribution, distribution of the WHO region and continents, and Human Development Index (HDI). We assessed the correlation of the proportion of Muslim populations, the total population of the countries, number of suicides, continent, income group, political system, and HDI score with the suicide rate. The median suicide rate was 5.45 (IQR = 4.8); 2.9 (IQR = 4) in females and 7.45 (IQR = 8.2) in males per 100,000 population. The males had a significantly higher rate and the highest suicide rate was found in Africa. There are inverse associations between the total suicide rate, the rate in males, and females with HDI, and the income of the country. Furthermore, the suicide rate was significantly higher in countries with democratic systems compared to non-democratic countries. The findings suggest that ecological parameters may have an etiological role on suicides in Muslim countries where HDI and income are inversely associated with suicide rates.

"I lost so much more than my partner" - Bereaved partners' grief experiences following suicide or physician-assisted dying in case of a mental disorder

BACKGROUND

There is a lack of existing research on grief following the intentional death of people suffering from a mental disorder. Our study aims to provide insight into grief experiences and social reactions of bereaved persons who lost their life partners, who were suffering from a mental disorder, to physician-assisted dying (PAD) or suicide.

METHODS

For this mixed-methods research, we conducted a survey and in-depth interviews with 27 persons living in the Netherlands and bereaved by the death of their life partners. The deceased life partners suffered from a mental disorder and had died by physician-assisted dying (n = 12) or suicide (n = 15). Interviews explored grief experiences and social reactions. In the survey we compared self-reported grief reactions of partners bereaved by suicide and PAD using the Grief Experience Questionnaire.

RESULTS

Compared to suicide, physician-assisted dying was associated with less severe grief experiences of the bereaved partners. Participants reported that others rarely understood the suffering of their deceased partners and sometimes expected them to justify their partners' death. Following physician-assisted dying, the fact that the partner's euthanasia request was granted, helped others understand that the deceased person's mental suffering had been unbearable and irremediable. Whereas, following suicide, the involvement of the bereaved partners was sometimes the focus of judicial inquiry, especially, if the partner had been present during the death.

CONCLUSION

When individuals suffering from a mental disorder die by suicide or PAD, their bereaved partners may experience a lack of understanding from others. Although both ways of dying are considered unnatural, their implications for bereaved partners vary considerably. We propose looking beyond the dichotomy of PAD versus suicide when studying grief following the intentional death of people suffering from a mental disorder, and considering other important aspects, such as expectedness of the death, suffering during it, and partners' presence during the death.

Psychiatric and Psychosocial Factors of Suicide Decedents and Survivor of Suicide Loss: Psychological Autopsy Study of Incheon City in South Korea

In South Korea, the suicide rate is more than double the OECD average, and precise identification of the cause is required for suicide prevention. Psychological autopsy is used to reveal factors related to suicidal behavior; however, such studies are lacking in Korea. This study investigated the factors related to suicide using psychological autopsies in Incheon, a major city in Korea. In total, 46 cases were investigated using the Korea-Psychological Autopsy Checklist (K-PAC), and data on mental health conditions and psychosocial factors of suicide decedents and their families were analyzed. It was estimated that 87% of individuals of suicides had a mental health condition before death, but only 15.2% continued treatment or counseling. Most individuals who died of suicide showed warning signs before death, but only 19.6% of survivors of suicide loss noticed them. Mental health concerns before and after the death of the individual were also identified in more than half of their families. To prevent suicide, intensive and continuous treatment for psychiatric conditions and prompt recognition of active response to suicide warning signs are required. Care for the mental health of family members is also important.

Analysis of Motives and Factors Connected to Suicidal Behavior in Patients Hospitalized in a Psychiatric Department

(1) Background: This study aimed to investigate the motives and factors connected to suicidal behavior in 121 hospitalized patients with intentional self-harm (diagnosis X 60-81 according to the ICD-10); (2) Methods: Suicidal behavior of the patient was assessed from data obtained by psychiatric examinations and by the Columbia Suicide Severity Rating Scale. Analysis of data to identify the patients’ reason and motives behind suicidal behavior in a group of patients with a suicide attempt (SA, n = 80) and patients with Non-Suicidal Self-Injurious Behavior (NSSIB, n = 41) was carried out; (3) Results: Results showed that patients with affective disorder have a 19-times higher rate of SA against other diagnoses. Patients with personality disorders have a 32-times higher rate of NSSIB than patients with other diagnoses. Living alone and the absence of social support increased the likelihood of SA. Qualitative data analysis of patients’ statements showed different themes in the justification of motives for suicidal behavior between SA and NSSIB cases. Significant differences were shown for non-communicated reasons, loneliness, social problems, extortion, and distress; (4) Conclusions: The evaluation of patients’ verbal statements by qualitative analysis during the psychiatric examination should be considered in clinical practice. It should be considered to include self-poisoning in the criteria of the Non-suicidal Self-Injury diagnostic categories.

Prenatal origins of suicide mortality: A prospective cohort study in the United States

Most suicide research focuses on acute precipitants and is conducted in high-risk populations. Yet, vulnerability to suicide is likely established years prior to its occurrence. In this study, we aimed to investigate the risk of suicide mortality conferred by prenatal sociodemographic and pregnancy-related factors. Offspring of participants (N = 49,853) of the Collaborative Perinatal Project, a U.S. population-based cohort of pregnancies enrolled between 1959 and 1966, were linked to the U.S. National Death Index to determine their vital status by the end 2016. We examined associations between sociodemographic factors during pregnancy, pregnancy complications, labor and delivery complications, and neonatal complications with suicide death coded according to ICD-9/10 criteria. By the end of 2016, 3,555 participants had died. Of these, 288 (214 males, 74 females) died by suicide (incidence rate = 15.6 per 100,000 person-years, 95% Confidence Interval [CI] = 13.9-17.5). In adjusted models, male sex (Hazard Ratio [HR] = 2.98, CI: 2.26-3.93), White race (HR = 2.14, CI = 1.63-2.83), low parental education (HR = 2.23, CI = 1.38-3.62), manual parental occupation (HR = 1.38, CI = 1.05-1.82), being a younger sibling (HR = 1.52, CI = 1.10-2.11), higher rates of pregnancy complications (HR = 2.36, CI = 1.08-5.16), and smoking during pregnancy (HR = 1,28, CI = 0.99-1.66) were independently associated with suicide risk, whereas birth and neonatal complications were not. Consistent with the developmental origins of psychiatric disorders, vulnerability to suicide mortality is established early in development. Both sociodemographic and pregnancy factors play a role in this risk, which underscores the importance of considering life course approaches to suicide prevention, possibly including provision of high-quality prenatal care, and alleviating the socioeconomic burdens of mothers and families.

Depression and suicidal behavior in South Asia: a systematic review and meta-analysis

BACKGROUND

Estimates of depression in suicidal behavior in South Asia would help to formulate suicide prevention strategies in the region that hasn't been assessed yet.

OBJECTIVES

We aimed to systematically assess the prevalence of depression in fatal and non-fatal attempts of suicide in eight South Asian countries.

METHODS

We searched Medline, Embase, and PsychINFO by specific search terms to identify articles assessing depression in fatal and non-fatal attempts of suicide in South Asian countries published between 2001 and 2020. Two separate meta-analyses were conducted for fatal and non-fatal attempts. Due to the high heterogeneity of studies (96-98%), random-effects models were used to calculate pooled prevalence rates.

RESULTS

A total of 38 studies was identified from five south Asian countries (India [27], Pakistan [6], Sri Lanka [3], Nepal [1], and Bangladesh [1]). The majority of studies (n = 27) were published after 2010. Twenty-two studies reported non-fatal attempts, and sixteen reported suicide. The prevalence of depression among non-fatal attempts ranged from 14% to 78% where the pooled prevalence rate was 32.7% [95% CI 26-39.3%]. The prevalence of depression among suicides ranged from 8% to 79% where the pooled prevalence estimate was 37.3% [95% CI 26.9-47.6%].

CONCLUSIONS

This review revealed the pooled prevalence of depression among fatal and non-fatal suicidal attempts in South Asian countries, which seems to be lower when comparedto the Western countries. However, a cautious interpretation is warranted due to the heterogeneity of study methods, sample size, and measurement of depression.

Psychological Autopsy Studies of Suicide in South East Asia

BACKGROUND

Psychiatric disorders have been identified as an important risk factor for suicide. However, different psychological autopsy studies have revealed different prevalences at different times and places.

OBJECTIVE

We aimed to see the distribution of psychological autopsy studies and the prevalence of mental disorders among suicides and identify major risk factors in Southeast Asian countries.

METHOD

We scrutinized psychological autopsy studies published in the World Health Organization (WHO) South-East Asia (SEA) region countries. We also searched the available bibliographies to identify the studies in the region so that all the possible articles could be included.

RESULTS

Out of the 11 countries, 14 psychological autopsy studies were identified in five SEA countries (Bangladesh [1], India [9], Indonesia [1], Nepal [1], and Sri Lanka [2]). Seven studies (50%) used a case-control study design, and eight (57.1%) were carried out in urban settings. The prevalence of psychiatric disorders in case-control studies was from 37% to 88%. Stressful life event was identified as a major risk factor in all the case-control studies.

CONCLUSION

Psychological autopsy studies have not been conducted in 6 out of 11 countries of the SEA region. The presence of pre-existing psychiatric morbidity and stressful life events were the two most common risk factors noted across settings, even though there is wide heterogeneity in samples, study design, instruments, and study settings.

Psychological autopsy study and risk factors for suicide in Muslim countries

BACKGROUND

Suicide and risk factors have been poorly studied in the Muslim-majority countries that hinder the formulation of prevention strategies and affect suicide prevention eventually.

OBJECTIVES

We aimed at identifying and analyzing the psychological autopsy studies assessing the risk factors for suicide conducted in Muslim-majority countries.

METHODS

We did a search to trace all the available psychological autopsy studies in the Muslim countries with the search term "psychological autopsy study in Muslim countries." We also checked the available bibliographies to identify the psychological autopsy studies in the Muslim countries so that all the possible studies could be included.

RESULTS

Out of the Muslim countries, only eight psychological autopsy studies were identified in five countries (Bangladesh [1], Indonesia [1], Iran [1], Pakistan [2], and Turkey [3]). Six studies adopted a case-control study design, and all were carried out in urban settings. The prevalence of psychiatric disorders among case-control studies varied from 52.8% in Turkey to 96% in Pakistan. Psychiatric illness, self-harm, and stressful life events were the commonly replicated risk factors for suicide across studies.

CONCLUSIONS

Psychological autopsy studies have been conducted only in five Muslim countries revealing that the risk factor for suicide is certainly under-researched in the incumbent countries. This review identified a similar list of risk factors for suicide, namely, psychiatric disorder, past non-fatal attempts, and adverse life events compared to the Western countries even though the rate varies.

Incomplete homicide-suicide in Hunan China from 2010 to 2019: characteristics of surviving perpetrators

BACKGROUND

The mental and psychological conditions of the individuals involved in homicide followed by suicide (H-S) are still unclear, especially in China. Information on these aspects cannot be accurately obtained due to the death of perpetrators. This study aims to demonstrate the characteristics of incomplete H-S with surviving perpetrators, which provide the possibility to obtain detailed mental and psychological information.

METHODS

This study explores incomplete H-S events occurred in Hunan, China from 2010 to 2019, in which the surviving perpetrators received a forensic psychiatric assessment. Three aspects of information, i.e., the subject's demographic, clinical and criminal information, were recorded and analysed.

RESULTS

125 incomplete H-S incidents involved 166 victims were found in the current study. A total of 112 (89.6%) perpetrators were diagnosed with mental disorders, but only 56 of them had a history of consultation due to mental problems, and only one of them adhered to treatment. In most cases, the motivation is related to the psychopathological states, with the most common diagnosis being major depression, followed by schizophrenia. Gender difference was significant among the subjects: females were more likely to have a suicidal history, to be diagnosed as major depression and to be motivated by delirious altruism and family problems.

CONCLUSIONS

This study indicated that psychopathology might be a predisposing factor, which highlighted the importance of mental state assessment for the population involved in incomplete H-S. A clearer understanding of the role of mental disorders might be helpful for the intervention of H-S.

Neurobiological Basis of Increased Risk for Suicidal Behaviour

According to the World Health Organization (WHO), more than 700,000 people die per year due to suicide. Suicide risk factors include a previous suicide attempt and psychiatric disorders. The highest mortality rate in suicide worldwide is due to depression. Current evidence suggests that suicide etiopathogenesis is associated with neuroinflammation that activates the kynurenine pathway and causes subsequent serotonin depletion and stimulation of glutamate neurotransmission. These changes are accompanied by decreased BDNF (brain-derived neurotrophic factor) levels in the brain, which is often linked to impaired neuroplasticity and cognitive deficits. Most suicidal patients have a hyperactive hypothalamus–pituitary–adrenal (HPA) axis. Epigenetic mechanisms control the above-mentioned neurobiological changes associated with suicidal behaviour. Suicide risk could be attenuated by appropriate psychological treatment, electroconvulsive treatment, and drugs: lithium, ketamine, esketamine, clozapine. In this review, we present the etiopathogenesis of suicide behaviour and explore the mechanisms of action of anti-suicidal treatments, pinpointing similarities among them.

Relationship between impulsivity and suicide among the rural elderly in China: a case-control psychological autopsy study

Background

The relationship between impulsivity and suicide is inconsistent in different populations. Hence, the relationship between impulsivity and suicide still needs to be studied among the elderly population. The present study intends to explore the relationship between impulsivity and suicide among the rural Chinese elderly.

Methods

A case-control psychological autopsy study was conducted from February 1, 2014 to December 18, 2015 among rural residents over the age of 60 who died by suicide. The sample consisted of 242 suicides as the case group and 242 living individuals as the control group. Data on demographic characteristics, impulsivity, previous history of suicide attempts, social support, negative life events, and suicidal behavior were collected.

Results

Our study found that impulsivity increased the risk of suicide. The case group showed a higher Barratt Impulsiveness Scale score compared with the control group (p < 0.001), which indicates that impulsivity was higher among the elderly suicides. In addition, regression analyses show that impulsivity (odds ratio: 1.03, 95% confidence interval: 1.01–1.06) is an independent risk factor of suicide, after controlling for the effects of marital status, education, family annual income, being left behind, social support, and negative life events. Finally, compared with elderly who do not have a history of attempted suicide, elderly with a history of attempted suicide showed higher impulsivity (p = 0.001).

Macro-level mental health system indicators and cross-national suicide rates

Background

The relationship between macro-level mental health system indicators and population suicide rates is an area of contention in the literature, necessitating an analysis of current cross-national data to document any new trend in the relationship.

Objective

This study investigated whether mental health system indicators are associated with national suicide rates.

Method

Using an ecological study design and multivariate non-parametric robust regression models, data on suicide rates and mental health system indicators of 191 countries retrieved from WHOs 2017 Mental Health Atlas were compared.

Results

Findings revealed that the average suicide mortality rate was significantly higher in high- income countries, relative to low-income countries. High-income countries are significantly more likely to have high number of mental health professionals, mental health policies and legislation, independent mental health authority and suicide prevention programs. These mental health system indicators demonstrated significant and positive association with suicide, suggesting that countries scoring high on these factors have higher odds of being categorized as high suicide risk countries.

Conclusion

The findings have several implications for policy and practice, including the need to make existing mental health systems very responsive to suicide prevention.

Suicide Prevention in HIV Treatment Centres: Population Attributable Risk Analysis of Treating Common Mental Disorders

The aim was to establish the potential reduction in non-fatal suicidal behaviour (NFSB) that could be achieved by treating common mental disorders (CMDs) among persons receiving HIV treatment. Data were collected from antiretroviral therapy (ART) patients in South Africa (n = 688). Structured Clinical Interviews assessed CMDs and the Mini International Neuropsychiatric Interview assessed 1-month prevalence of NFSB and suicide risk. Population Attributable Risk (PAR) analysis established the potential reduction in prevalence of NFSB and suicide risk that could be achieved by treating CMDs, with the simplifying assumption of a causal relationship between psychopathology and suicidality. Treating CMDs could result in as much as a 63.9% proportional reduction in the prevalence of suicide ideation, 84.2% proportional reduction in the prevalence of suicide plan, and 63.4% proportional decrease in prevalence of suicide risk. There is potential to significantly reduce NFSB among ART patients. Pragmatic trials are needed to evaluate the effects of treating CMDs in HIV treatment centres.

Evidence for an association between inflammatory markers and suicide: a cohort study based on 359,849 to 462,747 Taiwanese adults

BACKGROUND

Biological markers of suicide risk have the potential to inform prevention and treatment efforts. It has recently been hypothesised that inflammation may influence mood and in turn suicide risk. We investigated the association between indicators of systemic inflammation and suicide in a large cohort of Taiwanese adults.

METHODS

White blood cell (WBC) count and levels of C-reactive protein (CRP) were measured in 462,747 and 359,849 adults in the Taiwan MJ cohort, respectively. The associations between WBC, CRP and suicide risk were investigated using Cox proportional hazards models adjusting for a range of potential confounding factors.

RESULTS

During a mean 15.1 and 15.8 years of follow-up, 687 and 605 suicides were identified in participants who had information on WBC and CRP respectively. There was an association of suicide with WBC count (adjusted hazard ratio [aHR] = 1.13 per 1 standard deviation increase of log-transformed WBC, 95% confidence interval [CI] 1.05, 1.22). The association was driven by the highest quintile of WBC count (aHR = 1.39, 95% CI 1.09, 1.77; reference: the lowest quintile). No association between CRP and suicide was found.

LIMITATIONS

Our cohort was from a privately-run health check-up programme and had a lower suicide rate than that in the general population.

CONCLUSIONS

Individuals with the highest WBC counts may have increased risk of suicide. Peripheral markers of inflammation are potential biomarkers of suicide risk; however, this seems to vary by population and the marker investigated and could be influenced by a range of confounding factors.

Risk factors for suicide in Bangladesh: case-control psychological autopsy study

BACKGROUND

Suicide is an important, understudied public health problem in Bangladesh, where risk factors for suicide have not been investigated by case-control psychological autopsy study.

AIMS

To identify the major risk factors for suicide in Dhaka, Bangladesh.

METHODS

We designed a matched case-control psychological autopsy study. We conducted a semi-structured interview with the next-of-kin of 100 individuals who died by suicide and 100 living controls, matched for age, gender and area of residence. The study was conducted from July 2019 to July 2020.

RESULTS

The odds ratios for the risk factors were 15.33 (95% CI, 4.76-49.30) for the presence of a psychiatric disorder, 17.75 (95% CI, 6.48-48.59) for life events, 65.28 (95% CI, 0.75-5644.48) for previous attempts and 12 (95% CI, 1.56-92.29) for sexual abuse.

CONCLUSIONS

The presence of a psychiatric disorder, immediate life events, previous suicidal attempts and sexual abuse were found as significant risk factors for suicide in Dhaka, Bangladesh.

Trust, conversations and the 'middle space': A qualitative exploration of the experiences of physiotherapists with clients with suicidal thoughts and behaviours

In Australia, physiotherapists are registered healthcare practitioners who possess the knowledge and skills to care for clients with poor physical health as a result of musculoskeletal, neurological, and respiratory conditions. Although physiotherapists are not considered a primary profession in the Australian mental health workforce, the association between suicide and poor physical health suggests that they may encounter clients with suicidal thoughts and behaviours. We used a qualitative approach inspired by phenomenology to explore the experiences of nine physiotherapists who encountered clients with suicidal thoughts and behaviours. We used a combination of focus groups and in-depth interviews to collect this data. The data were analysed inductively using framework analysis. The main themes identified in the data were: i) the importance of trust, ii) the mechanism of conversation, and iii) the 'middle space'. The middle space refers to the experience of working with clients at risk of low or medium risk of suicide. A trusting practitioner-client relationship was reported to be essential in facilitating the disclosure of suicidal thoughts and behaviours. Physiotherapists also reported that less structured subjective assessments encourage clients to talk more openly, which in turn facilitates the disclosure of suicidal thoughts and behaviours. Once the disclosure of suicidal thoughts and behaviours occurred, physiotherapists reported a lack of confidence regarding role clarity and issues associated with this. Difficulties were most evident during encounters with clients with low to medium suicide risk due to a lack of confidence in the accuracy of assessment of these clients. The findings suggest that physiotherapists are well placed to detect and/or receive disclosure of suicidal thoughts and behaviours, as well as the need for physiotherapists to be trained in how to support clients who disclose suicidal thoughts and behaviours.

Tailored Activation of Middle-Aged Men to Promote Discussion of Recent Active Suicide Thoughts: a Randomized Controlled Trial

PURPOSE

Middle-aged men are at high risk of suicide. While about half of those who kill themselves visit a primary care clinician (PCC) shortly before death, in current practice, few spontaneously disclose their thoughts of suicide during the visits, and PCCs seldom inquire about such thoughts. In a randomized controlled trial, we examined the effect of a tailored interactive computer program designed to encourage middle-aged men's discussion of suicide with PCCs.

METHODS

We recruited men 35-74 years old reporting recent (within 4 weeks) active suicide thoughts from the panels of 42 PCCs (the unit of randomization) in eight offices within a single California health system. In the office before a visit, men viewed the intervention corresponding to their PCC's random group assignment: Men and Providers Preventing Suicide (MAPS) (20 PCCs), providing tailored multimedia promoting discussion of suicide thoughts, or control (22 PCCs), composed of a sleep hygiene video plus brief non-tailored text encouraging discussion of suicide thoughts. Logistic regressions, adjusting for patient nesting within physicians, examined MAPS' effect on patient-reported suicide discussion in the subsequent office visit.

RESULTS

Sixteen of the randomized PCCs had no patients enroll in the trial. From the panels of the remaining 26 PCCs (12 MAPS, 14 control), 48 men (MAPS 21, control 27) were enrolled (a mean of 1.8 (range 1-5) per PCC), with a mean age of 55.9 years (SD 11.4). Suicide discussion was more likely among MAPS patients (15/21 [65%]) than controls (8/27 [35%]). Logistic regression showed men viewing MAPS were more likely than controls to discuss suicide with their PCC (OR 5.91, 95% CI 1.59-21.94; P = 0.008; nesting-adjusted predicted effect 71% vs. 30%).

CONCLUSIONS

In addressing barriers to discussing suicide, the tailored MAPS program activated middle-aged men with active suicide thoughts to engage with PCCs around this customarily taboo topic.

Perceptions of stakeholders about the role of health system in suicide prevention in Ghizer, Gilgit-Baltistan, Pakistan

Background

Suicide is a serious global public health problem, with more than 800,000 people dying by suicide worldwide every year. 79% of suicides happen in Low and Middle-Income Countries (LMICs), where lack of national suicide prevention programs coupled with inadequate MH facilities for early identification and treatment of mental disorders add to seriousness of the problems. Although there is paucity of research, studies suggest that the rate of suicide in district Ghizer, Gilgit-Baltistan (GB), in northern Pakistan may be higher compared to rest of the country.

Methods

This study aimed to explore the perceptions of stakeholders about the role of the health system at District Ghizer, GB using a qualitative descriptive exploratory research design. A total of 12 face to face in-depth interviews were conducted from the stakeholders using purposive sampling technique.

Results

The study results led to three broad themes, 1) Suicide as A Social Issue, 2) Role of Health System in Suicide Prevention, and 3) Challenges for Health System in Suicide Prevention. Theme one was sub-categorized into; a) Perceived situations contributing to suicide, b) Environmental factors. Theme two was subdivided into; a) Major hurdles for Health system, b) Lack of MH services in the available health system. Theme three was subdivided into; a) Lack of collaboration across-sectors, b) Unavailability of MH professionals, and c) Financial issues. The study findings reveal that there are multiple challenges for health system including, lack of awareness on mental issues, shortage of resources and lack of collaboration in the community. Moreover, existing policies or strategies need to be modified to overcome the existing challenges for the effective prevention.

Conclusion

This study emphasized creating awareness about MH issues, introduction of school health programs, parental counseling session and strengthening of the health system by allocating suitable budget for MH issues and suicide prevention strategies.

Suicide in DSM-5: Current Evidence for the Proposed Suicide Behavior Disorder and Other Possible Improvements

Suicide continues to be one of the greatest challenges faced by mental health clinicians and researchers, an issue made worse by increasing trends in the global suicide rate. Suicide behavior disorder (SBD) was introduced in DSM-5 as a disorder for further consideration and potential acceptance into the diagnostic system. There are numerous positive developments that would arise from the addition of a suicide-related diagnosis. Utilizing the 2009 guidelines established by Kendler and colleagues, the present review examines the evidence for SBD's validity and discusses the diagnosis' potential clinical benefits and limitations. Altogether, growing evidence indicates that SBD has preliminary validity and benefit. SBD presents with several significant limitations, however, and possible alternative additions to future DSMs are highlighted.

Is suicidality a mental disorder? Applying DSM-5 guidelines for new diagnoses

Suicidality-specific diagnoses have been proposed recently, but suicidologists are only just beginning to evaluate their merits. To advance this discussion, I introduce the term suicidal syndrome to describe the underlying entity, present a rationale for why a formal diagnosis is necessary, define the major features of the syndrome, and show how the syndrome could meet the requirements for new diagnostic candidates used in the development of the DSM-5. Against this backdrop, I examine common objections to a suicidality-specific diagnosis. Finally, I discuss several challenges with the creation of new diagnostic entities as they apply to suicidal syndrome.

The case for case-control studies in the field of suicide prevention

Much of our knowledge about the risk factors for suicide comes from case-control studies that either use a psychological autopsy approach or are nested within large register-based cohort studies. We would argue that case-control studies are appropriate in the context of a rare outcome like suicide, but there are issues with using this design. Some of these issues are common in psychological autopsy studies and relate to the selection of controls (e.g. selection bias caused by the use of controls who have died by other causes, rather than live controls) and the reliance on interviewing informants (e.g. recall bias caused by the loved ones of cases having thought about the events leading up to the suicide in considerable detail). Register-based studies can overcome some of these problems because they draw upon contain information that is routinely collected for administrative purposes and gathered in the same way for cases and controls. However, they face issues that mean that psychological autopsy studies will still sometimes be the study design of choice for investigating risk factors for suicide. Some countries, particularly low and middle income countries, don't have sophisticated population-based registers. Even where they do exist, there will be variable of interest that are not captured by them (e.g. acute stressful life events that may immediately precede a suicide death), or not captured in a comprehensive way (e.g. suicide attempts and mental illness that do not result in hospital admissions). Future studies of risk factors should be designed to progress knowledge in the field and overcome the problems with the existing studies, particularly those using a case-control design. The priority should be pinning down the risk factors that are amenable to modification or mitigation through interventions that can successfully be rolled out at scale.

Characteristics of patients with cancer who die by suicide: Coronial case series in an Australian state

OBJECTIVE

Suicide rates are elevated in epidemiological studies, but extrapolating population level data to the individual patient cancer is difficult, and there is a dearth of studies examining how suicidality might be linked to the cancer experience. We examine the cancer-suicide correlates to explore clinical implications and future research directions.

METHOD

We used a novel database to examine all suicide deaths reported to the Coroners Court of Victoria between 2009 and 2013 in individuals with active, diagnosed cancer. Cases were classified in relation to whether cancer had been a probable, possible, or unlikely influence on suicidal ideation. Sociodemographic, clinical, health service contacts, and suicide method data were analysed to describe the characteristics of individuals with cancer at the time of their suicide.

RESULTS

There were 2870 suicide deaths, and 118 cases met inclusion criteria. Clinically distinct patient subgroups emerged through a contrast between those cases where the data suggested a correlate between cancer and suicide, and those where the data did not. The former group had many more cancer-related health problems than the latter group, who had a higher burden of psychiatric illness that predated their cancer diagnosis. The intent to suicide was known to most clinicians.

CONCLUSIONS

All clinicians working with cancer patients should be prepared to explore suicidal ideation. Understanding how the patient conceptualises suicidality with respect to cancer experience and mental health may be of central importance in determining whether mental health care is best provided as part of cancer care, or through a separate mental health service.

Risk factors for suicide in rural Italy: a case-control study

PURPOSE

Increased frequency of suicide in rural areas of Tuscany has been described since the 1970s. A case-control study was conducted in 2014 and 2015. The objective of this study was to identify major individual risk factors related to suicides in six rural districts of Tuscany.

METHODS

Cases were identified as all 128 suicides occurred in six rural districts between 2009 and 2013. Controls (three for each case) were matched for age, sex, and general practice. Information was collected from GPs using a structured questionnaire. Univariate and multivariate analyses were carried out to investigate the association between individual risk factors and suicide.

RESULTS

Informants for 91 cases of the 128 identified cases were successfully interviewed (response rate 71.1%). About 40.5-65.9% suicide cases and 11.4-20.0% of controls had some psychiatric pathology, accordingly to different definitions. Univariate conditional regression analysis showed that living in isolated houses (OR 2.48), living alone (OR 2.97), not being married (OR 2.63), low income (OR 2.73), psychiatric pathology (OR 9.70), psychotropic medication (OR 5.58), problems with relatives (OR 14.78), psychiatric family history (OR 5.67), and suicidal ideation (OR 15.61) were all risk factors. Practising religion (OR 0.27) was the only protective factor identified. Multivariate regression identified two independently and significantly associated variables namely, psychiatric pathology (OR 8.87) and living alone (OR 2.30).

CONCLUSIONS

Results of this study showed, similarly to recent research, that not all suicide events are the results of psychiatric pathology. Prevention strategies should, therefore, target both socio-economic and clinical risk factors.