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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Characteristics of Patients Who Complete Suicide and Suicide Attempts While Undergoing Treatment in Norway: Findings from Compensation Claims Records

The aim of this study was to identify characteristics that differentiate patients who complete suicide (SC) from patients with suicide attempts (SA) while undergoing treatment in Norway. We examined data from the Norwegian System of Patient Injury Compensation (Norsk Pasientskade Erstatning-NPE). Data were extracted from NPE case records from a 10-year period (2009-2019) for 356 individuals who attempted (n = 78) or died by (n = 278) suicide. The two groups differed significantly in the types of medical errors identified by experts. Inadequate suicide risk assessment tended to be proportionally and significantly more prevalent among SC compared to SA. There was a weak but significant trend that SA had received medication only, whereas SC had received both medication and psychotherapy. There were no significant differences with respect to age group, gender, diagnostic category, number of previous suicide attempts, inpatient/outpatient status, or category of responsible clinic. We conclude that suicide attempters and suicide completers differed in terms of identified medical errors. Focusing on the prevention of these and other types of errors could help to reduce the number of suicides of patients in treatment.

Trends and characteristics of attempted and completed suicides reported to general practitioners before vs during the COVID-19 pandemic in France: Data from a nationwide monitoring system, 2010-2022

BACKGROUND

Most studies published to date have investigated the impact of the COVID-19 pandemic on suicidal acts using hospital data. Trends from primary care in a country such as France are crucial, as individuals may not consult hospital services after suicide attempts (SAs) but rather see their general practitioner (GP).

OBJECTIVES

We aimed to evaluate whether the incidence and characteristics of SAs and completed suicides (CSs) reported to French GPs were different during the COVID-19 pandemic than those of before.

METHODS AND FINDINGS

We conducted a retrospective observational study using data from a nationwide monitoring system, the French Sentinel Network (FSN). All SAs and CSs reported by GPs to the FSN from January 1, 2010, to March 10, 2022 were included. The annual incidence rates (IRs) and the characteristics of SAs and CSs during the pandemic (March 11, 2020, to March 10, 2022) were compared to those of before. In total, 687 SAs and 169 CSs were included. The IRs remained stable for SAs and CSs before and during the pandemic (overlap in confidence intervals). The mean IRs were 52 (95%CI = 44; 57) per 100,000 inhabitants for SAs during the pandemic versus 47 [36; 57] during the pre-pandemic period (p = 0.49), and 5 (95%CI = 2; 9) for CSs versus 11 [6; 16] (p = 0.30). During the pandemic, SA were slightly different from those before in terms of age and occupational status (young/students and older/retirees over-represented), history of consultation and expression of suicidal ideas to GP (more frequent), and CS in terms of occupational status (students over-represented) (p<0.05).

CONCLUSION

The COVID-19 pandemic had no major effect on the overall incidence of SAs and CSs reported to French GPs. However, more suicidal acts were reported among younger and older individuals. Suicidal patients and GPs have adapted by improving the expression of suicidal ideas.

Prevalence and factors associated with suicidal behavior among trans women in Rio de Janeiro, Brazil

BACKGROUND

Trans women face disproportionate burden of adverse health outcomes, including mental health issues. Very little is known about suicidal behavior among trans women in low- and middle-income settings, such as Brazil. We aimed to estimate the prevalence of lifetime suicidal behavior and to identify its associated factors among Brazilian trans women.

METHODS

This was a cross-sectional study conducted among 345 trans women living in Rio de Janeiro, Brazil. We examined the prevalence of suicidal behavior (ideation and suicide attempt) and its associated factors using stepwise backward Poisson regression analysis with robust variance.

RESULTS

Suicidal ideation was present among 47.25% of participants, and the prevalence of lifetime suicide attempt was 27.25%. Trans women with prior physical violence perpetrated by a family member had significantly higher prevalence of suicidal ideation (adjusted prevalence ratios [aPR]1.37), whereas those who reported sex work had lower prevalence ratio of suicidal ideation (aPR 0.76). Suicide attempt was significantly associated with living alone (aPR 1.48), physical violence by a casual partner (aPR 1.92), and sexual violence by a family member (aPR 1.69). Depression was significantly associated with both outcomes (aPR 1.90 for suicidal ideation and aPR 2.21 for suicide attempt).

CONCLUSION

Suicidal behavior prevalence rates among Brazilian trans women were alarming and directly linked to violence and poor mental health. Effective mental health and public health policies addressing violence against trans women are urgently needed to prevent suicidal behavior among this highly vulnerable population.

Applying machine learning on health record data from general practitioners to predict suicidality

BACKGROUND

Suicidal behaviour is difficult to detect in the general practice. Machine learning (ML) algorithms using routinely collected data might support General Practitioners (GPs) in the detection of suicidal behaviour. In this paper, we applied machine learning techniques to support GPs recognizing suicidal behaviour in primary care patients using routinely collected general practice data.

METHODS

This case-control study used data from a national representative primary care database including over 1.5 million patients (Nivel Primary Care Database). Patients with a suicide (attempt) in 2017 were selected as cases (N = 574) and an at risk control group (N = 207,308) was selected from patients with psychological vulnerability but without a suicide attempt in 2017. RandomForest was trained on a small subsample of the data (training set), and evaluated on unseen data (test set).

RESULTS

Almost two-third (65%) of the cases visited their GP within the last 30 days before the suicide (attempt). RandomForest showed a positive predictive value (PPV) of 0.05 (0.04-0.06), with a sensitivity of 0.39 (0.32-0.47) and area under the curve (AUC) of 0.85 (0.81-0.88). Almost all controls were accurately labeled as controls (specificity = 0.98 (0.97-0.98)). Among a sample of 650 at-risk primary care patients, the algorithm would label 20 patients as high-risk. Of those, one would be an actual case and additionally, one case would be missed.

CONCLUSION

In this study, we applied machine learning to predict suicidal behaviour using general practice data. Our results showed that these techniques can be used as a complementary step in the identification and stratification of patients at risk of suicidal behaviour. The results are encouraging and provide a first step to use automated screening directly in clinical practice. Additional data from different social domains, such as employment and education, might improve accuracy.

Management of work-related common mental disorders in general practice: a cross-sectional study

BACKGROUND

General practitioners (GPs) often manage individuals with work-related common mental disorders (CMD: depressive disorders, anxiety and alcohol abuse). However, little is known about the ways in which they proceed. The aim of this study is to analyze GPs' management and patterns of referral to other health professionals of patients with work-related CMD and associated factors.

METHOD

We used data from a cross-sectional study of 2027 working patients of 121 GPs in the Nord - Pas-de-Calais region in France (April - August 2014). Statistical analyses focused on patients with work-related CMD detected by the GP and examined the ways in which GPs managed these patients' symptoms. Associations between patient, work, GP and contextual characteristics and GPs' management were explored using modified Poisson regression models with robust variance.

RESULTS

Among the 533 patients with work-related CMD in the study, GPs provided psychosocial support to 88.0%, prescribed psychotropic treatment to 82.4% and put 50.7% on sick leave. Referral rates to mental health specialists and occupational physicians were respectively 39.8 and 26.1%. Several factors including patients' characteristics (occupational and sociodemographic), GPs' characteristics and environmental data were associated with the type of management used by the GP.

CONCLUSION

Our study emphasizes the major and often lonesome role of the GP in the management of patients with work-related CMDs. Better knowledge of the way GPs manage those patients could help GPs in their practice, improve patients care and be a starting point to implement a more collaborative care approach.

Incidence of and sociological risk factors for suicide death in patients with leukemia: A population-based study

OBJECTIVES

Suicide is closely related to sociological factors, but sociological analyses of suicide risk in leukemia are lacking. This study is the first to use the Surveillance, Epidemiology, and End Results Program (SEER) database to analyze sociological risk factors for suicide death in leukemia patients.

METHODS

A retrospective search of the SEER database was conducted. Logistic regression was used to identify independent risk factors for suicide death. Variables significant in the univariate logistic regression models were subsequently analyzed using multivariate regression.

RESULTS

The death rate was highest in California (1.73%). Suicide mortality was more common during the 1970s and 1980s, after which it trended downward. Young age at diagnosis (18-34 vs. >64 years: odds ratio [OR] = 1.537, 95% confidence interval [CI] = 1.007-2.347; 35-64 vs. >64 years: OR = 1.610, 95% CI = 1.309-1.979), being male (OR = 1.518, 95% CI = 1.230-1.873), and living where a high proportion of people have at least a bachelor's degree (>50% vs. <20%: OR = 8.115, 95% CI = 5.053-13.034) significantly increased suicide death risk.

CONCLUSION

Our findings could increase clinician awareness of and appropriate support for leukemia patients at risk of death by suicide.

Management in primary care at the time of a suicide attempt and its impact on care post-suicide attempt: an observational study in the French GP sentinel surveillance system

Background

We aimed to describe primary care management at the time of a suicide attempt (SA) and after the SA.

Methods

An observational (cross-sectional) study was conducted among 166 sentinel GPs within France (a non-gatekeeping country) between 2013 and 2017 for all GP’s patients who attempted suicide. Measurements: frequency of patients 1) managed by the GP at the time of the SA, 2) addressed to an emergency department (ED), 3) without care at the time of the SA, and 4) managed by the GP after the SA and factors associated with GP management at the time of and after the SA.

Results

Three hundred twenty-one SAs were reported, of which N = 95 (29.6%) were managed by the GP at the time of the SA, N = (70.5%) were referred to an ED, and N = (27.4%) remained at home. Forty-eight (14.9%) patients did not receive any care at the time of the SA and 178 (55.4%) were managed directly by an ED. GPs were more likely to be involved in management of the patient at the time of the SA if they were younger (39.2% for patients < 34 years old; 22.9% for those 35 to 54 years old, and 30.3% for those more than 55 years old p = 0.02) or the SA involved a firearm or self-cutting (51.9%) versus those involving drugs (23.7%); p = 0.006). After the SA, GPs managed 174 patients (54.2%), more often (60%) when they provided care at home at the time of the SA, p = 0.04; 1.87 [1.07; 3.35]. No other factor was associated with management by GPs after the SA.

Conclusions

The study faced limitations: data were not available for patients managed solely by specialists during their SA and results may not be generalisable to countries with a stronger gatekeeping system. We concluded that GPs are involved in the management of patients at the time of a SA for a third of patients. EDs are the major provider of care at that time. Half patients consulted GPs after the SA and connections between GPs and ED upon discharge should be improved.

Epidemiology of Suicide/Suicide Attempt and Its Association with Individual, Family, and Social Factors in Eastern Part of Iran: A Historical Cohort Study

BACKGROUND

Suicide/suicide attempt, as a major public health problem, has been included among anti-social behaviors. We aimed to investigate the epidemiology of suicide and some associated individual, family, and social factors.

METHODS

A historical cohort study was conducted among all cases (748 persons) reports related to suicide/suicide attempt that register in hospital reporting system and health care center in Gonabad and Bajestan, Iran, from 2009 to 2014. The required data were extracted through a checklist. Descriptive (mean and standard deviation) and analytic statistics (t-test, Chi-square, and logistic regression) applied to analyzed data. All data were analyzed using SPSS software.

RESULTS

Of the 748 reported suicide attempters, 17 cases (2.3%) had completed suicide. The annual average incidence rate of suicide was 110.03 per 100,000 populations. The mean age of suicide attempt had significantly decreased during the time (P=0.007). Furthermore, a significant association was observed between outcome of suicide and place of residence (P=0.019), history of physical illnesses (P=0.002), and method of suicide (P=0.001).

CONCLUSION

Due to trend of age among suicide attempters, considering intervention programs of suicide prevention for school pupils and university students especially individuals residing in rural areas, as well as individuals suffering from physical illness would be effective to reduce the rate of suicide.

Secretory Acid Sphingomyelinase in the Serum of Medicated Patients Predicts the Prospective Course of Depression

Major depressive disorder (MDD) is a highly prevalent and devastating psychiatric illness with strong individual and societal burdens. However, biomarkers to improve the limited preventive and therapeutic approaches are scarce. Multilevel evidence suggests that the pathophysiological involvement of sphingolipids particularly increases the levels of ceramides and the ceramide hydrolyzing enzyme, acid sphingomyelinase. The activity of secretory acid sphingomyelinase (S-ASM) and routine blood parameters were determined in the serum of patients with current (unmedicated n = 63, medicated n = 66) and remitted (n = 39) MDD and healthy subjects (n = 61). Depression severity and anxiety and their 3-weeks prospective course of treatment were assessed by psychometric inventories. S-ASM activity was not different between the four groups, did not decrease during treatment, and was not lower in individuals taking medication that functionally inhibited ASM. However, S-ASM correlated positively with depression severity only in remitted patients. High enzyme activity at inclusion predicted milder clinician-evaluated and self-rated depression severity (HAM-D, MADRS, BDI-II) and state anxiety at follow-up, and was related to stronger improvement in these scores in medicated patients. S-ASM was strongly and contrariwise associated with serum lipids in unmedicated and medicated females. These findings contribute to a better understanding of the pathomechanisms underlying depression and the development of clinical strategies and biomarkers.

Discussing suicidality with depressed patients: an observational study in Dutch sentinel general practices

OBJECTIVES

This paper aims to describe the degree to which general practitioners (GPs) explore suicidal behaviour among depressed patients in the Netherlands.

DESIGN

An observational study of consultations between GPs and depressed patients.

SETTING

39 sentinel GP practices within the Netherlands in 2017.

PARTICIPANTS

Patients with a registration of depression.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measure is suicide exploration by the GP. Secondary outcome measures at patient level, assessed by surveying GPs, include prevalence and severity of suicidal thoughts. Secondary outcome measures at GP level include follow-up actions of GP and reasons not to explore suicidality.

RESULTS

A total of 1034 questionnaires were included in the analyses. GPs assessed and explored suicidality in 44% of patients with depression (66% in patients with a new episode of depression). GPs explored suicidal feelings more often in patients with a new episode of depression (OR 4.027, p<0.001, 95% CI 2.924 to 5.588), male patients (OR 1.709, p<0.001, 95% CI 1.256 to 2.330) or younger patients (OR 1.017, p<0.001, 95% CI 1.009 to 1.026). Multilevel analysis showed that 22% of the variation in suicide exploration is due to differences in GP practice. Thirty-eight per cent of the patients who were asked by their GP, reported (severe) suicidal ideation. Most GPs (68%) did not explore suicidal feelings because they thought the patient would not be suicidal.

CONCLUSION

GPs explored suicidal thoughts in less than half of all depressed patients and in two-thirds of patients with a new episode of depression. Suicide prevention training is recommended to enhance suicide exploration.

Factors associated with hospitalization after self-poisoning in France: special focus on the impact of alcohol use disorder

BACKGROUND

Previous studies have identified factors associated with admission to hospital after suicide spectrum behaviors. In this study, we aim to identify specific factors associated with psychiatric hospitalization after self-poisoning. Given earlier findings suggesting that alcohol use disorder is not associated with hospital admission, we also aim to consider its impact, as well as blood alcohol concentrations, on hospitalization decisions after a suicide attempt.

METHODS

We studied the association between demographic features, suicide intent, psychiatric characteristics and admission to hospital in self-poisoning patients in an emergency department in France.

RESULTS

Suicide intent, a past history of suicide attempts, bipolar disorder and depression were associated with psychiatric hospital admissions. Despite alcohol use disorder being known to be associated with a suicide risk, it was not linked with psychiatric hospitalization. A positive blood alcohol concentration in the emergency department likewise had no association with admission to a psychiatric ward for inpatient care.

CONCLUSIONS

Our findings were similar to those reported for other suicide spectrum behaviors. Alcohol use disorder was not associated with admission for inpatient psychiatric care, whereas depression clearly was. The cause of this discrepancy must be determined in future research.

Work intensity in men and work-related emotional demands in women are associated with increased suicidality among persons attending primary care

BACKGROUND

A large proportion of persons died by suicide are employed at the time of death and work-related factors partly contribute to suicide risk. Our aim was to examine the association between multiple aspects of work organization and suicidal ideation in a study conducted in primary care.

METHODS

Data came from a study of 2027 working patients attending a GP representative of patients in the Nord Pas-de-Calais region in France (April-August 2014). Suicidality was assessed using the MINI (Mini International Neuropsychiatric Interview). Six emergent worked-related factors were explored (work intensity, emotional demands, autonomy, social relationships at work, conflict of values, insecurity of work). Several covariates were considered: patient's and GP's characteristics, and area-level data (material and social deprivation, psychiatrist and GPs' density, suicide attempts and suicide rates).

RESULTS

8.0% of participants reported suicidal ideation in the preceding month (7.5% of men and 8.6% of women, p = .03). In multivariate analyses adjusted for covariates, suicidality was significantly associated with work intensity (OR = 1.65; 95%CI [1.18-2.31]) in men and with work-related emotional demands (OR = 1.35; 95%CI [1.01-1.80]) in women. Area-level data were not associated.

LIMITATIONS

Our cross-sectional study cannot assess the direction of the relationships under study.

CONCLUSION

Our results emphasise a central role for GPs in suicide prevention among workers and highlight the importance of work-related factors with regard to suicidality in primary care.

Effectiveness of General Practitioner training to improve suicide awareness and knowledge and skills towards depression

BACKGROUND

General Practitioners (GPs) are well placed as gatekeepers for managing depression and suicidal ideation but not always well prepared. Capacity building has therefore been recommended as a useful strategy for suicide prevention. This study aimed to examine whether GPs' knowledge and attitudes towards and confidence to deal with depression and suicide improve after following a training program.

METHODS

As part of the OSPI-Europe multilevel intervention, a standardized training on depression and suicide was provided to 208 GPs in three European countries. Core outcomes were assessed using the Depression Attitude Questionnaire, the Attitude towards Suicide Prevention Scale, and the Morriss Confidence Scale. Data were collected before and after training, and at three to six months follow-up.

RESULTS

At baseline, GPs demonstrated various stigmatizing attitudes towards depression and low optimism about the therapeutic treatment of depression. They showed moderately positive attitudes towards suicide prevention but felt little confident in dealing with depression and suicide in daily practice. The training resulted in improved knowledge, attitudes and confidence regarding depression and suicide and their prevention and treatment. At follow-up, only the increase in confidence to deal with depression and suicide was sustained.

LIMITATIONS

The Depression Attitude Questionnaire has rather weak psychometric properties. Other external factors may have contributed to the observed training effects as the study included no control group.

CONCLUSIONS

The OSPI-Europe training program was able to improve the GPs' attitudes towards suicide prevention, several attitudes towards depression and its treatment as well as the GPs' confidence to deal with depression and suicide in everyday practice. At follow, only the GPs' confidence to deal with depression and suicide was preserved.

Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017

Aim: To examine rates of contact with primary and mental health care prior to suicide in men and women and across a range of age categories. Method: The authors performed a systematic review of 44 studies from 2000 to 2017 of which 36 reported rates on contact with primary health care and 14 reported on contact with mental health care prior to suicide. Results: Contact with primary health care was highest in the year prior to suicide with an average contact rate of 80%. At one month, the average rate was 44%. The lifetime contact rate for mental health care was 57%, and 31% in the final 12 months. In general, women and those over 50 years of age had the highest rates of contact with health care prior to suicide. Conclusions: Contact with primary health care prior to suicide is common even in the final month before death. The findings presented in this study highlight the importance of placing suicide prevention strategies and interventions within the primary health care setting.

Trends in suicidal behaviour in Dutch general practice 1983-2013: a retrospective observational study

OBJECTIVES

To analyse trends in suicidal behaviour as reported by the Dutch sentinel general practices from 1983 to 2013. Second, to examine the relationship between suicidal behaviour and several patient characteristics. Finally, to compare the relationship between suicidal behaviour and patient characteristics before (1983-2007) and after (2008-2013) the start of the crisis.

SETTING

40 general practices in the Netherlands during the period 1983-2013.

PARTICIPANTS

Patients with an ICPC code of P77 (suicide attempt).

PRIMARY AND SECONDARY OUTCOMES

Primary outcomes were age-adjusted and gender-specific trends in reported suicides (342) and suicide attempts (1614). Secondary outcomes were the relationship between suicidal behaviour and age, household composition, history of depression, recognition of suicide ideation, treatment before the suicidal behaviour and contact within the past month before suicidal behaviour for the period 1983-2013. Additionally, separate frequencies for the periods 1983-2007 and 2008-2013 were presented.

RESULTS

Join-point analyses revealed a significant rise in male suicides from 2008 (b=0.32, SE=0.1, p=0.008), and an increase in male suicide attempts since 2009 (b=0.19, SE=0.04, p<0.001). Female suicidal behaviour showed a steady decrease from 1989 to 2013(b=-0.03, SE=0.007, p<0.0001 for female suicide, b=-0.02, SE=0.002, p<0.001 for female attempts). Before 2007, a history of depression was reported in 65% (168/257) of the suicides. After the start of the recession, a depression was recognised in 44% (22/50) of the patients who died by suicide.

CONCLUSIONS

Since 2008, there was a rise in the male suicide rate while female suicide behaviour has continued to decline. General practitioners less often reported a history of depression within patients who died due to suicide after 2007 than before. Training in the early recognition of suicide ideation in depressive patients might improve suicide prevention in primary care.

Climate change but not unemployment explains the changing suicidality in Thessaloniki Greece (2000-2012)

INTRODUCTION

Recently there was a debate concerning the etiology behind attempts and completed suicides. The aim of the current study was to search for possible correlations between the rates of attempted and completed suicide and climate variables and regional unemployment per year in the county of Thessaloniki, Macedonia, northern Greece, for the years 2000-12.

MATERIAL AND METHODS

The regional rates of suicide and attempted suicide as well as regional unemployment were available from previous publications of the authors. The climate variables were calculated from the daily E-OBS gridded dataset which is based on observational data

RESULTS

Only the male suicide rates correlate significantly with high mean annual temperature but not with unemployment. The multiple linear regression analysis results suggest that temperature is the only variable that determines male suicides and explains 51% of their variance. Unemployment fails to contribute significantly to the model. There seems to be a seasonal distribution for attempts with mean rates being higher for the period from May to October and the rates clearly correlate with temperature. The highest mean rates were observed during May and August and the lowest during December and February. Multiple linear regression analysis suggests that temperature also determines the female attempts rate although the explained variable is significant but very low (3-5%)

CONCLUSION

Climate variables and specifically high temperature correlate both with suicide and attempted suicide rates but with a different way between males and females. The climate effect was stronger than the effect of unemployment.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Attempted and completed suicide in primary care: not what we expected?

BACKGROUND

General Practitioners (GPs) play a central role in suicide prevention. This study aims to compare the characteristics of individuals who attempt suicide to those who complete suicide in a same primary care setting.

METHODS

We compared the characteristics and GP's management of all patients with attempted (N=498, SA) or completed suicide (N=141, SC) reported to the GPs'French Sentinelles surveillance system (2009-2013).

RESULTS

Compared to patients who attempted suicide, those who completed suicide were more likely to be male, older and to have used a more lethal method; for men they were less likely to have a history of previous suicide attempt and prior contacts with their GP. In terms of GPs' management, we found no differences between the SA and SC groups in the identification of psychological difficulties and in the care, but GPs were more likely to provide psychological support to the SA group. During the last consultation, the SC group expressed suicidal ideas more frequently than the SA group (26.7% vs. 14.8%, p<0.01), only for women.

LIMITATIONS

The network may have missed cases and selected more serious SA.

CONCLUSIONS

Individuals who commit suicide differ from those who attempt suicide in terms of demographic characteristics and by sex, of history of suicide attempt, previous contact and expressed suicidal ideas. We show that GPs do not act more intensively with patients who will commit suicide, as if they do not foresee them. Current prevention programs particularly in primary care should be tailored.

Factors associated with hospitalization after suicide spectrum behaviors: results from a multicenter study in Spain

The objective of this study was to identify factors associated with hospital admission after suicide spectrum behaviors. Patients' characteristics, the nature of the suicidal behavior, admission rates between centers, and factors associated with admission have been examined in suicide spectrum presentations to emergency departments in 3 Spanish cities. The intent of the suicidal behavior had the greatest impact on hospitalization. Older age, living alone, self-harm method not involving drug overdose, previous history of suicide spectrum behaviors, and psychiatric diagnosis of schizophrenia, mood, or personality disorder were independently associated with being admitted. There was a 3-fold between-center difference in the rate of hospitalization. Widespread differences in the rate of hospitalization were primarily accounted for by characteristics of the individual patients and their suicidal behavior.

Factors affecting the presence of depression, anxiety disorders, and suicidal ideation in patients attending primary health care service in Lithuania

OBJECTIVE

The aim of this study was to establish prevalence, recognition, and risk factors for mental disorders and suicidal ideation in PC patients.

DESIGN

A cross-sectional survey based on standard mental health evaluation.

SETTING

Lithuanian primary care.

SUBJECTS

998 patients from four urban PC clinics.

MAIN OUTCOME MEASURES

Current mental disorders and suicidal ideation assessed using the Mini International Neuropsychiatric Interview (MINI).

RESULTS

According to the MINI, 27% of patients were diagnosed with at least one current mental disorder. The most common mental disorders were generalized anxiety disorder (18%) and major depressive episode (MDE) (15%), followed by social phobia (3%), panic disorder (3%), and post-traumatic stress disorder (2%). Some 6% of patients reported suicidal ideation. About 70% of patients with current mental disorder had no documented psychiatric diagnosis and about 60% received no psychiatric treatment. Greater adjusted odds for current MDE were associated with being widowed or divorced patients (odds ratio, OR = 1.8, 95% CI 1.2-2.8) and with lower education (OR = 1.6, 95% CI 1.1-2.3), while greater adjusted odds for any current anxiety disorder were found for women (OR = 1.9, 95% CI 1.3-2.8) and for patients with documented insomnia (OR = 2.2, 95% CI 1.2-4.2). Suicidal ideation was independently associated with use of antidepressants (OR = 5.4, 95% CI 1.7-16.9), with current MDE (OR = 2.9, 95% CI 1.5-5.8), and with excessive alcohol consumption (OR = 2.0, 95% CI 1.1-3.8).

CONCLUSIONS

Depression, anxiety disorders, and suicidal ideation are prevalent but poorly recognized among PC patients. The presence of current MDE is independently associated with marital status and with lower education, while current anxiety disorder is associated with female gender and insomnia. Suicidal ideation is associated with current MDE, and with antidepressants and alcohol use.

Preventing the onset of major depression based on the level and profile of risk of primary care attendees: protocol of a cluster randomised trial (the predictD-CCRT study)

BACKGROUND

The 'predictD algorithm' provides an estimate of the level and profile of risk of the onset of major depression in primary care attendees. This gives us the opportunity to develop interventions to prevent depression in a personalized way. We aim to evaluate the effectiveness, cost-effectiveness and cost-utility of a new intervention, personalized and implemented by family physicians (FPs), to prevent the onset of episodes of major depression.

METHODS/DESIGN

This is a multicenter randomized controlled trial (RCT), with cluster assignment by health center and two parallel arms. Two interventions will be applied by FPs, usual care versus the new intervention predictD-CCRT. The latter has four components: a training workshop for FPs; communicating the level and profile of risk of depression; building up a tailored bio-psycho-family-social intervention by FPs to prevent depression; offering a booklet to prevent depression; and activating and empowering patients. We will recruit a systematic random sample of 3286 non-depressed adult patients (1643 in each trial arm), nested in 140 FPs and 70 health centers from 7 Spanish cities. All patients will be evaluated at baseline, 6, 12 and 18 months. The level and profile of risk of depression will be communicated to patients by the FPs in the intervention practices at baseline, 6 and 12 months. Our primary outcome will be the cumulative incidence of major depression (measured by CIDI each 6 months) over 18 months of follow-up. Secondary outcomes will be health-related quality of life (SF-12 and EuroQol), and measurements of cost-effectiveness and cost-utility. The inferences will be made at patient level. We shall undertake an intention-to-treat effectiveness analysis and will handle missing data using multiple imputations. We will perform multi-level logistic regressions and will adjust for the probability of the onset of major depression at 12 months measured at baseline as well as for unbalanced variables if appropriate. The economic evaluation will be approached from two perspectives, societal and health system.

DISCUSSION

To our knowledge, this will be the first RCT of universal primary prevention for depression in adults and the first to test a personalized intervention implemented by FPs. We discuss possible biases as well as other limitations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01151982.

Particular difficulties faced by GPs with young adults who will attempt suicide: a cross-sectional study

Background

Suicide is a major public health problem in young people. General Practitioners (GPs) play a central role in suicide prevention. However data about how physicians deal with suicidal youths are lacking. This study aims to compare young adult suicide attempters (from 18 to 39 years old) with older adults in a primary care setting.

Methods

A cross-sectional study was carried. All suicide attempts (N=270) reported to the French Sentinel surveillance System from 2009 to 2011 were considered. We conducted comparison of data on the last GP’s consultation and GPs’ management in the last three months between young adults and older adults.

Results

In comparison with older adults, young adults consulted their GP less frequently in the month preceding the suicidal attempt (40.9 vs. 64.6%, p=.01). During the last consultation prior to the suicidal attempt, they expressed suicidal ideas less frequently (11.3 vs. 21.9%, p=.03). In the year preceding the suicidal attempt, GPs identified depression significantly less often (42.0 vs. 63.4%, p=.001). In the preceding three months, GPs realized significantly less interventions: less psychological support (37.5 vs. 53.0%, p=.02), prescribed less antidepressants (28.6 vs. 54.8%, p<.0001) or psychotropic drugs (39.1 vs. 52.9%, p=.03) and made fewer attempts to refer to a mental health specialist (33.3 vs. 45.5%, p=.05).

Conclusion

With young adults who subsequently attempt suicide, GPs face particular difficulties compared to older adults, as a significant proportion of young adults were not seen in the previous six months, as GPs identified less depressions in the preceding year and were less active in managing in the preceding three months. Medical training and continuing medical education should include better instruction on challenges relative to addressing suicide risk in this particular population.

Sociodemographic and psychopathological risk factors in repeated suicide attempts: gender differences in a prospective study

BACKGROUND

The prevention of the repetition of suicide attempts is an important feature of the care of attempters but current data fail to give actual predictors of repetition. The aim of this study was to characterize sociodemographic and psychopathological features and risk factors associated with future repetition of suicide attempts in two years. The study focused on differences between men and women.

METHODS

273 participants selected in psychiatric emergency units after their admission for a suicide attempt (index) were included in the study. Subsequent suicide attempts occurring within a two year follow-up were identified from the regional observatory of suicide attempts. At inclusion, sociodemographic variables and psychopathological data were collected. In particular, psychometric evaluations were performed using the following scales: BDI-SF, SIS, BIS and BDHI. The lifetime history of suicide attempt was also noted.

RESULTS

Repetition of suicide attempt in 2 years was associated with current follow up and treatment, a personal history of multiple suicide attempt, post traumatic stress disorder, current recurrent psychotic syndrome and substance misuse. Specific features of men and women repeaters have been identified. Men repeaters were characterized by substance use disorders whereas the re-attempt in women was associated with current follow up and treatment, post traumatic stress disorder and higher BDI-SF score.

CONCLUSIONS

Repeaters must be considered as a specific population among suicide attempters and gender differences must be taken into account in this particular population in order to promote more personalized prevention programs for suicidal recurrence and completed suicide.

Living alone and deliberate self-harm: a case-control study of characteristics and risk factors

BACKGROUND

An increasing proportion of the UK population live alone. Little is known about deliberate self-harm (DSH) patients who live alone. We conducted a study of the characteristics of DSH patients who live alone using data from the Oxford Monitoring System for Attempted Suicide.

METHOD

Data on patients presenting to the general hospital in Oxford with an episode of DSH between 1993 and 2006 were analysed by gender and age group (15-24 years, 25-54 years and 55+ years) and according to whether or not they lived alone.

RESULTS

In total, 1,163/7,865 (14.8%) patients lived alone. Having a problem with social isolation was more common in those living alone compared with those living with others, especially in those aged 55+ years. In the 25-54 years age group several variables concerning psychiatric problems were more common in those living alone, as was higher suicide intent associated with the current DSH episode and past DSH, and for females, repetition of DSH within 12 months. In patients aged 55+ years those living alone were more likely to have problems due to bereavement. Significantly more individuals living alone died from any cause. More also died by suicide, although the difference between the groups was non-significant after adjusting for age.

CONCLUSIONS

These results have implications for psychiatric services assessing DSH patients who live alone, since, depending on the patient's age and living circumstances, different psychiatric and social interventions may be needed. Middle-aged DSH patients who live alone appear to be particularly vulnerable. DSH patients who live alone may not have supportive social networks and may be at increased risk of repetition of DSH and suicide.

Disability weights for suicidal thoughts and non-fatal suicide attempts

BACKGROUND

Although there are disability weights available for a wide range of health states, these do not include suicidality. This makes it difficult to evaluate the severity of suicidality in comparison with other health states. The aim of this study therefore is to estimate disability weights for suicidal thoughts and for mental distress involved in non-fatal suicide attempts.

METHODS

A Dutch expert panel of sixteen medical practitioners who were knowledgeable about suicidality estimated disability weights (DWs) for twelve health states by interpolating them on a calibrated Visual Analogue Scale. The DWs for ten of these health states had been estimated in previous studies and were used to determine the external consistency of the panel. The other two concerned health states for suicidal thoughts and non-fatal suicide attempts. The resulting DWs could vary between 0 (best imaginable health state) and 1 (worst imaginable health state).

RESULTS

Both internal (Cronbach's α = 0.98) and external consistency of the panel were satisfactory. The DWs for suicidal thoughts and non-fatal suicide attempts were estimated to be 0.36 and 0.46 respectively.

LIMITATIONS

The panel was relatively small, which resulted in broad confidence intervals.

CONCLUSIONS

Suicidal thoughts are considered to be as disabling as alcohol dependence and severe asthma. The mental distress involved in non-fatal suicide attempts is thought to be comparable in disability to heroin dependence and initial stage Parkinson's. These results demonstrate the severity of suicidality.

Violência autoinfligida e anos potenciais de vida perdidos em Minas Gerais, Brasil

Os dados mundiais evidenciam que, aproximadamente, um milhão de pessoas cometeram violência autoinfligida, em 2000, e as consequências têm sido alarmantes. Uma pessoa morre por esse motivo a cada 40 segundos, e outra atenta contra a própria vida a cada três segundos. Estudo exploratório, objetivando a análise epidemiológica de mortalidade por violência autoinfligida do Estado de Minas Gerais, por meio do cálculo do Coeficiente de Mortalidade Padronizado e Anos Potenciais de Vida Perdidos. A mortalidade, no período de 1996 a 2007, foi 4,29 óbitos por 100.000 habitantes, sendo superior nos homens (6,90) em relação às mulheres (1,73). A faixa etária de 40 a 59 anos atingiu mortalidade de 7,0 óbitos por 100.000 habitantes. Em relação aos anos de vida perdidos a média da idade de óbitos manteve-se em torno dos 40 anos, evidenciando a perda do potencial social do sujeito acometido pela violência autoinfligida.

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

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

Requests for euthanasia in general practice before and after implementation of the Dutch Euthanasia Act

BACKGROUND

The Netherlands was the first country in the world to implement a Euthanasia Act in 2002. It is unknown whether legalizing euthanasia under strict conditions influences the number and nature of euthanasia requests.

AIM

To investigate changes in the number of, and reasons for, requests for euthanasia in Dutch general practice after implementation of the Euthanasia Act.

DESIGN OF STUDY

Retrospective dynamic cohort study comparing 5 years before (1998-2002) and 5 years after (2003-2007) implementation of the Act.

METHOD

Standardised registration forms were used to collect data on requests for euthanasia via the Dutch Sentinel Practice Network. This network of 45 general practices is nationally representative by age, sex, geographic distribution, and population density.

RESULTS

The mean annual incidence of requests before implementation amounted to 3.1/10,000 and thereafter to 2.8/10,000 patients. However, trends differed by sex. The number of requests by males decreased significantly from 3.7/10,000 to 2.6/10,000 (P = 0.008); the requests by females increased non-significantly from 2.6/10,000 to 3.1/10,000. Before and after implementation, cancer remained the major underlying disease for requesting euthanasia: 82% versus 77% for men; 73% versus 75% for females. Pain was a major reason for a request, increasing in the period before implementation (mean 27%), but declining in the period thereafter (mean 22%). Loss of dignity became a less important reason after implementation (from 18% to 10%, P = 0.04), predominantly due to a marked decrease in the number of females citing it as a reason (from 17% to 6%, P = 0.02).

CONCLUSION

There was no increase in demand for euthanasia after implementation of the Euthanasia Act. Pain as a reason for requesting euthanasia showed an increasing trend before implementation, but declined thereafter. Loss of dignity as a reason declined, especially in females.

A survey of Dutch GPs' attitudes towards help seeking and follow-up care for relatives bereaved by suicide

BACKGROUND

Relatives who are bereaved by suicide likely consult their GP when they feel the need for professional help. GPs may play a key role in establishing who is at risk for adverse consequences of the loss as they are familiar with relatives' possible psychiatric vulnerabilities. The availability of evidence-based services for relatives of suicide victims is limited. Successful implementation of services needs analysis of key factors considered critical in the achievement of changes. We investigated GPs' management of help requests of relatives bereaved by suicide and examined determinants of GPs willingness to refer for evidence-based follow-up care.

METHODS

A cross-sectional survey among 488 GPs in the northern part of The Netherlands.

RESULTS

A 44% response was achieved (n = 214) during the last 3 years, 38 (18%) were exposed to suicide, 21 (10%) to help requests without being exposed to suicide and 52 (24%) to both suicide and help requests. Out of 106 requests, 69 (65%) were handled by the GP; 60 (57%) were either directly or additionally referred, principally for mental health care. Suicide exposure and female gender were associated with the doctor's perception that follow-up care following a loss through suicide is useful. The perception that help is useful increased the likelihood of GPs' referral for evidence-based follow-up care.

CONCLUSIONS

GPs support the availability of evidence-based follow-up care for relatives of suicide victims. To modify GPs' key role in referring relatives for it, GPs should be well informed of its usefulness and to whom.

[Epidemiological analysis of morbidity and mortality from suicide among adolescents in Minas Gerais, Brazil]

This study is a descriptive epidemiological analysis of morbidity and mortality from suicide in people aged 10 to 19 years living in the state of Minas Gerais. The source of the mortality data were the data available in the Mortality Information System, DATASUS of the Ministry of Health, over the period 1980-2002. The morbidity data were collected from the Hospital Information System, over the period 1998-2003. Absolute and relative simple frequencies of 2.338 hospitalizations and 1.212 deaths from attempted suicide and suicide over the chosen period were analyzed according to sex, age and method used. The population data used for calculating rates was extracted from the census conducted by the Brazilian Institute of Geography and Statistics. The International Classification of Diseases - ICD 9, from the years 1980 to 1995 and the 10th review since 1996, codes E950 to E959 and X60 to X84, were adopted respectively. The highest hospitalization rates were found among women. Self-poisoning was the most common method for attempting suicide in both sexes. However, adolescent males had the highest mortality rates and the most common methods of suicide (hanging and use of firearms) were more lethal than the method commonly chosen by females (self-poisoning). Based on these findings, the authors emphasize the need for preventing these events among young people.

Perceived social isolation in a community sample: its prevalence and correlates with aspects of peoples' lives

Although there are many studies reporting perceived social isolation or loneliness and their correlates in specific groups, there are few modern prevalence studies. This study reports on the prevalence of perceived social isolation in an Australian community sample. Randomly sampled Australian adults (n = 3,015) were interviewed using a standard questionnaire. In addition to perceived social isolation assessed by the Friendship Scale, data were collected on socio-demographic variables and chronic health conditions. The findings suggest that while most participants were socially connected, 9% reported some social isolation and 7% were isolated or very isolated. Perceived social isolation varied by gender and age group, region of birth, relationship, labourforce, and income status. A key finding was that younger adults had higher probabilities of being classified as being socially isolated than did older participants. Depression was very strongly associated with perceived social isolation. Other health conditions or life experiences associated with it were hearing, incontinence and lifetime trauma exposure. The demographic characteristics and chronic health conditions associated with perceived social isolation are structural circumstances of peoples' lives. Given there are poor long-term health outcomes, including early death and suicide, there are clear public health implications for those trapped by these life circumstances.

Is suicide prevention properly taught in medical schools?

OBJECTIVE

To determine the need and feasibility of developing a national suicide prevention (SP) curriculum for undergraduate medical students.

DESIGN

Exploratory study using semi-structured phone interviews and surveys. Data was obtained from ten (out of 15) Australian Medical Schools (AMS), 373 medical students from one Queensland medical school, and 24 Australian General Practitioners, between April and June, 2006.

RESULTS

Convergent views of AMS, medical students, and GPs revealed a high need and support for SP curricula, especially on skills-based education. Students who previously received SP education rated themselves significantly higher on skills-based SP abilities than those who had not. Over one-third of GPs had not received SP training from their universities (37.5%), yet 66% had experienced a case of suicide among their patients, and a third recorded on average a case of suicide every two years. The majority of students and GPs rated themselves as least competent on skills-based SP capabilities, yet rated these capabilities very high in importance for the medical profession. Whilst 80% of AMS provides some form of SP education, the quantity and quality of this is divergent. All AMS indicated support for a more uniformed SP curriculum, identified priority SP topics and delivery mechanisms, and 80% agreed to participate in a future piloting of a SP curriculum.

CONCLUSIONS

SP curriculum may positively impact on student's perceived competency. Skills-based SP curricula were highly recommended to improve 'hands-on' assessment, intervention and management capabilities. Further consultation is required with all AMS to specify structure and resource needs for a national SP curriculum.

The burden of testosterone deficiency syndrome in adult men: economic and quality-of-life impact

INTRODUCTION

Testosterone deficiency syndrome (TDS) causes a wide range of symptoms that can lead to significant morbidity. Preliminary evidence has also linked TDS with premature mortality and with a number of comorbid diseases including diabetes and metabolic syndrome. Such associations can lead to substantial economic and quality-of-life implications, the magnitude of which remains largely unknown.

AIM

To review the economic and quality-of-life consequences of a largely untreated condition and to consider the likely health economic benefits of testosterone treatment.

METHODS

A systematic review of four main areas: epidemiological evidence of the magnitude of TDS, estimates of cost of illness, impact on quality-of-life, and cost-effectiveness of testosterone treatment.

MAIN OUTCOME MEASURE

Review of peer-reviewed literature.

RESULTS

The lack of clear universally accepted diagnostic criteria and the uncertainty surrounding the link between TDS and some of its consequences complicate the estimation of the burden of illness of TDS. Consequences of TDS that potentially lead to increased economic burden include depression, sexual dysfunction, mild cognitive impairment, osteoporosis, cardiovascular disease, and mortality. However, although good evidence exists demonstrating an association between TDS and sexual dysfunction and cognitive impairment, evidence is less strong for depression, the incidence of fractures and mortality, and highly controversial for cardiovascular disease. The consequences that are likely to impact on patients' quality of life include sexual function, energy levels, body composition, mood, and cognitive function.

CONCLUSION

Understanding the burden is only the first step decision makers need to take to decide whether to allocate scarce resources to treat the condition. To make informed decisions on when and who to treat information is also needed on the cost-effectiveness of available treatments. Such data would highlight the benefits of treatment of TDS to physicians, patients, and to society as a whole.

Redes centinela sanitarias en España. Consenso para una guía de principios y métodos

Since the eighties, health sentinel networks have been active in our country, but with a variety of objectives, methods and different development levels in the autonomous communities. The necessity of standardising the management and harmonising the indicators has concluded in a research project on the Spanish health sentinel networks, one of whose objectives is to establish a guide for work principles and methods. A panel of 23 experts has made a study using the Delphi method to agree, in three consecutive phases, a definition of sentinel network, the objectives and the management principles and other aspects related to the organisation and functioning. Altogether, 41 questions were gathered from a previous draft which needed 80% of consensus in the first phase and 70% in the second. All the experts participated in the first phase, 22 in the second and 20 in the third. A consensus was achieved on 36 questions in the first phase and in 4 of the remaining ones in the second. In the third phase the shape of the guide document was given. The Delphi consensus method has been extremely useful in the resolution of discrepancies and divergences. The experts who were selected outside of the sentinel networks contributed with a wider vision on the objectives and applicability of the health sentinel networks in Spain.

Internet-based monitoring of influenza-like illness (ILI) in the general population of the Netherlands during the 2003-2004 influenza season

BACKGROUND

An internet-based survey of influenza-like illness (ILI)--the Great Influenza Survey or GIS--was launched in the Netherlands in the 2003-2004 influenza season. The aim of the present study was to validate the representativeness of the GIS population and to compare the GIS data with the official ILI data obtained by Dutch GPs participating in the Dutch Sentinel Practice Network.

METHOD

Direct mailings to schools and universities, and repeated interviews on television and radio, and in newspapers were used to kindle the enthusiasm of a broad section of the public for GIS. Strict symptomatic criteria for ILI were formulated with the assistance of expert institutes and only participants who responded at least five times to weekly e-mails asking them about possible ILI symptoms were included in the survey. Validation of GIS was done at different levels: 1) some key demographic (age distribution) and public health statistics (prevalence of asthma and diabetes, and influenza vaccination rates) for the Dutch population were compared with corresponding figures calculated from GIS; 2) the ILI rates in GIS were compared with the ILI consultation rates reported by GPs participating in the Dutch Sentinel Practice Network.

RESULTS

13,300 persons (53% of total responders), replied at least five times to weekly e-mails and were included in the survey. As expected, there was a marked under-representation of the age groups 0-10 years and 81->90 years in the GIS population, although the similarities were remarkable for most other age groups, albeit that the age groups between 21 and 70 years were slightly overrepresented. There were striking similarities between GIS and the Dutch population with regard to the prevalence of asthma (6.4% vs. 6.9%) and the influenza vaccination rates, and to a lesser degree for diabetes (2.4% vs. 3.5%). The vaccination rates in patients with asthma or diabetes, and persons older than 65 years were 68%, 85%, and 85% respectively in GIS, while the corresponding percentages in the Dutch population were 73%, 85% and 87%. There was also a marked similarity between the seasonal course of ILI measured by GIS and the GPs. Although the ILI rate in GIS was about 10 times higher, the curves followed an almost similar pattern, with peak incidences occurring in the same week.

CONCLUSION

The current study demonstrates that recruitment of a high number of persons willing to participate in on-line health surveillance is feasible. The information gathered proved to be reliable, as it paralleled the information obtained via an undisputed route. We believe that the interactive nature of GIS and the appealing subject were keys to its success.