Suicide within 12 months of mental health service contact in different age and diagnostic groups: National clinical survey

Clozapine may consistently protect from suicidal behaviors while other antipsychotics may lack a specific protective effect: a comprehensive VigiBase study interpreted in the context of the prior literature

BACKGROUND

In the United States, clozapine was first approved for treatment-resistant schizophrenia and then for suicidality in schizophrenia psychoses. Systematic reviews support clozapine's anti-suicidal effect, but the forensic literature stresses its lethality during overdoses.

RESEARCH DESIGN AND METHODS

Clozapine reports to the international pharmacovigilance database (VigiBase) were analyzed for suicidal ideation, suicide attempts, intentional overdose, and completed suicides from introduction to 1 January 2024. VigiBase uses the information component (IC) as a disproportionality analysis.

RESULTS

The clozapine ICs (range: other antipsychotics) were: 1) suicidal ideation IC = 0.570 with IC025 = 0.454 to IC975 = 0.680 (IC = 3.568 for aripiprazole and 1.729 for risperidone), 2) suicide attempt IC = 1.428 with IC025 = 1.323 to IC975 = 1.529 (IC = 4.150 for quetiapine and 2.968 for risperidone), 3) intentional overdose: IC = 0.995 with IC025 = 0.864 to IC975 = 1.120 (IC = 4.080 for quetiapine and 1.957 for aripiprazole), and 4) completed suicide IC = 1.133 with IC025 = 1.026 to IC975 = 1.235 (IC = 4.648 for quetiapine and 2.160 for risperidone). In summary, all clozapine ICs were significantly lower. We found 2391 clozapine-treated patients on the suicidality spectrum (627 cases with suicidal ideation, 752 with suicide attempt, 488 with intentional overdose, and 731 with completed suicide) but many were taking other antipsychotics. The most frequent reporting countries were the United States, the United Kingdom, and Croatia.

CONCLUSION

This pharmacovigilance study, with all its inherent limitations, provides independent proof, not overlapping with prior literature, that clozapine may have specific strong anti-suicidal effects that do not appear to be present in other antipsychotics. Further VigiBase studies are needed to compare the lethality of an intentional overdose of clozapine (14.3%) with other antipsychotics.

Healthcare utilization and comorbidity shortly before suicide mortality in patients with attention-deficit/hyperactivity disorder: a nested case-control study

BACKGROUND

Few studies have analyzed healthcare utilization before suicide among individuals with attention-deficit/hyperactivity disorder (ADHD). This study examined the pattern of healthcare utilization and comorbidities shortly before death among patients with ADHD who died by suicide and compared these data with those of living controls. This study used Taiwan's National Health Insurance Research Database to identify patients with ADHD (N = 379,440) between January 1, 2001, and December 31, 2016. Subsequently, the researchers identified 159 suicide decedents by linking each patient with the National Mortality Database. By conducting a nested case-control study with risk-set sampling from the ADHD cohort, the researchers selected 20 age- and sex-matched controls (n = 3180) for each patient who died by suicide (cases). The researchers then applied conditional logistic regression to investigate differences in healthcare utilization as well as psychiatric and physical comorbidities between case patients and controls. Case patients had higher healthcare utilization within 3 months before suicide, particularly in the psychiatry, emergency, internal medicine, neurosurgery, and plastic surgery departments. These patients also had higher risks of psychiatric comorbidities, including schizophrenia, bipolar disorder, depressive disorder, and sleep disorder, as well as physical comorbidities such as hypertension and other forms of heart disease. Among patients with ADHD, suicide decedents had increased healthcare utilization and higher risks of specific psychiatric and physical comorbidities than living controls. Thus, for suicide prevention among individuals with ADHD, suicide risk must be detected early and comorbidities should be adequately managed.

Comorbidity and Overlaps between Autism Spectrum and Borderline Personality Disorder: State of the Art

Despite the relationship between Autism spectrum disorder (ASD) and personality disorders (PD) still being scarcely understood, recent investigations increased awareness about significant overlaps between some PD and autism spectrum conditions. In this framework, several studies suggested the presence of similarities between BPD and ASD symptoms and traits, based on the recent literature that increasingly reported increased comorbidity rates and significant symptomatologic overlaps between the two conditions. The aim of this review is to describe the available studies about the prevalence of the association between different forms of autism spectrum (full-fledged clinical conditions as well as subthreshold autistic traits) and BPD. Despite some controversial results and lack of homogeneity in the methods used for the diagnostic assessment, the reviewed literature highlighted how subjects with BPD reported higher scores on tests evaluating the presence of AT compared to a non-clinical population and hypothesized the presence of unrecognized ASD in some BPD patients or vice versa, while also describing a shared vulnerability towards traumatic events, and a greater risk of suicidality in BPD subjects with high autistic traits. However, the specific measure and nature of this association remain to be explored in more depth.

Psychological Effects Of Unemployment Across The Lifespan: A Synthesis Of Relevant Literature

Amid ongoing global economic uncertainty and long-standing efforts to tackle age discrimination and increase older workers' labor force engagement, it is pertinent to consider age differences in the individual effects of joblessness. This is paramount for informing support services, policy formulation, and research. This article is based on a literature review of international peer reviewed quantitative research that has examined the relationship between age, psychological wellbeing and unemployment. Two hundred and twenty-six studies were screened and 36 were included. No relevant qualitative studies were identified. Among the studies, there was a broad consensus that there are age differences in terms of the psychological consequences of unemployment. However, they showed mixed evidence, and critical conceptual and methodological deficiencies were identified. We conclude that the body of evidence is weak and that drawing from it for the development of practice and policy in support of jobless individuals is to be cautioned against.

Risk of suicide ideation in comorbid substance use disorder and major depression

BACKGROUND

Suicidal behaviour is commonly associated with major depression (MD) and substance use disorders (SUDs). However, there is a paucity of research on risk for suicide ideation among individuals with comorbid SUDs and MD in the general population.

OBJECTIVES

This study investigated the associated risk of suicide ideation in comorbid SUDs-cannabis use disorder (CUD), alcohol use disorder (AUD), drug use disorder (DUD) with major depressive episode (MDE) in a nationally representative sample.

METHODS

Multilevel logistic regression models were used to analyze the 2012 Canadian Community Health Survey- Mental Health (CCHS-MH) data. This is a cross-sectional survey of nationally representative samples of Canadians (n = 25,113) aged 15 years and older residing in the ten Canadian provinces between January and December 2012. Diagnoses of MDE, AUD, DUD, and CUD were based on a modified WHO-CIDI, derived from DSM-IV diagnostic criteria.

RESULTS

Comorbidity was found to be the strongest predictor of suicide ideation. Compared to those with no diagnosis of either a SUD or MDE, individuals with a comorbid diagnosis of AUD with MDE, CUD with MDE, or DUD with MDE were 9, 11 and 16 times more likely to have 12-month suicide ideation respectively. A diagnosis of MDE was a significant predictor of 12-month suicide ideation with about a 7-fold increased risk compared with individuals not diagnosed with either MDE or a SUD.

CONCLUSION

Suicide is a preventable public health issue. Our study found a significantly increased risk of suicide ideation among persons who have comorbid SUD with MD. Effective integration of mental health and addictions services could mitigate the risk of suicide and contribute to better outcomes.

A comparative autopsy study of the injury distribution and severity between suicidal and accidental high falls

Falls are the second cause of accidental deaths worldwide. Falls from height are also a common method of suicide. The aim of this study is to compare the characteristics of the victims, the circumstances of the fall and the severity and distribution of the injuries reported in an autopsy case series of falls from height. This study is a retrospective analysis of consecutive autopsy cases of suicidal and accidental falls from height which were investigated in the Department of Forensic Medicine and Toxicology of the National and Kapodistrian University of Athens during the period 2011-2019. The recorded variables included demographic data of the victim, height of fall, length of hospital stay, toxicological results, the existence and location of injuries and Injury Severity Score (ISS). Victims of suicidal falls were younger (55.53 vs. 62.98, p = 0.001), they fell from higher heights (12.35 vs. 5.18 m, p < 0.001), and they sustained more severe injuries compared with victims of accidental falls (ISS 51.01 vs. 40.88, p < 0.001). Injuries in the thorax, abdomen, pelvis, upper and lower extremities were more frequently observed after a suicidal fall (93.6% vs. 67.3%, 72.1% vs. 21.4%, 72.1% vs. 27.6%, 42.9% vs. 15.3%, 45.7% vs. 13.3%, respectively-p < 0.001), probably due to the higher height of fall. Our study outlines the differences in the profile of the victims and in the severity of injuries caused by falls from height depending on the intention of the victim to fall. However, a distinctive injury pattern in victims of suicidal falls was not demonstrated.

Pre-Existing Medical Conditions: A Systematic Literature Review of a Silent Contributor to Adult Drowning

Medical conditions can increase drowning risk. No prior study has systematically reviewed the published evidence globally regarding medical conditions and drowning risk for adults. MEDLINE (Ovid), PubMed, EMBASE, Scopus, PsycINFO (ProQuest) and SPORTDiscus databases were searched for original research published between 1 January 2005 and 31 October 2021 that reported adult (≥15 years) fatal or non-fatal drowning of all intents and pre-existing medical conditions. Conditions were grouped into the relevant International Classifications of Diseases (ICD) codes. Eighty-three studies were included (85.5% high-income countries; 38.6% East Asia and Pacific region; 75.9% evidence level III-3). Diseases of the nervous system (n = 32 studies; 38.6%), mental and behavioural conditions (n = 31; 37.3%) and diseases of the circulatory system (n = 25; 30.1%) were the most common categories of conditions. Epilepsy was found to increase the relative risk of drowning by 3.8 to 82 times, with suggested preventive approaches regarding supervised bathing or showering. Drowning is a common suicide method for those with schizophrenia, psychotic disorders and dementia. Review findings indicate people with pre-existing medical conditions drown, yet relatively few studies have documented the risk. There is a need for further population-level research to more accurately quantify drowning risk for pre-existing medical conditions in adults, as well as implementing and evaluating population-level attributable risk and prevention strategies.

Innovations in suicide prevention research (INSPIRE): a protocol for a population-based case-control study

BACKGROUND

Suicide deaths have been increasing for the past 20 years in the USA resulting in 45 979 deaths in 2020, a 29% increase since 1999. Lack of data linkage between entities with potential to implement large suicide prevention initiatives (health insurers, health institutions and corrections) is a barrier to developing an integrated framework for suicide prevention.

OBJECTIVES

Data linkage between death records and several large administrative datasets to (1) estimate associations between risk factors and suicide outcomes, (2) develop predictive algorithms and (3) establish long-term data linkage workflow to ensure ongoing suicide surveillance.

METHODS

We will combine six data sources from North Carolina, the 10th most populous state in the USA, from 2006 onward, including death certificate records, violent deaths reporting system, large private health insurance claims data, Medicaid claims data, University of North Carolina electronic health records and data on justice involved individuals released from incarceration. We will determine the incidence of death from suicide, suicide attempts and ideation in the four subpopulations to establish benchmarks. We will use a nested case-control design with incidence density-matched population-based controls to (1) identify short-term and long-term risk factors associated with suicide attempts and mortality and (2) develop machine learning-based predictive algorithms to identify individuals at risk of suicide deaths.

DISCUSSION

We will address gaps from prior studies by establishing an in-depth linked suicide surveillance system integrating multiple large, comprehensive databases that permit establishment of benchmarks, identification of predictors, evaluation of prevention efforts and establishment of long-term surveillance workflow protocols.

Healthcare utilization and psychiatric and physical comorbidities before suicide mortality in patients with methamphetamine use disorder: A nationwide case-control study

BACKGROUND

Since the late 1990s, methamphetamine use has become a considerable public health concern. Despite high suicide rates among methamphetamine users, studies exploring medical utilization and psychiatric and physical comorbidities before suicide are scant. We aim to examine the pattern of medical utilization and distribution of comorbidities shortly before suicide in methamphetamine users who died of suicide and compared these data with those of living methamphetamine users.

METHODS

From Taiwan's National Health Insurance Research Database, we identified the cohort with methamphetamine use disorder (n = 23,248) between January 1, 2001, and December 31, 2005. We identified 5972 deceased patients (of whom 745 died of suicide) by linking each patient with the national mortality database during the study period. By conducting a nested case-control study with risk-set sampling, from the methamphetamine cohort, we selected four age- and sex-matched controls for each patient who died of suicide (cases). We applied conditional logistic regression to investigate differences in medical utilization and physical and psychiatric comorbidities between cases and controls.

RESULTS

Cases had higher medical utilization within 3 months before suicide, particularly in the departments of psychiatry, internal medicine, emergency, and family practice. Cases had higher risks of physical comorbidities, including pneumonia and renal disease, and psychiatric comorbidities, including depressive disorder, sleep disorder, drug-induced mental disorder, schizophrenia, and bipolar disorder.

CONCLUSIONS

The findings of increased medical utilization and the higher risks of physical and psychiatric comorbidities in cases are crucial for developing specific interventions to prevent suicide in this patient population.

Suicide After Contact With Child and Adolescent Mental Health Services-A National Registry Study

BACKGROUND

Research has shown a strong association between suicide and mental disorders, and people in contact with services for mental health and substance use are known to be at high risk of suicide. Still, few studies have previously described suicide among young people in contact with Child and Adolescent Mental Health Services.

AIM

The aim of this study is to examine the prevalence of contact and suicide rates by gender and age groups, and to describe patient demographics and service utilization in secondary mental health services.

METHODS

All young people in contact with Child and Adolescent Mental Health Services in the year prior to death in the period 2008-2018 were identified by linking the Norwegian Cause of Death Registry and the Norwegian Patient Registry. We estimated the prevalence of contact and suicide rates among those with and without contact, by gender and age groups. Characteristics of treatment contact were compared between boys and girls. Variables with significant differences were entered into a multivariate logistic regression model using gender as an outcome.

RESULTS

More girls (39.7%) than boys (11.8%) had contact with Child and Adolescent Mental Health Services in the year prior to death. Among girls, suicide rates per 100,000 patients increased linearly in the age groups 10-13, 14-16, and 17-19 years: 5, 22, and 38 per 100,000 patients, respectively. Among boys, the suicide rate increased sharply from 7 per 100,000 patients in the age group 14-16 years to 40 per 100,000 patients in the 17-19-year-old group. In the age-adjusted multivariate model, boys were 4.07 (1.22-14.44, p = 0.024) times more likely to have terminated contact at the time of death.

CONCLUSION

This study shows gender differences in both suicide rates and service utilization among young people in contact with Child and Adolescent Mental Health Services before suicide, and future studies should focus on identifying the causes of these gender differences in service contact.

Aerobic Exercise Mediates Neural Inefficiency Among Adolescents At Risk for Suicide

This study examined the electroencephalograpy (EEG) coherence and working memory performance effects of a 9-week exercise program on a small group of adolescents at high suicide risk. We randomly assigned 26 adolescents at high suicide risk (based on their scores on the Adolescents Mental Health Inventory- AMHI) into equal sized exercise and no-exercise groups. Before and after the 9-week exercise program, all participants performed the Sternberg working memory task, during which we recorded their EEGs, with electrodes placed at F3, F4, C3, C4, P3, P4, T3, T4, O1, and O2 regions (using the International 10-20 system of EEG electrode placement). We measured working memory performance and inter-hemispheric (F3-F4, C3-C4, T3-T4, P3-P4, O1-O2) and intra-hemispheric (F3-C3, F3-T3, F3-P3, F3-O1, F4-C4, F4-T4, F4-P4, F4-O2) EEG coherence as an index of the participants' underlying neural efficiency. While we found no significant group differences in working memory performances, the exercise group, relative to the no-exercise group, exhibited lower inter- and intra-hemispheric EEG coherence while performing the working memory task. These EEG differences may reflect a mediating effect of aerobic exercise on these participants' neural efficiency.

Long-Acting Injectable Antipsychotics: Analysis of Prescription Patterns and Patient Characteristics in Mental Health from a Spanish Real-World Study

BACKGROUND AND OBJECTIVE

Long-acting injectable antipsychotics (LAIs) have been widely studied in schizophrenia and evidence suggests that they could be also used for the treatment of bipolar and schizoaffective disorders. Nonetheless, there are no studies evaluating their role in other psychiatric disorders. We aimed to evaluate the use of the newest monthly and 3-monthly LAIs-aripiprazole once monthly, paliperidone 1- and 3-monthly (PP1M, PP3M)-against the 2-weekly LAIs, using the following clinical outcomes: (1) the number of hospital re-admissions, (2) the number of documented suicidal behaviors/attempts, and (3) the use of concomitant treatments, including benzodiazepines, oral antipsychotics, and biperiden.

METHODS

A total of 431 patients were included who were treated with the corresponding LAI over at least 12 months and were previously diagnosed with a psychiatric disorder. Statistical analyses were performed using an ANCOVA model, Student's t test, and the Pearson's r test.

RESULTS

Our results showed significantly decreased re-admissions using PP3M versus the bi-weekly LAIs and aripiprazole once monthly, while no significant differences were found in suicidal behavior. Furthermore, we found a significantly lower intake of benzodiazepines in PP1M and PP3M groups versus the bi-weekly and aripiprazole once-monthly groups. In addition, patients treated with PP1M and PP3M used a significantly lower dose of haloperidol equivalents versus the bi-weekly LAIs group. Finally, significantly higher doses of biperiden were used by the bi-weekly LAIs group.

CONCLUSION

In conclusion, paliperidone LAIs reduced hospital re-admissions and, as aripiprazole once monthly, lowered concomitant psychiatric medication versus the bi-weekly LAIs. Further research and analysis of subgroups are needed; however, these findings might be useful for clinicians.

What are the sociodemographic and gender determinants of non-fatal self-harm in older adult users and non-users of antidepressants? A national population-based study

BACKGROUND

Late-life self-harm (SH) is often linked to depression. However, very few studies have explored the role of other factors and their interaction with depression in the occurrence of late-life SH. The objective of this research was to examine sociodemographic and gender factors associated with non-fatal SH, in older adults with and without antidepressant therapy.

METHODS

We used national longitudinal register data from a total cohort of all Swedish residents aged ≥75 years between 2006 and 2014 (N = 1,413,806). Using personal identity numbers, we linked individuals' data from numerous national registers. We identified all those with at least one episode of non-fatal self-harm (regardless of level of intent to die) and matched 50 controls to each case. A nested case-control design was used to investigate sociodemographic factors associated with non-fatal SH in the total cohort and among antidepressant users and non-users. Risk factors were analysed in adjusted conditional logistic regression models for the entire cohort and by gender.

RESULTS

In all, 2242 individuals had at least one episode of a non-fatal SH (980 men and 1262 women). Being unmarried was a risk factor for non-fatal SH in men but not in women. Among users of antidepressants, higher non-fatal SH risk was observed in those born outside the Nordic countries (IRR: 1.44; 95% CI: 1.11-1.86), whereas in AD non-users increased risk was seen in those from Nordic countries other than Sweden (IRR: 1.58; 95% CI: 1.08-2.29). Antidepressant users with higher education had an increased risk of non-fatal SH (IRR: 1.34; 95% CI: 1.12-1.61), in both men and women.

CONCLUSIONS

Foreign country of birth was associated with increased risk for non-fatal SH in older adults with and without AD therapies. Being married was a protective factor for non-fatal SH in men. The complex association between sociodemographic factors and use of antidepressants in the occurrence of self-harm in older men and women indicates the need for multifaceted tailored preventive strategies including healthcare and social services alike.

Belief in suicide prevention myths and its effect on helping: a nationally representative survey of Australian adults

BACKGROUND

Debunking suicide myths, such as 'asking someone about suicide could make them start thinking about it' is a common strategy in suicide prevention education. However, there has been little research investigating the relationship between suicide myths and helping behavior toward people at risk of suicide. We aimed to identify sociodemographic characteristics associated with belief in eight common suicide myths and the associations between beliefs in these myths and helping intentions and behaviors toward a family member or friend in severe distress or at risk of suicide.

METHODS

We conducted a random digit dial (mobile and landline) survey of 3002 Australian adults. We asked respondents about their beliefs in suicide myths, intentions to help a person in severe distress or at risk of suicide presented in a vignette, and helping actions taken toward such a person in the last 12 months. We weighted this data to be representative of the Australian population. Regression analyses were undertaken to determine associations between sociodemographic and exposure characteristics and beliefs in suicide myths, and between beliefs in myths and helping intentions and behaviors.

RESULTS

Being male, speaking a language other than English at home and being over 60 years were associated with the strongest beliefs in suicide myths. The strongest and most consistent associations were found between belief in the myth 'asking someone about suicide could make them start thinking about it', risk assessment intentions and behaviours and intentions to undertaken actions not recommended for suicide prevention.

CONCLUSIONS

Identifying those sociodemographic groups most likely to believe in suicide myths allows targeted intervention for suicide prevention education 'debunking' suicide myths. By isolating those myths that are most commonly believed, and their specific effects on helping intentions and behaviors, suicide prevention educators can target these specific myths to have the most effect on helping behavior. Our findings suggest that targeting the myth 'asking someone about suicide could make them start thinking about it' may have the greatest effects on helping behavior, and that men, those aged over 60 years and those speaking a language other than English at home could most benefit from myth 'debunking'.

Fatal intentional drowning in Australia: A systematic literature review of rates and risk factors

INTRODUCTION

Unintentional drowning deaths are only part of the drowning profile, with little attention being paid to intentional drowning in Australia. Strategies for the prevention of intentional drowning deaths are likely to be different from unintentional. Quality documentation, analysis and dissemination of intentional deaths data is crucial for developing appropriate strategies for prevention.

OBJECTIVE

To conduct a systematic literature review to investigate the mortality rates and risk factors of intentional drowning deaths in Australia.

METHODS

A systematic search guided by PRISMA was performed using Ovid MEDLINE, CINAHL, PsycINFO (ProQuest), Scopus, Google Scholar, and BioMed Central databases to locate relevant original research articles published between 2007 and 2018.

RESULTS

Ten papers reporting the mortality rates and risk factors of intentional drowning deaths in Australia published between 2007 and 2018, with study periods of the included articles spanning from 1907 to 2012, were reviewed. Most studies investigated suicidal drowning deaths in Australia, none reported homicidal drowning deaths. The downward trend of fatal suicide drowning was identified in Australia. The annual rate of intentional drowning between 1994 and 2012 can be inferred from eight studies, ranging from 0.06 to 0.21 for nation-wide mortality rates. The highest annual state-wide mortality rate was identified in the state of Queensland, ranging from 0.02 to 0.11 per 100,000 individuals. Of four studies examining the risk factors of fatal intentional drowning in Australia, being of older age groups, being female, and the presence of substance use were identified as important factors for suicidal drowning deaths. The national-scale proportion of suicide drowning in Australia, ranging from 2% to 3% of all intentional self-harm deaths, was also identified.

CONCLUSION

Limited publications reporting the mortality rates and risk factors of intentional drowning deaths in Australia were identified. Being of older age groups and being female were recognised as factors for suicide drowning deaths, and psychoactive substances were widely identified amongst cases. Future research on improving death reporting systems and the legal framework for medico-legal death investigation, along with the investigation of the risk factors of intentional drowning, are required to inform the planning, implementation, and evaluation of prevention interventions for intentional drowning deaths in Australia.

Suicidal Risk Following Hospital Discharge: A Review

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Evaluate risk of suicide and suicide attempts following psychiatric hospitalization• Assess the relationship between suicide attempts and completed suicides BACKGROUND: Suicidal risks among psychiatric patients appear to be especially high soon after hospitalization. Given the importance of such outcomes, and the lack of recent reviews of post-discharge suicide attempt risks, we evaluated reported findings on the risk of suicide and attempts following psychiatric hospitalization.

METHODS

With systematic, computerized searching, we identified 48 studies (1964-2017) involving 1,700,785 subjects. Follow-up was limited to ≥12 months after discharge from psychiatric hospitalization to avoid inflation of annualized rates due to shorter exposure times.

RESULTS

The overall observed pooled, annualized rate of completed suicide was 241 (confidence interval, 238-243) per 100,000 person-exposure years in 41 studies, and for attempts, 722 (698-746) in 13 studies. In six studies (64,848 subjects) reporting on both suicides and attempts, the ratio of annualized rates for attempts/completed suicides was 8.79 (6.63-12.0). Among all 48 studies, cumulative distribution of suicidal events included 26.4% (25.9-26.9) within the initial month, 40.8% (40.2-41.4) within 3 months, and 73.2% (72.7-73.7) within 12 months of discharge.

CONCLUSIONS

Among patients recently discharged from psychiatric hospitalization, rates of suicide deaths and attempts were far higher than in the general population or even in unselected clinical samples of comparable patients, with a strong inverse association with time post-discharge. Improved monitoring and care of patients discharged from psychiatric hospitalization are needed, ideally with detailed planning and implementation of aftercare prior to discharge.

Efficacy and safety of oral SOCG in treatment of major depressive disorder: A protocol for a phase II, randomized, double-blind, placebo controlled, parallel-groups, dose finding exploratory study

INTRODUCTION

Major depressive disorder (MDD) is a common condition worldwide, and leads to degradation in quality of life and large socioeconomic costs. There has been increasing demand for new therapies with fewer side effects. SOCG (SOCG tablet) is a modified prescription of So-ochim-tang, which is widely used in Traditional Korean Medicine to treat MDD. We aim to evaluate the efficacy of SOCG in treating MDD, and identify the optimum dose.

DESIGN

The protocol we are following is that of a Phase II clinical trial with a randomized, double blinded, placebo controlled, and parallel design. One hundred forty-eight participants will be randomly divided into 4 groups and treated for 8 weeks.

OUTCOME MEASURES

The primary outcome will be the score in the Korean Version of the Hamilton Depression Rating Scale. Scores in the Korean version of the Beck Depression Inventory-II Korean Symptom Check List-95 (KSCL-95), State Trait Anxiety Inventory-Korean version, State- Trait Anger Expression Inventory- Korean version (STAXI-K), Insomnia Severity Index (ISI), and the EuroQol-5 Dimension (EQ-5D) will be considered as secondary outcomes.

DISCUSSION AND CONCLUSIONS

Demonstration of human safety and efficacy of SOCG in the present trial and identification of the appropriate dose will justify a New Drug Application and a phase III clinical trial. Further, we expect that this new antidepressant will be able to increase cure rates, and alleviate the burden of medical expenses.

TRIAL REGISTRATION NUMBER

Clinical Research Information Service, Republic of Korea (KCT0002763).

Suicidality in Borderline Personality Disorder

Borderline personality disorder (BPD) is associated with suicidal behaviors and self-harm. Up to 10% of BPD patients will die by suicide. However, no research data support the effectiveness of suicide prevention in this disorder, and hospitalization has not been shown to be useful. The most evidence-based treatment methods for BPD are specifically designed psychotherapies.

Pattern of intentional drowning mortality: a total population retrospective cohort study in Australia, 2006-2014

BACKGROUND

While a downward trend in unintentional drowning deaths in Australia has been observed, little is known about intentional drowning mortality. Limited information on intentional drowning death impedes the planning, implementation, and evaluation of prevention strategies. This study aims to describe rates of intentional fatal drowning in Australia and compare these to other categories of drowning.

METHODS

Data were sourced from the Australian Bureau of Statistics (ABS) over a 9-year period (2006-2014). Rates and trends of intentional drowning were compared with unintentional, water-transport related and undetermined intent drowning. Rates of intentional drowning deaths across gender, age groups, states/territories, remoteness of residence and First Peoples of Australia were calculated. Relative risk (RR) (95% confidence interval [CI]) was calculated, and chi-square tests of independence were performed (p < 0.05).

RESULTS

The crude mortality rate for intentional drowning deaths in Australia over the study period was 0.23/100000, lower than unintentional drowning (0.89/100000). Males were 1.6 (CI: 1.4-2.0) times more likely than females to intentionally drown, however females made up a significantly larger proportion of intentional drowning deaths (38.2%) compared to unintentional deaths (22.4%) (χ2 = 47.3; df = 1; p < 0.05). A significant linear association between age group and intentional drowning was observed (χ2 = 131.3; p < 0.05), with individuals aged 75 years and over 32.6 times more likely to intentionally drown. Non-Indigenous peoples were 4.1 times more likely to intentionally drown in comparison to First Peoples of Australia. Residents of Inner Regional, Outer Regional, and Major Cities were 4.2 times (CI: 0.6-30.0), 4.1 times (CI: 0.6-29.9), and 4.0 times (CI: 0.6-28.6) more likely to intentionally drown, respectively, compared with residents of Very Remote areas.

CONCLUSIONS

This study adds to the limited evidence currently available about intentional drowning rates and trends in Australia. Being male, of older age groups, non-Indigenous, residing in Inner and Outer Regional areas, and Major Cities were risk factors for intentional drowning deaths. Improving data collection systems and furthering understanding of the risk factors of intentional drowning, as well as the development, implementation, and evaluation of prevention programmes, are required to reduce the risk of intentional drowning death in Australia.

What Does Electroencephalography Coherence Tell Us about Memory Encoding in Adolescents at High Risk of Suicide?

BACKGROUND

Suicide is known to be closely related to depression, which is accompanied by cognitive decline.

OBJECTIVE

This study examined whether memory performance and cortical networking differ between high suicide risk and control groups depending on task difficulty.

METHODS

The participants were 28 high school students consisting of 14 suicide risk and 14 control subjects. Real-time electroencephalography signals were collected during a working memory task. Inter- and intrahemispheric coherences were analyzed.

RESULTS

Higher cortical networking during memory encoding was found in suicide risk adolescents compared to the control group. An increase in task difficulty heightened interhemispheric coherence.

CONCLUSIONS

Higher cortical networking in suicide risk adolescents seems to reflect activation of compensatory mechanisms in an attempt to minimize behavioral decline.

Importance of Messages for a Suicide Prevention Media Campaign

Abstract. Background: A suicide prevention media campaign aimed at family members and friends may be one useful population-level suicide prevention strategy for Australia. However, currently there is limited evidence of what messages would be acceptable and appropriate for inclusion. Aims: This expert consensus study aimed to identify messages that experts with lived experience of suicide risk and suicide prevention professionals believed were most important to include in such a suicide prevention campaign. Method: Using an online survey method, 127 participants with lived experience (lived experience group) and 33 suicide prevention professionals (suicide prevention professionals group) rated 55 statements, drawn from an earlier Delphi study, from very low priority to very high priority for inclusion in a suicide prevention campaign. Results: There was significant agreement within and between the two participant groups on the most highly rated messages for inclusion. The mostly highly rated messages were that family members or friends should ask directly about suicidal thoughts and intentions, listen to responses without judgment, and tell the person at risk that they care and want to help. Limitations: We restricted ratings to just one round and may therefore have limited the level of consensus achieved. Use of a predefined set of suicide prevention messages might also have prevented us from identifying other important messages. Lived experience participants were drawn from one source and this might bias their responses through exposure to common suicide prevention messages that influence their points of view. Conclusion: There is substantial agreement between professionals and people with lived experience on the most important messages to include in a suicide prevention campaign. These most highly rated messages could be adopted in a suicide prevention media campaign.

Reducing relapse and suicide in bipolar disorder: practical clinical approaches to identifying risk, reducing harm and engaging service users in planning and delivery of care – the PARADES (Psychoeducation, Anxiety, Relapse, Advance Directive Evaluation and Suicidality) programme

Background

Bipolar disorder (BD) costs £5.2B annually, largely as a result of incomplete recovery after inadequate treatment.

Objectives

A programme of linked studies to reduce relapse and suicide in BD.

Design

There were five workstreams (WSs): a pragmatic randomised controlled trial (RCT) of group psychoeducation (PEd) versus group peer support (PS) in the maintenance of BD (WS1); development and feasibility RCTs of integrated psychological therapy for anxiety in bipolar disorder (AIBD) and integrated for problematic alcohol use in BD (WS2 and WS3); survey and qualitative investigations of suicide and self-harm in BD (WS4); and survey and qualitative investigation of service users’ (SUs) and psychiatrists’ experience of the Mental Capacity Act 2005 (MCA), with reference to advance planning (WS5).

Setting

Participants were from England; recruitment into RCTs was limited to certain sites [East Midlands and North West (WS1); North West (WS2 and WS3)].

Participants

Aged ≥ 18 years. In WS1–3, participants had their diagnosis of BD confirmed by the Structural Clinical Interview for theDiagnostic and Statistical Manual of Mental Disorders.

Interventions

In WS1, group PEd/PS; in WS3 and WS4, individual psychological therapy for comorbid anxiety and alcohol use, respectively.

Main outcome measures

In WS1, time to relapse of bipolar episode; in WS2 and WS3, feasibility and acceptability of interventions; in WS4, prevalence and determinants of suicide and self-harm; and in WS5, professional training and support of advance planning in MCA, and SU awareness and implementation.

Results

Group PEd and PS could be routinely delivered in the NHS. The estimated median time to first bipolar relapse was 67.1 [95% confidence interval (CI) 37.3 to 90.9] weeks in PEd, compared with 48.0 (95% CI 30.6 to 65.9) weeks in PS. The adjusted hazard ratio was 0.83 (95% CI 0.62 to 1.11; likelihood ratio testp = 0.217). The interaction between the number of previous bipolar episodes (1–7 and 8–19, relative to 20+) and treatment arm was significant (χ2 = 6.80, degrees of freedom = 2;p = 0.034): PEd with one to seven episodes showed the greatest delay in time to episode. A primary economic analysis indicates that PEd is not cost-effective compared with PS. A sensitivity analysis suggests potential cost-effectiveness if decision-makers accept a cost of £37,500 per quality-adjusted life-year. AIBD and motivational interviewing (MI) cognitive–behavioural therapy (CBT) trials were feasible and acceptable in achieving recruitment and retention targets (AIBD:n = 72, 72% retention to follow-up; MI-CBT:n = 44, 75% retention) and in-depth qualitative interviews. There were no significant differences in clinical outcomes for either trial overall. The factors associated with risk of suicide and self-harm (longer duration of illness, large number of periods of inpatient care, and problems establishing diagnosis) could inform improved clinical care and specific interventions. Qualitative interviews suggested that suicide risk had been underestimated, that care needs to be more collaborative and that people need fast access to good-quality care. Despite SUs supporting advance planning and psychiatrists being trained in MCA, the use of MCA planning provisions was low, with confusion over informal and legally binding plans.

Limitations

Inferences for routine clinical practice from WS1 were limited by the absence of a ‘treatment as usual’ group.

Conclusion

The programme has contributed significantly to understanding how to improve outcomes in BD. Group PEd is being implemented in the NHS influenced by SU support.

Future work

Future work is needed to evaluate optimal approaches to psychological treatment of comorbidity in BD. In addition, work in improved risk detection in relation to suicide and self-harm in clinical services and improved training in MCA are indicated.

Trial registration

Current Controlled Trials ISRCTN62761948, ISRCTN84288072 and ISRCTN14774583.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 6. See the NIHR Journals Library website for further project information.

Personality and Suicidal Behavior in Old Age: A Systematic Literature Review

BACKGROUND

Suicide rates generally peak in the second half of life and are particularly high in older men; however, little is known about the contribution of dispositional factors to late-life suicide. Maladaptive personality traits have been strongly implicated in suicide among younger adults, but the extent to which they continue to play a role in late-life suicidal behavior is unclear. We also do not know whether specific personality profiles interact with the stressors of aging to cause suicidal behavior.

METHODS

We sought to synthesize the data on personality pathology in late-life suicidal ideation and behavior via a systematic review using the PubMed, Google Scholar, PsycInfo, Scopus, Ovid, Web of Science, Embase, and Cochrane search engines. The included key words related to three descriptors: "personality," "suicide," and "elderly." Included articles evaluated personality based on the Five-Factor Model (FFM) or ICD/DSM diagnostic criteria in older samples with minimum age cutoffs of 50 years or older. Our original search identified 1,183 articles, of which 31 were retained.

RESULTS

Included studies were heterogeneous in their design and personality measurements. Studies of categorical personality disorders were particularly scarce and suggested a stronger association with late-life suicidal ideation than with death by suicide. Only obsessive-compulsive and avoidant personality traits were associated with death by suicide in old age, but only in studies that did not control for depression. All personality constructs were positively linked to suicidal ideation, except for histrionic personality, which emerged as a negative predictor. Studies employing the FFM also indicated that older adults who died by suicide were less likely to display a maladaptive personality profile than elderly suicide attempters and younger suicide victims, having both lower levels of neuroticism and higher levels of conscientiousness than these comparison groups. Nevertheless, older suicide victims displayed lower levels of openness to experience than younger victims in two samples.

CONCLUSION

Maladaptive personality manifests in milder, subthreshold, and more heterogeneous forms in late-life vs. early-life suicide. An inability to adapt to the changes occurring in late life may help explain the association between suicide in old age and higher conscientiousness as well as obsessive-compulsive and avoidant personality disorders.

An Evaluation of the Implementation of the Australian ATAPS Suicide Prevention Services Initiative

The Access to Allied Psychological Services (ATAPS) Suicide Prevention Services initiative is an Australian Government-funded primary mental healthcare initiative providing free intensive psychological intervention for consumers at moderate risk of self-harm or suicide. Findings from a multi-method evaluation aimed at identifying whether the initiative is being implemented as stipulated within the operational guidelines, barriers and facilitators to implementation, and preliminary outcomes suggest that the Suicide Prevention Services are largely being implemented as stipulated in the Guidelines, but with some exceptions. In particular, service delivery barriers unique to rural and remote areas place limitations on implementation. Uptake of the ATAPS Suicide Prevention Services is high (10,428 consumers were referred to the Suicide Prevention Services between October 2008 and April 2013, and 86% of those attended at least one session), as is acceptance from organizations involved in its implementation.

Self-poisoning suicide deaths in people with bipolar disorder: characterizing a subgroup and identifying treatment patterns

OBJECTIVE

To characterize self-poisoning suicide deaths in BD compared to other suicide decedents.

METHODS

Extracted coroner data from all suicide deaths (n = 3319) in Toronto, Canada from 1998 to 2012. Analyses of demographics, clinical history, recent stressors, and suicide details were conducted in 5 subgroups of suicide decedents: BD self-poisoning, BD other methods, non-BD self-poisoning, non-BD other methods, and unipolar depression self-poisoning. Toxicology results for lethal and present substances were also compared between BD and non-BD self-poisoning subgroups as well as between BD and unipolar depression self-poisoning subgroups.

RESULTS

Among BD suicide decedents, self-poisoning was significantly associated with female sex, past suicide attempts, and comorbid substance abuse. In both the BD and non-BD self-poisoning groups, opioids were the most common class of lethal medication. For both groups, benzodiazepines and antidepressants were the most common medications present at time of death, and in 23% of the BD group, an antidepressant was present without a mood stabilizer or antipsychotic. Only 31% of the BD group had any mood stabilizer present, with carbamazepine being most common. No antidepressant, mood stabilizer, or antipsychotic was present in 15.5% of the BD group. Relative to unipolar depression self-poisoning group, the BD self-poisoning group evidenced higher proportion of previous suicide attempt(s) and psychiatry/ER visits in the previous week.

CONCLUSION

People with BD who die by suicide via self-poisoning comprise a distinct but understudied group. The predominant absence of guideline-concordant pharmacologic care comprises a crucial target for future policy and knowledge translation efforts.

Investigation of a Suicide Ideation Risk Profile in People With Co-occurring Depression and Substance Use Disorder

Disengagement from services is common before suicide, hence identifying factors at treatment presentation that predict future suicidality is important. This article explores risk profiles for suicidal ideation among treatment seekers with depression and substance misuse. Participants completed assessments at baseline and 6 months. Baseline demographics, psychiatric history, and current symptoms were entered into a decision tree to predict suicidal ideation at follow-up. Sixty-three percent of participants at baseline and 43.5% at follow-up reported suicidal ideation. Baseline ideation most salient when psychiatric illness began before adulthood, increasing the rate of follow-up ideation by 16%. Among those without baseline ideation, dysfunctional attitudes were the most important risk factor, increasing rates of suicidal ideation by 35%. These findings provide evidence of factors beyond initial diagnoses that increase the likelihood of suicidal ideation and are worthy of clinical attention. In particular, providing suicide prevention resources to those with high dysfunctional attitudes may be beneficial.

Ketamine for Treatment of Suicidal Ideation and Reduction of Risk for Suicidal Behavior

Ketamine, an NMDA receptor antagonist with efficacy as a rapid anti-depressant, has early evidence for action to reduce suicidal ideation. This review will explore several important questions that arise from these studies. First, how do we measure reductions in suicidal ideation that occur over minutes to hours? Second, are the reductions in suicidal ideation after ketamine treatment solely a result of its rapid anti-depressant effect? Third, is ketamine only effective in reducing suicidal ideation in patients with mood disorders? Fourth, could ketamine's action lead us to a greater understanding of the neurobiology of suicidal processes? Last, do the reductions in depression and suicidal ideation after ketamine treatment translate into decreased risk for suicidal behavior? Our review concludes that ketamine treatment can be seen as a double-edged sword, clinically to help provide treatment for acutely suicidal patients and experimentally to explore the neurobiological nature of suicidal ideation and suicidal behavior.

The postmortem proxy-based interview--future directions

The present study aims to provide an overview of the procedural and methodological challenges that need to be addressed when determining the content and application of postmortem proxy-based interviews and recommendations for meeting these challenges in future death investigations are outlined. Preliminary interview considerations are discussed and a step-by-step procedural algorithm for applying proxy-based interview protocol is supplied. A vulnerability-stress model is used for organizing the conceptualization of risk and protective factors into domains of theoretically similar factors. Techniques to improve data collected about mental disorders and stressful life events-variables addressed in nearly all psychological autopsy studies-are suggested, and the importance of examining certain understudied constructs (e.g., psychological factors, family history, select situational factors, childhood adversity, and protective factors) is emphasized. Given the convergence of findings across postmortem proxy-based interviews, whereby extracting postmortem psychiatric diagnoses is the rule, the next generation of studies must offer a point of departure from univariate models, by studying how and why well known exposures interact to produce suicide. In practical terms, targeting specific sub-populations and high-risk individuals can serve as the basis for constructing and testing different clinical hypothesis, which in turn may yield insights into the underlying etiological heterogeneity of suicide.

Social media and suicide prevention: a systematic review

AIM

Social media platforms are commonly used for the expression of suicidal thoughts and feelings, particularly by young people. Despite this, little is known about the ways in which social media can be used for suicide prevention. The aim of this study was to conduct a systematic review to identify current evidence pertaining to the ways in which social media are currently used as a tool for suicide prevention.

METHODS

Medline, PsycInfo, Embase, CINHAL and the Cochrane Library were searched for articles published between 1991 and April 2014. English language articles with a focus on suicide-related behaviour and social media were included. No exclusion was placed on study design.

RESULTS

Thirty studies were included; 4 described the development of social media sites designed for suicide prevention, 6 examined the potential of social media in terms of its ability to reach or identify people at risk of suicide, 15 examined the ways in which people used social media for suicide prevention-related purposes, and 5 examined the experiences of people who had used social media sites for suicide prevention purposes. No intervention studies were identified.

CONCLUSION

Social media platforms can reach large numbers of otherwise hard-to-engage individuals, may allow others to intervene following an expression of suicidal ideation online, and provide an anonymous, accessible and non-judgmental forum for sharing experiences. Challenges include difficulties controlling user behaviour and accurately assessing risk, issues relating to privacy and confidentiality and the possibility of contagion. Social media appears to hold significant potential for suicide prevention; however, additional research into its safety and efficacy is required.

Can an Internet-based intervention reduce suicidal ideation, depression and hopelessness among secondary school students: results from a pilot study

AIM

Little evidence exists regarding the efficacy of suicide prevention programmes among the youth. This pilot study aimed to test the effects of a specifically designed, eight-module Internet-based programme on suicidal ideation among secondary school students.

METHODS

The study employed a pre-test/post-test design. Outcomes of interest were suicidal ideation, depression and hopelessness. Participants were recruited via the school well-being team, were assessed at baseline and immediately post-intervention. The intervention was delivered weekly at the young persons' school.

RESULTS

Twenty-one students completed all eight modules and a post-intervention assessment, and constitute the observed case sample used for the analysis. Overall levels of suicidal ideation, depressive symptoms and hopelessness decreased significantly over the course of the study.

CONCLUSIONS

This was a small pilot study with no control group. However, significant reductions were seen in suicidal ideation, depressive symptoms and hopelessness, indicating that Internet-based interventions may hold promise when it comes to reducing suicide risk among youth. Further investigation is warranted.

Suicide in late-life depression with and without comorbid anxiety disorders

OBJECTIVE

Comorbid anxiety in depression increases the risk of suicidal ideation and behavior, although data on death by suicide are scarce. We compared characteristics of depressed elderly patients with and without anxiety disorders who died by suicide.

METHODS

From a 16-year clinical survey of all suicides in the UK (n = 25,128), we identified 1909 cases aged ≥60 years with a primary diagnosis of depression and no comorbidity other than anxiety disorders. Clinical characteristics of cases with (n = 333, 17.4%) and without (n = 1576) comorbid anxiety disorders were compared by logistic regression adjusted for demographic differences.

RESULTS

Compared with cases without comorbid anxiety disorders, cases with comorbid anxiety disorders were more likely to have a duration of illness over 1 year (OR(1-5 years)  = 1.4 [95% CI: 1.0-1.9], p = 0.061; OR(≥5 years)  = 1.4 [95% CI: 1.6-2.8], p < 0.001), were more frequently prescribed psychotropic drugs other than antidepressants, lithium, and antipsychotics (OR = 2.1 [95% CI: 1.6-2.7], p < 0.001) and were more distressed during their last contact with services (OR = 1.3 [95% CI: 1.0-1.7], p = 0.037). In contrast, clinicians estimated the immediate and long-term suicidal risks lower in those with comorbid anxiety disorders (OR = 0.6 [95% CI: 0.3-0.9], p = 0.011 and OR = 0.7 [95% CI: 0.6-1.0], p = 0.028, respectively).

CONCLUSION

Among depressed suicide cases, a comorbid anxiety disorder was identified in one out of six cases and associated with a higher prevalence of several suicide risk factors. This is important, as the detection of anxiety disorders comorbid to depression seems rather low and even when recognized clinicians rated such individuals as at low suicide risk.

Excess cause-specific mortality in in-patient-treated individuals with personality disorder: 25-year nationwide population-based study

BACKGROUND

Although personality disorders are associated with increased overall mortality, less is known about cause of death and personality type.

AIMS

To determine causes of mortality in ICD personality disorders.

METHOD

Based on data from Swedish nationwide registers, individuals admitted to hospital with a primary diagnosis of personality disorder between 1987 and 2011 were followed with respect to mortality until 31 December 2011. Standardised mortality ratios (SMRs) with 95% confidence intervals and underlying causes of death were calculated.

RESULTS

All-cause SMRs were increased, overall and in all clusters, for natural as well as unnatural causes of death. The overall SMR was 6.1 in women and 5.0 in men, as high as previously reported for anorexia nervosa, with higher rates in cluster B and mixed/other personality disorders. The SMR for suicide was 34.5 in women and 16.0 in men for cluster B disorders. Somatic and psychiatric comorbidity increased SMRs.

CONCLUSIONS

The SMR was substantially increased for all personality disorder clusters. Thus, there was an increased premature mortality risk for all personality disorders, irrespective of category.

Epidemiology, neurobiology and pharmacological interventions related to suicide deaths and suicide attempts in bipolar disorder: Part I of a report of the International Society for Bipolar Disorders Task Force on Suicide in Bipolar Disorder

OBJECTIVES

Bipolar disorder is associated with elevated risk of suicide attempts and deaths. Key aims of the International Society for Bipolar Disorders Task Force on Suicide included examining the extant literature on epidemiology, neurobiology and pharmacotherapy related to suicide attempts and deaths in bipolar disorder.

METHODS

Systematic review of studies from 1 January 1980 to 30 May 2014 examining suicide attempts or deaths in bipolar disorder, with a specific focus on the incidence and characterization of suicide attempts and deaths, genetic and non-genetic biological studies and pharmacotherapy studies specific to bipolar disorder. We conducted pooled, weighted analyses of suicide rates.

RESULTS

The pooled suicide rate in bipolar disorder is 164 per 100,000 person-years (95% confidence interval = [5, 324]). Sex-specific data on suicide rates identified a 1.7:1 ratio in men compared to women. People with bipolar disorder account for 3.4-14% of all suicide deaths, with self-poisoning and hanging being the most common methods. Epidemiological studies report that 23-26% of people with bipolar disorder attempt suicide, with higher rates in clinical samples. There are numerous genetic associations with suicide attempts and deaths in bipolar disorder, but few replication studies. Data on treatment with lithium or anticonvulsants are strongly suggestive for prevention of suicide attempts and deaths, but additional data are required before relative anti-suicide effects can be confirmed. There were limited data on potential anti-suicide effects of treatment with antipsychotics or antidepressants.

CONCLUSION

This analysis identified a lower estimated suicide rate in bipolar disorder than what was previously published. Understanding the overall risk of suicide deaths and attempts, and the most common methods, are important building blocks to greater awareness and improved interventions for suicide prevention in bipolar disorder. Replication of genetic findings and stronger prospective data on treatment options are required before more decisive conclusions can be made regarding the neurobiology and specific treatment of suicide risk in bipolar disorder.

Suicide in patients suffering from late-life anxiety disorders; a comparison with younger patients

BACKGROUND

Anxiety disorders are assumed to increase suicide risk, although confounding by comorbid psychiatric disorders may be one explanation. This study describes the characteristics of older patients with an anxiety disorder who died by suicide in comparison to younger patients.

METHOD

A 15-year national clinical survey of all suicides in the UK (n = 25,128). Among the 4,481 older patients who died by suicide (≥ 60 years), 209 (4.7%) suffered from a primary anxiety disorder, and 533 (11.9%) from a comorbid anxiety disorder. Characteristics of older (n = 209) and younger (n = 773) patients with a primary anxiety disorder were compared by logistic regression adjusted for sex and living arrangement.

RESULTS

Compared to younger patients, older patients with a primary anxiety disorder were more often males and more often lived alone. Although 60% of older patients had a history of psychiatric admissions and 50% of deliberate self-harm, a history of self-harm, violence, and substance misuse was significantly less frequent compared to younger patients, whereas physical health problems and comorbid depressive illness were more common. Older patients were prescribed significantly more psychotropic drugs and received less psychotherapy compared to younger patients.

CONCLUSION

Anxiety disorders are involved in one of every six older patients who died by suicide. Characteristics among patients who died by suicide show severe psychopathology, with a more prominent role for physical decline and social isolation compared to their younger counterparts. Moreover, treatment was less optimal in the elderly, suggesting ageism. These results shed light on the phenomenon of suicide in late-life anxiety disorder and suggest areas where prevention efforts might be focused.

Her life ended jumping from the fifth floor: the importance of scene investigation and the need for restrictive means to prevent jumping suicide

In January 2014, a dead woman was found lying near the back entrance of a building belonging to Bari University Hospital compound. After the external examination and identification of the corpse, through history, circumstances, and postmortem findings, it was supposed that the woman probably committed suicide, by jumping from the nearby building. But only after additional investigation of the scene was it possible to locate the window through which the victim had jumped, by assessing the height from which she leapt. We underline the importance of the examination of the scene. It has to be done with circumspection, even in cases that could be considered routine, paying attention to details, not excluding things that, at first glance, seem to be unnecessary. Inspection needs time, patience and accuracy, knowledge, competence, and intuition and must be the result of an efficient team action. Furthermore the occurrence of suicides, particularly jumping from a height, among immediate postdischarge psychiatric patients, stresses the importance of immediate follow-up treatment and alternative preventive strategies, considering, of course, the feasibility of structural means.

Constructing the Suicide Risk Index (SRI): does it work in predicting suicidal behavior in young adults mediated by proximal factors?

Suicide is a key concern among young adults. The aim of the study was to (1) construct a suicide risk index (SRI) based on demographic, situational, and behavioral factors known to be linked to suicidal behavior and (2) investigate whether the association between the SRI and suicidal behavior was mediated by proximal processes (personal factors, coping strategies, and emotional states). Participants consisted of 7,558 individuals aged 17-25 years (M = 20.35, SD = 1.91). Nearly 22% (n = 1,542) reported self-harm and 7% (n = 499) had attempted suicide. Mediation analysis revealed both a direct effect (ß = .299, 95% CI = [.281, .317], p < .001), and a mediated effect (ß = .204, 95% CI = [.186, .222], p < .001), between the risk index and suicidal behavior. The strongest mediators were levels of self-esteem, depression, and avoidant coping. Interventions to increase self-esteem, reduce depression, and encourage adaptive coping strategies may prevent suicidal behavior in young people.

Suicide in bipolar disorder: characteristics and subgroups

OBJECTIVES

The development of more sophisticated models for understanding suicide among people with bipolar disorder (BD) requires diagnosis-specific data. The present study aimed to elucidate differences between people who die by suicide with and without BD, and to identify subgroups within those with BD.

METHODS

Data on all suicide deaths in the city of Toronto from 1998 to 2010 were extracted from the Office of the Chief Coroner of Ontario, including demographics, clinical variables, recent stressors, and details of the suicide. Comparisons of person- and suicide-specific variables between suicide deaths among those with BD (n = 170) and those without (n = 2,716) were conducted, and a cluster analysis was performed among the BD suicide group only.

RESULTS

Those in the BD suicide group were more likely than those in the non-BD suicide group to be female [odds ratio (OR) = 1.75, 95% confidence interval (CI): 1.27-2.42; p = 0.001], to have made a past suicide attempt (OR = 2.01, 95% CI: 1.45-2.80; p < 0.0001), and to have had recent contact with psychiatric or emergency services (OR = 1.59, 95% CI: 1.00-2.52; p = 0.049). Five clusters were identified within the BD group, with differences between clusters in age; sex; marital status; living circumstances; past suicide attempts; substance abuse; interpersonal, employment/financial, and legal/police stressors; and rates of death by fall/jump or self-poisoning.

CONCLUSIONS

The present findings identified differences between BD and non-BD suicide groups, providing support to the utilization of an illness-specific approach to better understanding suicide in BD. Subgroups of BD suicide deaths, if replicated, should also be incorporated into the design and analysis of future studies of suicide in BD.

Psychiatric and psycho-social characteristics of suicide completers: a comprehensive evaluation of psychiatric case records and postmortem findings

Objectives

To explore the demographic, psychosocial and clinical characteristics of individuals known to the mental health services, who died by probable suicide in the West of Ireland.

Methods

Postmortem reports between January 2006 and May 2012 detailed 153 individuals who died by probable suicide, 58 of whom attended the mental health services. Relevant socio-demographic and clinical data was extracted from individuals’ lifetime case notes.

Results

Recurrent depressive disorder (44%) was the most common diagnosis and hanging the most common method of death (58%). Of individuals who died by hanging, 79% previously attempted suicide by the same method. For individuals with a documented history of depression, only 32% had antidepressants detected in their toxicology reports. Similarly, only one individual (20%) with schizophrenia had antipsychotics detected in their toxicology report.

Conclusions

Individuals who died by probable suicide, most commonly died by hanging and drowning; with previous attempts of hanging particularly prevalent in the group who subsequently died by hanging. At the time of death, less than one-third of individuals according to toxicology reports were taking the medication that was last prescribed to them by the mental health services suggesting a high rate of treatment non-concordance in individuals who died by probable suicide.

Characteristics of attempted suicide by patients with schizophrenia compared with those with mood disorders: a case-controlled study in northern Japan

Recent reports suggest a lifetime suicide risk for schizophrenia patients of approximately 5%. This figure is significantly higher than the general population suicide risk consequently, detection of those at risk is clinically important. This study was undertaken to define the characteristics of suicide attempts by schizophrenia patients compared with attempts by patients with mood disorders. All patients were diagnosed using the ICD-10 criteria. The study population comprised 65 patients with F2 disorders (schizophrenia, schizotypal and delusional disorders), i.e., “the F2 group”, and 94 patients with F3 disorders (mood disorders), i.e., “the F3 group”, who presented in the clinical setting of consultation-liaison psychiatry. The F2 group had a significantly younger mean age and significantly higher ratios of ‘past/present psychiatric treatment’ and ‘more than 3 months interruption of psychiatric treatment’. In contrast, the ratios of ‘physical disorder comorbidity’, ‘alcohol intake at suicide attempt’ and ‘suicide note left behind’ were significantly higher in the F3 group. The F2 group attempted suicide by significantly more serious methods. Furthermore, ‘hallucination-delusion’ was the most prevalent motive in the F2 group and was the only factor that showed a significant association with the seriousness of the method of suicide attempt (OR = 3.36, 95% CI: 1.05–11.33).

Cardiovascular fitness in early adulthood and future suicidal behaviour in men followed for up to 42 years

BACKGROUND

Cardiovascular fitness influences many aspects of brain function. However, the relationship between cardiovascular fitness and suicidal behaviour is unknown. Therefore, we aimed to determine whether cardiovascular fitness at age 18 years is associated with future risk of suicide attempt/death.

METHOD

We performed a population-based Swedish longitudinal cohort study of male conscripts with no previous or ongoing mental illness (n = 1,136,527). The conscription examination, which took place during 1968-2005, included the cycle ergonometric test and tests of cognitive performance. Future risk of suicide attempt/death over a 5- to 42-year follow-up period was calculated with Cox proportional hazards models controlling for several confounders including familial factors.

RESULTS

At least one suicide attempt was recorded for 12,563 men. Death by suicide without a prior attempt was recorded in 4814 additional individuals. In fully adjusted models low cardiovascular fitness was associated with increased risk for future attempt/death by suicide [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.64-1.94]. The HR changed only marginally after exclusion of persons who received in-patient care for depression (HR 1.76, 95% CI 1.61-1.94). Poor performance on both the cardiovascular fitness and cognitive tests was associated with a fivefold increased risk of suicide attempt or suicide death (HR 5.46, 95% CI 4.78-6.24).

CONCLUSIONS

Lower cardiovascular fitness at age 18 years was, after adjustment for a number of potential confounders, associated with an increased risk of attempt/death by suicide in adulthood. It remains to be clarified whether interventions designed to improve fitness in teens can influence the risk of suicidal behaviour later in life.

Gender and racial differences for suicide attempters and ideators in a high-risk community corrections population

BACKGROUND

Community corrections populations are a high-risk group who carry multiple suicide risk factors.

AIMS

To identify factors correlated with historical suicide attempts and ideation among African-American men, African-American women, White men, and White women in a community corrections population.

METHOD

Self-report data from 18,753 enrollees in community corrections were analyzed. Multinomial logistic regression analyses were conducted to determine associations between historical suicidal ideation and attempts among the four demographic groups.

RESULTS

Participants with historical suicide attempts tended to be younger, White, female, be taking psychotropic medication, have a history of physical or sexual abuse, and meet criteria for dependence on alcohol, amphetamines, cocaine, opioids, or sedatives. Five variables were commonly associated with suicide attempts for all four race/gender groups: younger age, being on disability or retirement, taking psychotropic medication, history of sexual or physical abuse, and cocaine dependence. Other demographic variables had race or gender specificities as risk factors for suicide attempts.

CONCLUSIONS

Participants had high rates of historical suicide attempts with unique correlates differentiating attempters from ideators among different racial and gender groups. Cocaine dependence was universal predictor of suicide attempts, while other substance dependencies show specific racial and gender profiles associated with suicide attempts.

Suicide in bipolar disorder in a national English sample, 1996-2009: frequency, trends and characteristics

BACKGROUND

Bipolar disorder (BD) has been reported to be associated with high risk of suicide. We aimed to investigate the frequency and characteristics of suicide in people with BD in a national sample.

METHOD

Suicide in BD in England from 1996 to 2009 was explored using descriptive statistics on data collected by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI). Suicide cases with a primary diagnosis of BD were compared to suicide cases with any other primary diagnosis.

RESULTS

During the study period 1489 individuals with BD died by suicide, an average of 116 cases/year. Compared to other primary diagnosis suicides, those with BD were more likely to be female, more than 5 years post-diagnosis, current/recent in-patients, to have more than five in-patient admissions, and to have depressive symptoms. In BD suicides the most common co-morbid diagnoses were personality disorder and alcohol dependence. Approximately 40% were not prescribed mood stabilizers at the time of death. More than 60% of BD suicides were in contact with services the week prior to suicide but were assessed as low risk.

CONCLUSIONS

Given the high rate of suicide in BD and the low estimates of risk, it is important that health professionals can accurately identify patients most likely to experience poor outcomes. Factors such as alcohol dependence/misuse, personality disorder, depressive illness and current/recent in-patient admission could characterize a high-risk group. Future studies need to operationalize clinically useful indicators of suicide risk in BD.

Enhancing health-care workers' understanding and thinking about people living with co-occurring mental health and substance use issues through consumer-led training

BACKGROUND

Stigma and judgemental assumptions by health workers have been identified as key barriers to accessing health care for people living with co-occurring mental health and substance use issues (dual diagnosis).

OBJECTIVE

To evaluate the effectiveness of consumer-led training by people with dual diagnosis in improving the knowledge, understanding and role adequacy of community health staff to work with this consumer group.

METHODS

A controlled before-and-after study design with four waves of quantitative data collection was used. Qualitative data were collected to explore participants' views about training. Participants were staff from two community health services from Victoria, Australia. Recruitment occurred across various work areas: reception, oral health, allied health, counselling and health promotion. At baseline, all participants attended a 4-h clinician-led training session. The intervention consisted of a 3-h consumer-led training session, developed and delivered by seven individuals living with dual diagnosis. Outcome measures included understanding of dual diagnosis, participants' feelings of role adequacy and role legitimacy, personal views, and training outcomes and relevance.

RESULTS

Consumer-led training was associated with a significant increase in understanding. The combination of clinician-led and consumer-led training was associated with a positive change in role adequacy.

CONCLUSIONS

Consumer-led training is a promising approach to enhance primary health-care workers' understanding of the issues faced by dual-diagnosis consumers, with such positive effects persisting over time. Used alongside other organizational capacity building strategies, consumer-led training has the potential to help address stigma and judgemental attitudes by health workers and improve access to services for this consumer group.

Comparison of the clinical features of suicide attempters by jumping from a height and those by self-stabbing in Japan

BACKGROUND

A history of psychiatric disorders is a high risk for suicide. The present study compared the clinical features of psychiatric patients in Japan who attempted suicide by jumping from a height and those who attempted suicide by self-stabbing.

METHODS

We compared two groups of suicide attempters who were hospitalized for both physical and psychiatric treatment (n=202). We compared the psychiatric diagnoses and clinical features between those who attempted suicide by jumping from a height (N=147) and those who did so by self-stabbing (N=55).

RESULTS

The self-stabbing group (mean age 52.3 years) was significantly older compared to the jumping group (mean age 37.9 years). A significantly higher proportion of females were found in the jumping group. Jumping from a height was significantly associated with schizophrenia spectrum disorders, whereas self-stabbing was significantly associated with mood disorders.

LIMITATIONS

The results were drawn from data from a single hospital in a large urban city, and the study population did not include subjects who completed their suicide attempts.

CONCLUSIONS

Our findings show that differences in suicide methods (here, between jumping from a height and self-stabbing) may be related to suicide attempters' psychiatric diagnosis, gender and age. It is thus important to obtain a more detailed background information about a patient's suicide attempt and to create suicide prevention plans in accord with individuals' psychiatric diagnosis, age and gender, especially among those who have attempted suicide by jumping from a height or self-stabbing.

Association of suicide rates, gun ownership, conservatism and individual suicide risk

OBJECTIVES

The purpose of the study was to examine the association of suicide rates, firearm ownership, political conservatism, religious integration at the state level, and individual suicide risk. Social structural and social learning and social integration theories were theoretical frameworks employed. It was hypothesized that higher suicide rates, higher state firearm availability, and state conservatism elevate individual suicide risk.

METHOD

Data were pooled from the Multiple Cause of Death Files. Multilevel logistic regression models were fitted to all deaths occurring in 2000 through 2004 by suicide.

RESULTS

The state suicide rate significantly elevated individual suicide risk (AOR = 1.042, CI = 1.037, 1.046). Firearm availability at the state level was associated with significantly higher odds of individual suicide (AOR = 1.004, CI = 1.003, 1.006). State political conservatism elevated the odds of individual suicides (AOR = 1.005, CI = 1.003, 1.007), while church membership at the state level reduced individual odds of suicide (AOR = 0.995, CI = 0.993, 0.996). The results held even after controlling for socioeconomic and demographic variables at the individual level.

CONCLUSION

It was concluded that the observed association between individual suicide odds and national suicide rates, and firearm ownership cannot be discounted. Future research ought to focus on integrating individual level data and contextual variables when testing for the impact of firearm ownership. Support was found for social learning and social integration theories.

Mortality of 403 patients with mood disorders 48 to 52 years after their psychiatric hospitalisation

The purpose is to analyse differences in mortality among patients with major depressive disorders (MDD), bipolar-II (BP-II), bipolar-I (BP-I) disorders and mania with or without minor depressive disorders and to identify risk factors of mortality. The sample represents all admissions for depression or mania over 5 years (1959-1963) to the Psychiatric Hospital of Zurich University, serving a large area. 403 patients were included and followed up every 5 years until 1985; thereafter, mortality data were collected repeatedly until 2009 when 352 (87 %) patients had died. Standardised mortality ratios (SMRs) were computed and survival analyses applied. With the exception of BP-II disorder, the three other diagnostic groups showed elevated SMRs. The group with mania had the highest SMR for cardiovascular deaths and the group with MDD the highest for deaths by suicide. Mortality was also high among patients with late-onset MDD. Across the diagnostic spectrum, we found differences in risk factors for mortality, such as a family history of suicides and personality type: more anxious patients with MDD lived longer, and among patients with BP disorders, more tense (aggressive) types had shorter lives. Long-term medication had a protective effect against mortality in patients with MDD during years 1-9 and in patients with BP disorders during years 1-19 after admission. We found marked differences in causes of death and risk factors between subgroups of mood disorders. For the purpose of further research, it would be recommendable to distinguish pure mania from bipolar disorders.

Age and gender differences in medical care utilization prior to suicide

BACKGROUND

Analysis of temporal patterns of medical care utilization prior to suicide may aid in developing suicide prevention programs. The aim of this study was to investigate age and gender differences in temporal patterns of medical care utilization during 1 year prior to suicide.

METHODS

Medical care utilization data of all suicide completers in the Republic of Korea whose death occurred in 2004 (7903 men and 3620 women) was used. Differences among the quarters in medical expenditures and number of medical care visits were analyzed using a repeated measures analysis. Total medical expenditures were compared to those of age- and gender-matched controls by multiple logistic regression analysis.

RESULTS

Among suicides, 84% (81% in men, 91% in women) contacted medical care in the year prior to suicide. In 10-39 year-old women, the number of medical care visits for gastrointestinal disease increased significantly during the final 3 months prior to suicide. All suicide completers showed that the number of medical care visits for psychiatric disorders increased significantly during the final 3 months with the exception of 10-19 year age group. Total medical expenditures during the year prior to suicide were elevated significantly and associated significantly with suicide risk (OR, 1.20; 95% CI, 1.19-1.21).

LIMITATIONS

Inaccuracies in the underlying disease and death statistics data may have led to misclassification bias.

CONCLUSIONS

Medical care utilization increased as the date of suicide approached. There are age and gender differences in medical care utilization in the year prior to suicide.

Characteristics of suicide attempts in patients diagnosed with schizophrenia in comparison with depression: a study of emergency room visit cases in Japan

We worked on characterizing suicide attempts in patients with schizophrenia in comparison with mood disorders. This study population comprised 260 patients with F2 disorders (ICD-10), i.e., "schizophrenic group" and 705 patients with F3 disorders, i.e., "depressive group" who presented at the psychiatric emergency department of our hospital for 8 years. They were compared in three age groups: young (≤24 years), middle-aged (25-44 years), and elderly (≥45 years). Multivariate logistic regression analysis identified factors associated with the seriousness of the suicide attempt method. The schizophrenic group (≥25 years) had a younger mean age and higher prevalences of "within-1-year suicide attempts" and "past suicide attempts" than the depressive group. The Schizophrenic group tended to use serious methods, such as "jumping from high places," "throwing oneself in front of an oncoming train," and "burning oneself," in their suicide attempts, with "hallucination-delusion" accounting for an overwhelmingly large percentage of suicide attempt motives, irrespective of the age group. In the elderly group, the ratio of "no-housemate" patients was high. In all age groups, jobless individuals were prevalent, and the schizophrenic group had lower LCU (Life Change Unit) scores than did the depressive group. The middle-aged cases of schizophrenic group had higher BPRS (Brief Psychiatric Rating Scale) scores and lower GAS (Global Assessment Scale) scores. Regarding factors influencing the seriousness of the methods, a history of within-1-year suicide attempts increased the method seriousness in the schizophrenic group. Years of education correlated with the method seriousness in the schizophrenic group. Low scores of overall health on the GAS increased the method seriousness in both groups.