Survival analysis of suicide risk after attempted suicide

Whole-brain structural and functional neuroimaging of individuals who attempted suicide and people who did not: A systematic review and exploratory coordinate-based meta-analysis

Suicide is the cause of death of approximately 800,000 people a year. Despite the relevance of this behaviour, risk assessment tools rely on clinician experience and subjective ratings. Given that previous suicide attempts are the single strongest predictors of future attempts, we designed a systematic review and coordinate-based meta-analysis to demonstrate whether neuroimaging features can help distinguish individuals who attempted suicide from subjects who did not. Out of 5,659 publications from PubMed, Scopus, and Web of Science, we summarised 102 experiments and meta-analysed 23 of them. A cluster in the right superior temporal gyrus, a region implicated in emotional processing, might be functionally hyperactive in individuals who attempted suicide. No statistically significant differences in brain morphometry were evidenced. Furthermore, we used JuSpace to show that this cluster is enriched in 5-HT1A heteroreceptors in the general population. This exploratory meta-analysis provides a putative neural substrate linked to previous suicide attempts. Heterogeneity in the analytical techniques and weak or absent power analysis of the studies included in this review currently limit the applicability of the findings, the replication of which should be prioritised.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

DESIGN

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

SETTING

Medical emergency inpatient unit in the south of Sweden.

PARTICIPANTS

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

OUTCOME MEASURE

Suicide.

RESULTS

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

CONCLUSIONS

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

The relationship between childhood trauma and suicidal ideation, the mediating role of identification of all humanity, indifference and loneliness

BACKGROUND

Research shows that childhood trauma has a detrimental impact on an individual's health, including suicidal ideation. In order to intervene with suicidal ideation, it is necessary to study the impact of childhood trauma on emotional and social functioning. This study explored the relationship between childhood trauma and suicidal ideation from the perspectives of indifference, identification with all humanity, and loneliness.

METHODS

A total number of 8,452 college students completed the study. Childhood trauma was measured by the short form of Childhood Trauma Questionnaire (CTQ-SF). The Identification With All Humanity scale (IWAH) was used to measure individual's ability to identify or not identify with humanity. For indifference, we used the Inventory of Callous-Unemotional Traits, and Loneliness was assessed by the Loneliness Scale. The relationship of indifference, identification with all humanity, and loneliness were explored to further understand the relationship between childhood trauma and suicidal ideation's correlations, regression analysis, and path analysis were employed for data analysis.

RESULTS

Childhood trauma was positively correlated with indifference, loneliness, and suicidal ideation, and negatively correlated with identification with all humanity (r = -0.140∼0.335, p < .001). Suicidal ideation was positively correlated with indifference and loneliness, and negatively correlated with identification with all humanity (r = -0.082∼0.260, p < .001). The results indicated that childhood trauma leads to indifference, which increases loneliness, and results in suicidal ideation (β = 0.073∼0.335, p < 0.001). If an individual with childhood trauma were to gain more recognition from social groups, this would reduce their loneliness and suicidal ideation (β = -0.125∼0.228, p < 0.001).

DISCUSSION

Individuals with childhood trauma were more likely to display apathy, including non-emotional behavior. This makes individuals lonelier and may increase suicidal ideation. However, if individuals are further recognized by others and social groups within their environment it is possible to intervene in this process.

The effects of alexithymia, experiential avoidance, and childhood sexual abuse on non-suicidal self-injury and suicidal ideation among Chinese college students with a history of childhood sexual abuse

BACKGROUND

Although previous studies have shown that childhood sexual abuse (CSA) experiences might be related to suicide-related thoughts and behaviours in later life, the effects of alexithymia and experiential avoidance (EA) on this relationship have remained unclear. The present study aimed to expand prior findings among Chinese college students with a history of CSA in order to further test the effects of alexithymia on the relationship between CSA and non-suicidal self-injury (NSSI) and suicidal ideation (SI), and its indirect effects on NSSI and SI through EA.

METHODS

The Childhood Sexual Abuse Questionnaire, the Toronto Alexithymia Scale-20, the Acceptance and Action Questionnaire-II, the Non-Suicidal Self-Injury Questionnaire, and the Symptom Checklist were completed by 6,834 college students (3,829 female).

RESULTS

Overall, 1404 (20.76%) Chinese college students reported experiences of CSA; students with CSA experiences reported higher rates of SI and NSSI than those without CSA (12.82% vs. 4.50%, 35.11% vs. 20.82%). CSA, alexithymia, and EA were positively related to NSSI and SI. The effect of alexithymia on the relationship between CSA and NSSI and SI were significant. The effects of EA on the relationship between alexithymia and NSSI and SI were significant, too.

LIMITATIONS

The major limitations of this study are its cross-sectional design and the use of self-report scales, especially retrospective self-reports (e.g., the Childhood Sexual Abuse Questionnaire).

CONCLUSIONS

This study cast light on the effects of alexithymia, EA, and CSA on NSSI and SI in Chinese college students with a history of CSA. These findings can contribute to the prevention and treatment of suicide-related thoughts and behaviours.

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

OBJECTIVES

The overall aim of this study is to gain greater knowledge about the risk of suicide among suicide attempters in a very long-term perspective. Specifically, to investigate possible differences in clinical risk factors at short (≤5 years) versus long term (>5 years), with the hypothesis that risk factors differ in the shorter and longer perspective.

DESIGN

Prospective study with register-based follow-up for 21-32 years.

SETTING

Medical emergency inpatient unit in the south of Sweden.

PARTICIPANTS

1044 individuals assessed by psychiatric consultation when admitted to medical inpatient care for attempted suicide during 1987-1998.

OUTCOME MEASURES

Suicide and all-cause mortality.

RESULTS

At follow-up, 37.6% of the participants had died, 7.2% by suicide and 53% of these within 5 years of the suicide attempt. A diagnosis of psychosis at baseline represented the risk factor with the highest HR at long-term follow-up, that is, >5 years, followed by major depression and a history of attempted suicide before the index attempt. The severity of a suicide attempt as measured by SIS (Suicide Intent Scale) showed a non-proportional association with the hazard for suicide over time and was a relevant risk factor for suicide only within the first 5 years after an attempted suicide.

CONCLUSIONS

The risk of suicide after a suicide attempt persists for up to 32 years after the index attempt. A baseline diagnosis of psychosis or major depression or earlier suicide attempts continued to be relevant risk factors in the very long term. The SIS score is a better predictor of suicide risk at short term, that is, within 5 years than at long term. This should be considered in the assessment of suicide risk and the implementation of care for these individuals.

Prospective prediction of suicide attempts in community adolescents and young adults, using regression methods and machine learning

BACKGROUND

The use of machine learning (ML) algorithms to study suicidality has recently been recommended. Our aim was to explore whether ML approaches have the potential to improve the prediction of suicide attempt (SA) risk. Using the epidemiological multiwave prospective-longitudinal Early Developmental Stages of Psychopathology (EDSP) data set, we compared four algorithms-logistic regression, lasso, ridge, and random forest-in predicting a future SA in a community sample of adolescents and young adults.

METHODS

The EDSP Study prospectively assessed, over the course of 10 years, adolescents and young adults aged 14-24 years at baseline. Of 3021 subjects, 2797 were eligible for prospective analyses because they participated in at least one of the three follow-up assessments. Sixteen baseline predictors, all selected a priori from the literature, were used to predict follow-up SAs. Model performance was assessed using repeated nested 10-fold cross-validation. As the main measure of predictive performance we used the area under the curve (AUC).

RESULTS

The mean AUCs of the four predictive models, logistic regression, lasso, ridge, and random forest, were 0.828, 0.826, 0.829, and 0.824, respectively.

CONCLUSIONS

Based on our comparison, each algorithm performed equally well in distinguishing between a future SA case and a non-SA case in community adolescents and young adults. When choosing an algorithm, different considerations, however, such as ease of implementation, might in some instances lead to one algorithm being prioritized over another. Further research and replication studies are required in this regard.

Interactions of immediate and long-term action regulation in the course and complications of bipolar disorder

Immediate and long-term mechanisms interact in the regulation of action. We will examine neurobiology and practical clinical consequences of these interactions. Long-term regulation of immediate behavioural control is based on analogous responses to highly rewarding or stressful stimuli: (i) impulsivity is a failure of the balance between activation and inhibition in the immediate regulation of action. (ii) Sensitization is a persistently exaggerated behavioural or physiological response to highly salient stimuli, such as addictive stimuli or inescapable stress. Sensitization can generalize across classes of stimuli. (iii) Impulsivity, possibly related to poor modulation of catecholaminergic and glutamatergic functions, may facilitate development of long-term sensitized responses to stressful or addictive stimuli. In turn, impulsivity is prominent in sensitized behaviour. (iv) While impulsivity and sensitization are general components of behaviour, their interactions are prominent in the course of bipolar disorder, emphasizing roles of substance-use, recurrent course and stressors. (v) Suicide is a complex and severe behaviour that exemplifies the manner in which impulsivity facilitates behavioural sensitization and is, in turn, increased by it, leading to inherently unpredictable behaviour. (vi) Interactions between impulsivity and sensitization can provide targets for complementary preventive and treatment strategies for severe immediate and long-term behavioural disorders. Progress along these lines will be facilitated by predictors of susceptibility to behavioural sensitization. This article is part of the theme issue 'Risk taking and impulsive behaviour: fundamental discoveries, theoretical perspectives and clinical implications'.

Impulsivity and Suicidal Behavior

Suicide is the leading cause of injury mortality in the United States and the second-leading cause of death in people aged 10-34 years. While many long-term risk factors are known, the short-term prediction of suicidal behavior remains elusive. Many characteristics of suicidal behavior cut across diagnoses, but suicide is increased in recurrent psychiatric disorders, addictive disorders, and trauma-related disorders. Suicide results from the interaction of short-term and long-term behavioral regulation. The shorter the time-course of the mechanism, the closer it is to actual suicidal behavior, and the harder it is to prevent. We will discuss the manner in which impulsivity, a major determinant of short-term suicide risk, interacts with longer-term risk factors, especially sensitization to addictive or traumatic stimuli. Impulsivity predisposes to sensitization; in turn, impulsivity is a prominent component of sensitized behavior. Impulsivity can be described as a general pattern of behavior ("trait" impulsivity), as responses that are not conformed to their context (action-impulsivity), or as inability to delay reward or to take future consequences into account (choice-impulsivity). Each of these contributes to suicidal behavior. The neural mechanisms of impulsivity and sensitization are analogous, and sensitization can produce rapidly fluctuating patterns of impulsive behavior, arousal, and anhedonia. In order to recognize and prevent suicidal behavior, it is necessary to identify factors associated with susceptibility to bouts of impulsive behavior in people at elevated long-term risk.

Meta-analysis of suicide rates among people discharged from non-psychiatric settings after presentation with suicidal thoughts or behaviours

OBJECTIVE

To quantify the suicide rate among people discharged from non-psychiatric settings after presentations with suicidal thoughts or behaviours.

METHOD

Meta-analysis of studies reporting suicide deaths among people with suicidal thoughts or behaviours after discharge from emergency departments or the medical or surgical wards of general hospitals.

RESULTS

A total of 115 studies reported 167 cohorts and 3747 suicide deaths among 248 005 patients during 1 263 727 person-years. The pooled suicide rate postdischarge was 483 suicide deaths per 100 000 person-years (95% confidence interval (CI) 445-520, prediction interval (PI) 200-770) with high between-sample heterogeneity (I²  = 92). The suicide rate was highest in the first year postdischarge (851 per 100 000 person-years) but remained elevated in the long term. Suicide rates were elevated among samples of men (716 per 100 000 person-years) and older people (799 per 100 000 person-years) but were lower in samples of younger people (107 per 100 000 person-years) and among studies published between 2010 and 2018 (329 per 100 000 person-years).

CONCLUSIONS

People with suicidal thoughts or behaviours who are discharged from non-psychiatric settings have highly elevated rates of suicide despite a clinically meaningful decline in these suicide rates in recent decades.

Psychological Inflexibility Predicts of Suicidal Ideation Over Time in Veterans of the Conflicts in Iraq and Afghanistan

Psychological inflexibility, or how individuals respond to distressing internal experiences, may be a modifiable risk factor for suicide in veterans. It was hypothesized that psychological inflexibility would predict suicidal ideation after accounting for established risk factors at baseline and 1 year later. Post-9/11 veterans (N = 309) completed clinical interview and self-report measures at baseline and 1-year follow-up. Results indicated that psychological inflexibility predicted severity of suicidal ideation at both baseline and 1 year later, after accounting for established risk factors. Psychological inflexibility is an important marker of risk for suicidal ideation, and could be a target for interventions aimed at reducing suicide.

Complexity of Wake Electroencephalography Correlates With Slow Wave Activity After Sleep Onset

Sleep electroencephalography (EEG) provides an opportunity to study sleep scientifically, whose chaotic, dynamic, complex, and dissipative nature implies that non-linear approaches could uncover some mechanism of sleep. Based on well-established complexity theories, one hypothesis in sleep medicine is that lower complexity of brain waves at pre-sleep state can facilitate sleep initiation and further improve sleep quality. However, this has never been studied with solid data. In this study, EEG collected from healthy subjects was used to investigate the association between pre-sleep EEG complexity and sleep quality. Multiscale entropy analysis (MSE) was applied to pre-sleep EEG signals recorded immediately after light-off (while subjects were awake) for measuring the complexities of brain dynamics by a proposed index, CI₁₋₃₀. Slow wave activity (SWA) in sleep, which is commonly used as an indicator of sleep depth or sleep intensity, was quantified based on two methods, traditional Fast Fourier transform (FFT) and ensemble empirical mode decomposition (EEMD). The associations between wake EEG complexity, sleep latency, and SWA in sleep were evaluated. Our results demonstrated that lower complexity before sleep onset is associated with decreased sleep latency, indicating a potential facilitating role of reduced pre-sleep complexity in the wake-sleep transition. In addition, the proposed EEMD-based method revealed an association between wake complexity and quantified SWA in the beginning of sleep (90 min after sleep onset). Complexity metric could thus be considered as a potential indicator for sleep interventions, and further studies are encouraged to examine the application of EEG complexity before sleep onset in populations with difficulty in sleep initiation. Further studies may also examine the mechanisms of the causal relationships between pre-sleep brain complexity and SWA, or conduct comparisons between normal and pathological conditions.

The age-specific characteristics of medically serious suicide attempters aged 15-45 years in rural China

This aim of this study was to identify unique characteristics of serious suicide attempters across different age groups. Face to face interviews were conducted with medically serious suicide attempters in rural hospitals in two provinces in China (n = 791). The sample included three age groups: 15-24, 25-34, and 35-45. While there were some consistent patterns that emerged across the age groups, there were also some significant age-related patterns that emerged. Serious suicide attempters aged 15-24 were more likely to be well educated, never married, hold Party membership, and impulsive, and to be least likely to perceive social support and be in a peasant occupation. This category also had the highest proportion of males, although still predominantly female. Those aged 24-25 were more likely to have a family history of suicide, somewhat educated, and moderately likely to be married. Those aged 35-45 were more likely to have limited education, to be ever married, to have mental disorders, to store pesticides in their home, and the least likely to be impulsive. These results highlight age-specific intervention strategies in addressing suicide.

Sex difference in risk period for completed suicide following prior attempts: Korea National Suicide Survey (KNSS)

OBJECTIVES

We provide an opportunity for implementing preventive interventions to decrease suicide mortality among prior suicide attempters. We aim to identify sex-specific high risk periods and factors for later suicide death among suicide attempters.

METHODS

8537 suicide attempters of Korea National Suicide Survey were collected from January 1, 2007 to December 31, 2011 and data on suicide death was obtained as of December 31, 2012. The risk period and risk factors for later suicide death was computed by Kaplan-Meier survival estimates and by plotting the hazard function using the Epanechnikov Kernal smoothing method and cox proportional hazard regression modeling.

RESULTS

The hazard for later suicide death was significant up to 10 months for females and 20 months for males. Age 50-69 years (HR, 3.29; [CI: 1.80-6.02] and not being intoxicated with alcohol (HR, 1.94 [1.27-2.97])) in male attempters were significant risk factors for later suicide death.

CONCLUSION

Risk for later suicide death was significantly increased during the first full year following index attempts for all with an addition 8 months of risk for males, especially those of advanced age who were sober at the time of attempt.

Risk Factors of a Suicide Reattempt by Seasonality and the Method of a Previous Suicide Attempt: A Cohort Study in a Japanese Primary Care Hospital

Suicide has a great impact on the individual whose life is lost and the bereaved family members. The risk of a suicide reattempt is particularly high during the first 12 months after a suicide attempt. In this cohort study, risk factors for a suicide reattempt were explored among 291 patients at suicide risk. Clinical and demographic data were collected from a Japanese primary care hospital. Past psychiatric history and multiple diagnoses were associated with suicide reattempts in both genders. Drug overdose, past psychiatric history, and the summer season were linked to suicide reattempts among males. Past psychiatric history and multiple diagnoses were linked to suicide reattempts among females. Appropriate assessment of past psychiatric history, season and method of suicide attempt, gender, and diagnosis may play a role in preventing suicide.

Who are likely to attempt suicide again? A comparative study between the first and multiple timers

BACKGROUND

Various explanations account for suicide incidents, and some patients continue to attempt afterwards and others never again. The suicide mortality rate increases with the number of serious attempts. The prevention of secondary attempt of suicide should be an important approach to reduce suicide mortality. However, the characteristics of the targeted population of repeated suicide attempters are understudied.

METHODS

This was a cross-sectional data collection from hospital emergency room from patients who had either attempted suicide for the first time (n=721) or for two or more times (n=70). The subjects were between 14 and 53years old and comprised 293 males and 498 females. In-depth interview was conducted for each suicide attempter with a semi-structural protocol. Demographic and social-psychological characteristics were compared between the two groups of suicide attempters. Logistic regression was used to identify independent predictors of multiple attempts.

FINDINGS

The two groups only differed in religion factor among demographic characteristics and multiple suicide attempters group have a higher percentage of subjects who reported to have a religion affiliation than first time suicide attempters. Multiple attempters were more likely to have family suicide history, physical illness, mental disorder, higher scores on Beck Hopelessness Scale (BHS) and Suicide Intent Scale (SIS) and lower scores on Duke Social Support Scale (DSSI). In the final regression model, family history of suicide, mental disorder, hopelessness and social support emerged as significant predictors of multiple suicide attempts.

CONCLUSION

Suicide attempters that have mental disorder, family history of suicide, higher level of hopelessness and lower level of social support are more likely to re-attempt suicide again. Social and clinical interventions may have to also focus on this sub-group of patients with these characteristics to effectively reduce suicide mortality rate.

The perniciousness of perfectionism: A meta-analytic review of the perfectionism-suicide relationship

OBJECTIVE

Over 50 years of research implicates perfectionism in suicide. Yet the role of perfectionism in suicide needs clarification due to notable between-study inconsistencies in findings, underpowered studies, and uncertainty about whether perfectionism confers risk for suicide. We addressed this by meta-analyzing perfectionism's relationship with suicide ideation and attempts. We also tested whether self-oriented, other-oriented, and socially prescribed perfectionism predicted increased suicide ideation, beyond baseline ideation.

METHOD

Our literature search yielded 45 studies (N = 11,747) composed of undergraduates, medical students, community adults, and psychiatric patients.

RESULTS

Meta-analysis using random effects models revealed perfectionistic concerns (socially prescribed perfectionism, concern over mistakes, doubts about actions, discrepancy, perfectionistic attitudes), perfectionistic strivings (self-oriented perfectionism, personal standards), parental criticism, and parental expectations displayed small-to-moderate positive associations with suicide ideation. Socially prescribed perfectionism also predicted longitudinal increases in suicide ideation. Additionally, perfectionistic concerns, parental criticism, and parental expectations displayed small, positive associations with suicide attempts.

CONCLUSIONS

Results lend credence to theoretical accounts suggesting self-generated and socially based pressures to be perfect are part of the premorbid personality of people prone to suicide ideation and attempts. Perfectionistic strivings' association with suicide ideation also draws into question the notion that such strivings are healthy, adaptive, or advisable.

High Early Suicide Risk in Elderly Patients After Self-Poisoning

This article reports the findings of a follow-up study of suicide mortality in elderly patients after an index episode of self-poisoning. A total of 222 consecutive patients (143 female) aged 65 years or older (mean age 76.5 years; range 65-100) presenting at the emergency department of the Karolinska University Hospital after self-poisoning during 1994-2000, were followed up for the cause of death by January 1, 2006. Survival analysis was applied to study suicide and death risk. Of the 15 suicides, 13 (87%) occurred during the first year after the index episode of self-poisoning (cumulative suicide risk 6.2%). The risk of dying of all causes during the first year was increased fourfold. Self-poisoning in both elderly men and women is associated with high early suicide risk.

Suicidal Behavior in Mood Disorders: Response to Pharmacological Treatment

Suicidal behavior is strongly associated with depression, especially if accompanied by behavioral activation, dysphoria, or agitation. It may respond to some treatments, but the design of scientifically sound, ethical trials to test for therapeutic effects on suicidal behavior is highly challenging. In bipolar disorder, and possibly also unipolar major depression, an underprescribed medical intervention with substantial evidence of preventive effects on suicidal behavior is long-term treatment with lithium. It is unclear whether this effect is specifically antisuicidal or reflects beneficial effects of lithium on depression, mood instability, and perhaps aggression and impulsivity. Antisuicidal effects of anticonvulsant mood stabilizers (carbamazepine, lamotrigine, valproate) appear to be less than with lithium. Further evaluation is needed for potential antisuicidal effects of atypical antipsychotics with growing evidence of efficacy in depression, particularly acute bipolar depression, while generally lacking risk of inducing agitation, mania, or mood instability. Short-term and long-term value and safety of antidepressants are relatively secure for unipolar depression but uncertain and poorly tested for bipolar depression; their effects on suicidal risk in unipolar depression may be age-dependent. Sedative anxiolytics are virtually unstudied as regards suicidal risks. Adequate management of suicidal risks in mood disorder patients requires comprehensive, clinically skillful monitoring and timely interventions.

Poisons admissions in Edinburgh 1981-2001: agent trends and predictors of hospital readmissions

Self-poisoning is a major public health problem. This study describes patterns of admissions and readmissions from self-poisoning to the Royal Infirmary of Edinburgh from 1981 to 2001. A database on hospital discharges with a diagnosis (ICD-9/10) of poisoning between 1981 and 2001 was used. Annual admissions were described for seven main drug categories, and proportions of patients readmitted within 1-5 years from first admission, were computed for each category. Cox proportional hazards regression was used to evaluate prognostic factors for readmission risk over 1981-2001. For both sexes, admissions increased from the early to mid 1990s, and declined thereafter. The proportion readmitted varied with the drug taken at first admission, from 11.9% (95% CI: 10.8-13%) for non-opiate analgesics, to 17.6% (16.5-18.7%) for benzodiazepines. Deprivation was positively related to readmission risk after first admissions with paracetamol (P<0.001) and benzodiazepines (P<0.001). Timing of first admissions involving paracetamol (P<0.01), benzodiazepines (P<0.001), antidepressants (P<0.001), non-opiate analgesics (P<0.001), and opiates (P<0.05), was inversely associated with readmission risk. In patients admitted for drug overdose, readmission risk is influenced by type of drug taken at first admission. Information on drug type used in self-poisoning may assist in identifying patients at risk for future events, and in reducing hospital read-missions.

What Can Influence Iranian Suicide Attempters to Go Through the Process of Non-Fatal Suicide Act Once Again? A Preliminary Report

The thrust of this study was to examine some of the psycho-social risk factors for the recurrence of non-fatal suicide attempt in a sample of 1121 inmates admitted between April 2012 to June 2013 at the toxicology emergency ward, Noor Medical Centre, Isfahan, Iran. Out of the total participants, 240 of them reported history of suicide attempt and assumed the status of case group. The remaining 881 patients were admitted first their attempt and constituted the control group. Cases were compared to the controls with respect to select demographic features (i.e. age, sex, education, occupation, marital status, type of residence, and locale), current suicide attempt method, family history of suicide and drug abuse, history of psychiatric disorder, physical ailment and physical disability, substance abuse and alcohol use, psychiatric diagnosis, and recent life hassles (i.e. interpersonal, occupational, financial, medical, and home affairs). We used a structured interview schedule to interview the participants. Psychiatric diagnosis was based on the DSM-IV criteria. Data were computer analyzed using SPSS.21 and administering statistical analysis including Chi Square, t-student, and logistic regression. Demographic risk factors for recurrence of suicide attempts at the univariate level included occupational status [Crud odds Ratio (COR) = 0.53] and type of residence (COR = 1.40). Medical and psychiatric risk factors at the univariate level included substance abuse (COR = 1.97), physical ailment (COR = 1.76), alcohol use (COR = 1.84), psychiatric disorder (COR = 3.69), and history of suicide in the family of origin (COR = 1.86). Recent life hassles risk factors at the univariate level included financial constraints (COR = 1.46) and medical emergencies (COR = 3.48). A multivariate logistic regression model identified five variables (i.e. substance abuse, alcohol use, psychiatric illness, suicide in family, and medical emergencies) that were statistically associated with an increased risk for recurrence of nonfatal suicide attempt. The model predicted chances of repeating suicide attempt correctly 79 % of the time. These observations indicate that people who report to the toxicology emergency ward for nonfatal suicide not only need immediate relief but also careful psychiatric and social assessments which subsequently may lead to psychiatric admission and comprehensive community interventions.

Non-fatal repetition of self-harm in Taipei City, Taiwan: cohort study

BACKGROUND

Repeat self-harm is an important risk factor for suicide. Few studies have explored risk factors for non-fatal repeat self-harm in Asia.

AIMS

To investigate the risk of non-fatal repeat self-harm in a large cohort of patients presenting to hospital in Taipei City, Taiwan.

METHOD

Prospective cohort study of 7601 patients with self-harm presenting to emergency departments (January 2004-December 2006). Survival analysis was used to examine the rates, timing and factors associated with repeat self-harm.

RESULTS

In total 778 (10.2%) patients presented to hospital with one or more further episodes of self-harm. The cumulative risk of non-fatal repetition within 1 year of a self-harm episode was 9.3% (95% CI 8.7-10.1). The median time to repetition within 1 year was 105 days. Females had a higher incidence of repeat self-harm than males (adjusted hazard ratio 1.25, 95% CI 1.05-1.48) but males had shorter median time to repetition (107 v. 80 days). Other independent risk factors for repeat self-harm within 1 year of an index episode were: young age, self-harm by medicine overdose and increasing number of repeat episodes of self-harm.

CONCLUSIONS

The risk of non-fatal repeat self-harm in Taipei City is lower than that seen in the West. Risk factors for repeat non-fatal self-harm differ from those for fatal self-harm. The first 3 months after self-harm is a crucial period for intervention.

Age-specific suicide mortality following non-fatal self-harm: national cohort study in Sweden

BACKGROUND

Possible age-related differences in risk of completed suicide following non-fatal self-harm remain unexplored. We examined associations between self-harm and completed suicide across age groups of self-harming patients, and whether these associations varied by violent index method, presence of mental disorder, and repeated self-harm.

METHOD

The design was a cohort study with linked national registers in Sweden. The study population comprised individuals aged ⩾10 years hospitalized during 1990-1999 due to non-fatal self-harm (n = 53 843; 58% females) who were followed for 9-19 years. We computed hazard ratios (HRs) across age groups (age at index self-harm episode), with time to completed suicide as outcome.

RESULTS

The 1-year HR for suicide among younger males (10-19 years) was 14.6 [95% confidence interval (CI) 4.1-51.9] for violent method and 8.4 (95% CI 1.8-40.0) for mental disorder. By contrast, none of the three potential risk factors increased the 1-year risks in the youngest females. Among patients aged ⩾20 years, the 1-year HR for violent method was 4.6 (95% CI 3.8-5.4) for males and 10.4 (95% CI 8.3-13.0) for females. HRs for repeated self-harm during years 2-9 of follow-up were higher in 10- to 19-year-olds (males: HR 4.0, 95% CI 2.0-7.8; females: HR 3.7, 95% CI 2.1-6.5). The ⩾20 years age groups had higher HRs than the youngest, particularly for females and especially within 1 year.

CONCLUSIONS

Violent method and mental disorder increase the 1-year suicide risk in young male self-harm patients. Further, violent method increases suicide risk within 1 year in all age and gender groups except the youngest females. Repeated self-harm may increase the long-term risk more in young patients. These aspects should be accounted for in clinical suicide risk assessment.

Association between body mass index and suicidal behaviors: a systematic review protocol

BACKGROUND

Suicide is among the leading causes of death worldwide. Suicide attempts and suicidal ideation are more common than completed suicide and are associated with psychological distress. These behaviors are considered risk factors of completed suicide. Considering the psychosocial stigma and medical comorbidities associated with obesity, an accumulating body of studies have investigated body mass index (BMI) as a potential risk factor of suicide. However, several cohort studies have demonstrated an inverse relationship between BMI and completed suicide, suggesting a protective effect of increasing BMI against completed suicide. The association between BMI and attempted suicide is more equivocal, with several studies reporting both positive and negative relationships between BMI and attempted suicide. The primary objective of this study is to systematically review the literature to determine the association between BMI and suicidal behavior (including completed suicide, attempted suicide, suicidal ideation) in an adult population (18 years and older). The secondary objective is to explore whether sex, age, and the method used in suicide modify the relationship between BMI and suicidal behavior.

METHODS/DESIGN

An electronic search will be conducted using PubMed/MEDLINE, PsycINFO, CINAHL, and EMBASE using a predefined search strategy; databases will be searched from their inception. Two authors (SP and RE) will independently screen articles using predefined inclusion and exclusion criteria and will extract pertinent data using a pilot tested extraction form. At all levels of screening, discrepancies between the two authors will be resolved by consensus, and in the case of disagreement, by consulting a third author (ZS). The primary outcomes include the association between BMI and completed suicide, attempted suicide, and suicidal ideation. If appropriate, a meta-analysis will be conducted. Risk of bias and quality of evidence will be assessed.

DISCUSSION

The results of this systematic review will inform health care professionals and researchers about whether BMI has a significant role in suicidal behavior and psychological well-being.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014014739 .

Female attempted suicide patients with low HDL levels are at higher risk of suicide re-attempt within the subsequent year: a clinical cohort study

Our aims were, to clarify the blood lipid differences [Total serum cholesterol (TC), High-density lipoprotein (HDL), Low density lipoprotein (LDL), Triglyceride (TG)] between female patients who had attempted suicide and controls and to determine whether we could use the patients׳ initial lipid profiles to predict suicide re-attempt within the subsequent year. A total of 284 participants (110 cases and 174 controls) were recruited, with no differences in body mass index, age, blood sampling time and gender. Blood samples were collected from all participants for serum lipid profiles and assayed in an auto-analyzer. We divided the suicide re-attempter group into suicide attempters in the subsequent year (SSY) and suicide attempters after the subsequent year (SASY). The TC, LDL, and TG levels were significantly lower in the suicidal group than in the control group. HDL was significantly higher in the suicidal group than in the control group. Low TG (<70mg/dL) (OR (odds ratio)=12.8; 95% CI (confidence interval)=5.4-30.5; p<0.0001)and low LDL/HDL (<1.8) (OR=4.1; 95% CI=1.8-9.3; p=0.001) were significantly associated with a current suicide attempt. HDL levels in the SSY (41.5±4.5mg/dL) were lower than in the non-suicide attempters group (NSA) (50.9±10.3mg/dL) and SASY (58.7±12.8mg/dL)(d.f.=2, F=5.2, p=0.007). Serum HDL level may be a potential candidate predictor for the future risk of suicidality.

Suicide history and mortality: a follow-up of a national cohort in the United States

Little is known about the cause-specific deaths among young suicide attempters from the general population, and the time window for intervention to reduce the elevated rate of death was unclear. We analyzed a nationally representative sample of young adults (17-39 years old) who participated in the third National Health and Nutrition Examination Survey (NHANES III, 1988-1994) and were followed up with vital status through December 31, 2006. The history of attempted suicide was associated with an increased rate for all-cause death (HR = 1.52 [95% CI = 0.92-2.52]) with borderline statistical significance. Previous suicide attempters experienced a 3-fold (HR = 2.68[=1.01-7.09]) increased rate for cardiovascular diseases (CVD), and a 7-fold (HR = 7.10 [95% CI = 1.37-36.9]) increased rate of death due to completed suicide compared with non-attempters. The survival curves of the attempters declined rapidly for the first 3 years of follow-up, and the distance between curves remained consistent starting from the third year to the end of the follow-up. Prevention services should be tailored not only for suicide, but also for cardiovascular diseases among populations with suicidal tendency, and the service should be intensified within first 3 years after suicidal behaviors occur.

Factors associated with choice of high lethality methods in suicide attempters: a cross-sectional study

Background

Most attempted suicides have a low lethality, but hanging, drowning, and jumping from a great height have a high risk of completed suicide. The aim of this study was to assess the sociodemographic profiles of patients who attempted suicide using high lethality methods relative to all other methods of attempted suicide.

Methods

We retrospectively investigated all attempted suicides treated at a tertiary university hospital in Seoul between January 2008 and February 2012. The following variables were considered: the patients’ attempted suicide methods, age, sex, history of attempted suicides, previous psychiatric history, occupation, and living conditions. The suicide methods were categorized into two groups: high lethality (e.g., hanging, falling, and drowning) and low lethality methods (e.g., self-poisoning and cutting). We investigated risk factors related to the choice of high lethality methods.

Results

A total of 560 patients were enrolled in this study. Deliberate self-poisoning was the most common method of attempted suicide (61.6%), followed by cutting (22.5%), hanging (10.4%), falling (4.1%), and drowning (1.4%). In logistic regression analyses, odds ratios for the choice of high lethality methods were 1.02 (95% CI = 1.01 to 1.03, p < .01), 7.22 (95% CI = 3.06 to 17.04, P < .01), and 0.59 (95% CI = 0.35 to 0.99, p = .04) for age, previous attempted suicide with a high lethality method, and alcohol co-ingestion, respectively.

Conclusions

Our findings indicated that age and past attempted suicide using a high lethality method are associated with the use of high lethality methods for attempting suicide.

The prevalence and psychosocial correlates of suicide attempts among inpatient adolescent offspring of Croatian PTSD male war veterans

Despite evidence that children of male war veterans with combat-related posttraumatic stress disorder (PTSD) are at particularly high risk for behavior problems, very little is currently known about suicidal behaviors in this population of youth. This study aimed to examine the prevalence and psychosocial correlates of suicide attempts among psychiatrically hospitalized adolescent offspring of Croatian male PTSD veterans. Participants were psychiatric inpatients, ages 12-18 years. Self-report questionnaires assessed demographics, suicide attempts, psychopathology, parenting style, and family functioning. The prevalence of suicide attempts was 61.5% (65.2% for girls and 58.0% for boys). Internalizing symptoms, family dysfunction, lower levels of maternal and paternal care, and paternal overcontrol were significantly associated with suicide attempts. Our findings suggest that suicide attempts are common among inpatient adolescent offspring of male PTSD veterans and that interventions targeting both adolescent psychopathology and family relationships are needed for adolescents who have attempted suicide.

Gender differences in suicide attempters: a retrospective study of precipitating factors for suicide attempts at a critical emergency unit in Japan

BACKGROUND

There is a shortage of empirical data concerning precipitating factors for suicides in Japan. The purpose of the present study was to clarify gender differences of precipitating factors for suicide attempts in Japan.

METHODS

The subjects were high-lethality suicide attempters who were admitted to the Nippon Medical School Hospital Critical Care Medical Center between March 1, 2010 and March 31, 2012. Precipitating factors for suicide attempt, method of suicide attempt, psychiatric diagnoses and other sociodemographic data were collected from the patients' medical records retrospectively, and statistical analyses were performed for categorical variables of male/female.

RESULTS

The total number of subjects was 193 (88 males and 105 females). The rate of subjects attempting suicide by poisonous gas was significantly higher in males while that of subjects attempting suicide by drug overdose was significantly higher in females. The rate of subjects diagnosed with "major depressive disorder, bipolar disorder" was significantly higher in males while that of subjects diagnosed with "personality disorders" or "dysthymic disorder" was significantly higher in females. Subjects with "health problems", "financial problems", "work problems", "debts (others)" or "unwanted transfer" were significantly more numerous among males; subjects with "family problems", "parent-child relations" or "loneliness" were significantly more frequently found among females.

CONCLUSIONS

Mental disorders were the most common precipitating factor for suicide attempts regardless of gender. Significant gender differences were observed in psychiatric diagnoses, methods of suicide attempt and psychosocial problems. This indicates the necessity of suicide prevention measures corresponding to these gender differences.

Comparison of suicide attempts in schizophrenia and major depressive disorder: an exploratory study

INTRODUCTION

Schizophrenia and major depressive disorder (MDD) are among the most common psychiatric diagnoses associated with suicide. There is a dearth of published research systematically comparing suicidal behavior in schizophrenia and MDD. The present study aimed to compare suicide attempts in schizophrenia and MDD.

METHODS

In this hospital-based, cross-sectional study, 50 outpatients each of schizophrenia and MDD were evaluated for their sociodemographic characteristics. In subjects with a history of suicide attempt(s), additional information related to the attempt(s) was obtained. Suicide Intent Scale (SIS) was used to assess the suicidal intent and Mini International Neuropsychiatric Interview (MINI) was used to measure the current suicidal risk.

RESULTS

Thirty-four percent and 44% of patients with schizophrenia and MDD, respectively, attempted suicide. The attempters in schizophrenia compared to those in MDD were younger and more likely to be single (unmarried, separated or divorced). Suicidal intent was stronger in schizophrenia, while the attempters with MDD were more often preoccupied with a death wish and reported that stressful life events influenced the attempt. There were no differences in the attempt methods of the two groups. Current suicidal risk was higher in attempters compared to the non-attempters in schizophrenia as well as MDD.

DISCUSSION

Suicide attempts in schizophrenia and MDD have similar features, with quite a few notable differences, which have been discussed at length in the present paper.

The Interaction Effect Between Low Income and Severe Illness on the Risk of Death by Suicide After Self-Harm

Background: Previous Western studies have reported that the prevalence of death by suicide within 1 year after self-harm was 0.5–2%; however, no studies have focused on the Far East. Aims: To calculate the prevalence of death by suicide after self-harm over different lengths of follow-up time and to determine the predictors of death by suicide after self-harm. Method: Our study was based on 3,388 inpatients hospitalized between 2000 and 2007 in any of the 1,230 hospitals in Taiwan. Death by suicide after self-harm among the members of this cohort was tracked after 3 months, 6 months, and 1–8 years. The tracking continued until December 31, 2008. We analyzed the prevalence and risk factors of death by suicide after self-harm using Cox’s regression model. Results: Of the 3,388 individuals with a history of self-harm included in the study, 48 (1.4%) died by suicide after self-harm within 3 months and 97 (2.9%) within 1 year. In all, 144 (4.3%) died by suicide after self-harm within 8 years. The predictors of death by suicide were violent methods (such as hanging, drowning, firearms, and jumping), low income, and severe illness. Moreover, an interaction effect was noted between low income and severe illness on the outcome (death by suicide). Conclusion: It seems that effective healthcare for individuals who engage in self-harming behavior would benefit from supplementing medical care with social assistance, such as the support of a social worker.

Evidence for the management of adolescent depression

Adolescent depression is a prevalent and disabling condition resulting in emotional suffering and social and educational dysfunction. Care for adolescent depression is suboptimal and could be improved through the development and use of quality indicators (QIs). This article reports on the development of a care pathway and QIs for the primary and specialty care management of adolescent depression from case identification through symptom remission. It presents evidence from a review of adolescent clinical practice guidelines and research literature to support QIs at critical nodes in the pathway, and describes implications for practice based on existing evidence. Barriers to measure development are identified, including gaps in empirical evidence, and a research agenda is suggested.

Extreme obesity is associated with suicidal behavior and suicide attempts in adults: results of a population-based representative sample

OBJECTIVE

A number of studies have revealed that the number of completed suicides decreases with increasing body mass index (BMI). However, only few studies have evaluated the association between suicidal behavior, suicide attempts, and the various BMI categories. The aim of this study was to determine whether obesity is positively associated with increased suicide attempts and suicidal behavior with consideration of gender differences.

METHODS

In a representative German population-based sample (N = 2436), interviews were conducted in 2011 to examine the prevalence of suicide attempts and suicidal behavior in participants in the different BMI categories. Logistic regression analyses were conducted for suicidal behavior and suicide attempts to examine the association between obesity status and suicidality, controlling for confounding variables. Suicidal behavior was assessed by the Suicidal Behaviors Questionnaire-Revised (SBQ-R), which is a four-item self-report measure of suicidal thoughts and past attempts. BMI was calculated from participants' self-reported height and weight.

RESULTS

Analyses revealed that extremely obese participants (BMI ≥ 40.0) had a prevalence rate of suicidal behavior of 33% for female respondents and 13% for male respondents and rates for suicide attempts of 27% for female and 13% for male respondents. No significant gender differences could be found for any of the weight categories. Furthermore, adjusted odd ratios (AOR) showed a significant difference in suicidal behavior in class I obesity (OR, 3.02 [1.50-6.08] and class III obesity (OR, 21.22 [6.51-69.20]. AORs for suicide attempts showed significantly greater odds for class I obesity (OR, 3.49 [1.76-6.90] and class III obesity (OR, 12.43 [3.87-39.86] compared to the normal weight group.

CONCLUSION

These results support a positive relationship between suicidal behavior, suicide attempts, and obesity. However contrary to previous findings, no gender differences were found. The findings support the introduction of routine screening for suicidal behavior in extreme obese individuals.

Risk and predictors of suicide and non-suicide mortality following non-fatal self-harm in Northern Taiwan

OBJECTIVE

To investigate the risk and predictors of suicide and non-suicide mortality after self-harm in a Taiwanese population.

METHOD

Between July 2006 and June 2008, 3,299 individuals who harmed themselves were recruited to a population-based self-harm register in Taoyuan County, Taiwan. They were followed until December 2008, with record linkage for date and cause of death in a national mortality database.

RESULTS

In total, 115 individuals died, 52 through suicide. The risks of suicide and non-suicide mortality in the first year were 1.5 and 2.2%, respectively, representing an approximately 75-fold and 5-fold age- and gender-standardized increase compared with the general population in Taiwan. Male gender, rural residence, more lethal methods of self-harm and self-cited stressors for the index self-harm episode (unemployment, and chronic somatic illness) were independent risk factors for suicide mortality. Male gender, older age, rural residence and more lethal methods of self-harm were also independent risk factors for non-suicide mortality. The association between of unemployment as a cited reason for self-harm and later suicide was strongest in men and in those aged more than 45 years.

CONCLUSIONS

Relatively high rates of suicide and non-suicide mortality were found following self-harm. Suicide prevention needs to take into account of risk factors for fatal repetition of self-harm.

Sheehan Suicidality Tracking Scale (S-STS): reliability, convergent and discriminative validity in young Italian adults

BACKGROUND AND PURPOSE

The Sheehan Suicidality Tracking Scale (S-STS) is a patient self-report or clinician-administered rating scale that tracks spontaneous and treatment-emergent suicidal ideation and behaviors. This study set out to evaluate the reliability, convergent and divergent validity of the S-STS in a sample of college students, a population with a high risk of completed and attempted suicide.

METHODS

Cross-sectional, survey design. Participants (303 undergraduate students; males: 42%) completed several measures assessing psychological distress (General Health Questionnaire; GHQ); self-esteem (Rosenberg Self Esteem Scale; RSES); social support (Modified Social Support Survey; MOSSS); and suicidal behavior, including ideation and attempts (S-STS).

RESULTS

Both internal consistency and test-retest stability were excellent for the S-STS-global score. The S-STS subscale on suicide ideation also showed good reliability, while the subscale on suicidal behavior showed some inconsistency at retest. Convergent and divergent validity of S-STS was confirmed. All S-STS items loaded on a single factor, which had an excellent fit for the unidimensional model, thus justifying the use of the S-STS as a screening tool. In a mediation model, self-esteem and social support explained 45% of the effects of psychological distress on suicide ideation and behavior as measured by the S-STS-global score.

CONCLUSIONS

This study provided promising evidence on the convergent, divergent, internal consistency and test-retest stability of the Sheehan Suicidality Tracking Scale. The cross-sectional design and lack of measures of hopelessness and helplessness prevent any conclusion about the links of suicidal behavior with self-esteem and social support.

One-year follow up after admission to an emergency department for drug overdose in Japan

AIM

The aim of the study was to investigate the incidence of and risk factors for repetition of suicidal behavior within a year after admission for drug overdose in Japan.

METHODS

Patients admitted to the emergency department of a general public hospital in Tokyo for drug overdose of prescribed medicine and/or over-the-counter drugs between March 2008 and February 2009 were followed up after 1 year. Demographic characteristics, previous suicide attempts, and mental health state were examined by self-report questionnaire and interview at recovery from the initial attempt. Information about suicidal behavior during the follow-up period was obtained from the outpatient psychiatrists by postal questionnaire 1 year after discharge.

RESULTS

Of 190 patients admitted to the emergency department, 132 patients answered the questionnaire and had the interview. Information about thefollow-up period for 66 patients was obtained. Of the 66 patients, 28 patients attempted suicide again and two patients committed suicide during the 1-year follow-up period. Psychiatric diagnosis of personality disorder and denial of suicidal intent at the time of recovery were associated with increased risk for another suicide attempt. Lethality levels of suicidal behaviors before and after admission were associated with each other.

CONCLUSION

The rate of fatal and non-fatal suicide attempt within a year after admission for self-poisoning was substantial. Psychiatric diagnosis of personality disorder was a risk factor for repetition of suicide attempt. Clinicians should pay attention to the means of previous suicide attempts even though the patient denies suicidal intent at recovery.

Risk factors for fatal and nonfatal repetition of suicide attempts: a literature review

OBJECTIVES

This review aimed to identify the evidence for predictors of repetition of suicide attempts, and more specifically for subsequent completed suicide.

METHODS

We conducted a literature search of PubMed and Embase between January 1, 1991 and December 31, 2009, and we excluded studies investigating only special populations (eg, male and female only, children and adolescents, elderly, a specific psychiatric disorder) and studies with sample size fewer than 50 patients.

RESULTS

The strongest predictor of a repeated attempt is a previous attempt, followed by being a victim of sexual abuse, poor global functioning, having a psychiatric disorder, being on psychiatric treatment, depression, anxiety, and alcohol abuse or dependence. For other variables examined (Caucasian ethnicity, having a criminal record, having any mood disorders, bad family environment, and impulsivity) there are indications for a putative correlation as well. For completed suicide, the strongest predictors are older age, suicide ideation, and history of suicide attempt. Living alone, male sex, and alcohol abuse are weakly predictive with a positive correlation (but sustained by very scarce data) for poor impulsivity and a somatic diagnosis.

CONCLUSION

It is difficult to find predictors for repetition of nonfatal suicide attempts, and even more difficult to identify predictors of completed suicide. Suicide ideation and alcohol or substance abuse/dependence, which are, along with depression, the most consistent predictors for initial nonfatal attempt and suicide, are not consistently reported to be very strong predictors for nonfatal repetition.

A Nation-Wide Evidence-Based Data Analysis of Repeated Suicide Attempts

Background: Taiwan is a high-risk area for suicide. Repeated suicide attempts are an important factor of suicide mortality. Yet there has been little research on the factors associated with repeated suicidal behavior in Taiwan. Aims: To explore the characteristics of repeated suicide attempts. Methods: Data were obtained from the National Health Insurance Research Database for 2005 to 2008. We then classified repeated suicide attempts into single method, two different methods, and three different methods. Results: A total of 1,004 inpatients were admitted to Taiwanese hospitals due to repeated suicide attempts, and the use of a single suicide method constituted the majority of the cases (71%). Risk factors related to repeated suicide attempts included being female, aged 30–39, suicide by poisoning using solid and/or liquid substances, the fall season, living in Northern Taiwan, more psychiatric nature of injury codes (N-codes), seeking medical attention from a psychiatrist, receiving more surgeries or procedures, a longer length of stay in a hospital, coming from a low-income background, and having a serious illness. Conclusions: Consultation and treatment are particularly crucial for patients with mental illnesses and other concomitant diseases, so that the psychiatric symptoms such as auditory and visual hallucinations can be controlled.

The characteristics of serious suicide attempters in Japanese adolescents--comparison study between adolescents and adults

BACKGROUND

Suicide is the leading cause of death among Japanese adolescents, and they may commit suicide differently from adults. However, there are few studies in medical-based data concerning adolescent patients seriously attempting suicide. We aimed to explore the characteristics of serious suicide attempts in Japanese adolescents, comparing them with those in adults.

METHODS

We investigated adolescents who seriously attempted suicide and were treated at the Critical Care Medical Center (CCMC) of Nippon Medical School Hospital between 2000 and 2010, and we compared them with adult suicide attempters treated during 2009. We retrospectively studied medical records and collected clinical data and socio-demographic factors, including age, sex, psychiatric symptoms or diagnosis, methods of suicide attempt, motives for suicide attempt, previous deliberate self-harm, previous psychiatric history, parent loss experience, and previous psychiatric history in the family.

RESULTS

Adolescent attempters were 15 males and 44 females, 13 to 18 years old (mean 16.39). Adult attempters were 37 males and 65 females, 19 to 79 years old (mean 39.45). In comparison to adult attempters, adolescent attempters were more frequently diagnosed with Borderline Personality Disorder (BPD), had more school problems and parent loss experience, but they had less financial problems. Gender differences between adolescents and adults were examined, and male adolescent attempters were found to be more frequently diagnosed with schizophrenia and had less financial problems than their adult counterparts, while female adolescent attempters were more frequently diagnosed with BPD, had more school problems and parent loss, but they had less previous psychiatric history than their adult counterparts.

CONCLUSIONS

Our findings indicated that adolescent attempters were more frequently diagnosed with BPD and had more school problems and parent loss experience but had less financial problems. Additionally, in male adolescent attempters, identifying patients with schizophrenia seemed important, as it was their most frequent psychiatric diagnosis. For female adolescents, adequately assessing family function and interpersonal conflicts seemed important, as they were more often diagnosed with BPD and had more school and family problems.

[About epidemiology of suicidal behavior: an investigation in the health-service district of Brixen]

OBJECTIVE

Aim of this investigation is to find out how many parasuicids as well as suicides are commited and which epidemiological characteristics (sex, age, substance addictions, relationships, job, life-events and suicide attempts in past) show people who commit suicide, and people who commiting parasuicide. After that we try to find variables predicting a suicide or variables what show a vulnerability to commit suicide.

METHODS

Clinicans assess patients who commit parasuicide by the WHO-Parasuicide-Monitoring-Questionnaire and suicide victims by interview with the bereaved. Afterwards, data are assimilated and aggregated.

RESULTS

In this period a mean of 37 (SD = 7.78) parasuicides and 6.32 (SD = 3.79) suicides happened yearly. The sample shows different characteristics in age, sex, life-events in the run-up to the action, job situation and parasuicide(s) in past. No differences were found between relationship and substance abuse/addiction and regarding both types of suicidal behavior.

CONCLUSION

The incidence concerning suicide is slightly lower; the incidence with regard to parasuicide is lower than in other samples. Demographic variables show that people commiting suicide differ from those who commit parasuicide.

A nationwide, population-based, long-term follow-up study of repeated self-harm in Taiwan

Background

Previous follow-up studies of repeated self-harm show that the cumulative risk of repeated self-harm within one year is 5.7%–15%, with females at greatest risk. However, relatively few studies have focused on the Far East. The objective of this study was to calculate the cumulative risk of repeated self-harm over different lengths of follow-up time (3 months, 6 months, and 1–8 years), to determine factors influencing repeated self-harm and to explore the interaction between gender and self-harm methods.

Methods

We used self-harm patient who hospitalized due to first-time self-harm between 2000 and 2007 from 1,230 hospitals in Taiwan. Hospitalization for repeated self-harm among members of this cohort was tracked after 3 months, 6 months, and 1–8 years. Tracking continued until December 31, 2008. We analyzed the cumulative risk and risk factors of repeated self-harm by using negative binomial regression.

Results

Of the 39,875 individual study samples, 3,388 individuals (8.50%) were found to have repeatedly self-harmed. The cumulative risk of repeated self-harm within three months was 7.19% and within one year was 8%. Within 8 years, it was 8.70%. Females were more likely to repeatedly self-harm than males (RR = 1.21, 95% CI = 1.15–1.76). The main method of self-harm was solid or liquid substances (RR = 1.88, 95% CI = 1.23–2.04) or cutting or piercing (RR = 1.36, 95% CI = 1.02–1.82), and in patients with psychiatric disorders were more likely to self-harm (RR = 1.61, 95% CI = 1.48–1.75).

Conclusions

The key time for intervention for repeated self-harm is within three months. Appropriate prevention programs should be developed based on gender differences.

The hypothesis of a continuum in suicidality: a discussion on its validity and practical implications

The idea of a progression in suicide phenomena, from death wishes to suicide attempts and completed suicides, is quite old and widely present in literature. This model of interpreting suicidality has great relevance in preventative approaches, since it gives the opportunity of intercepting suicidal trajectories at several different stages. However, this may not be the case for many situations, and the hypothesis of a continuum can be true only in a limited number of cases, probably embedded with a specific psychopathological scenario (e.g. depression) and with a frequency that should not permit generalisations. This paper reviews the available evidence about the existence and validity of this construct, and discusses its practical implications.

Shame-proneness in attempted suicide patients

BACKGROUND

It has been suggested that shame may be an important feature in suicidal behaviors. The disposition to react with shame, "shame-proneness", has previously not been investigated in groups of attempted suicide patients. We examined shame-proneness in two groups of attempted suicide patients, one group of non-suicidal patients and one group of healthy controls. We hypothesized that the attempted suicide patients would be more shame-prone than non-suicidal patients and healthy controls.

METHODS

The Test of Self-Conscious Affect (TOSCA), which is the most used measure of shame-proneness, was completed by attempted suicide patients (n = 175: 105 women and 3 men with borderline personality disorder [BPD], 45 women and 22 men without BPD), non-suicidal psychiatric patients (n = 162), and healthy controls (n = 161). The participants were convenience samples, with patients from three clinical research projects and healthy controls from a fourth research project. The relationship between shame-proneness and attempted suicide was studied with group comparisons and multiple regressions. Men and women were analyzed separately.

RESULTS

Women were generally more shame-prone than men of the same participant group. Female suicide attempters with BPD were significantly more shame-prone than both female suicide attempters without BPD and female non-suicidal patients and controls. Male suicide attempters without BPD were significantly less shame-prone than non-suicidal male patients. In multiple regressions, shame-proneness was predicted by level of depression and BPD (but not by attempted suicide) in female patients, and level of depression and non-suicidality in male patients.

CONCLUSIONS

Contrary to our hypothesis and related previous research, there was no general relationship between shame-proneness and attempted suicide. Shame-proneness was differentially related to attempted suicide in different groups of suicide attempters, with significantly high shame-proneness among female suicide attempters with BPD and a negative relationship between shame-proneness and attempted suicide among male patients. More research on state and trait shame in different groups of suicidal individuals seems clinically relevant.

Age of first suicide attempt in men and women: an admixture analysis

OBJECTIVES

To define different subgroups of suicide attempters according to age at onset of suicide attempts.

METHODS

Participants were 229 suicide attempters (147 females; 82 males) admitted to a general hospital in Madrid, Spain. We used admixture analysis to determine the best-fitting model for the age at onset of suicide attempts separated by sex.

RESULTS

The best fitted model for the age at onset of suicide attempts was a mixture of two gaussian distributions. Females showed an earlier age at onset of suicide attempts in both Gaussian distributions (mean ± S.D.) (26.98 ± 5.69 and 47.98 ± 14.13) than males (32.77 ± 8.11 and 61.31 ± 14.61). Early-onset female attempters were more likely to show borderline personality disorder than late-onset female attempters (OR = 11.11; 95% CI = 2.43-50.0).

CONCLUSIONS

Age at onset of suicide attempts characterizes different subpopulations of suicide attempters.

Suicide and non-suicide mortality after self-harm in Taipei City, Taiwan

BACKGROUND

Most previous studies of long-term mortality risk following self-harm have been conducted in Western countries with few studies from Asia.

AIMS

To investigate suicide and non-suicide mortality after non-fatal self-harm in Taipei City, Taiwan.

METHOD

Prospective cohort study (median follow-up 3.3 years) of 7601 individuals presenting to hospital with self-harm (January 2004 to December 2006). Standardised mortality ratios (SMRs) for suicide and non-suicide mortality were calculated.

RESULTS

Suicide risk in the year following self-harm was over 100 times higher than in the general population (SMR = 119.6, 95% CI 99.6-142.5). Males and middle-aged and older adults had the highest subsequent risk of suicide. Compared with people who took an overdose, individuals who used hanging or charcoal burning in their index episode had the highest risk of suicide. For non-suicide mortality the SMRs were 6.7 (95% CI 5.7-7.8) in the first year and 4.4 (95% CI 3.9-4.9) during the whole follow-up period.

CONCLUSIONS

Patterns of increased all-cause and suicide mortality following an episode of self-harm are similar in Taipei City to those seen in Western countries. Designing better aftercare following non-fatal self-harm, particularly for those with underlying physical disorders or who have used lethal self-harm methods, should be a priority for suicide prevention programmes in Asia.

Suicide Intent Scale in the prediction of suicide

OBJECTIVE

To assess the predictive value of the Suicide Intent Scale in patients with high suicide risk. The secondary aim was to assess if the use of the factors of the Suicide Intent Scale may offer a better predictive value in suicide risk detection. Finally a shorter version of the scale was created after an item analysis.

METHOD

Eighty-one suicide attempters were assessed with the Beck's Suicide Intent Scale (SIS). All patients were followed up for cause of death. Receiver-operating characteristic (ROC) curves and tables were created to establish the optimal cut-off values for SIS and SIS factors to predict suicide.

RESULTS

Seven patients committed suicide during a mean follow up of 9.5 years. The major finding was that mean SIS scores distinguished between suicides and survivors. The positive predictive value was 16.7% and the Area Under Curve (AUC) was 0.74. Only the planning subscale reached statistical significance. Four items were used to test a shorter version of the SIS in the suicide prediction. The positive predictive value was 19% and the AUC was 0.82.

CONCLUSIONS

The Suicide Intent Scale is a valuable tool in clinical suicide risk assessment, a shorter version of the scale may offer a better predictive value.