Epidemiologic surveys as tools for studying suicidal behavior: a review

The association between somatic symptoms and suicidal ideation in Chinese first-episode major depressive disorder

BACKGROUND

Somatic symptoms are prevalent in patients with major depressive disorder (MDD) and often associated with a high risk of suicide. However, which somatic symptoms display as significant risk factors for suicidal ideation (SI) is still poorly understood in MDD.

METHODS

Two thousand and seventeen Chinese patients with first-episode MDD from the National Survey on Symptomatology of Depression were included in this study. A doctor-rating assessment questionnaire was constructed to evaluate depression related somatic symptoms, and stepwise logistic regression analysis was performed to explore the relationship between somatic symptoms and SI.

RESULTS

Our results showed a high prevalence of current SI in first-episode MDD (50.87%), while no significant gender differences (53.32% vs. 49.26%, P = 0.076) were observed. In addition, patients who have more somatic symptoms would be at the higher risk to elicit SI, and stepwise logistic regression analysis indicated that age (β = -0.020, P < 0.001), Pre-verbal physical complaints (β = 0.356, P = 0.001), Sensory system complaints (β = 0.707, P = 0.000), Other pain conditions (β = 0.434, P < 0.001), Late insomnia (β = 0.267, P = 0.008), Hypersomnia (β = 0.936, P < 0.001), Weight loss (β = 0.272, P = 0.006), Hyposexuality (β = 0.513, P = P < 0.001) were strongly associated with current SI in first-episode Chinese major depression.

CONCLUSIONS

Somatic symptoms are strongly associated with SI in first-episode MDD. It is suggestive for clinicians to show concerns for patients' somatic symptoms in practice.

Forensic pathology and forensic epidemiology of suicides in allegheny county, pennsylvania : A 10-year retrospective review (1990-1999)

Suicide has assumed epidemic proportions and constitutes a major public health issue throughout the United States. Suicide remains one of the top eight leading causes of death, accounting for approximately 30,000 deaths annually. The understanding and prevention of suicide requires a multidisciplinary approach that involves psychosocial and medical specialties starting with a forensic analysis of the characteristics of suicide. The aim of this 10-year (1990-1999) retrospective study was threefold: first, to examine the forensic epidemiological characteristics of suicides examined by the Allegheny County Coroner's Office; second, to describe emerging epidemiological patterns of suicide; and finally, to make recommendations for preventive measures. A total of 1447 suicides were identified, with 1164 males (80%) and 283 females (20%) resulting in a male to female ratio of 4:1. The race distribution comprised 90% whites, 9% blacks, and 1% other races. The age of suicide victims ranged from 13 to 96 years old with a peak within the 31- to 40-year-old age group, which represented 24.5% of all suicides. Overall, 40% of the victims were single and more blacks than whites were single. The greatest number of suicides occurred in July, with the least in December. Suicides most frequently occurred between 9:01 AM and 3:00 PM. Suicide notes were present in 29% of all suicides. Firearm injuries, hanging, and drug overdose were the leading methods of suicide. Use of firearms was the leading method of suicide among both sexes. Female drug overdose deaths outnumbered male drug overdose deaths. The 10 most common overdose drugs were all central nervous system depressants, with amitriptyline being the most common prescription overdose drug. Based on reported antecedent trends in suicides, we make two recommendations regarding suicide prevention: (1) physicians should be educated to replace the prescription of older and more toxic antidepressants such as amitriptyline with newer and less toxic antidepressants such as serotonin reuptake inhibitors; and (2) firearms should be made inaccessible to individuals with risk factors for suicide, especially in the home.

Suicidality and Its Risk Factors in Korean People with Epilepsy: A MEPSY Study

Background and Purpose

People with epilepsy (PWE) are more likely to experience suicidality, with suicidal ideation and attempts, than people without epilepsy (PWoE). The aims of the present study were to determine 1) the characteristics of suicidality in Korean PWE, 2) whether PWE with suicidality receive psychiatric intervention, and 3) the risk factors for suicidality.

Methods

Patients who consecutively visited epilepsy clinics at secondary- and tertiary-care hospitals were recruited (n=684), along with age- and sex-matched PWoE (n=229). The presence of current major depressive disorder (MDD), generalized anxiety disorder (GAD), and/or suicidality was established using the Mini International Neuropsychiatric Interview-Plus Version 5.0.0. The Korean version of the Liverpool Adverse Events Profile (K-LAEP) was applied to detect adverse effects of antiepileptic drugs (AEDs).

Results

Suicidality was present in 208 (30.4%) of the 684 PWE. The rate of suicidality was 4.6 times higher among PWE than PWoE, and 108 (15.7%) PWE had suicidal ideation and had attempted suicide. Among those who had attempted suicide, 40.7% had made at least two attempts. The most common method of suicide attempt was drug overdose (34.9%). Unfortunately, of the 208 PWE with suicidality, 136 (65.4%) did not receive psychiatric intervention. The risk factors for suicidality were MDD [odds ratio (OR)=6.448, 95% confidence interval (CI)=3.739-11.120, p<0.001], GAD (OR=3.561, 95% CI=1.966-6.452, p<0.001), item scores of 3 or 4 on the K-LAEP (OR=2.688, 95% CI=1.647-4.387, p<0.001), and a history of febrile convulsion (OR= 2.188, 95% CI=1.318-3.632, p=0.002).

Conclusions

Suicidality is more prevalent in PWE than in PWoE. Clinicians should monitor psychiatric disorders and the adverse effects of AEDs in PWE in an attempt to reduce the incidence of suicidal ideation or suicide attempts in this patient population.

Reducing the burden of suicide in the U.S.: the aspirational research goals of the National Action Alliance for Suicide Prevention Research Prioritization Task Force

BACKGROUND

The National Action Alliance for Suicide Prevention Research Prioritization Task Force (RPTF) has created a prioritized national research agenda with the potential to rapidly and substantially reduce the suicide burden in the U.S. if fully funded and implemented.

PURPOSE

Viable, sustainable scientific research agendas addressing challenging public health issues such as suicide often need to incorporate perspectives from multiple stakeholder groups (e.g., researchers, policymakers, and other end-users of new knowledge) during an agenda-setting process. The Stakeholder Survey was a web-based survey conducted and analyzed in 2011-2012 to inform the goal-setting step in the RPTF agenda development process. The survey process, and the final list of "aspirational" research goals it produced, are presented here.

METHODS

Using a modified Delphi process, diverse constituent groups generated and evaluated candidate research goals addressing pressing suicide prevention research needs.

RESULTS

A total of 716 respondents representing 49 U.S. states and 18 foreign countries provided input that ultimately produced 12 overarching, research-informed aspirational goals aimed at reducing the U.S. suicide burden. Highest-rated goals addressed prevention of subsequent suicidal behavior after an initial attempt, strategies to retain patients in care, improved healthcare provider training, and generating care models that would ensure accessible treatment.

CONCLUSIONS

The Stakeholder Survey yielded widely valued research targets. Findings were diverse in focus, type, and current phase of research development but tended to prioritize practical solutions over theoretical advancement. Other complex public health problems requiring input from a broad-based constituency might benefit from web-based tools that facilitate such community input.

Risk factors for suicide in epilepsy patients

ABSTRACT: 

Suicidal behavior is not uncommon in epilepsy patients. Risk factors for suicidal ideation are associated with social and vocational disturbances, such as low economic status, lack of social support and unemployment and psychiatric comorbidity. In epilepsy patients, interictal dysphoric disorder presents a depressive mood that may be associated with episodic suicidal ideation. Suicide may occur among patients with very severe epilepsy, but also in patients that recently achieved a complete seizure freedom. Recent research suggests that almost a third of epilepsy patients that endorsed suicidal ideation were euthymic or had only very mild depressive symptoms. People with epilepsy should be specifically asked about their psychiatric problems and potential suicidal ideation. Neurobiology of suicidal behavior in epilepsy patients is still unclear.

The role of Violence Against Women Act in addressing intimate partner violence: a public health issue

Intimate partner violence (IPV) is defined as violence committed by a current or former boyfriend or girlfriend, spouse or ex-spouse. Each year, 1.3 to 5.3 million women in the United States experience IPV. The large number of individuals affected, the enormous healthcare costs, and the need for a multidisciplinary approach make IPV an important healthcare issue. The Violence Against Women Act (VAWA) addresses domestic violence, dating violence, sexual assault, and stalking. It emphasizes development of coordinated community care among law enforcement, prosecutors, victim services, and attorneys. VAWA was not reauthorized in 2012 because it lacked bipartisan support. VAWA 2013 contains much needed new provisions for Native Americans; lesbian, gay, bisexual, transgender, gay, and queer (LGBTQ) individuals; and victims of human trafficking but does not address the large amount of intimate partner violence in America's immigrant population. There are important remaining issues regarding intimate partner violence that need to be addressed by future legislation. This review examines the role of legislation and addresses proposals for helping victims of IPV.

How often, or how many ways: clarifying the relationship between non-suicidal self-injury and suicidality

This study clarified the association of maladaptive, potentially self-damaging behaviors with suicidality. Specifically, we examined whether greater frequency (i.e., how often) or greater versatility (i.e., how many ways) of several self-damaging behaviors, including non-suicidal self-injury (NSSI), substance use, and disordered eating, increased risk for suicide. Participants who engaged in NSSI (N = 142) completed questionnaires assessing suicidal and self-damaging behavior at baseline and engagement in suicidal behaviors (e.g., ideation, attempts, talking about suicide) 3 months later. Results suggest that the versatility rather than frequency of self-damaging behaviors is most robustly associated with suicide risk. Engaging in multiple methods of NSSI and using a greater number of illicit substances were positively associated with suicide risk. Further, versatility of NSSI interacted with depression to predict suicide risk at 3-month follow-up such that highly depressed participants who engaged in more methods of NSSI exhibited highest risk, whereas those who engaged in more methods with low depression exhibited the lowest risk.

The suicidal process: age of onset and severity of suicidal behaviour

PURPOSE

The concept of the suicidal process implies a progression from behaviour of relatively low intent to completed suicide. Evidence from the literature has given rise to the speculation that the age of onset of an early form of the suicidal process may be associated with the ultimate seriousness of suicidal behaviour. This study was designed to test the hypothesis that early onset of the first stage of the suicidal process, a wish to die, is associated with increases in the ultimate position along the suicidal process dimension.

METHODS

Questions on the appearance and timing of suicidal process components (a death wish, ideation, plan, or attempt) were embedded in a telephone survey on mental health and addictions in the workforce. Records of those that had experienced suicidal behaviour were examined for the effects on the age of onset of the first death wish as a function of the level of severity of suicidal behaviour, gender, and depression.

RESULTS

The findings showed that increases in suicidal intent were associated with lowered age of the first death wish. This pattern held true for depressed and non-depressed persons alike.

CONCLUSIONS

The results support the notion that the early onset of a supposed precursor of suicidal behaviour, a death wish in this case, adds to its ability to portend more serious problem levels in later stages of life. Furthermore, mood operates independently in its association with the timing of such suicidal behaviour, suggesting that the effect of a relatively youthful appearance of a wish to die cannot be explained by early onset depression.

Adolescents' self-reported suicide attempts, self-harm thoughts and their correlates across 17 European countries

BACKGROUND

  Suicide is a leading cause of death among adolescents in Europe. Self-harm thoughts and behaviours are documented precursors of completed suicide. It is therefore of great importance to investigate the prevalence of suicide thoughts and attempts and their correlates, with the aim of preventing this major life-threatening public health problem. This study provides cross-national European data on self-reported suicidal thoughts and attempts among adolescents.

METHODS

  Data were obtained from 45,806 high school students aged 15-16 years from 17 countries that participated in the European School Survey Project on Alcohol and Other Drugs (ESPAD) 2007 school survey. The standardised methods of the ESPAD survey ensure comparability across countries. Students completed an anonymous questionnaire in their classrooms. The prevalences of suicidal thoughts and attempts are reported as well as their sociodemographic and psychosocial correlates identified in logistic regression.

RESULTS

  The median prevalence of any lifetime self-reported suicide attempt was 10.5% across the participating countries (range 4.1%-23.5%). The median of frequent self-harm thoughts (at least five times) was 7.4% (range 2.1%-15.3%). Suicidal behaviour and thoughts had significant associations with gender, substance use, family integrity and socioeconomic status. Countries with higher prevalence of substance use tended to have a weaker association between substance use and self-reported suicide attempts.

CONCLUSION

  Although self-reported self-harm thoughts and suicide attempts vary in prevalence within Europe, there are common correlates across countries. These have an important impact on understanding the phenomenon of suicide among young people and in guiding prevention.

Increasing self-reported suicide attempts by adolescents in Greece between 1984 and 2007

PURPOSE

This study examines trends in self-reported suicide attempts by Greek adolescents.

METHODS

Data were obtained from five nationwide school probability surveys, each of approximately 8,000-10,000 adolescents aged 14-18 years, carried out from 1984 to 2007. Students answered an anonymous questionnaire in their classrooms supervised by research assistants. Logistic regression analysis used as dependent variable any self-reported suicide attempts and as independent variables basic sociodemographic information and the year of the survey.

RESULTS

Self-reported suicide attempts doubled in prevalence from 7.0% in 1984 to 13.4% in 2007. Female gender (odds ratio OR 2.49, 95% confidence interval CI 2.30-2.71), living in a single parent family (OR 1.91, CI 1.73-2.11), lower paternal education (OR 1.20, CI 1.10-1.31) and living in a major city (OR 1.17, CI 1.08-1.27 for Greater Athens and OR 1.13, CI 1.00-1.28 for Thessaloniki) were significantly associated with suicide attempts. A larger increase among males, from 2.4 to 8.4%, compared to females (11.5 to 17.9%) contributed to a decrease in gender differences.

CONCLUSIONS

Changes in Greek society during the last 30 years, including loosening of family ties, increased drug use and stress because of the demands of school work, are hypothesised to have had an impact on the increasing trend in suicide attempts among adolescents.

The Suicidal Process and Self-Esteem

Background: It has not been made clear whether self-esteem is associated with the severity of suicidal behavior. Aims: To test the association between responses to a self-esteem inventory and levels of suicidal behavior as conceptualized in the notion of the suicide process. Methods: Questions on the severity of suicidal behavior over the lifespan (death wishes, ideation, plans, and attempts), as well as a self-esteem inventory, were administered to 227 university undergraduates. Results: A negative relationship was found between the level of suicidality and self-esteem. As hypothesized, there were fewer cases in each succeeding level of seriousness of suicidal behavior. However, nearly all cases from any particular level were contained in the cohort of individuals who had displayed suicidal behavior at a less serious level. Conclusions: This suggests a possible progression through each of the stages of suicidal behavior, with very few cases showing a level of suicidal behavior that was not associated with a previous, less serious, form. It was hypothesized that early entry into the suicidal process may be indicated by low self-esteem, thus, allowing for a more timely preventive intervention.

Prevalências de ideação, plano e tentativa de suicídio: um inquérito de base populacional em Campinas, São Paulo, Brasil

O objetivo foi estimar as prevalências ao longo da vida de ideação, planos e tentativas de suicídio na população. Quinhentos e quinze indivíduos residentes em Campinas, São Paulo, Brasil, foram selecionados utilizando-se amostragem estratificada por conglomerados e avaliados por entrevista do Estudo Multicêntrico de Intervenção no Comportamento Suicida. Calculamos prevalências ponderadas, com os respectivos intervalos de 95% de confiança (IC95%). As prevalências foram de 17,1% (IC95%: 12,9;21,2) para ideação, 4,8% (IC95%: 2,8;6,8) para planos e 2,8% (IC95%: 0,09;4,6) para tentativas de suicídio. O comportamento suicida foi mais freqüente em mulheres e em adultos jovens. A existência de um plano de como tirar a própria vida, em termos de freqüência, situa-se próximo da tentativa (relação de 5:3). De cada três tentativas de suicídio, apenas uma chegou a ser atendida em um serviço médico. As prevalências se assemelham à maioria dos estudos de outros países. É essencial coletar diretamente na comunidade informações sobre o comportamento suicida, abarcando-o em sua abrangência.

How often does deliberate self-harm occur relative to each suicide? A study of variations by gender and age

Deliberate self-harm (DSH; i.e., nonfatal self-poisoning or self-injury) occurs much more frequently than suicide, yet there has been little detailed investigation of the comparative rates of DSH and suicide. We conducted a study of how rates of DSH relate to suicide rates across the life cycle by gender and by method of estimation of DSH rates, using 10 years of data from a local system for monitoring DSH presentations to a general hospital and national and local suicide statistics. The rate-ratio of DSH to suicide was 36 (95% CI 34.9-37.1) based on annual person-based rates of DSH episodes and was nearly five times higher in females (87.9; 95% CI 84.4-91.6) than in males (18.7; 95% CI 17.9-19.6). The ratio varied markedly across the life cycle, decreasing from more than 200 in teenagers to less than 10 in persons aged 60 years and over. The difference in the ratio between females and males also decreased over the life cycle. There were very similar findings when local suicide rates were used. These patterns were replicated when the data were analyzed, first, on the basis of all episodes of DSH during the study period, but with expectedly larger DSH:suicide ratios (e.g., overall 52.7; 95% CI 51.4-54.1), and second, on the basis of individual persons only engaging in DSH during the study period, but with smaller ratios (e.g., overall 26.2; 95% CI 25.4-27.2). The DSH:suicide rate ratios for those with high and low suicidal intent were similar within age groups except for those aged 60 years and over, in whom there was a greater proportion of high intent acts. These findings illustrate how the nature of self-harming behavior may vary in intention across the life cycle and between the genders, and provide a basis for further comparative work of this kind.

PSYCHOSOCIAL FACTORS IN PATIENTS WITH CHRONIC KIDNEY DISEASE: The Psychiatric Landscape of Withdrawal

Withdrawal from dialysis is an appropriate decision for situations in which the burdens of treatment outweigh the benefits. Alternately, it can be viewed as a public health problem and suicide equivalent that contributes to the high mortality of end-stage renal disease (ESRD). More than one in five deaths of patients with ESRD are preceded by dialysis cessation, and approximately 15,000 Americans died last year following a determination to stop this life-support treatment. This article discusses what is known about the psychosocial aspects of the patients who terminate dialysis, the role of depression and other psychiatric disorders, the family perspective, and the relationship of these decisions to suicide.

Younger onset of depression is associated with greater suicidal intent

BACKGROUND

Age of onset of major depression seems to be dropping in Western nations. Early onset usually predicts a more serious illness with a relatively poor prognosis. Since depression is associated with suicide, this begs the question of whether early onset of depression is associated with the degree of intent of suicidal behaviour, and whether this relationship differs according to gender.

METHODS

Relevant responses from 9,282 residents of the United States were drawn from a nationally representative community survey conducted in 2001 through 2003 using the W.H.O. version of the Composite International Diagnostic Interview. The primary outcome measure was the retrospectively determined age of first major depressive episode.

RESULTS

Younger age of onset for depression was associated with higher levels of suicidal intent, irrespective of age at the time of interview. A significant interaction between level of intent and age at interview appeared to be accounted for by the later onset among those in the eldest cohort who reported an absence of suicidal behaviour. The influence of suicidal intent on onset of depression was greater for women than for men.

CONCLUSIONS

The earlier the age of first symptoms of major depressive episode, the higher the degree of suicidal intent, irrespective of age at interview and gender, although the more pronounced trend for women suggests a greater sensitivity to underlying factors that may involve depression and lead to suicide risk.

Pathways to suicidality across ethnic groups in Canadian adults: the possible role of social stress

BACKGROUND

Ethnicity is an important determinant of mental health outcomes including suicidality (i.e. suicidal ideation and suicide attempt). Understanding ethnic differences in the pathways to suicidality is important for suicide prevention efforts in ethnically diverse populations. These pathways can be conceptualized within a social stress framework.

METHOD

The study examines ethnic differences in the pathways to suicidality in Canada within a social stress framework. Using data from the Canadian Community Health Survey Cycle 1.1 (CCHS 1.1) and path analysis, we examined the hypotheses that variations in (1) socio-economic status (SES), (2) sense of community belonging (SCB), (3) SES and SCB combined, and (4) SES, SCB and clinical factors combined can explain ethnic differences in suicidality.

RESULTS

Francophone whites and Aboriginals were more likely to report suicidality compared to Anglophone whites whereas visible minorities and Foreign-born whites were least likely. Disadvantages in income, income and education, income and its combined effect with depression and alcohol dependence/abuse led to high rates even among the low-risk visible minority group. Indirect pathways for Asians differed from that of Blacks and South Asians, specifically through SCB. With the exception of SCB, Aboriginals were most disadvantaged, which exacerbated their risk for suicidality. However, their strong SCB buffered the risk for suicidality across pathways. Disadvantages in education, income and SCB were associated with the high risk for suicidality in Francophone whites.

CONCLUSIONS

Francophone whites and Aboriginals had higher odds of suicidality compared to Anglophone whites; however, some pathways differed, indicating the need for targeted program planning and prevention efforts.

Suicide among Asian Americans: what do we know? What do we need to know?

The current review begins with an acknowledgment of the diversity within the Asian American population as well as the scarcity of information on suicide among this particular racial/ethnic minority group. In analyzing what is known and what still needs to be learned about suicide among Asian Americans, the current article provides a critical review of significant factors such as age, gender, religious and spirituality issues, acculturation, social support, familial dynamics, social integration as well as gay/lesbian/bisexual orientations. In examining these factors, recommendations related to interventions and the existing research gaps are also discussed.

Gender differences in bipolar disorder type 1: a 48-week prospective follow-up of 72 patients treated in an Italian tertiary care center

To explore gender differences in bipolar I disorder, we compared the longitudinal treatment outcome and baseline demographic and clinical characteristics of 27 male and 45 female adult subjects who were treated for an acute affective episode and longitudinally followed for a period of up to 48 weeks. Females were more likely to report a history of suicidal gestures and a comorbid panic disorder; males were more likely to present with a comorbid obsessive-compulsive disorder, and there was a trend for a more frequent history of alcohol or substance abuse. No significant differences were found between the genders for the time to remission from the index episode, number of recurrences, and time spent with any clinical or subclinical mood symptom during the 48 weeks of maintenance treatment. Although differences may exist between bipolar I male and female subjects, prospective course does not seem to reveal differences in a 48-week period, at least when similar treatment strategies are adopted.

Epidemiology of nonfatal deliberate self-harm in the United States as described in three medical databases

The absence of validated U.S. rates of nonfatal suicidal behavior places risk management and injury prevention programs at danger of being poorly informed and inadequately conceptualized. In this study we compare estimated rates of intentional self-harm from two ongoing surveys (National Electronic Injury Surveillance System-All Injury Program-NEISS-AIP; National Hospital Ambulatory Medical Care Survey-NHAMCS) to data from the Toxic Exposure Surveillance System. Results suggest that, for every 2002-2003 suicide, there were 12 (NEISSAIP) or 15 (NHAMCS) self-harm-related emergency department visits, and for every intentional self-poisoning death there were 33 intentional overdoses reported to poison control centers, of which two ultimately went untreated.

Chronic medical conditions and wishes to die among older primary care patients

OBJECTIVE

To determine the prevalence of wishes to die and the medical correlates of wishes to die among primary care patients aged 65 years and older.

METHOD

Three-hundred and fifty-five adults with and without significant depressive symptoms who were screened in primary care offices and invited to participate completed a baseline in-home assessment. Participants were interviewed using standardized measures of medical conditions, functional status, and psychological status. Thoughts of death and wishes to die were assessed with standard questions from the Composite International Diagnostic Interview (CIDI) Depression Section.

RESULTS

The weighted point prevalence of thoughts of death was 9.7% and 6.1% for the wish to die. Several medical conditions were associated with a wish to die, for example myocardial infarction (MI). In multivariate models that adjusted for potentially influential characteristics, the association between a history of MI and the wish to die remained statistically significant (odds ratio (OR) = 3.32, 95% confidence interval (CI) (1.26, 8.75).

CONCLUSIONS

Thoughts of death and a wish to die are common in older primary care patients and were more likely among persons with chronic medical conditions. Persons with a history of myocardial infarction may be particularly vulnerable to a wish to die.

The development of a brief screening instrument for depression and suicidal ideation for elderly: the Depression and Suicide Screen

The early detection of depression and suicidal ideation is essential for the prevention of suicide in the community. This study therefore aimed to develop a brief screen for depression and suicidal ideation that can be easily administered in primary-care settings. The Self-rating Depression Scale (SDS), the Hospital Anxiety and Depression Scale (HADS) and a modified version of the Composite International Diagnostic Interview (CIDI) were administered by 353 residents of a single community aged 64 years and over. A five-item screen was derived from SDS and HADS, using CIDI as the external criterion (study 1). The scale was modified so that it was more appropriate for our use, and was labeled the Depression and Suicide Screen (DSS). Its validity and reliability were examined among a further 382 residents of the same community aged 64 years and over, using the Short-Form Geriatric Depression Scale (GDS-S) as the external criterion (study 2). The DSS was internally consistent (Cronbach's alpha=0.62). Its reliability in detecting depression (defined as >or= 6 in GDS-S) and suicidal ideation (screened out by the inquiry by our trained staff) was 0.768 and 0.721, respectively. For depression, the sensitivity was 0.705; specificity, 0.729; positive predictive value (PPV), 0.446; negative predictive value (NPV), 0.888; and the overall diagnostic power, 0.723. For suicidal ideation, its sensitivity was 0.698; specificity, 0.693; PPV, 0.317; NPV, 0.926; and overall diagnostic power, 0.694. The DSS demonstrated a reasonable level of sensitivity and specificity in identifying both depression and suicidal ideation among the elderly within a community.

Intimate partner sexual assault against women and associated victim substance use, suicidality, and risk factors for femicide

In order to establish the frequency of substance use, following and attributed to sexual assault, and describe the danger for femicide and suicidality for women physically and sexually abused compared to physically-abused only women, a personal interview of 148 African-American, Hispanic, and white English and Spanish-speaking abused women was completed. Women who reported more than one sexual assault were 3.5 (95% CI, 0.9, 13.4) times more likely to report beginning or increasing substance use compared to women who reported only one sexual assault. Sexually assaulted women reported significantly (p=.002) more risk factors for femicide compared to physically- abused only women. Specific to suicide, women reporting sexual assault were 5.3 (95% CI, 1.3, 21.5) times more likely to report threatening or attempted suicide within a 90-day period compared to physically-abused only women. The health assessment and intervention of intimate partner violence must extend beyond injury to include behavior risk sequelae of substance abuse and suicidality.

How does a suicide attempter eat differently from others? Comparison of macronutrient intakes

OBJECTIVE

Issues of the subtle effects of diet and nutrition on suicidal behaviors are rarely examined. This study describes the differences in dietary intakes of macronutrients between individuals who had ever made a suicide attempt and those who never had.

METHODS

We examined the data of 7631 non-institutionalized adults ages 17 to 39 y who completed a mental disorder diagnostic interview and a 24-h dietary recall as a part of the Third National Health and Nutrition Examination Survey, 1988 to 1994. Multivariable adjusted means of daily caloric intake and energy percentage from macronutrients were calculated for individuals who had a history of lifetime suicide attempt(s) (n = 408) and compared with those who did not.

RESULTS

After adjustment for covariates, including socioeconomic indicators, health risk factors, and history of medical and psychiatric illnesses, we observed that the means of daily caloric intake, cholesterol, and energy percentages from carbohydrate, total fat, saturated fat, monounsaturated fat, and protein did not differ significantly between attempters and non-attempters. However, energy percentage from polyunsaturated fat was lower in attempters than in non-attempters. Mean percentages +/- standard error for smoking attempters, non-smoking attempters, smoking non-attempters, and non-smoking non-attempters were 5.5 +/- 0.4 (P = 0.01), 6.7 +/- 0.2 (P = 0.02), 7.5 +/- 1.4 (P = 0.78), and 7.2 +/- 0.1 (reference), respectively, in men, and 6.3 +/- 0.4 (P = 0.01), 7.2 +/- 0.2 (P = 0.07), 7.3 +/- 1.0 (P = 0.89), and 7.5 +/- 0.1 (reference), respectively, in women. Dietary fiber intake was also lower in attempters than in non-attempters. These differences were independent of daily caloric intake.

CONCLUSIONS

Individuals with a history of suicide attempt have low intakes of polyunsaturated fat and fiber. Potential deleterious effects of low intake of polyunsaturated fat and fiber among suicide attempters merit further investigation.

The prevalence of suicidal phenomena in adolescents: a systematic review of population-based studies

The results of a systematic review of the international literature on the prevalence of suicidal phenomena in adolescents, including the influence of survey method, gender, and ethnicity are reported. The literature was searched using six electronic databases to identify all population-based studies of self-reported suicidal phenomena; 128 studies were included, comprising 513,188 adolescents. The mean proportion of adolescents reporting they had attempted suicide at some point in their lives was 9.7% (95% CI, 8.5-10.9), and 29.9% (95% CI, 26.1-33.8) of adolescents said they had thought about suicide at some point. Females were significantly more likely than males to report most suicidal phenomena. A lower prevalence of some suicidal phenomena was found for Asian populations. The prevalence of suicidal phenomena varied depending on the terminology used and tended to be higher in studies employing anonymous questionnaires than in studies employing non-anonymous methods (questionnaires or interviews), although most of these differences were not statistically significant.

Personality as a mediator of demographic risk factors for suicide attempts in a community sample

The aim of this study was to determine whether personality might partially explain associations between sociodemographic factors and self-reported suicide attempts. This analysis was motivated by reports that certain personality traits are logical targets for intervention, whereas sociodemographic characteristics are not generally modifiable. Data were from a postal survey sent to community residents who were previously selected at random (N = 912). Age, gender, health-insurance status, education, self-reported health, and marital history were identified as relevant sociodemographic predictors of having made one or more lifetime suicide attempts. Risk associated with each of these variables was mediated by the personality traits of self-directedness (SD) and harm avoidance (HA). In a multiple logistic-regression analysis constrained to sociodemographic predictors, only young age, female sex, poor self-reported health, and Medicaid status remained as predictors of suicide attempts. When personality factors were added to the model, all of the sociodemographic predictors except Medicaid status were rendered nonsignificant or marginally significant. Risk associated with gender was primarily related to HA, risk associated with poor self-reported health was mediated by both HA and SD, and the risk associated with young age was primarily mediated by SD; the last was the largest mediation effect observed. In contrast, risk associated with receipt of Medicaid, presumed to indicate low socioeconomic status, was not mediated by personality. We conclude that risk associated with certain nonmodifiable demographic factors is often mediated by potentially modifiable intrapersonal factors, such as SD.

Rates and risk factors for suicide, suicidal ideation, and suicide attempts in chronic epilepsy

Studies of causes of death among people with epilepsy suggest that the lifetime prevalence rate of suicide is elevated. Although not all of the studies have reported an increased risk for suicide, the collective data yield an average rate of approximately 12% among people with epilepsy, compared with 1.1-1.2% in the general population. The increased risk for suicide appears to affect children and adolescents as well as adults. Rates of suicide attempts have also been reported to be elevated among people with epilepsy. A suicide attempt is a significant risk factor for completed suicide. Certain psychiatric disorders, including primary mood disorders, also increase the risk for suicide. Among people with epilepsy, psychiatric comorbidity is common, and rates of mood disorders, particularly major depression, have consistently been reported to be elevated. Other potential risk factors are family issues, physical health, personality, life stress, previous suicidal behavior, and access to firearms. Assessing severity of risk helps to determine the appropriate level of intervention. The suicidality module of the Mini-International Neuropsychiatric Interview is a practical tool to help quantify current suicide risk.

Population attributable risk of major depression for suicidal ideation in a random and representative community sample

BACKGROUND

The importance of depression in suicidal behaviour and suicidal ideation is usually determined on clinical samples. However, public health planning also requires population data. This study utilised the population attributable risk statistic in determining the importance of major depression as a contributing factor to suicidal ideation in a random and representative sample of the population.

METHOD

Major depression and suicidal ideation as well as demographic and clinical data were delineated in a random and representative population sample of 3010 subjects. The population attributable risk statistic was used to determine the contribution of major depression to suicidal ideation.

RESULTS

Multivariate analysis demonstrated that major depression was the major contributor to the risk for suicidal ideation with a population attributable risk of 56.6%.

CONCLUSIONS

These results, utilising different measures of depression and suicidal ideation to those few previous population attributable risk studies examining this issue, confirm the overwhelming importance of major depression as a contributing factor to suicidal ideation in the community.

Exposure to suicide: incidence and association with suicidal ideation and behavior: United States, 1994

Exposure to the suicide of another is common, but the magnitude and effects of such exposure are not well quantified. From a national random telephone survey of U.S. adults, we estimated the 12-month incidence of exposure to suicide and its association with suicidal ideation, planning, and behavior. Of 5,238 respondents, 342 (a weighted 7.0% representing 13.2 million persons) reported knowing a suicide decedent from the previous year. Univariate analysis showed persons reporting such exposure were significantly more likely to describe suicidal ideation and behavior than those unexposed; multivariate analysis showed no association. Though the risk related to suicide exposure may be small, given the magnitude of exposure, it may warrant intervention efforts because of its potential societal impact.

Suicide attempts among gay and bisexual men: lifetime prevalence and antecedents

OBJECTIVES

We examined lifetime prevalence of suicide attempts and psychosocial correlates in a large population-based sample of men who have sex with men (MSM).

METHODS

A telephone probability sample of US urban MSM (n = 2881) were interviewed between November 1996 and February 1998.

RESULTS

Twenty-one percent had made a suicide plan; 12% had attempted suicide (almost half of those 12% were multiple attempters). Most who attempted suicide made their first attempt before age 25. Although prevalence of parasuicide (i.e., attempted suicide) has remained constant across birth cohorts, mean age at initial attempts has declined.

CONCLUSIONS

MSM are at elevated risk for suicide attempts, with such risk clustered earlier in life. Some risk factors were specific to being gay or bisexual in a hostile environment.

Differences in nonfatal suicide behaviors among Mexican and European American middle school children

This report describes ethnic and gender differences in suicide ideation among two large samples of middle school students in New Mexico (n = 2,140) and Texas (n = 1,302). Students completed a self-administered questionnaire on suicide ideation and psychosocial risk factors. Mexican Americans in both samples reported significantly higher prevalence of suicide ideation than did their European American counterparts. Mexican Americans were 1.8 times more likely to have high suicide ideation than European Americans. The suicide ideation risk for Mexican Americans remained unchanged in both samples after adjusting for gender, age, family structure, depression, low social support, and self-esteem. This study indicates that ethnicity plays an important role in suicidal ideation, but the mechanism remains unclear.

Epidemiology of suicidal ideation and help-seeking behaviors among the elderly in Japan

This study offers an analysis of the elderly (over 65 years of age) among a general community population in terms of the percentages of: (i) persons with recurring thoughts of death and/or of committing suicide, and (ii) people who have consulted others, including medical professionals, with regard to these problems. Among 433 elderly over the age of 65 in one community in a town in Aomori Prefecture, 358 agreed to participate in the project. Forty-four participants (12.3%) responded that they had either 'thoughts of death' or 'thoughts of suicide', and these thoughts had continued for more than 2 weeks in 12 participants (3.4%). Only 15 of the 44 suicidal elderly responded that they had consulted someone about their problems. Although there are many elderly people exhibiting a subclinical depressive state with recurring thoughts of death or thoughts of suicide, the number of people who consult family members, professionals, or others is very low. This suggests the importance of community networking through educational activities so that people can more readily talk to and support one another.

Loneliness in relation to suicide ideation and parasuicide: a population-wide study

Some links between loneliness and different manifestations of suicidal conduct have been reported in variety of subgroups (e.g., college students, the elderly, psychiatric patients). We tested this hypothesis by using the results of a population-wide survey. Strong associations among suicide ideation, parasuicide and different ways of being lonely and alone, defined either subjectively (i.e., the feeling), or objectively (i.e., living alone or being without friends), were observed. Moreover, prevalence of suicide ideation and parasuicide increased with the degree of loneliness. Only minimal differences between men and women were found.

Methodological Issues in Community Surveys of Suicide Ideators and Attempters

Summary: There have been quite a number of community studies in recent years, with surveys being conducted among the general population, in schools, and among the elderly. While all of these studies have greatly contributed to our understanding of suicidal behavior, because of different approaches toward methodology and definitions, they also have some limitations. These limitations spring mainly from the fact that definitions of suicidal ideation and behavior vary widely across studies, which makes comparisons between studies unreliable. The different utilization of methodology is another problem that can impact the comparability of the community studies.

The Measurement of Suicidal Ideation

A four-item suicidal ideation subscale of the GHQ-28 has been used previously to assess suicidal ideation on the basis of its face validity. In order to further validate its use, this study compared scores on this scale with scores on a well-established suicidal intent scale. There was a significant correlation between scores of that subscale and the self-report component as well as the overall score of the suicidal intent scale, thereby confirming its validity in providing a standardized method for comparing suicidal ideation in different populations.

Suicidal ideation and suicide attempts among adult Danes

This study describes the prevalence of suicidal ideation and attempted suicide in a representative survey among adults in Denmark and gives the proportion of people reporting a suicide attempt that results in contact with the health care system. The data for the 1994 Danish national health interview survey were collected by personal interview and a self-administered questionnaire. A subsample of 1362 individuals participated in the part of the survey that addressed suicidal behaviour (64% of the random sample). The results show that 6.9% reported having had suicidal thoughts within the past year. Averaging across all age groups the overall prevalence of people reporting ever having made a suicide attempt was 3.4% and the one-year prevalence was 0.5%. Suicidal ideation was more prevalent among young people than among older people, whereas ever-attempted suicide showed no age gradient. Both suicidal ideation and ever-attempted suicide were more prevalent among economically inactive people (e.g. unemployed) and among unmarried or divorced people. We estimate that 50-60% of suicide attempts reported in a representative, national survey become known to the healthcare system.

Suicide attempts and ideation among adults in Addis Ababa, Ethiopia

Attempted suicide is one of the major risk factors for completed suicide, is associated with psychiatric disorders, and is also a potentially fatal event. We describe here a study of suicide attempts and ideation in a representative sample of 10,203 adults in Addis Ababa. The study was conducted between January and March 1994. The prevalence of current suicidal ideation was 2.7%. Lifetime prevalence of suicidal attempt was 0.9%. Most of the attempts (66%) occurred when subjects were under 25 years of age. Hanging was the preferred method for men and poisonings for women. There were no significant associations between suicide attempt and sex, ethnicity or religion. Current suicidal ideation was more common in men than women, odds ratio (95% confidence interval), OR (95% CI): 0.67 (0.48, 0.93). There was a statistically significant trend of decreasing risk of ideation with increasing age and educational attainment. There was a 68% decrease in the risk of ideation in the 60 years of age and above group compared to the 15-24 year group: OR (95% CI): 0.32 (0.16, 0.62). Marital status, ethnicity, and religion were not associated with suicidal ideation.

Identification of suicide risk factors using epidemiologic studies

Suicide is a complex outcome of multiple, inter-related factors. This article presents the epidemiology of completed and attempted suicide and discusses the known risk factors for suicide within a framework designed to encourage a systematic approach to theory testing and prevention. Mental and addictive disorders, frequently in co-occurrence, are the most powerful risk factors for suicide in all age groups, accounting for over 90 percent of all completed suicides. In combination with proximal risk factors such as access to firearms or other lethal means, recent and severe stressful life events, and intoxication, they can form the necessary and sufficient conditions for suicide.