ABCB1 gene polymorphisms and violent suicide attempt among survivors

IntroductionThose suicide attempters that choose violent methods dramatically diminish the possibility of survival. Completed suicide using violent means, which is common among first-time suicide attempters, was recently found to be more likely among T allele carriers in the three most common ABCB1 SNPs, encoding for P-gp. Thus, this study examined, for the first time, whether these ABCB1 SNPs were associated with the use of violent means among survivors of a suicide attempt.Material and methodsSuicide attempters (n = 578, 87.4% women; of whom 16.6% committed a violent intent) were genotyped for exonic SNPs in the ABCB1 (C1236T, G2677T/A, C3435T). The relations of the three genotypes and of the TTT haplotype with the use of a violent suicide method were evaluated separately. The impact of confounds on these variables was controlled.ResultsA higher frequency (p = 0.02) of suicide attempters using violent methods was found among those carrying the ABCB1 haplotype (1236TT-2677TT-3435TT). Since gender and number of previous suicide attempts were identified as confounds, the relation was tested in the subset of women who were first-time attempters or second- and more-time attempters. The ABCB1 haplotype increased the risk more than three times in those women attempting a violent suicide for the first time (OR = 3.6; CI95%: 1.08–12.09; p = 0.04).DiscussionThe ABCB1 haplotype (1236TT-2677TT-3435TT) was related to the use of a violent suicide attempt method. Genotyping for these three ABCB1 SNPs may be helpful to detect people at risk of first suicide intents using violent methods.     

Sex differences in risk factors for suicide after attempted suicide

Abstract.Aim: This study aims to investigate suicide risk factors after attempted suicide and whether and how these risk factors differ between the sexes.Method: A total of 1052 suicide attempters admitted to the Medical Emergency Inpatient Unit, Lund University Hospital, Sweden were followed up concerning suicide and death from other causes after a median period of 6 years and 5 months. In all, 50 persons committed suicide during follow-up. At the index suicide attempt, socio-demographic data and information about clinical characteristics were gathered in a standardised manner. Risk factors were identified among these data using survival analyses for the whole sample and for each sex separately.Result: Men had a higher frequency of suicide and a greater overall mortality than women. Cox regressions showed that suicide attempt(s) prior to the index attempt and the use of a violent method for the index attempt were risk factors for men only, whereas older age and a high suicidal intent (Beck SIS score) were female ones. Major depression was a risk factor for both sexes.Conclusion: More attention probably needs to be paid to the importance of gender in assessment of suicide risk and treatment of suicide attempters.     

Concurrent adversities and suicide attempts among Sami and non-Sami adolescents: the Norwegian Arctic Adolescent Study (NAAHS)

Background: Little is known about connections between adolescent suicide attempts (SA) and concurrent adversities.

Aims: In a cross-sectional study, the authors wanted to investigate prevalences, additive effects of adversities, family and peer relations, gender, divorce and poverty, and ethnic differences between Sami and non-Sami youth.

Methods: In an adolescent community population encompassing 4881 adolescents of 15–16 years of age, youth with and without self-reports of attempted suicide the last year were compared on 12 concurrent adversities, on scales assessing family and peer functioning, and on sociodemographic variables.

Results: The prevalence of attempted suicide the last year was 5.3%, and more girls (8.8%) than boys (1.8%). All 12 concurrent adversities were strongly related to SA. The suicide attempters reported two and a half times as many adversities as non-attempters. A strong multiple additive relationship was found. Multivariately, among boys, the strongest risk factors were suicide among friends (OR?=?9.4), and suicide in the family or in the neighbourhood (OR?=?4.8). Among girls, sexual abuse (OR?=?5.2) and parent mental problems (OR?=?4.6) were strongest related to SA. Suicide attempters reported more divorce and poverty, more conflicts with parents, and less family support and involvement. Totally, Sami youth reported more SA and more concurrent adversities than non-Sami peers.

Conclusion: Adolescent suicide attempters are heavily burdened with concurrent adversities. Clinicians should be aware of gender differences in risk factors, and should ask about abuse and suicide or attempts among relatives and peers. A family perspective in clinical work is needed.     

Elderly suicide attempters with depression are often diagnosed only after the attempt

OBJECTIVE: No previous study has comprehensively investigated the pattern of health care contacts among elderly subjects attempting suicide. The present study compared elderly suicide attempters with younger attempters, before and after attempted suicide, in terms of health care contacts, clinical diagnoses of mental disorders, and characteristics predicting lack of treatment contact after the index attempt. METHODS: All consecutive 1198 suicide attempters treated in hospital emergency rooms in Helsinki, Finland, from 15.1.1997 to 14.1.1998 were identified and divided into two age groups: (1) elderly suicide attempters aged 60 years or more (n = 81) and (2) suicide attempters aged under 60 years (n = 1117). RESULTS: During the final 12 months before the attempt, the majority of elderly suicide attempters had a contact with primary health care, but their mood disorders were likely to have remained undiagnosed before the index attempt. In primary health care, only 4% had been diagnosed with a mood disorder before the attempt, but 57% after (p < 0.001). After the suicide attempt, most elderly suicide attempters were referred for aftercare, two thirds having contact with psychiatric care. CONCLUSIONS: For purposes of preventing suicidal behaviour, screening for depression, plus further education on recognition, diagnosis and treatment of mood disorders among the elderly in primary health care setting are needed.     

重复自杀行为众多影响因素分析

目的探讨重复自杀行为者的特点及其自杀的危险因素。方法采用WHO健康量表、Beck抑郁自评量表、自杀强度量表等对115例住院的自杀未遂者实施调查,并追踪随访6年,对整个病程中仅有单次自杀行为和重复自杀行为两类人群住院时人文特点及评估资料进行比较。结果115例自杀未遂者中重复自杀行为24例,占20.9%。24例重复自杀行为者就诊治疗时年龄42.6±13.2岁,WHO健康量表得分7.04±5.64,Beck抑郁自评得分26.25±17.36,自杀强度得分10.04±4.94,16例(66.7%)患有精神疾病;91例单次自杀行为者年龄32.6±13.9岁,WHO健康量表得分15.91±5.61,Beck抑郁自评得分6.82±10.51,自杀强度得分7.76±3.97,20例(22.0%)患有精神疾病。重复与单次自杀行为者比较,两组在年龄、WHO健康量表、Beck抑郁自评得分、自杀强度得分、有无精神疾病以及自杀方式、是否真的想死、是否存在困扰1年以上躯体病或残疾、未来没有希望、身体健康状况自评方面存在明显差异(均P<0.05)。回归分析显示,自杀强度得分与是否真的想死得分相加代表的自杀致死倾向(P=0.036,OR=2.85,β=1.047),WHO健康量表与身体健康自评得分相加所代表的健康心理状态(P=0.026,OR=0.320,β=-1.141)进入回归方程。结论重复自杀行为者多患有精神疾病,抑郁心境、无望、自杀强度高等。有效评估这些因素对了解或防范未遂者再次出现自杀风险有重要意义。     

A 5-year follow-up study of suicide attempts

Johnsson Fridell E, Öjehagen A, Träskman-Bendz L. A 5-year follow-up study of suicide attempts. Acta Psychiatr Scand 1996: 93: 151–157. Q Munksgaard 1996. Seventy-five patients were admitted to the ward of the Lund Suicide Research Center following a suicide attempt. After 5 years, the patients were followed up by a personal semistructured interview covering sociodemographic, psychosocial and psychiatric areas. Ten patients (13%) had committed suicide during the follow-up period, the majority within 2 years. They tended to be older at the index attempt admission, and most of them had a mood disorder in comparison with the others. Two patients had died from somatic diseases. Forty-two patients were interviewed, of whom 17 (40%) had reattempted during the follow-up period, most of them within 3 years. Predictors for reattempt were young age, personality disorder, parents having received treatment for psychiatric disorder, and a poor social network. At the index attempt, none of the reattempters had diagnoses of adjustment disorders or anxiety disorders. At follow-up, reattempters had more psychiatric symptoms (SCL-90), and their overall functioning (GAF) was poor compared to those who did not reattempt. All of the reattempters had had long-lasting treatment (> 3 years) as compared to 56% of the others. It is of great clinical importance to focus on treatment strategies for the vulnerable subgroup of self-destructive reattempters.     

Three-year mortality rate of suicide attempters in consultation-liaison service

Objective: Suicide attempters might be sent to the emergency room for urgent medical intervention. Some with more severe physical morbidity may be hospitalised, and psychiatrists might be consulted for suicide evaluation. The aim of our study was to investigate the three-year all-cause mortality rate of hospitalised suicide attempters with regard to the effect of consultation-liaison services, and to identify any risk factors associated with mortality.

Methods: Between 2002 and 2006, 196 inpatients from medical or surgical wards in a general hospital who had consulted psychiatrists because of suicide attempts were collected consecutively. We traced their mortality incidence during a three-year period, and calculated the mortality rate and time (days) to death.

Results: Three-year all-cause mortality was 20.4%, and there was a higher risk of mortality in the first two years after the index suicide attempt. In the adjusted Cox regression model, associated risks included male gender, older age, diagnosis of depressive disorders and lack of psychiatric follow-up.

Conclusions: We found that hospitalised suicide attempters had higher all-cause mortality after discharge, and determined that psychiatric follow-up is helpful. More attention should be paid to those with potential risk factors, and timely intervention is suggested in order to reduce mortality.     

A proposed model of the development of suicidal ideations

BackgroundSuicidal ideations may precede suicide attempts. They are of particular concern in psychiatric populations because psychopathology is a major risk factor for suicide. The factors affecting the development of suicide ideations may differ among psychiatric patients with and without a previous suicide attempt and individuals without a psychiatric diagnosis.ObjectivesThe aim of this study is to develop a model of suicide ideation in psychiatric patients and the general population.MethodThe study included 196 participants: 92 psychiatric patients with a previous suicide attempt (“attempters”); 47 psychiatric patients who had never attempted suicide (“non-attempters”); and 57 healthy control subjects. Data were collected on socio-demographic parameters, clinical history, and details of the suicide attempts. Participants completed a battery of psychological instruments assessing aggression–impulsivity, mental pain (including depression and hopelessness) and communication difficulties, in addition to negative life events. Findings were correlated with suicidal ideation by group.ResultsThe correlations of the different variables with suicidal ideation differed between suicide attempters and non-attempters; therefore, the model was analyzed separately for each group. The study yielded three major findings: negative life events had a significant effect on both anger-in and impulsivity in non-attempters but not in attempters; hopelessness moderately contributed to suicidal ideations in attempters but not in non-attempters; loneliness contributed significantly to depression in non-attempters but was less distressing in attempters.ConclusionThe mechanism underlying suicidal ideation appears to differ between psychiatric patients who have previously attempted suicide and those who have not, supporting a dual model of suicidal ideation. Although this is only a preliminary study, these findings are important for furthering our understanding of the process of transition of suicidal thoughts to completion of suicide. These results need further replication with a larger cohort of subjects.     

Hypothalamic–pituitary–adrenal axis hyperactivity is associated with decreased brain-derived neurotrophic factor in female suicide attempters

Introduction: Both decreased levels of brain-derived neurotrophic factor (BDNF) and hypothalamic–pituitary–adrenal (HPA) axis dysregulation may be involved in the pathophysiology of suicidal behaviour, as well as cognitive symptoms of depression. Pre-clinical and clinical studies have shown interactions between HPA-axis activity and BDNF, but this has not been studied in a clinical cohort of suicidal subjects. The purpose of this study was, therefore, to investigate associations between HPA-axis activity and BDNF in suicide attempters. Furthermore, this study examined the relationship between the HPA-axis, BDNF, and cognitive symptoms in suicidal patients. Since previous data indicate gender-related differences in BDNF and the HPA axis, males and females were examined separately.

Method: Seventy-five recent suicide attempters (n?=?41 females; n?=?34 males) were enrolled in the study. The Dexamethasone Suppression Test (DST) was performed and BDNF in plasma were analysed. Patients were evaluated with the Comprehensive Psychopathological Rating Scale (CPRS) from which items ‘Concentration difficulties’ and ‘Failing memory’ were extracted.

Results: Only among females, DST non-suppressors had significantly lower BDNF compared to DST suppressors (p?=?0.022), and there was a significant correlation between post-DST serum cortisol at 8 a.m. and BDNF (r_s?=??0.437, p?=?0.003). Concentration difficulties correlated significantly with post-DST cortisol in all patients (r_s?=?0.256, p?=?0.035), in females (r_s?=?0.396, p?=?0.015), and with BDNF in females (r_s?=??0.372, p?=?0.020).

Conclusion: The findings suggest an inverse relationship between the HPA-axis and BDNF in female suicide attempters. Moreover, concentration difficulties may be associated with low BDNF and DST non-suppression in female suicide attempters.     

Trait impulsivity in suicide attempters: Preliminary study

Suicide attempt is a risk factor for suicide. To investigate trait impulsivity among suicide attempters, 93 attempters admitted to an emergency department and 113 healthy controls were evaluated using the Japanese version of the Barratt Impulsiveness Scale (BIS‐11J). Impulsivity was analyzed in relation to clinical data in the attempters. Total BIS‐11J, attention impulsiveness, and motor impulsiveness scores were significantly higher in the attempters than in the controls. Both total BIS‐11J and non‐planning impulsiveness scores were significantly higher in attempters with schizophrenia and other psychotic disorders among the diagnostic groups. Control of impulsivity should be considered as one of the targets for suicide prevention.     

Discordance between family report and clinical assessment of suicide attempts: a prospective study from the emergency department

BackgroundDeveloping accurate identification methods for individuals with suicide attempts and providing them with follow-up care and supports can be a vital component of all comprehensive suicide prevention strategies. However, because of the difficulties concerning one’s intentions behind injurious behaviour, identifying suicide attempts is a challenge for families and clinicians.AimsThe aim of this study was to investigate the differences between family report and clinical assessment for suicide attempts in the emergency department (ED).MethodsA total of 148 patients with suspected suicide attempts (SSAs) and 148 family caregivers in the ED were enrolled. The suicide risk module of the Chinese version of the MINI International Neuropsychiatric Interview and the self-report measure were used to assess those with SSA’s suicidal behaviours. The Family Adaptability and Cohesion Evaluation Scales and semi-structured interviews were used to investigate the characteristics of suicide risk and demographics of patients with SSA, as well as the rate and influencing factors of omitted suicide attempts reported by family caregivers.ResultsThe underreporting rate for family reported suicide attempts in the ED was 69.0%. The suicide attempts group indicated lower mean scores on perceptions of family resources, adaptability and cohesion. Patients'' suicide risk rating (OR=0.152, 95% CI: 0.037 to 0.620, p=0.009), adult-children relationship (OR=5.037, 95% CI: 1.478 to 17.167, p=0.010) and caregiver’s age (OR=0.279, 95% CI: 0.103 to 0.757, p=0.012) might be associated with underreporting by families. If patients committed suicide attempts through a falling injury or medication overdose, their families may have misreported the suicide attempt.ConclusionsThe discordance of suicide attempt records between family report and clinical assessment reveals the limitations of family self-reports when identifying suicide attempts. Interviews and observations, together with information from certain diagnoses, should be combined to accurately identify suicide attempters in the ED.     

Suicide risk in female suicide attempters not responding to a follow-up study

The 95 patients not responding to a follow-up study of 227 female suicide attempters differed from the responders in that fewer of them were undergoing psychiatric treatment at the time of the suicide attempt and fewer were referred for psychiatric outpatient aftercare following the suicide attempt. Yet, the subsequent occurrence of suicide was no higher in the group of nonresponders than in the group of responders. This study again underlines the difficulty of predicting recurrent suicidal behavior, even in a high-risk group of suicide attempters.     

Suicide by charcoal burning in Taiwan: implications for means substitution by a case-linkage study

Objective This study estimated the incidence of suicide mortality among suicide attempters in Taiwan and assessed the extent of means substitution among subjects with a non-fatal attempt and a subsequent fatal attempt during the study period. Methods A total of 5,261 suicide attempters registered in a surveillance system of a metropolitan catchment area from 2004 to 2005 were followed through 2005. Linkage to the death certification system revealed that 72 died by suicide. The association of completed suicide with the suicide method used at index attempt was examined using Cox proportional hazards regression. Incidence rate for the subsequent lethal suicide was estimated based on life tables. Results The 1-year incidence rate of suicide mortality was 0.017: 0.026 in males and 0.013 in females. There was a strong association between burning charcoal as the method used at the index attempt (relative hazard = 4.1, P < 0.001) and completed suicides. Those who used the method of burning charcoal at the index attempt frequently used the same means in a subsequent attempt leading to suicide mortality. However, a majority of suicide completers (59.1%) who died by burning charcoal had used a different method at their index attempt. Conclusions Persons who attempt suicide by charcoal burning are a high-risk group for completed suicide. Those who burned charcoal in a suicide attempt were likely to use the same method in a later lethal attempt, and charcoal burning was a frequent cause of death among those who used different methods in earlier attempts. Charcoal burning should be a target for suicide prevention efforts.     

Beyond the mental pain: A case-control study on the contribution of schizoid personality disorder symptoms to medically serious suicide attempts

BackgroundClinical and research findings have highlighted the role of interpersonal factors in suicidal behavior with high levels of intent and lethality. Schizoid personality disorder (SPD) is at the extreme end of interpersonal difficulties. Thus, we aimed to understand the contribution of SPD symptoms to suicide behavior and specifically to more lethal suicide attempts.MethodFour groups were investigated (N = 338): medically serious suicide attempters, medically non-serious suicide attempters, psychiatric and healthy controls. SPD symptoms, mental pain variants, and clinical characteristics were assessed.ResultsOverall, attempters were characterized by higher levels of most SPD symptoms. Solitary lifestyle and emotional detachment were higher among medically serious suicide attempters relative to less-serious attempters. Emotional detachment doubled the risk for high lethality, beyond mental pain variables.ConclusionsSPD symptoms of interpersonal difficulties and low levels of emotional expressions are important risk factors for more severe suicidal behavior. Implications for identification of at-risk groups for suicide are discussed.     

Clinical predictors of suicidal acts after major depression in bipolar disorder: a prospective study

Objective:  This study determined the clinical predictors of suicidal behavior during a 2-year follow-up of patients with bipolar disorder presenting with a major depressive episode (MDE).
Method:  Sixty four patients with DSM-III-R bipolar disorder were assessed at presentation for treatment of an MDE. Correlates of past suicidal behavior were determined by comparing patients with and without a history of suicide attempts using a t -test, Wilcoxon test or chi-squared test of independence on individual explanatory variables. Putative predictors of attempts during the follow-up period were tested separately using Cox proportional hazards regression analysis.
Results:  Twelve of 64 patients had at least one suicide attempt in the follow-up period, five of them attempted in the first 2 months and seven around or shortly after the 1-year follow-up visit. All attempters had a history of past suicide attempts. Most predictors of future suicidal behavior were correlates of past suicidal behavior. Family history of suicide acts and comorbid borderline personality disorder predicted early attempts, while younger age, high hostility scores, number of past attempts, subjective pessimism as reflected in depression and suicidal ideation, and few reported reasons for living predicted suicidal acts during the whole period.
Conclusion:  In this data set of bipolar patients we noted an intriguing picture of two clusters of suicide attempts. Hostility was the strongest risk factor. These findings may have implications in both the identification of at-risk patients and the timing of clinical interventions including aggressive pharmacotherapeutic prophylaxis to prevent relapse or recurrence of depressive symptomatology.     

Mental illness and social integration among suicide attempters in Copenhagen

In order to describe a population of suicide attempters in an affluent suburb of Copenhagen, 100 patients were interviewed, randomly chosen from a group of 246 patients referred to psychiatric consultation after a suicide attempt. The group consisted of 71 women and 29 men. Single status, abuse, and previous suicide attempts occurred frequently as did suicide among first-degree relatives. The most frequent reason for a suicide attempt was conflict with partners. In comparison with the normal population in the same catchment area, the patients were alone and felt lonely, but no difference was found in the group's relation to the labor market. After a four-year follow-up period, 9 persons had died by suicide. Borderline personality disorder and affective psychosis, no employment, 2 or more previous attempts, violent method and potential lethal attempt proved to be predictors of suicide later on. Alcohol and drug abuse, lack of social support and loneliness did not influence the risk.     

Suicide and attempted suicide in general practice, 1979-1986

Using data from the Continuous Morbidity Registration Sentinel Stations over the period 1979-1986, the authors tried to determine the incidence and the characteristics of patients in general practice who attempted or committed suicide. Almost half of the suicide attempts and suicides had contacted their general practitioner (GP) shortly before the suicidal act. A minority of these cases were recognized by the GP as having a high suicide risk. In almost 70% of the suicides and 58% of the suicide attempters the GPs reported the existence, currently or previously, of a depressive episode. About half of both the suicides and the suicide attempters had been treated or seen by mental health professionals or social workers. Given the fact that suicide and suicide attempt are relatively rare events in general practice, and given the fact that for the patients who contact their GP shortly before the suicidal act, it is not at all certain whether they present clearly recognizable signs of suicide risk at that time, the authors conclude that GPs cannot play an important role in the prevention of suicidal behaviour.     

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

BackgroundVarious 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.MethodsThis 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 53 years 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.FindingsThe 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.ConclusionSuicide 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.     

No Association of COMT Val158Met Polymorphism with Suicidal Behavior or CSF Monoamine Metabolites in Mood Disorders

The suicide rate has been paralleled by an upward trend of unemployment in Hong Kong since 1997. This study aims to explore the unknown suicide-related factors among the unemployed. This information is useful in developing culturally specific suicide prevention initiatives related to unemployment. Seventy-six suicide deceased and 15 life subjects who were unemployed were selected from a previous psychological autopsy study. Logistic regression models were employed to estimate the relative suicide risks among the unemployed people. Among the unemployed, the suicide deceased were more likely to be male, had suffered from psychiatric illness, and had attempted suicide before. They also had acquired less competent social problem solving skills. Comparison with a small control group creates a generalizability problem. Suicide prevention for the unemployed could be done through mental health awareness programs; problem-solving skills training for attempters and males; and vocational training and job opportunities for discharged psychiatric patients and rehabilitees.