Cerebrospinal fluid monoamine metabolites and suicide

Prospective studies of the serotonergic system and suicide report that low 5-hydroxyindolacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) and a history of attempted suicide predict suicide risk. Low CSF homovanillic acid (HVA) is reported to be associated with past and future lethality of suicide attempts but not with suicide. The interrelationships between monoamine metabolites, violent method, suicide intent and lethality of suicidal behaviour are complex. We hypothesized that CSF 5-HIAA and HVA levels are related to suicide intent, violence and lethality of suicidal behaviour. Fifteen male suicide attempters admitted to a psychiatric ward at the Karolinska University Hospital and eight healthy male volunteers were submitted to lumbar puncture and CSF 5-HIAA and HVA were assayed. Suicide intent with the Beck Suicide Intent Scale (SIS), lethality and violence of suicidal behaviour were assessed. All patients were followed up for causes of death. Six suicides and one fatal accident were identified with death certificates. Mean CSF 5-HIAA but not CSF HVA differed between suicides and survivors. Violent suicides had higher suicide intent and CSF 5-HIAA than non-violent suicides. In violent suicides, CSF 5-HIAA levels were negatively correlated with SIS. Greater suicide intent may be associated with greater aggressive intent and predicts a violent suicide method.     

Season of birth associated with the age and method of suicide

A recent study reported season of birth variation in CSF levels of 5-HIAA and HVA, with low 5-HIAA for February to April and high HVA for October to January (Chotai & Åsberg, 1999). We therefore analysed data on all completed suicides during 1952--1993 in the county of Västerbotten in northern Sweden (1466 cases), regarding these birth seasons in relation to suicide method and sociodemographic variables. Those with suicide age under 45 years were more likely than older suicides to have been born during February to April, significantly so compared to October to January. This was more pronounced for the later birth-year cohort (born in 1931 or later). Those who preferred hanging rather than poisoning or petrol gases were significantly more likely born during February to April. Those who preferred poisoning rather than hanging were significantly more likely born during October to January, particularly for the later birth-year cohort. The results regarding suicide method were somewhat more pronounced for males. The results of the study are compatible with a hypothesis of season of birth variation in CSF monoamine metabolites.     

有严重躯体疾病老年自杀死亡者的特征及其有无精神障碍者间的比较

目的了解有严重躯体疾病的老年自杀死亡者的特征并比较有无精神障碍者特征的异同。方法由精神科医师运用心理解剖方法对全国23个疾病监测点上报的≥55岁的304例自杀案例的家属和周围知情人进行调查,分析其中178例(58.6%)报告自杀死亡前1年内有严重躯体疾病者的自杀特征。结果178例自杀死亡者中,女性占41.6%;79.2%居住在乡村;58.4%从未上过学;38.8%丧偶;25.8%有自杀未遂既往史;10.7%一级血缘亲属有自杀行为;43.3%服农药或鼠药自杀,32.6%上吊;68.0%自杀当时有精神障碍,主要是重性抑郁障碍;仅5.1%自杀当时有人在场。有、无精神障碍者在社会人口经济学特征、有无自杀未遂史和自杀行为家族史、负性生活事件导致的慢性心理压力和急性应激强度以及自杀前一个月的生命质量等方面的差异无统计学意义(P均大于0.05)。结论有严重躯体疾病老年人自杀死亡最常见的两种方式是服毒和上吊,2/3有精神障碍,但有无精神障碍者的自杀相关特征无明显不同。     

Season of birth associated with the age and method of suicide

Abstract

A recent study reported season of birth variation in CSF levels of 5-HIAA and HVA, with low 5-m for February to April and high HVA for October to January (Chotai & Asberg, 1999). We therefore analysed data on all completed suicides during 1952–1993 in the county of Västerbotten in northern Sweden (1466 cases), regarding these birth seasons in relation to suicide method and sociodemographic variables. Those with suicide age under 45 years were more likely than older suicides to have been born during February to April, significantly so compared to October to January. This was more pronounced for the later birth-year cohort (born in 1931 or later). Those who preferred hanging rather than poisoning or petrol gases were significantly more likely born during February to April. Those who preferred poisoning rather than hanging were significantly more likely born during October to January, particularly for the later birth-year cohort. The results regarding suicide method were somewhat more pronounced for males. The results of the study are compatible with a hypothesis of season of birth variation in CSF monoamine metabolites.     

Suidical ideation in severe depression

Suicidal ideation and communication were investigated for 89 suicide victims with a primary severe depression and matched controls. The selection of patients was based on multiaxial ratings of all hospitalised patients between 1956 and 1969. A blind record evaluation was performed, including scores on Beck's Scale for Suicidal Ideation and additional items apart from that scale. There was no relation between high scores on the Beck's scale and completed suicide. In the male group, suicidal ideation “beyond one's own will” was related to suicide. Female suicides that had made an attempt showed higher suicidal ideation than female suicides who had not. A substantial minority of the women (22%) committed suicide without showing any previous intent. Only 5% of the male suicides had shown no previous intent to commit suicide. Received: 4 December 1998 / Accepted: 8 February 2000     

Celebrity Suicides and Their Differential Influence on Suicides in the General Population: A National Population-Based Study in Korea

ObjectiveAlthough evidence suggests that there is an increase in suicide rates in the general population following celebrity suicide, the rates are heterogeneous across celebrities and countries. It is unclear which is the more vulnerable population according to the effect sizes of celebrity suicides to general population.MethodsAll suicide victims in the general population verified by the Korea National Statistical Office and suicides of celebrity in South Korea were included for 7 years from 2005 to 2011. Effect sizes were estimated by comparing rates of suicide in the population one month before and after each celebrity suicide. The associations between suicide victims and celebrities were examined.ResultsAmong 94,845 suicide victims, 17,209 completed suicide within one month after 13 celebrity suicides. Multivariate logistic regression analyses revealed that suicide victims who died after celebrity suicide were significantly likely to be of age 20-39, female, and to die by hanging. These qualities were more strongly associated among those who followed celebrity suicide with intermediate and high effect sizes than lower. Younger suicide victims were significantly associated with higher effect size, female gender, white collar employment, unmarried status, higher education, death by hanging, and night-time death. Characteristics of celebrities were significantly associated with those of general population in hanging method and gender.ConclusionIndividuals who commit suicide after a celebrity suicide are likely to be younger, female, and prefer hanging as method of suicide, which are more strongly associated in higher effect sizes of celebrity suicide.     

CORONER'S VERDICTS IN THE ELDERLY: A SUICIDE OR AN OPEN VERDICT?

Objectives. To identify variables, other than legal definitions, that may have influenced North Cheshire's Coroner in returning a verdict of ‘suicide’ or an ‘open verdict’ on unexpected deaths of the elderly. Design. Retrospective review of all coroner's verdicts in North Cheshire during a 5-year period 1989–1993. Material. Forty-seven ‘suicide’ and ‘open verdict’ deaths in North Cheshire between 1989 and 1993 as defined in ICD classification ‘E’ codes E950–E959 and E980–E989, respectively, that were returned on the deceased aged 65 and above who died within North Cheshire. Findings. Logistic regression analysis suggests that the Coroner's decision may be influenced by: intimation of intent, psychiatric history and method of death. Sex of the deceased, history of attempted suicide, social setting and history of alcohol problems did not appear significantly associated with coroner's verdict. © 1997 by John Wiley & Sons, Ltd.     

15～24岁人群自杀特征及危险因素的病例对照研究

目的了解全国15～24岁自杀死亡者的特征,并通过与其他伤害死亡案例的比较了解青年自杀的危险因素。方法由精神科医师运用心理解剖方法对全国有地理代表性的23个疾病监测点上报的15～24岁的88例自杀案例(自杀组)和76例其他伤害死亡案例(对照组)的家属和周围知情人进行深入调查。结果(1)自杀组的平均受教育年限为(6.2±3.2)年,59%为女性,88%居住在乡村,82%服毒或服药自杀,26%为现婚,76%自杀前一直在工作或学习,26%有自杀未遂既往史,14%有血缘关系的人曾有自杀行为,31%朋友或熟人有过自杀行为,50%自杀当时有精神疾病,18%曾因心理问题寻求过帮助。(2)有既往自杀未遂史(经单因素分析)、自杀前2周有抑郁症状、自杀当时急性应激强度大和自杀前1个月生命质量低(后3项经多因素logistic回归分析)是自杀的危险因素。结论15～24岁自杀死亡者中50%有精神疾病,仅极少数自杀死亡者曾因心理问题寻求帮助。自杀未遂既往史、近2周有抑郁症状、经历急性负性生活事件和近1个月生命质量低为青年自杀死亡的主要危险因素。     

Biogenic amine turnover and serum cholesterol in suicide attempt

The investigation of biological correlates of suicidal behavior is important in searching for possible changes in neuronal systems activity related to that behavior, so that pharmacological interventions may be proposed, especially in high-risk subjects. In a sample of 111 subjects admitted in a general hospital after suicide attempt, we studied the turnover of neurotransmitters by measuring the urinary output of the main metabolites of serotonin, dopamine and noradrenaline (5-HIAA, HVA, MHPG respectively), as well as serum cholesterol, and compared them to those of a group of 62 healthy controls. Venous blood samples and urine samples were collected within 24 hours of admission. Psychiatric diagnosis was made according to DSM-IIIR criteria and assessment of suicide intent with Beck's Suicidal Intent Scale (SIS). Fifty-four (54) subjects received the diagnosis of adjustment disorder, 25 of depression, 16 of schizophrenia and 16 of personality disorder. Fourteen subjects (14) had employed a violent mode of attempt. Urinary MHPG was found significantly higher in all diagnostic groups compared to controls. No difference was found concerning the excretion of HVA and 5-HIAA. Serum total cholesterol was found significantly lower both in violent and non-violent attempters compared to controls after correcting for age. No difference in serum cholesterol or MHPG was found between violent and non-violent attempts. Serum cholesterol and MHPG correlated negatively, while the correlations between cholesterol and 5-HIAA or HVA were not significant. Our results confirm previous reports of lower serum cholesterol in attempted suicide. They are also indicative of an increased noradrenaline turnover in subjects who attempt suicide, at least within 24 hours after the attempt. Whether this activation precedes or follows the attempt because of the specific stress, can not be answered at present. Received: 30 January 2001 / Accepted: 19 December 2001     

The significance of suicide notes in the elderly

Suicide notes are traditionally considered as markers of the severity of the suicide attempt and are said to provide valuable insight into the thinking of suicide victims before the fatal act. Few studies have described the characteristics of elderly suicide note-writers and their final thoughts. This study is a retrospective view of suicide notes obtained from coroners' records of all elderly suicides in Cheshire over a period of 10 years, 1989-1998. Out of 125 suicides, 54 (43%) had suicide notes, which were reported in the coroner's records. Of these there were 31 (57%) male and 23 (43%) female subjects. Elderly suicide note-leavers were more likely to be unknown to psychiatric services (p < 0.01) and to have used a non-violent method of suicide (p < 0.01). Sex, marital status, social isolation, mental or physical morbidity did not appear to be linked with leaving a suicide note. More cases that took an overdose, used plastic bags, electrocuted themselves, or used car exhaust also left suicide notes. Those who died by more violent means such as hanging, drowning, jumping from height, immolation or wounding appeared less likely to have left a suicide note. No statistically significant difference in the content of the suicide notes was observed in relation to sex or age. Many elderly are isolated and may have no one to write a note to, while others have lost the ability to express themselves. Therefore, it is not possible to say that the different incidence of note leaving observed for suicide was due to differing levels of suicidal intent. Although only a proportion of elderly suicide victims leave suicide notes, the absence of a suicide note must not be considered an indicator of a less serious attempt.     

Suicidal behavior among Finnish fire setters

Histories of serious suicide attempts and slashing were investigated among Finnish fire setters. Medical and criminal records of 304 fire setters were examined to compare those who had attempted suicide with those who had not, and those who had slashed themselves with those who had not using biological, diagnostic, and demographic variables. Major mood disorders, father’s alcoholism, and suicidal motive of fire setting (self-immolation) were significantly associated with suicide attempts. Paternal violent alcoholism, father’s criminality, and suicidal motive of fire setting were significantly associated with slashing. Among fire setters, non-lethal slashing is a predictor of serious suicidality. Associations between psychiatric diagnoses, family history, and suicidality among fire setters are similar to those reported for suicidal patients with mood and substance abuse diagnoses. Therefore, studying fire setters, who exhibit an extremely high incidence of suicidal behavior, is an effective way to elucidate psychobiology of suicidal behaviors.     

Skin conductance habituation and cerebrospinal fluid 5-hydroxyindoleacetic acid in suicidal patients

The concentration of 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) and psychophysiologic variables, such as habituation of the skin conductance response, were measured in 35 drug-free, suicidal inpatients. Twenty-four patients were hospitalized after a suicide attempt, and another 11 had suicidal ideation. The suicide attempters were classified into nonviolent (drug overdoses taken orally, or a single wrist cut) and violent (all other methods). As in previous studies, the suicide attempters had significantly lower CSF concentrations of 5-HIAA compared with healthy, matched controls. The distribution of habituation rate was bimodal (slow and fast habituators). All violent attempters were fast habituators, as were all four patients who in a one-year follow-up were found to have completed a suicide (all by violent methods). The lowest frequency of fast habituators was found in the group of patients with suicidal ideation. There was no correlation between CSF 5-HIAA and habituation rate. A combination of these two variables yielded a highly significant correlation with type of suicide behavior, both retrospectively and prospectively.     

Suicide among Italian adolescents: 1970–2002

The purpose of the present study was to analyze sex and regional differences in the suicide rate of adolescents and the methods they used for suicide in Italy during the period 1970–2002. Temporal trends and regional variations in suicide for Italian adolescents were retrieved from the Italian database on mortality for the period 1970–2002, collected by the Italian Census Bureau and processed by the Italian National Institute of Health-Statistics Unit. In the period 1970–2002, 3,069 adolescent suicides were monitored in Italy. Analyses of these suicides identified significant differences by region of residence and sex. Males were 2.1 times more likely than females to kill themselves. Male and female suicides had inverse trends in the years analyzed, so that the sex difference at the present time is the result of a continuous increase in male suicides and a decrease in female suicides since 1970. The dramatic peaks observed over the time period studied cannot be attributed to a single cause, indicating that further studies are needed to better understand the phenomenon.     

Suicide Methods and Presence of Intoxicating Abusable Substances: Some Clinical and Public Health Implications

Toxicological studies have reported the presence of alcohol in about a third of suicides. Some have suggested that the presence of alcohol might predispose suicidal people to use particular methods, e.g., guns, although, in general, this does not appear to be the case. More recently, comprehensive toxicological studies have provided data on the detection of all intoxicating abusable substances (IAS) among suicides. The purpose of this report is to examine the presence of two samples of suicides to see if any relationships between presence of IAS at post mortem toxicology and any specific suicide method. The samples included 179 suicides from San Diego, California (1981–1982), and 225 suicides from Mobile, Alabama (1990–1995) for which comprehensive toxicological examination had been conducted. Methods were grouped into more immediately fatal (MIF) and less immediately fatal (LIF) categories. The most common method in each category (guns and overdoses respectively) were examined separately as well. The same proportions of men (51%) and women (65%) were positive for any IAS in both locations. There were no significant differences in the proportions of suicides that were positive for IAS between the sample totals or by gender or age groups (under age 30 and age 30 and over) for any of the methods or categories examined. Significantly more of the Mobile suicides were by MIF methods than in San Diego for both genders, almost totally attributable to the use of guns. The use of guns for suicide in Mobile (and the state of Alabama) was also significantly higher than the rest of the U.S. in the early 1990's. Nonetheless, the suicide rates for men and women in Mobile (and Alabama) were no higher than for the overall U.S. rates. We conclude that potentially suicidal people should be advised to avoid intoxicating abusable substances of any kind. We also suggest that physicians should avoid prescribing such substances to depressed or suicidal patients.     

Month of Birth,a Risk Factor for Violent Behaviour in Suicidal Patients Admitted in Emergency?

Although there are numerous publications on the existing link between month of birth and suicide, only two studies focus on suicide attempts and auto-aggressive behavior. Research data suggest that month of birth is related to a variation of 5-HIAA in the cerebrospinal fluid, which correlates with violent behavior (VB). Therefore, the aim of this study is to search, for the first time, for a possible link between month of birth and the occurrence of VB in emergency, for patients admitted for a suicide attempt with medication. This is a 10 months prospective study among all the patients of the canton of Geneva, Switzerland, admitted in emergency for a suicide attempt with medication. During a 10 months study period we included 493 patients, of which 77 (15.62%) presented VB. Higher incidence of VB was found in subjects where born at the end of winter and the beginning of spring, with a maximum for April and a minimum for December. In spite of a relatively small number of subjects, it seems promising to study the occurrence of VB as a function of month of birth in patients admitted in emergency for a suicide attempt.

Levosulpiride in somatoform disorders: A double-blind,placebo-controlled cross-over study

BACKGROUND: Suicide notes may provide valuable information about suicide victims' final thoughts, and thus may be considered as markers of the severity of the suicide attempt. However, very few studies have described the characteristics of elderly suicide note-writers and their final thoughts. INTRODUCTION: To explore whether there is a difference between those who do and do not leave a note among the elderly victims of Fatal Self Harm (FSH). Also to examine the content of suicide notes and their clinical significance. METHODS: We carried out a retrospective review of suicide notes obtained from coroners' records of FSH in all over 60 years of age in Cheshire over a period of 13 years (1989-2001). The term 'Fatal Self Harm' was applied to all those who were subjects of coroner's inquests and attracted verdicts of suicide, misadventure and open verdicts. RESULTS: In 71 cases (33%) (43 males, 28 females) (61% M, 39% F) suicide notes were reported in the coroner's records. The variables that appeared to differ significantly between the note-leavers and non-note-leavers were: a suicide verdict, not known to psychiatric services, and method of FSH ( P < 0.05). Gender, marital status, history of DSH, social isolation, mental or physical morbidity did not appear to differ between the two groups. More of those who took an overdose, used plastic bags, electrocuted themselves or used car exhaust fumes left suicide notes. Those who died by hanging, jumping from a height, immolation or wounding appeared equally likely to leave or not to leave a suicide note. Significantly fewer cases who died by drowning left suicide notes ( P < 0.01). No statistically significant difference in the content of suicide notes was observed in relation to gender or age. CONCLUSION: The failure to identify consistent parameters that could differentiate between note-leavers and non-note-leavers only leads to the conclusion that a minority of suicide victims leave suicide notes. Suicide note-writers may not be typical of the average suicide case and information elicited from the study of suicide notes may only apply to note-writers and not to suicide in general. However, the absence of a suicide note must not be considered an indicator of a less serious attempt. (Int J Psych Clin in Pract 2002; 6: 155-161)     

Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards

Introduction

One thousand five hundred suicides take place on inpatient psychiatry units in the United States each year, over 70% by hanging. Understanding the methods and the environmental components of inpatient suicide may help to reduce its incidence.

Methods

All Root Cause Analysis reports of suicide or suicide attempts in inpatient mental health units in Veterans Affairs (VA) hospitals between December 1999 and December 2011 were reviewed. We coded the method of suicide, anchor point and lanyard for cases of hanging, and implement for cutting, and brought together all other reports of inpatient hazards from VA staff for review.

Results

There were 243 reports of suicide attempts and completions: 43.6% (106) were hanging, 22.6% (55) were cutting, 15.6% (38) were strangulation, and 7.8% (19) were overdoses. Doors accounted for 52.2% of the anchor points used for the 22 deaths by hanging; sheets or bedding accounted for 58.5% of the lanyards. In addition, 23.1% of patients used razor blades for cutting.

Conclusions

The most common method of suicide attempts and completions on inpatient mental health units is hanging. It is recommended that common lanyards and anchor points be removed from the environment of care. We provide more information about such hazards and introduce a decision tree to help healthcare providers to determine which hazards to remove.     

Effects of sunshine on suicide rates

ObjectivesSeasonal spring peaks of suicide are well described in epidemiological studies, but their origin is poorly understood. More recent evidence suggests that this peak may be associated with the increase in the duration of sunshine in spring. We investigated the effect of number of sunshine hours per month on suicide rates in Austria between 1996 and 2006.MethodsSuicide data, differentiated by month of suicide, sex, and method of suicide (violent vs nonviolent methods), were provided by Statistics Austria. Data on the average number of sunshine hours per month were calculated from 39 representative meteorological stations (provided by the Austrian Central Institute for Meteorology and Geodynamics). For statistical analysis, analysis of variance tests, Kruskal-Wallis tests, and Pearson correlation tests were used.ResultsA total of 16 673 suicides with a median of 126 ± 19.8 suicides per month occurred in the examined period. A clear seasonal pattern was observed, with suicide frequencies being highest between March and May and lowest between November and January (df = 11, F = 5.2, P < .0001) for men (df = 11, F = 4.9, P < .0001) and women (df = 11, F = 2.4, P = .008). The average number of sunshine hours per month was significantly correlated with the number of suicides among both sexes (r = .43, P < .0001), violent methods (r = .48, P < .0001) but not with nonviolent methods (r = .03, P = .707).ConclusionsThis study shows that seasonal changes in sunshine account for variations in the number of suicides and especially violent suicides. We propose that sunshine, via interactions with serotonin neurotransmission, may trigger increased impulsivity and promote suicidal acts. However, because of the hypothesis-generating design of this study, more research is needed to further clarify the role of sunshine in triggering neurobiologic changes, which might contribute to suicidal behavior.     

Le suicide dans l'institution

More than 50 % of suicides are by patients who have been or are still followed-up. The prevalence of suicidal crises is high (32 %) and stable in populations of chronic psychiatric patients. Suicidal risk factors are well known, nevertheless they are more particularly high during acute crises and are lower when the psychiatric illness is chronic. Five percent of the suicides are committed during hospitalization. Most of them occur on the first month following admission, in the first week of an acute psychotic crisis, within the year after hospitalization, prior to the hospital discharge. The rate of suicide is particularly important in psychiatric institutions because most of their patients are suffering from schizophrenia and/or depression, two diseases with high rates of suicide. Some suicidal risk factors specific to schizophrenia have been identified such as the schizoid-affective form of the disease, patient care that has been delayed, a chronic disease with numerous acute episodes, short and frequent admissions in a hospital, involuntary hospitalisations, extrapyramidal side effects and disruption of treatment. The vulnerability appears to be maximum during the first week and/or the three months after discharge from the hospital, during the first year following the diagnosis and during acute episodes, especially the first one. In the second part of this work, we will examine the legal aspects, based on the main recent court cases relative to hospital liability. The fault usually consists in lack of surveillance and involves the liability of the hospital. The assessment of the adequacy of the measures taken for the medical care of a patient and in particular his/her supervision depends on the predictability of the suicidal act; the severity of the psychiatric illness and more particularly on previous suicidal attempts; previous fugues from the hospital and previous violent acting out especially on the occasion of previous hospitalisations. To avoid reciprocal projections when there is a suicidal act it is essential to work with family and attendants, to obtain clear and exact information about the psychiatric illness and to ensure both medical and administrative care.     

Elderly suicide in Finland

Suicide mortality among the elderly is high in most Western countries. We investigated the characteristics of suicide victims 65 years or older in a nationwide psychological autopsy study, the research phase of the National Suicide Prevention Project in Finland. This study population included all completed suicides (N = 1,397, of whom 211 were 65 years or older) that occurred in Finland during a 12-month research period in 1987-1988. The elderly suicide victims were found to have used violent suicide methods more often than the young. Although almost 70% of the elderly persons who had committed suicide had been in contact with health care services during the month before their death, their suicidal intentions were rarely communicated in these contacts. They had been referred to psychiatric services less often than the young, and only 8% had received adequate antidepressive medication. The fact that most elderly suicides have contact with health care services during their final month suggests a potential for suicide prevention. However, the major obstacle to this is the poor recognition of mental disorders and suicidal ideation among the elderly.