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.     

Attempted suicide in Europe: rates,trend.S and sociodemographic characteristics of suicide attempters during the period 1989–1992. Results of the WHO/EURO Multicentre Study on Parasuicide

Schmidtke A, Bille-Brahe U, DeLeo D, Kerkhof A, Bjerke T, Crepet P, Haring C, Hawton K, Lönnqvist J, Michel K, Pommereau X, Querejeta I, Phillipe I, Salander-Renberg E, Temesvary B, Wasserman D, Fricke S, Weinacker B, Sampaio-Faria JG. Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989–1992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatr Scand 1996: 93: 327–338. © Munksgaard 1996. The World Health Organization/EURO Multicentre Project on Parasuicide is part of the action to implement target 12 of the WHO programme, ‘Health for All by the Year 2000’, for the European region. Sixteen centres in 13 European countries are participating in the monitoring aspect of the project, in which trends in the epidemiology of suicide attempts are assessed. The highest average male age-standardized rate of suicide attempts was found for Helsinki, Finland (314/100000), and the lowest rate (45/100000) was for Guipuzcoa, Spain, representing a sevenfold difference. The highest average female age-standardized rate was found for Cergy-Pontoise, France (462/100000), and the lowest (69/100000) again for Guipuzcoa, Spain. With only one exception (Helsinki), the person-based suicide attempt rates were higher among women than among men. In the majority of centres, the highest person-based rates were found in the younger age groups. The rates among people aged 55 years or over were generally the lowest. For the majority of the centres, the rates for individuals aged 15 years or over decreased between 1989 and 1992. The methods used were primarily ‘soft’ (poisoning) or cutting. More than 50% of the suicide attempters made more than one attempt, and nearly 20% of the second attempts were made within 12 months after the first attempt. Compared with the general population, suicide attempters more often belong to the social categories associated with social destabilization and poverty.     

Deliberate self-poisoning and self-injury in older people

Patients aged 55 and over who were referred to a general hospital between 1976 and 1987 because of self-poisoning or self-injury were studied. The 675 individuals comprised 8.7% of suicide attempters of all ages. The mean annual rate of attempts in the 55-64 year age group was almost double that of the 65+ age group. In the younger age group the female:male ratio of rates for the whole study period was 1.3, whereas in the older age group it was close to unity. Rates were highest in the divorced of both sexes and also high in single and widowed males. Married males had particularly low rates. Relatively few people were receiving psychiatric care at the time of their attempts. There was no evidence of any major change in rates of attempted suicide during the study period, unlike in younger people in whom rates have declined. However, there were changes in the substances used for self-poisoning, with a very marked decline in the use of barbiturates and increasing use of non-opiate analgesics, especially paracetamol. Repetition of attempts within one year of a first attempt during the study period occurred in nearly one in 10 cases.     

A comparison of the medical lethality of suicide attempts in bipolar and major depressive disorders

Objectives:  Among mood disorders, bipolar disorder (BPD) is often noted to involve the highest rates of suicide attempts and possibly of completion. This study sought to determine whether suicide attempters with BPD exhibit suicide attempts with higher lethality than attempters with major depressive disorder (MDD) and to explore differences in clinical features associated with suicidal acts.
Methods:  Mood disordered suicide attempters were interviewed about Axis I and II diagnoses, lifetime history of suicide attempts, suicidal intent, suicidal ideation, the medical lethality of their most severe suicide attempt, severity of depression, hopelessness, lifetime aggression, and impulsivity.
Results:  The maximum lethality of suicidal acts tended to be higher among BPD attempters compared with those with MDD. However, there were no differences in the number of suicide attempts, intent to die or suicidal ideation. Suicide attempters with BPD reported higher levels of aggression and impulsivity but less hopelessness compared with MDD attempters. These differences could not be explained by Cluster B personality disorder comorbidity. Of note, within the BPD group, but not the MDD group, males reported suicidal acts with higher lethality. Multivariate analyses suggested that risk for more lethal suicide attempts is associated with BPD and male sex and that bipolar males appear to be especially vulnerable to these behaviors.
Conclusions:  Males with BPD make more lethal suicide attempts than females with BPD, an effect not observed among the MDD sample. Our findings suggest that higher rates of suicidal behavior in BPD may be due to a specific effect of BPD on males, leading to more dangerous suicidal behaviors. This effect, together with the larger proportion of males in the BPD group compared with the MDD group may lead to higher rates of reported attempted and completed suicide.     

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.     

Suicide attempts among adolescents in Switzerland: prevalence,associated factors and comorbidity

Switzerland has one of the highest rates of adolescent suicide in Europe, but the prevalence of suicidal thoughts and attempts is unknown. The objective of this paper is to assess the prevalence of suicidal ideation and behaviour among Swiss teenagers and to identify the factors associated with suicide attempts. A self-administered anonymous questionnaire was distributed to a representative sample of 9268 15- to 20-year-old adolescents attending school or college. Six items focused on suicidal ideation and conduct. Multivariate analyses were performed to identify the health variables associated with suicide attempts. About 55% of the adolescents had no suicidal concerns; 26% reported suicidal thoughts, 15% reported suicidal plans and 3% reported suicide attempts. Suicide attempters reported significantly more problems in four areas, namely health behaviour, life events, social relationships and mental health. In conclusion, many factors associated with suicide attempts represent detectable behaviours. Thus health professionals could use this knowledge to be more effective in suicide prevention among adolescents.     

Trends in Attempted Suicide in Adolescents and Young Adults in Gent, 1986–1995

This paper describes gender-specific trends in the occurrence and methods of attempted suicide in adolescents and young adults between 1986 and 1995 in Gent. The overall pattern emerging from this study is that following a decrease in the rates of attempted suicide in the second half of the 1980s, rates have clearly increased in the 1990s, especially among adolescent males. A slight predominance of female attempters was found in the 15 to 19 age group while among young adults the female to male ratio was approximately 1.0. Deliberate self-poisoning was involved in the vast majority of attempts, although among young adults significantly more males than females used deliberate self-injury to attempt suicide. In view of increasing rates of suicide among young people in many countries and of the association between attempted suicide and suicide, further study of trends and characteristics of attempted suicide among young people is warranted.     

Suicide in Lithuania During the Years of 1990 to 2002

Lithuania, among other Eastern European countries, has the highest suicide rates in the world. While the mid 1980's experienced a sharp decline in suicidality, the year of 1991 began a new increase in suicide rates, reaching an estimated 44.7 per 100,000 persons in the year of 2002. The ratio of male to female rates was 4.5 to 6.1 in the years of 1990 to 2002. The suicide mortality of rural inhabitants, especially men, has been growing even more intensely, occurring twice as often as among their urban counterparts. When looking at the age factor, the highest suicide risk is for middle-aged men. Among the males aged 45 to 54 years suicide rates reach 154.6. The most common method of suicide remains hanging, both for males and females. The underlying reasons of the suicide spread in Lithuania are multi determined.     

Association between familial suicidal behavior and frequency of attempts among depressed suicide attempters

Objective: Only a few studies have examined whether a family history of suicide influences the severity of suicidal acts and the results have been inconsistent. The current study aimed to examine whether a family history of suicidal acts predicts severity of suicide attempts. Method: 190 suicide attempters aged 18–75 years with a lifetime history of major depression were assessed for first‐degree family history of suicidality and severity of suicide attempts (number and lethality of prior suicide attempts and age at first attempt). Results: Regression analyses indicate that a positive family history of suicidal behaviors predicts a greater number of suicide attempts. Reasons for living predict number and lethality of prior attempts. Conclusion: It is critical to assess for family history of suicidal behavior when treating depressed suicide attempters as it may serve as an indicator of the risk of repeat suicide attempt and as a guide for treatment.     

Suicide attempts and personality disorder

OBJECTIVE: The purpose of the present study was to compare clinical characteristics of suicide attempters with or without personality disorders. METHOD: A systematic sample (n = 114) of patients from consecutive cases of attempted suicide referred to general hospitals in Helsinki was interviewed and diagnosed according to DSM-III-R. Forty-six subjects with DSM-III-R personality disorders were identified and divided into clusters A (n = 4), B (n = 34) and C (n = 8). These subjects were compared with 65 suicide attempters without personality disorders in terms of clinical characteristics and treatment received. RESULTS: Suicide attempters with personality disorders more often had a history of previous suicide attempts and lifetime psychiatric treatment than comparison subjects. However, suicide attempts did not differ in terms of suicide intent, hopelessness, lethality or impulsiveness between subjects with or without personality disorders. CONCLUSION: Although suicidal behaviour is a more persistent feature among those with personality disorders, their clinical characteristics at the time of a suicide attempt may not differ from those without personality disorders.     

Violent and nonviolent suicide attempts--a controlled Rorschach study

Rorschach records from 20 patients who had made active, violent suicide attempts were compared with records from 20 patients who had taken drug overdoses and 20 psychiatric control patients who had not made a suicide attempt. Ego function ratings showed that violent attempters were more paranoid than both other groups and less able to cope with conflict situations, to handle dysphoric affect and to differentiate between reality and imagination. Violent attempters had lower level of cognitive maturity than controls and tended to produce fabulized combination responses, suggesting cognitive slippage, and distorted human content responses, indicating pathological object relationships. Nonviolent attempters did not differ from controls. Six patients, all from the violent attempt group, completed suicide within a follow-up period of 4 years. Compared with the survivors, they were less tolerant of dysphoric affect and showed more pronounced decline of developmental level within cards. Completers could be identified on the Rorschach at 55% sensitivity and 93% specificity.     

Risk of suicide attempt and suicide death in patients treated for bipolar disorder

OBJECTIVES: To evaluate demographic and clinical predictors of suicide attempt and suicide death in a population-based sample of people treated for bipolar disorder (BD). METHODS: Computerized records were used to identify 32,360 individuals treated for BD at two large prepaid health plans. Suicide attempts were identified using computerized records of outpatient visit diagnoses and hospital discharge diagnoses. Suicide deaths were identified using state death certificate data. RESULTS: Overall event rates were 1.06 per 1,000 person-years for suicide death, 5.6 per 1,000 person-years for suicide attempt leading to hospitalization, and 13.9 per 1,000 person-years for suicide attempt not leading to hospitalization. Men had a significantly lower rate of suicide attempt [hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.56-0.83] but a higher rate of suicide death (HR 2.70, 95% CI 1.69-4.31). Suicide attempts were significantly more frequent among younger patients, but suicide deaths did not vary significantly by age. Substance use comorbidity was significantly related to risk of suicide attempt (HR 2.53, 95% CI 2.07-3.09) but not to risk of suicide death (HR 1.02, 95% CI 0.54-1.93). Comorbid anxiety disorder was associated with significantly higher risk of both suicide attempt (HR 1.40, 95% CI 1.14-1.72) and suicide death (HR 1.81, 95% CI 1.09-2.99). CONCLUSIONS: Among people treated for BD, risk of suicide death is significantly related to male sex and comorbid anxiety disorder. The predictors of suicide death differ markedly from predictors of suicide attempt.     

自杀未遂者出院18个月应对方式与社会支持的病例对照研究

目的探讨自杀未遂者自杀行为发生后18个月时的应对方式与社会支持。方法采用应对方式问卷、社会支持量表对111例自杀未遂者(自杀后18个月)及与其性别、年龄和居住地匹配的111例无自杀行为者进行调查并比较。结果自杀未遂者问题解决、求助、客观支持、主观支持、支持利用度、支持总分明显低于对照组,而退避、自责得分明显高于对照组,差异有统计学意义(t值为3.12～6.24,P均小于0.05)。73例无精神疾病自杀未遂者问题解决、求助、客观支持、主观支持、支持利用度、支持总分明显低于其匹配的对照组,差异有统计学意义(t值为2.48～5.88,P均小于0.05)。有精神疾病自杀未遂组问题解决、求助得分比无精神疾病组明显低,而退避、自责得分明显高于无精神疾病组,差异均有统计学意义(t值为2.22～5.48,P均小于0.05),两组社会支持方面得分差异无统计学意义(P0.05)。结论出院18个月时的自杀未遂者应对方式和社会支持系统依然不良,具有持续性。自杀干预工作应努力提高自杀未遂者的应对能力和支持感受,以减少他们再自杀的可能性。     

Hopelessness,impulsiveness and intent among suicide attempters with major depression,alcohol dependence,or both

The present study examined differences in hopelessness, impulsiveness and suicide intent between suicide attempters with either major depression or alcohol dependence, comorbid major depression and alcohol dependence, and those without these disorders. A sample of 114 patients from consecutive cases of attempted suicide referred to a general hospital in Helsinki was interviewed and diagnosed according to DSM-III-R. Suicide intent was measured by the Beck Suicide Intent Scale (SIS) and hopelessness was assessed by the Beck Hopelessness Scale (HS). Impulsiveness of the suicide attempt was measured by two items of the SIS. Suicide attempters with major depression without comorbid alcohol dependence had higher suicide intent and lower impulsiveness than attempters with non-depressive alcohol dependence. Suicide attempts may differ between subjects with major depression, alcoholism or both disorders in terms of impulsiveness and suicide intent.     

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.     

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。     

Do weather,day of the week,and address affect the rate of attempted suicide in Hong Kong?

Summary In the whole year of 1986, psychiatrists saw a total of 307 attempted suicide cases presenting to a regional general hospital in Hong Kong, whether admitted or not. They were committed by 295 different people. There was no significant correlation between the number of attempts and the temperature, relative humidity, rainfall or relative duration of sunshine. Comparison with the general population revealed no evidence that suicide attempters were more likely to live in high density public housing blocks or on higher floor levels. Detailed analysis of the address of each attempter also did not support the social contagion theory of attempted suicide. Yet the suicide attempters were more likely to live in temporary structures, many inhabitants of which were new immigrants. Moreover, suicide attempts by housewives were found to reach a peak on Sundays. The implications of these findings are discussed.     

The Accuracy of Prevalence Estimations for Suicide Attempts. How Reliably Do Adolescents and Young Adults Report Their Suicide Attempts?

This study explores the accuracy of prevalence estimations for suicide attempts. Data came from the Early Developmental Stages of Psychopathology (EDSP) Study, a prospective community study (mean follow-up period was 42 months) of 3,021 respondents aged 14 to 24 years at the outset of the study. Suicide attempters are at least 1.6 times more likely to drop out than subjects with no suicide attempts and suicidal ideas. A total of 8% of all suicide attempters answered in the negative the depression-related gate questions of all surveys. One-third of all baseline suicide attempters did not report their suicide attempt again at the four years later assessment. In particular, 80% of all nonreporters were female, and almost 60% were aged 14–17 at baseline.     

Suicide attempts in a cohort of drug abusers: a 5-year follow-up study

A group of 125 drug abusers admitted consecutively for detoxification and short-term rehabilitation were followed up 5 years after discharge. They were asked about possible suicide attempts in a semi-structured face-to-face interview. Nearly half of the group (45%) reported having attempted suicide at some point in their life. The most common reasons given were the loss of a person whom they loved, and feelings of loneliness. Only three respondents reported using their drug of choice in the attempt(s). The suicide attempters were more often found to have been in child psychiatric treatment earlier, and to have experienced loss of significant others in childhood, than those who did not report attempting suicide. At follow-up the suicide attempters indicated that they experienced more depressive moods and more severe psychological problems than those who had never made a suicide attempt. The importance of assessing the risk of suicide attempts among drug addicts in order to be able to take measures to prevent future suicidal behaviour is emphasized.     

Recommended care for young people (15–19 years) after suicide attempts in certain European countries

Data on recommended care for young people aged 15–19 years after attempted suicide from nine European research centres during the period 1989–1992 were analysed in terms of gender, history of previous suicide attempt and methods used. Altogether 438 suicide attempts made by 353 boys and 1,102 suicide attempts made by 941 girls were included. Analyses of the total data from all centres showed that young people with a history of previous suicide attempt and those using violent methods had significantly higher chance of being recommended aftercare than first-time attempters or those choosing self-poisoning. There were no significant differences of being recommended care between genders. Logistic regression analyses of the material were performed and the results were similar. Both having previous attempted suicide (odds ratio 2.0, 95% CI 1.53–2.61) and using “hard” methods (odds ratio 1.71, 95% CI 1.49–1.96) were significantly associated with increased possibility of being recommended aftercare. When individual centres were analysed, large disparities of recommended care after suicide attempts were found and there were no uniform criteria of recommending care for young suicide attempters in Europe. Accepted: 23 August 1999