The concept of violent suicide,its underlying trait and neurobiology: A critical perspective

Suicide is one of the leading causes of death and represents a significant public health problem world-wide. Individuals who attempt or die by suicide represent a highly heterogeneous population. Recently, efforts have been made to identify sub-populations and variables to categorize them. A popular dichotomy in suicide research of the past years is violent versus non-violent suicide - based on the method. This dichotomy is important given that there is an association between method of attempted suicide and risk of subsequent death by suicide. The differentiation concerning suicide methods is also critical regarding preventive efforts. In this review, we have tried to approach the concept of violent suicide from different perspectives, including a discussion about its definition and overlapping categories. In addition, we have critically discussed aggression as underlying trait, the question of intent to die, and sociodemographic, environmental, neuropsychological, and neurobiological factors potentially associated with violent suicide.     

Transmission des certificats de décès au CépiDc-Inserm en cas de mort suspecte en France,depuis 2000

Background

The purpose of this study is to assess variability in death certificates’ transmission related to suspicious deaths.

Suicidal behavior-advances in clinical and neurobiological research and improvement of prevention strategies

Suicide is the 14^th leading cause of death worldwide. It is responsible for 1%-5% of all mortality. This article highlights the latest developments in universal, selective, and indicated prevention strategies. Concerning universal suicide prevention, current research has shown that strategies such as restricting access to lethal means (e.g., control of analgesics and hot-spots for suicide by jumping) and school-based awareness programs are most efficacious. Regarding selective prevention, substantial progress can be expected in psychological screening methods for suicidal behavior. The measurement of implicit cognition proved to be more valid in predicting future suicide attempts than classic clinical assessment. Latest developments are smartphone-based interventions and real-time monitoring of suicidal behavior. Great effort has been made to establish valid neurobiological screening methods (e.g., genetic and epigenetic risk factors for suicide, hypothalamic-pituitary-adrenal axis) without yielding a major bre-akthrough. Potentially, multiple biomarkers rather than a single one are necessary to identify individuals at risk. With regard to indicated prevention in form of psychopharmacological treatment, recent pharmacoepidemiological studies and meta-analyses have supported a protective role of antidepressants, lithium, and clozapine. However, the data concerning a specific anti-suicidal effect of these drugs are currently not consistent. Promising results exist for ketamine in reducing suicidal ideation, independently of its antidepressant effect. Concerning psychotherapy, recent findings suggest that psychotherapeutic interventions specifically designed to prevent suicide re-attempts are most efficacious. Specifically, cognitive behavioral therapy and psychodynamic therapy approaches proved to decrease the number of suicide re-attempts significantly.     

Genome-wide association studies of suicidal behaviors: A review

Suicidal behaviors represent a fatal dimension of mental ill-health, involving both environmental and heritable (genetic) influences. The putative genetic components of suicidal behaviors have until recent years been mainly investigated by hypothesis-driven research (of “candidate genes”). But technological progress in genotyping has opened the possibilities towards (hypothesis-generating) genomic screens and novel opportunities to explore polygenetic perspectives, now spanning a wide array of possible analyses falling under the term Genome-Wide Association Study (GWAS). Here we introduce and discuss broadly some apparent limitations but also certain developing opportunities of GWAS. We summarize the results from all the eight GWAS conducted up to date focused on suicidality outcomes; treatment emergent suicidal ideation (3 studies), suicide attempts (4 studies) and completed suicides (1 study). Clearly, there are few (if any) genome-wide significant and reproducible findings yet to be demonstrated. We then discuss and pinpoint certain future considerations in relation to sample sizes, the units of genetic associations used, study designs and outcome definitions, psychiatric diagnoses or biological measures, as well as the use of genomic sequencing. We conclude that GWAS should have a lot more potential to show in the case of suicidal outcomes, than what has yet been realized.     

认知行为治疗伴自杀行为抑郁症的效果分析

目的探讨认知行为治疗伴自杀行为抑郁症患者的效果。方法选取伴自杀行为抑郁症患者160例．根据数字表法分为观察组与对照组,各80例,对照组给予常规护理干预,观察组给予认知行为干预,干预周期均为10周。比较两组的抑郁评分和身心健康评分。结果两组干预后的抑郁评分均低于干预前,观察组干预后的抑郁评分低于对照组,差异有统计学意义（P〈0．05）。观察组的生理功能、生理职能、社会功能和总体健康评分均明显高于对照组,差异有统计学意义（P〈0．05）。结论认知行为治疗伴自杀行为抑郁症患者能缓解抑郁症状,改善预后及身心健康,值得推广应用。     

Suicide Among Young People in the Americas

PurposeTo examine suicide mortality trends among young people (10–24 years of age¹) in selected countries and territories of the Americas.MethodsAn ecological study was conducted using a time series of suicide mortality data from 19 countries and one territory in the Region of the Americas from 2001 to 2008, comprising 90.3% of the regional population. The analyses included age-adjusted suicide mortality rates, average annual variation in suicide mortality rates, and relative risks for suicide, by age and sex.ResultsThe mean suicide rate for the selected study period and countries/territory was 5.7/100,000 young people (10–24 years), with suicide rates higher among males (7.7/100,000) than females (2.4/100,000). Countries with the highest total suicide mortality rates among young people (10–24 years) were Guyana, Suriname, Nicaragua, El Salvador, Chile, and Ecuador; countries with the lowest total suicide mortality rates included Mexico, Venezuela, Cuba, and Brazil, and the U.S. territory of Puerto Rico. During this period, there was a significant increase in suicide mortality rates among young people in the following countries: Argentina, Chile, Ecuador, Mexico, and Suriname; countries with significant decreases in suicide mortality rates included Canada, Colombia, Cuba, El Salvador, and Venezuela. The three leading suicide methods in the Americas were hanging, firearms, and poisoning.ConclusionsSome countries of the Americas have experienced a rise in adolescent and youth suicide during the study period, with males at a higher risk of committing suicide than females. Adolescent and youth suicide policies and programs are recommended, to curb this problem. Methodological limitations are discussed.     

Association of geomagnetic disturbances and suicides in Japan, 1999–2010

Objectives

Previous studies have shown a positive relationship between geomagnetic disturbances and an increased incidence of suicide. The Japanese suicide rate is the ninth highest in the world, but there have been no reports examining the relationship between geomagnetic disturbance and the number of suicides, and, therefore, this paper examines this relationship.

Methods

The number of Japanese suicides per month from January 1999 to December 2010 was obtained, and it was found that a total of 262,596 males and 102,539 females committed suicide during this period. To adjust the other factors which affect the number of suicides, a multiple linear regression analysis with backward elimination was carried out, with the monthly number of suicides as the response variable and the monthly mean K index value, monthly mean number of sunspots, monthly mean unemployment rate, proportion of elderly people (%), monthly mean air pressure (hPa), monthly mean air temperature (°C), monthly mean humidity (%), and monthly mean day length (h) as the explanatory variables.

Results

In the multiple linear regression analysis for males, the monthly mean K index value was associated with the monthly number of suicides, but in females, the monthly mean K index value was not associated with the monthly number of suicides.

Conclusion

In this study, we generated a hypothesis that geomagnetic disturbances may trigger male suicides.     

A Two-site Pilot Randomized 3 Day Trial of High Dose Left Prefrontal Repetitive Transcranial Magnetic Stimulation (rTMS) for Suicidal Inpatients

BackgroundSuicide attempts and completed suicides are common, yet there are no proven acute medication or device treatments for treating a suicidal crisis. Repeated daily left prefrontal repetitive transcranial magnetic stimulation (rTMS) for 4–6 weeks is a new FDA-approved treatment for acute depression. Some open-label rTMS studies have found rapid reductions in suicidality.DesignThis study tests whether a high dose of rTMS to suicidal inpatients is feasible and safe, and also whether this higher dosing might rapidly improve suicidal thinking. This prospective, 2-site, randomized, active sham-controlled (1:1 randomization) design incorporated 9 sessions of rTMS over 3 days as adjunctive to usual inpatient suicidality treatment. The setting was two inpatient military hospital wards (one VA, the other DOD).PatientsResearch staff screened approximately 377 inpatients, yielding 41 adults admitted for suicidal crisis. Because of the funding source, all patients also had either post-traumatic stress disorder, mild traumatic brain injury, or both.TMS methodsRepetitive TMS (rTMS) was delivered to the left prefrontal cortex with a figure-eight solid core coil at 120% motor threshold, 10 Hertz (Hz), 5 second (s) train duration, 10 s intertrain interval for 30 minutes (6000 pulses) 3 times daily for 3 days (total 9 sessions; 54,000 stimuli). Sham rTMS used a similar coil that contained a metal insert blocking the magnetic field and utilized electrodes on the scalp, which delivered a matched somatosensory sensation.Main outcome measurePrimary outcomes were the daily change in severity of suicidal thinking as measured by the Beck Scale of Suicidal Ideation (SSI) administered at baseline and then daily, as well as subjective visual analog scale measures before and after each TMS session. Mixed model repeated measures (MMRM) analysis was performed on modified intent to treat (mITT) and completer populations.ResultsThis intense schedule of rTMS with suicidal inpatients was feasible and safe. Minimal side effects occurred, none differing by arm, and the 3-day retention rate was 88%. No one died of suicide within the 6 month followup. From the mITT analyses, SSI scores declined rapidly over the 3 days for both groups (sham change −15.3 points, active change −15.4 points), with a trend for more rapid decline on the first day with active rTMS (sham change −6.4 points, active −10.7 points, P = 0.12). This decline was more pronounced in the completers subgroup [sham change −5.9 (95% CI: −10.1, −1.7), active −13 points (95% CI: −18.7, −7.4); P = 0.054]. Subjective ratings of ‘being bothered by thoughts of suicide’ declined non-significantly more with active rTMS than with sham at the end of 9 sessions of treatment in the mITT analysis [sham change −31.9 (95% CI: −41.7, −22.0), active change −42.5 (95% CI: −53.8, −31.2); P = 0.17]. There was a significant decrease in the completers sample [sham change −24.9 (95% CI: −34.4, −15.3), active change −43.8 (95% CI: −57.2, −30.3); P = 0.028].ConclusionsDelivering high doses of left prefrontal rTMS over three days (54,000 stimuli) to suicidal inpatients is possible and safe, with few side effects and no worsening of suicidal thinking. The suggestions of a rapid anti-suicide effect (day 1 SSI data, Visual Analogue Scale data over the 3 days) need to be tested for replication in a larger sample.Trial registrationClinicalTrials.gov Identifier: NCT01212848, TMS for suicidal ideation.     

Defining the need for blood and blood products transfusion following suicide bombing attacks on a civilian population: A level I single-centre experience

Introduction

Knowledge of patterns of blood use in the care of mass casualty settings is important for preparedness of medical centre resources and for maximising survival when blood supplies are limited. Our objectives were to review of our experience with the use of blood products and define the utilisation of blood transfusion following suicide bombing attacks.

Patients and methods

We conducted a retrospective analysis of blood and blood product transfusion following civilian bombing attacks at a level I trauma centre in Jerusalem, Israel from 2000 to 2005. The study group consisted of 137 patients who were admitted following 17 suicide bombing attacks which were carried out in Jerusalem during the 5-year period. Demographic data, number of units of blood and blood products transfused and the need for massive transfusions were recorded and analyzed.

Results

Fifty-three patients received blood transfusions (38.7%). There were 33 males (62.2%) with a median ISS of 13 (range 4–25). These 53 patients received 524 PRBC, 42 WB, and 449 FFP. The mean number of PRBC transfused/admitted patient was 3.82 units (range 0–59). Thirty patients (21.9%) received 236 PRBC (45% of total PRBC) at the first 2 h. The ratio of ordered to transfused blood was 946:524. The FFP:PRBC ratio for all transfused patients was 1:1.17. The number of PRBC transfused per attack correlated with the number of patients admitted per attack. The most commonly transfused blood type was A (52.3%). Only 18 units of uncrossed-matched blood were transfused (3.3% of total). 14 patients (10.2%) received massive transfusions. These patients received 399 PRBC (76.1% of total units transfused) and the average number of PRBC transfused was 28.5/patient (10–59).

Conclusions

More than 1/3 of casualties admitted following civilian bombing attacks received transfusions, most in the first 2 h. Large-scale attacks will require more blood and blood products than small-scale attacks. Twice the number of PRBC ordered than transfused reflects a known trend for over-triage during the initial assessment following bombing attacks. One tenth of patients received massive transfusion.