Attempted suicide predicts suicide risk in schizophrenia spectrum psychosis

Background: People with schizophrenia have an increased risk of suicide and attempted suicide is suggested to be an important risk factor. Aim: Our objective was to assess the cumulative survival, predictive values and odds ratios of attempted suicide for suicide in a long-term cohort of patients with schizophrenia spectrum psychosis with and without previous attempted suicide. Method: Inpatients (n=224) hospitalized with schizophrenia spectrum psychosis were followed for a mean of 25 years. All patients were followed up for causes of death. Information on suicide attempt before the end of the observation period was retrieved from medical records. Results: Eight percent died by suicide during the follow-up. Eighteen percent of suicide attempters died by suicide. Two percent of non-attempters died by suicide. There was a strong association between previous suicide attempt and suicide in men and women. Odds ratio for attempters vs. non-attempters was 10. Suicide risk was almost three times higher in male than female suicide attempters. Conclusion: Previous attempted suicide is an important risk factor for suicide in both men and women with schizophrenia spectrum psychosis, particularly in male suicide attempters. The suicide risk remains high over a long period. Continuous assessment of risk factors and appropriate treatment are crucial for this patient group to prevent suicide.     

Alcohol problems, mental disorder and mental health among suicide attempters 5-9 years after treatment by child and adolescent outpatient psychiatry

Many studies report associations between alcohol problems, mental disorder, mental health and suicidal behaviour. Still, more knowledge is needed about possible differential characteristics of these factors in risk groups. This naturalistic and retrospective study included former patients who received emergency treatment in child and adolescent outpatient clinics for their mental health problems. One hundred patients were personally interviewed 5-9 years after treatment referral about alcohol problems and mental disorders. Also, they completed questionnaires about 11 indicators of mental health. At the follow-up, those who had attempted suicide during the follow-up period had more alcohol problems and mental disorders than the non-attempters. However, no association was found between suicide attempt in the follow-up period and the mental health indicators. Among the attempters, a high psychological burden as indicated by mental health disorders and poor mental health were associated with suicide re-attempt (lifetime) and an intention to die.     

Risk of repetition of suicide attempt, suicide or all deaths after an episode of attempted suicide: a register-based survival analysis

OBJECTIVE: This study was undertaken in order to estimate the incidence of repetition of suicide attempt, suicide and all deaths, and to analyse the influence of psychiatric illness and socio-demographic factors on these. METHOD: The study is a Danish register-based survival analysis that retrieved personal data on socio-economic, psychiatric and mortality conditions from various registers. Hazards were estimated using Cox regression with a time-dependence covariate. Suicide-attempters (2.614) and non-attempters (39.210)were analysed being matched by gender, age and place of residence. RESULTS: The average follow-up period for suicide-attempters was 3.88 years, during which 271 (10.37%) of them died. By comparison, death occurred four times more often among suicide-attempters than among non-attempters. Suicide was far more common among attempters (61, 2.33%) than among non-attempters (16, 0.04%). A proportion of the attempters (31.33%) repeated their attempt within the follow-up period. The most reliable predictors for suicide and death were repetition, suicide attempt method and treatment for mental illness. The most reliable predictors for repetition were age, gender and mental illness. DISCUSSION: Individuals with a history of suicide attempts form a well-defined high-risk group for suicide, and are in need of treatment immediately after the episode. Somatic and psychiatric staff must be informed about the risk factors for subsequent suicidal behaviour after an episode of attempted suicide. Furthermore, departments that are in contact with suicidal individuals need action plans to ensure that all such individuals are discharged to proper treatment immediately after the suicide attempt.     

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.     

Neurocognitive functioning and suicidality in schizophrenia spectrum disorders

Objective

The aim of this study was to investigate whether suicide attempters had higher IQ, better executive functioning, or were more impulsive as measured by neuropsychological tests than non-attempters in a group of patients with schizophrenia spectrum disorders.

Method

One hundred seventy-four patients with schizophrenia spectrum disorders were assessed with a clinical interview for diagnosis, suicidality, symptoms and function, and underwent an extensive neurocognitive test battery.

Results

There were no statistically significant differences in any neurocognitive domains between lifetime suicide attempters and non-attempters, or between patients with different rates of suicide attempts. Currently suicidal patients were significantly more impulsive (had poorer inhibitory control) than currently non-suicidal patients, but this difference was mediated by positive psychotic symptoms.

Conclusion

The findings indicate that among patients with schizophrenia spectrum disorders, there are no significant differences in IQ or neurocognitive functioning between suicide attempters and non-attempters.     

The dexamethasone suppression test and completed suicide

The present study was undertaken to further explore the relationship between the dexamethasone suppression test (DST) and suicide. Depressed inpatients who had undergone the DST at index admission and later committed suicide (n = 13) were matched for age, gender, diagnosis, and type of DST (1 mg, 2 mg) with depressed inpatients from the same hospital and study time period to form 2 groups: a suicide attempter group (n = 25) and a nonattempter group (n = 28). The suicide completers group had significantly higher 1600 postdexamethasone cortisol levels than the suicide attempters group and a significantly higher 1600 rate of DST nonsuppression compared with the suicide attempter + nonattempter combined group. Although the rate of DST nonsuppression did not differ between the suicide attempter and nonattempter groups, serious attempters had significantly higher 1600 cortisol levels and a statistically higher proportion of patients who completed suicide than nonserious attempters.(ABSTRACT TRUNCATED AT 250 WORDS)     

Life events as precipitants of suicide attempts among first-time suicide attempters, repeaters, and non-attempters

The aims of this study were to investigate risk factors for suicide attempts and propose a model explaining the associations among life events and suicide status. We assessed 263 subjects admitted following a suicide attempt to the Division of Psychiatry of the Department of Neurosciences of the University of Parma and compared them with 263 non-attempter clinical control subjects. Attempters reported significantly more adverse life events both in the last 6 months, and between the ages of 0-15 years than non-attempters. A multinomial logistic regression analysis with stepwise forward entry indicated that the best model to explain suicide status was one which included life events in the last 6 months, life events during age 0-15 years, and their interaction. First-time attempter status (vs. non-attempters) was more likely to be linked to life events in the last 6 months, the interaction between life events in the last 6 months and life events during age 0-15 years, and low social support. Those attempters with one or more prior attempts (repeat attempters) were more likely than non-attempters to be linked to the interaction between life events in the last 6 months and life events during age 0-15 years, and to higher rates of psychopharmacological treatment before the index admission. Guided by these findings, monitoring the impact of early-life and recent events in vulnerable individuals should be part of risk assessment and treatment.     

Neurocognition and suicidal behaviour in an Irish population with major psychotic disorders

OBJECTIVES: Although neurocognitive deficits are seen as core to schizophrenia the association between suicidality and neurocognition has received little attention. Our aim was to examine the relationship between neurocognitive variables and suicidal behaviour in patients with schizophrenia and schizoaffective disorder. METHODS: Seventy-eight patients with DSM-IV diagnoses of schizophrenia or schizoaffective disorder were categorised as either having attempted suicide or not having attempted suicide based on clinical interview and chart review. Attempters and non-attempters were compared on an extensive neuropsychological battery examining pre-morbid and current general cognitive functioning, episodic memory, and executive functioning. RESULTS: Suicide attempters tended to out perform non-attempters across all areas of executive functioning, and showed significantly better performances on measures of attention and verbal fluency. After controlling for relevant clinical and demographic variables, the differences between attempters and non-attempters remained significant for measures of attention (F = 4.97, p = 0.03) and verbal fluency (F = 4.28, p = 0.04). CONCLUSION: This study adds to existing data that suicide attempters with schizophrenia or schizoaffective disorder may have higher cognitive functioning than non-attempters. In particular, the preservation of higher executive function may influence the ability to initiate and plan suicidal behaviour.     

Alexithymia and suicidal behavior

A number of factors including hopelessness have been identified as amplifying suicide risk. Alexithymia has recently been investigated as a predictor of suicidal behavior. The prevalence of the personality trait alexithymia in suicide attempters as well as other predictors of suicidal behavior were investigated in this study. One hundred suicide attempters were compared to 60 healthy controls on the measures of hopelessness, alexithymia, depression and suicidal ideation. First-timers and repetitive suicide attempters, males and females, married and unmarried suicide attempters were compared to each other in the suicide attempter group. The correlations of hopelessness, depression and alexithymia with suicidal intent and suicide lethality were investigated. The suicide attempter group did not display significantly higher scores on the alexithymia measure, compared to healthy controls. Alexithymia neither seemed to be a prevalent personality trait in suicide attempters nor a sensitive predictor of suicidality. The subscales of Toronto Alexithymia Scale measuring difficulty in identification and expression of feelings also did not reveal a significant difference between the two groups. Suicide attempters were more depressive, more hopeless and displayed greater suicidal ideation than healthy controls. Severity of depression was a stronger predictor of suicidal intent than hopelessness in the suicide attempter group. The lethality of the suicide attempt did not correlate with any of the psychometric measures. These findings propose that difficulty in the identification and articulation of feelings does not comprise a risk factor for suicidal behavior.     

Aggression–impulsivity,mental pain,and communication difficulties in medically serious and medically non-serious suicide attempters

Background

Unbearable mental pain, depression, and hopelessness have been associated with suicidal behavior in general, while difficulties with social communication and loneliness have been associated with highly lethal suicide attempts in particular. The literature also links aggression and impulsivity with suicidal behavior but raises questions about their influence on the lethality and outcome of the suicide attempt.

Objectives

To evaluate the relative effects of aggression and impulsivity on the lethality of suicide attempts we hypothesized that impulsivity and aggression differentiate between suicide attempters and non-attempters and between medically serious and medically non-serious suicide attempters.

Method

The study group included 196 participants divided into four groups: 43 medically serious suicide attempters; 49 medically non-serious suicide attempters, 47 psychiatric patients who had never attempted suicide; and 57 healthy control subjects. Data on sociodemographic parameters, clinical history, and details of the suicide attempts were collected. Participants completed a battery of instruments for assessment of aggression–impulsivity, mental pain, and communication difficulties.

Results

The medically serious and medically non-serious suicide attempters scored significantly higher than both control groups on mental pain, depression, and hopelessness (p < .001 for all) and on anger-in, anger-out, violence, and impulsivity (p < .05 for all), with no significant difference between the two suicide attempter groups. Medically serious suicide attempters had significantly lower self-disclosure (p < .05) and more schizoid tendencies (p < .001) than the other three groups and significantly more feelings of loneliness than the medically non-serious suicide attempters and nonsuicidal psychiatric patients (p < .05). Analysis of aggression–impulsivity, mental pain, and communication variables with suicide lethality yielded significant correlations for self-disclosure, schizoid tendency, and loneliness. The interaction between mental pain and schizoid traits explained some of the variance in suicide lethality, over and above the contribution of each component alone.

Conclusions

Aggression–impulsivity and mental pain are risk factors for suicide attempts. However, only difficulties in communication differentiate medically serious from medically non-serious suicide attempters. The combination of unbearable mental pain and difficulties in communication has a magnifying effect on the risk of lethal suicidal behavior.     

Characteristics of HIV patients who attempt suicide

OBJECTIVE: To examine the risk factors for suicidal behaviour in human immunodeficiency virus (HIV) positive patients. METHOD: HIV substance dependent positive patients who had attempted suicide were compared with HIV substance dependent positive patients who had never attempted suicide for suicide risk factors. RESULTS: Among the 149 HIV positive patients examined almost half had attempted suicide. Significantly more HIV positive patients who had attempted suicide were female. Attempters were significantly younger than non-attempters. Significantly more of the attempters had a family history of suicidal behaviour. Attempters also reported significantly more childhood trauma, scored significantly higher for neuroticism, had experienced significantly more comorbidity with depression, and more of them had received antidepressant medication. CONCLUSION: These data suggest that both distal and proximal risk factors are involved in suicidal behaviour in HIV positive substance dependent patients.     

Shame-proneness in attempted suicide patients

ABSTRACT: BACKGROUND: It has been suggested that shame may be an important feature in suicidal behaviors. The disposition to react with shame, "shame-proneness", has previously not been investigated in groups of attempted suicide patients. We examined shame-proneness in two groups of attempted suicide patients, one group of non-suicidal patients and one group of healthy controls. We hypothesized that the attempted suicide patients would be more shame-prone than non-suicidal patients and healthy controls. METHOD: The Test of Self-Conscious Affect (TOSCA), which is the most used measure of shame-proneness, was completed by attempted suicide patients (n = 175: 105 women and 3 men with borderline personality disorder [BPD], 45 women and 22 men without BPD), non-suicidal psychiatric patients (n = 162), and healthy controls (n = 161). The participants were convenience samples, with patients from three clinical research projects and healthy controls from a fourth research project. The relationship between shame-proneness and attempted suicide was studied with group comparisons and multiple regressions. Men and women were analyzed separately. RESULTS: Women were generally more shame-prone than men of the same participant group. Female suicide attempters with BPD were significantly more shame-prone than both female suicide attempters without BPD and female non-suicidal patients and controls. Male suicide attempters without BPD were significantly less shame-prone than non-suicidal male patients. In multiple regressions, shame-proneness was predicted by level of depression and BPD (but not by attempted suicide) in female patients, and level of depression and non-suicidality in male patients. CONCLUSION: Contrary to our hypothesis and related previous research, there was no general relationship between shame-proneness and attempted suicide. Shame-proneness was differentially related to attempted suicide in different groups of suicide attempters, with significantly high shame-proneness among female suicide attempters with BPD and a negative relationship between shame-proneness and attempted suicide among male patients. More research on state and trait shame in different groups of suicidal individuals seems clinically relevant.     

Past suicidal ideation as an independent risk factor for suicide behaviours in patients with depression

Objectives: As South Korea has the highest incidence of completed suicides, the present study aimed to investigate the predictive power of the variables that have been associated with suicide attempts in Korean patients diagnosed with depression.

Methods: Hundred participants were divided into two groups: suicide attempters (31%) and suicide non-attempters (69%). Participants with a history of more than one suicidal attempt were assigned to the suicide attempter group. A hierarchical logistic regression analysis was performed to determine the predictive strengths of the variables that were likely to be associated with suicide attempts.

Results: After controlling for the effects of such variables as the severity of depressive symptoms, life stress events and impulsivity, the severity of past suicidal ideation was the most important predictive factor for discriminating suicide attempters from suicide non-attempters. The odds ratio for attempting suicide relative to not attempting suicide increased by a factor of 4.408 for each unit of increase in suicidal ideation.

Conclusions: The present study suggests that the most severe suicidal ideation throughout one’s entire life should not be overlooked and may be a major predictor of the risk of suicide.     

Effect of SNP at position 40237 in exon 7 of the TPH2 gene on susceptibility to suicide

OBJECTIVE: The novel tryptophan hydroxylase isoform (TPH2), being the rate-limiting enzyme in the biosynthesis of serotonin, has many biological functions and plays an important role as candidate gene in several psychiatric disorders. Here, an A-G single nucleotide polymorphism (SNP) at the position 40237 relative to 5'-end of TPH2 gene was selected for the association with suicide behavior. METHODS: The study population consisted of 102 MD patients with suicide behavior as attempters and 123 MD patients without suicide behavior as non-attempters. The TPH2 SNP was determined by sequencing on an ABI 3700 automated DNA sequencer. RESULTS: The A allele was significantly less frequent in attempters than in non-attempters (p=0.0067). Individuals with the A/A genotype showed a significantly lower risk of suicide behavior than those with the A/G or G/G genotype (OR=0.35). CONCLUSIONS: Our findings suggest that the A-G polymorphism of TPH2 may confer susceptibility to suicide behavior in MD patients.     

Attempted suicide in older depressed patients: effect of cognitive functioning.

The authors explored cognitive functioning and suicidal behavior in older depressed patients. Inpatients age 50 years or older (N=103) with major depression, 45 of whom had attempted suicide, were evaluated within 1 week of their hospital admission. Measures of suicidal behavior included suicide attempter status, the Suicide Intent Scale (SIS), ratings of method used (violent/nonviolent), and seriousness of injuries sustained (lethality). The Mini-Mental State Exam (MMSE) score measured cognitive impairment; covariates were age, gender, and living arrangement. The MMSE score was not associated with suicide attempter status, but for attempters, MMSE score showed a positive association with SIS score, but not method or lethality. Findings suggest that although cognitive disturbance may be associated with less-deliberate acts among older depressed suicide attempters, it does not appear to influence the potential lethality of their behavior.     

Relationships between attempted suicide, temperamental vulnerability, and violent criminality in a Swedish forensic psychiatric population.

The relationship between suicide attempts and different vulnerability factors was investigated in 61 male subjects during forensic psychiatric examination. Personality traits and psychopathy were determined by means of the Karolinska Scales of Personality (KSP) and the Psychopathy Checklist-Revised (PCL-R). Clinical diagnoses were determined by the use of Structured Clinical Interview for DSM-III-R (SCID). Platelet monoamine oxidase (MAO) activity was investigated in 58 subjects.Suicide attempters had extremely low socialization and high impulsive aggression. This was independent of a history of repeatedly criminal violence or not. They had higher PCL-R scores and lower levels of platelet MAO activity than non-attempters. No relationship was found between suicide attempts and repeated violent criminality. However, among the subjects with repeated criminal violence there was a highly significant difference between suicide attempters and non-attempters, indicating different personality profiles in violent offenders with and without suicidal behavior. Suicidal behavior was significantly associated with borderline personality disorder, but not with any other single DSM-III-R disorder. The results show a far more severe personality disturbance in suicide attempters than in other violent patients in this type of population. Suicidal behavior should therefore be evaluated and treated per se.     

Suicide attempters with Borderline Personality Disorder show differential orbitofrontal and parietal recruitment when reflecting on aversive memories

Suicidal behavior and difficulty regulating emotions are hallmarks of Borderline Personality Disorder (BPD). This study examined neural links between emotion regulation and suicide risk in BPD. 60 individuals with BPD (all female, mean age = 28.9 years), 46 of whom had attempted suicide, completed a fMRI task involving recalling aversive personal memories. Distance trials assessed the ability to regulate emotion by recalling memories from a third-person, objective viewpoint. Immerse trials assessed emotional reactivity and involved recalling memories from a first-person perspective. Behaviorally, both groups reported less negative affect on Distance as compared to Immerse trials. Neurally, two sets of findings were obtained. The first reflected differences between attempters and non-attempters. When immersing and distancing, attempters showed elevated recruitment of lateral orbitofrontal cortex, a brain region implicated in using negative cues to guide behavior. When distancing, attempters showed diminished recruitment of the precuneus, a region implicated in memory recall and perspective taking. The second set of findings related to individual differences in regulation success – the degree to which individuals used distancing to reduce negative affect. Here, we observed that attempters who successfully regulated exhibited precuneus recruitment that was more similar to non-attempters. These data provide insight into mechanisms underlying suicide attempts in BPD. Future work may examine if these findings generalize to other diagnoses and also whether prior findings in BPD differ across attempters and non-attempters.     

Gender-specific association between iron status and the history of attempted suicide: implications for gender paradox of suicide behaviors

PURPOSE: Iron deficiency (ID) has been linked with high impulsivity, and an increased risk of ID was reported among suicide attempters. We hypothesized that poor iron status might be prevalent among suicide attempters, who have high impulsivity. METHODS: As a part of the third National Health and Nutrition Examination Survey (1988-1994), a set of iron indices were measured in 2598 men and 2975 women aged 17-39 years, who completed a mental disorder diagnostic interview. RESULTS: Using non-attempters as reference within each gender, we observed a gender-dependent association between poor iron status and the history of attempted suicide. For male attempters (n=74), the prevalence ratios (PR) of abnormal serum ferritin, serum iron and protoporphyrin were 18.3 (95%CI=3.3-101.7), 3.2 (1.1-9.4) and 5.4(1.8-15.6). In contrast, the PR of abnormal serum ferritin for female attempters (n=217) was 0.3 (0.1-0.6). The hematological indices did not differ significantly between attempters and non-attempters among either men or women. Compared with non-attempters, male attempters were prone to a higher odds [17.5 (4.2-72.4)] while female attempters to a lower odds [0.6 (0.3-1.1)] of ID. CONCLUSION: These data suggest new opportunities for exploring biological bases of gender paradox of suicidal behaviors and a novel way to enhance therapeutic and preventive interventions against suicide.     

Comparison of completed and attempted suicide in Akita, Japan

To determine the factors underlying suicide in Akita prefecture, a questionnaire survey was conducted among members of the Akita Prefectural Medical Association (APMA), regarding suicide cases they attended. During the investigation period (1 July 2001-30 June 2002), the total number of suicide cases was 243 (138 completed, 105 attempted). Significant differences were identified between completed and attempted suicide groups in terms of gender, age distribution, and suicidal methods. Specifically, in the completed suicide group, the number of male completers exceeded that of female completers, the number of middle-aged or elderly completers was high, and the majority of completed suicide cases involved hanging as the suicide method. Conversely, in the attempted suicide group, the number of female attempters exceeded that of male attempters, younger attempters were frequent, hanging was rare, and drug overdose or cutting was common. In addition, the number of cases involving a history of previous suicide attempts was significantly higher in the attempted suicide group than in the completed suicide group. The results of the present study support the concept that the completed and attempted suicide groups are essentially of a different nature. Furthermore, the number of cases involving a history of previous suicide attempts was found to be significantly lower in the completed suicide group than in the attempted suicide group. This result indicates the difficulty in decreasing the number of completed suicides by simply providing intervention and care for individuals who have attempted suicide.