Excessive mortality and causes of death among patients with personality disorder with comorbid psychiatric disorders

Purpose

Excessive mortality has been seen in patients with personality disorder (PD), but it has not been well-studied when patients also have other psychiatric comorbidities. This study investigated the mortality rates and causes of death in an Asian cohort with PD.

Method

We enrolled patients ≥ 18 years of age with PD as defined by DSM-IV criteria (N = 1172), who had been admitted to a psychiatric service center in northern Taiwan between 1985 and 2008. By linking with the national mortality database (1985–2008), cases of mortality (n = 156, 13.3%) were obtained. We calculated the standardized mortality ratios (SMRs) to estimate the mortality gap between patients with PD and the general population. Stratified analyses of mortality rates by Axis I psychiatric comorbidity and sex were performed.

Results

Borderline PD (n = 391, 33.4%) was the dominant disorder among the subjects. The SMRs for all-cause mortality of PD alone, PD comorbid with non-substance use disorder(non-SUD), and PD comorbid with SUD were 4.46 (95% CI 1.94–6.98), 7.42 (5.99–8.85), and 15.96 (11.07–20.85), respectively. Among the causes of death, the SMR for suicide was the highest (46.92, 95% CI 34.29–59.56). The SMR for suicide in PD patients with comorbid SUD was unusually high (74.23, 95% CI 33.88-114.58). Women had a significant increase in suicide with an SMR of 59.00 (95% CI 37.89–80.11). Men had significant increase in SMRs for cardiovascular disease and gastrointestinal disease.

Conclusions

We found significant synergistic effects of PD and SUD on mortality risk. A personality assessment should be mandatory in all clinical settings to prevent premature death and detect SUD early.

     

Increased suicide risk and clinical correlates of suicide among patients with Parkinson's disease

IntroductionParkinson's disease (PD) is a debilitating, neurodegenerative condition frequently complicated by psychiatric symptoms. Patients with PD may be at higher risk for suicide than the general population, but previous estimates are limited and conflicting. The aim of this study is to estimate the suicide rate based on the clinical case registry and to identify risk factors for suicide among patients diagnosed with PD.MethodsThe target sample consisted of 4362 patients diagnosed with PD who were evaluated at a general hospital in Seoul, South Korea, from 1996 to 2012. The standardized mortality ratio for suicide among PD patients was estimated. In order to identify the clinical correlates of suicide, case-control study was conducted based on retrospective chart review. The 29 suicide cases (age: 62.3 ± 13.7 years; females: 34.5%) were matched with 116 non-suicide controls (age: 63.5 ± 9.2 years; females 56.9%) by the year of initial PD evaluation.ResultsThe SMR for suicide in PD patients was 1.99 (95% CI 1.33–2.85). Mean duration from time of initial diagnosis to suicide among cases was 6.1 ± 3.5 years. Case-control analysis revealed that male, initial extremity of motor symptom onset, history of depressive disorder, delusion, any psychiatric disorder, and higher L-dopa dosage were significantly associated with suicide among PD patients. Other PD-related variables such as UPDRS motor score were not significantly associated with death by suicide.ConclusionSuicide risk in PD patients is approximately 2 times higher than that in the general population. Psychiatric disorders, and also L-dopa medication need further attention with respect to suicide.     

Increased suicide risk in cancer patients in Tyrol/Austria

Objectives

To investigate whether suicide risk in Tyrol/Austria was increased for cancer patients as compared to the general population and whether subgroups at excess risk could be defined.

Study Design and Setting

Cohort design based on all malignant cancer cases diagnosed in Tyrol between 1991 and 2010 and excluding nonmelanoma skin cancer. Entry date was date of diagnosis of the index cancer; exit date was either date of suicide or date of death for reasons other than suicide or end of follow-up (Dec 31, 2011). Standardized mortality ratios (SMRs) were computed in the classical way after adjustment for sex, age and year of follow-up.

Results

For all cancer sites except nonmelanoma skin cancer, we observed a SMR of 1.86 [95% confidence interval (CI), 1.57–2.19]. Suicide risk was greatest during the first 6 months after diagnosis with an SMR of 4.74 (95% CI, 3.27–6.66) and was more than fivefold in cases with advanced Stage IV. We observed the greatest excess risk for suicide in patients with head and neck cancers (13 suicides; SMR, 4.73; 95% CI, 2.52–8.09) and lung cancer (14 suicides; SMR, 4.16; 95% CI, 2.27–6.98).

Conclusion

In our study population in Tyrol/Austria, we observed a twofold suicide risk in cancer patients as compared with the general population, with the excess risk concentrated in the period shortly after diagnosis and in patients with poor prognosis. Therefore, psychooncological care should be intensified in this group of patients.     

Total and cause-specific mortality in patients with personality disorders: the association between comorbid severe mental illness and substance use disorders

Purpose

To investigate the mortality in both in- and outpatients with personality disorders (PD), and to explore the association between mortality and comorbid substance use disorder (SUD) or severe mental illness (SMI).

Methods

All residents admitted to Norwegian in- and outpatient specialist health care services during 2009–2015 with a PD diagnosis were included. Standardized mortality ratios (SMRs) with 95% confidence intervals (CI) were estimated in patients with PD only and in patients with PD and comorbid SMI or SUD. Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) with 95% CIs in patients with PD and comorbid SMI or SUD compared to patients with PD only.

Results

Mortality was increased in both in- and outpatients with PD. The overall SMR was 3.8 (95% CI 3.6–4.0). The highest SMR was estimated for unnatural causes of death (11.0, 95% CI 10.0–12.0), but increased also for natural causes of death (2.2, 95% CI 2.0–2.5). Comorbidity was associated with higher SMRs, particularly due to poisoning and suicide. Patients with comorbid PD & SUD had almost four times higher all-cause mortality HR than patients with PD only; young women had the highest HR.

Conclusion

The SMR was high in both in- and outpatients with PD, and particularly high in patients with comorbid PD & SUD. Young female patients with PD & SUD were at highest risk. The higher mortality in patients with PD cannot, however, fully be accounted for by comorbidity.

     

Sleep,suicide behaviors,and the protective role of sleep medicine

Objective/BackgroundSleep disturbance is associated with suicidal thoughts and behaviors. The relationship of specific sleep disorders to suicide attempts is less well established. Whether treating sleep disorders reduces suicide attempts remains controversial.MethodsSuicide attempts, treatment utilization, and psychiatric diagnoses were extracted from electronic medical records and a suicide attempt database from the U.S. Department of Veterans Affairs. The sample (N = 60,102) consisted of patients with any record of suicide attempt in FY13-14 and a 1:1 case-control of patients with no record of attempt, who were propensity score-matched based on age, gender, and prior year mental health treatment utilization. Associations among sleep disorders and suicide attempt were examined via logistic regression. Covariates included depression, anxiety, posttraumatic stress disorder (PTSD), bipolar, schizophrenia, substance use disorder (SUD), medical comorbidity, and obesity.ResultsInsomnia (OR = 5.62; 95% CI, 5.39–5.86), nightmares (odds ratio, OR = 2.49; 95% confidence interval, CI, 2.23–2.77), and sleep-related breathing disorders (OR = 1.37; 95% CI, 1.27–1.48) were positively associated with suicide attempt after accounting for age, gender, treatment utilization, and comorbid sleep disorders. Furthermore, when controlling for depression, anxiety, PTSD, bipolar, schizophrenia, substance use disorder (SUD), medical comorbidity, and obesity, insomnia (OR = 1.51, 95% CI, 1.43–1.59) remained positively associated with suicide attempt nightmares (OR = 0.96; 95% CI, 0.85–1.09) nor sleep-related breathing disorders (OR = 0.87, 95% CI = 0.79–0.94). Additionally, sleep medicine visits 180 days prior to index date were associated with decreased likelihood of suicide attempt for individuals with sleep disorders (OR = 0.86; 95% CI, 0.79–0.94).ConclusionInsomnia is associated with suicide attempt among veterans. Sleep medicine visits were associated with a reduced risk of suicide attempt in sleep disordered patients. The assessment and treatment of sleep disorders should be considered in context of strategies to augment suicide prevention efforts.     

Suicide in people with epilepsy: How great is the risk?

Purpose:   Suicide is more common in populations with epilepsy, but estimates vary concerning the magnitude of the risk. We aimed to estimate the risk using meta-analysis.
Methods:   A literature search identified 74 articles (76 cohorts of people with epilepsy) in whom the number of deaths by suicide in people with epilepsy and the number of person–years at risk could be estimated. Standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated for each cohort, for groups of cohorts, and for the total population.
Results:   The overall SMR was 3.3 (95% CI 2.8–3.7) based on 190 observed deaths by suicide compared with 58.4 expected. The SMR was significantly increased in people with incident or newly diagnosed epilepsy in the community (SMR 2.1), in populations with mixed prevalence and incidence cases (SMR 3.6), in those with prevalent epilepsy (SMR 4.8), in people in institutions (SMR 4.6), in people seen in tertiary care clinics (SMR 2.28), in people with temporal lobe epilepsy (SMR 6.6), in those following temporal lobe excision (SMR 13.9), and following other forms of epilepsy surgery (SMR 6.4). The SMR was significantly low overall in two community-based studies of people with epilepsy and developmental disability.
Discussion:   We confirm that the risk of suicide is increased in most populations of people with epilepsy. Psychiatric comorbidity has been demonstrated to be a risk factor for suicide in the general population and in people with epilepsy, and such comorbidity should thus be identified and treated.     

Mortality and suicide rates in patients discharged from forensic psychiatric wards in Japan

BackgroundJapanese forensic mental health services for patients with psychiatric disorders under the Medical Treatment and Supervision Act was initiated in 2005; however, the prognosis of those patients is not well-known, particularly regarding mortality and suicide. This study aimed to evaluate the all-cause mortality and suicide rate in forensic psychiatric outpatients who had been discharged from forensic psychiatric wards in Japan.MethodsParticipants included 966 patients who had been discharged from forensic psychiatric wards. Data were collected from July 15, 2005 to July 15, 2018 at 29 of the 33 forensic psychiatric wards in Japan. Only the patients who provided written informed consent were included. We and collaborators at each forensic psychiatric ward identified demographic data of participants from the medical records for the inpatient treatment period. The reintegration coordinators, who belonged to the Ministry of Justice, investigated the prognosis of the participants during the outpatient treatment order period. We then connected demographic data and participants’ prognosis for analysis. The crude rates (CRs) and standardized mortality ratios (SMRs) were calculated to analyze all-cause mortality and suicide rates. Univariate analysis was performed to examine the factors associated with all-cause mortality and suicide rates using the Cox proportional hazards ratio model.ResultsThe participants included 3.3 times as many men (n = 739) compared to women (n = 227), and their combined mean age was 47.3 (SD = 12.9). The most common primary psychiatric diagnosis was psychotic disorders (81.3%). The mean follow-up period was 790.2 days (SD = 369.6). The total observation period was 2091.2 person-years. The CR for all-cause death was 812.9 per 100,000 person-years (95% CI [426.5, 1199.4]), while the SMR for all-cause death was 2.2 (95% CI [1.3, 3.5]). The CR for completed suicide was 478.2 per 100,000 person-years (95% CI [181.8, 774.6]). The suicide SMR was 17.9 (95% CI [8.6, 32.9]) overall, 7.7 (95% CI [2.5, 18.0]) for men, and 79.4 (95% CI [25.8, 185.2]) for women. Univariate analysis showed that women had higher completed suicide risk than men (hazard ratio = 3.599, 95% CI [1.041, 12.445]).ConclusionThe all-cause mortality and completed suicide rates were higher in participants than observed in the general population consistent with the results of previous international studies.     

Interictal dysphoric disorder in patients with localization-related epilepsy: Diagnostic relationships with DSM-IV psychiatric disorders and the impact of psychosocial burden

BackgroundSome patients with epilepsy develop intermittent and pleomorphic affective–somatoform symptoms, termed interictal dysphoric disorder (IDD). Other psychiatric disorders have been extensively investigated in patients with epilepsy, but there are few clinical studies investigating the comorbidity patterns of IDD and common psychiatric disorders (PDs). In particular, the impact of IDD on the psychosocial burden of patients remains unclear.MethodsThe participants were 128 adult Japanese outpatients with localization-related epilepsy (LRE). In order to determine the comorbidity patterns for IDD and PDs, we conducted a comprehensive diagnostic investigation for IDD and DSM-IV psychiatric disorders. Based on these analyses, participants were divided into groups according to the comorbidity patterns for IDD and PDs in order to compare both suicide risk and quality of life (QOL).ResultsThe findings indicated that 19.5% of participants had IDD, and 55.5% had PDs. Younger age at epilepsy onset and refractory complex partial seizures were associated with IDD, but the duration and type of epilepsy were not. Patients with IDD were more likely to have comorbid PDs as follows: mood disorders (odds ratio, OR: 8.30; 95% confidence interval, CI: 3.15–21.83), anxiety disorders (OR: 8.81; 95% CI: 3.30–23.49), and psychotic disorders (OR: 7.72; 95% CI: 2.83–21.06). Group comparisons demonstrated that there were no patients with IDD but without PD. Furthermore, patients with IDD and with PDs had a significantly higher suicide risk and lower QOL compared to the other groups, even after adjusting for the influences of confounding factors.ConclusionInterictal dysphoric disorder adds extreme psychosocial burden and is associated with multiple PDs in patients with LRE. The present study suggests that IDD has a specific prognostic significance. However, whether IDD is nosologically independent from conditions diagnosed using standardized psychiatric diagnostic systems such as DSM-IV must be further assessed by future research.     

Cause-specific mortality in Finnish forensic psychiatric patients

Purpose: To analyze the causes of mortality among patients committed to compulsory forensic psychiatric hospital treatment in Finland during 1980–2009 by categorizing the causes of mortality into somatic diseases, suicides and other unnatural deaths.

Materials and methods: The causes of mortality were analyzed among 351 patients who died during the follow-up. Standardized mortality ratio (SMR) was calculated as the ratio of observed and expected number of deaths by using the subject-years methods with 95% confidence intervals, assuming a Poisson distribution. The expected number of deaths was calculated on the basis of sex-, age- and calendar-period-specific mortality rates for the Finnish population.

Results: The vast majority (249/351) of deaths were due to a somatic disease with SMR of 2.6 (mean age at death 61 years). Fifty nine patients committed suicide with a SMR of 7.1 (mean age at death 40 years). Four patients were homicide victims (mean age at death 40 years) and 32 deaths were accidental (mean age at death 52 years). The combined homicides and accidental deaths resulted in a SMR of 1.7.

Conclusions: The results of this study point out that the high risk for suicide should receive attention when the hospital treatment and the outpatient care is being organized for forensic psychiatric patients. In addition, the risk of accidents should be evaluated and it should be assured that the patients receive proper somatic healthcare during the forensic psychiatric treatment and that it continues also in the outpatient setting.     

Self-harm induced somatic admission after discharge from psychiatric hospital – a prospective cohort study

BackgroundFew studies have examined rate and predictors of self-harm in discharged psychiatric patients.AimsTo investigate the rate, coding, timing, predictors and characteristics of self-harm induced somatic admission after discharge from psychiatric acute admission.MethodCohort study of 2827 unselected patients consecutively admitted to a psychiatric acute ward during three years. Mean observation period was 2.3 years. Combined register linkage and manual data examination. Cox regression was used to investigate covariates for time to somatic admission due to self-harm, with covariates changing during follow-up entered time dependently.ResultsDuring the observation period, 10.5% of the patients had 792 somatic self-harm admissions. Strongest risk factors were psychiatric admission due to non-suicidal self-harm, suicide attempt and suicide ideation. The risk was increased throughout the first year of follow-up, during readmission, with increasing outpatient consultations and in patients diagnosed with recurrent depression, personality disorders, substance use disorders and anxiety/stress-related disorders. Only 49% of the somatic self-harm admissions were given hospital self-harm diagnosis.ConclusionsSelf-harm induced somatic admissions were highly prevalent during the first year after discharge from acute psychiatric admission. Underdiagnosing of self-harm in relation to somatic self-harm admissions may cause incorrect follow-up treatments and unreliable register data.     

Temperaments in completed suicides: Are they different from those in suicide attempters and controls?

BackgroundTemperaments in completed suicides have never been assessed whereas there is substantial research on temperaments in attempted suicides and psychiatric patients.MethodsThe significant others of 18 completed suicides participated in this study in order to provide an assessment of temperaments, hopelessness, depression and the suicide risk of their loved ones. The data were compared with data from 244 psychiatric patients of whom 83 had attempted suicide in the previous month. The following instruments were used: the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto questionnaire (TEMPS-A), the Beck Hopelessness Scale (BHS), the Gotland Scale for Male Depression (GSMD), and the Mini International Neuropsychiatric Interview (MINI) module for assessing suicide risk.ResultsIndividuals who died by suicide more frequently had scores of 9 or higher on the BHS and higher MINI suicide risk scores compared with patients with mood disorders who had not attempted suicide in the previous month. Completed suicides also had lower scores on the TEMPS-A Cyclothymia and Anxiety scales and on the MINI suicide risk scale than mood disorder patients with a recent suicide attempt.LimitationsProxy assessment of variables through survivors can result in underestimation of psychiatric morbidity and other parameters investigated, and limits the generalization of our resultsConclusionsOur study adds information about temperamental subtypes and other variables in completed suicides and points to their difference from attempted suicides and non-suicidal psychiatric patients.     

Childhood Exposure to Psychological Trauma and the Risk of Suicide Attempts: The Modulating Effect of Psychiatric Disorders

ObjectiveWe examined whether childhood exposure to psychological trauma is associated with greater suicidality and whether specific psychiatric disorders modulate this association in a representative sample of Korean adults.MethodsThe Korean version of the Composite International Diagnostic Interview 2.1 was administered to 6,027 subjects aged 18-74 years. Subjects who experienced a traumatic event before the age of 18 years, the childhood-trauma-exposure group, were compared with controls without childhood trauma exposure.ResultsChildhood exposure to psychological trauma was associated with lifetime suicidal ideation (OR=3.19, 95% CI=2.42-4.20), suicide plans (OR=4.15, 95% CI=2.68-6.43), and suicide attempts (OR=4.52, 95% CI=2.97-6.88). These associations weakened after further adjustment for any psychiatric disorders, but they were not eliminated. The risk of suicide attempts related to childhood trauma increased with the presence of a concurrent alcohol use, depressive, or eating disorder.ConclusionIn terms of clinical implications, patients with these disorders who have a history of childhood trauma should be carefully assessed for their suicide risk and aggressively treated for psychiatric disorders.     

Incidence and method of suicide mortality in patients with schizophrenia: a Nationwide Cohort Study

Purpose

Suicide is a leading cause of death in patients with schizophrenia. This nationwide cohort study investigated the incidence of each suicide method in patients with schizophrenia compared with the general population.

Methods

In total, records of 174,039 patients with schizophrenia were obtained from the National Health Insurance Research Database in Taiwan from 2001 to 2016. This schizophrenia cohort was linked with the national mortality database, and 26,926 patients died during this follow-up period. Of the deceased, 3033 had died by suicide. Univariate Cox regression was used to estimate the demographic variables associated with suicide. We estimated the difference in the proportion of each suicide method used in patients with schizophrenia compared with the general population. The incidence and standardized mortality ratio (SMR) of each suicide method were calculated and stratified based on sex.

Results

Patients aged 25–34 years exhibited the highest suicide risk. Compared with the general population, patients with schizophrenia were more likely to commit suicide by jumping and drowning and less likely to use charcoal-burning and hanging. Women showed a higher incidence of suicide by drowning and jumping than did men. Comorbidity with substance use disorders (SUDs) was associated with a high suicide SMR (26.9, 95% confidence interval [CI] = 23.4–28.9), particularly for suicide by jumping (61.2, 95% CI = 48.3–76.3).

Conclusions

Patients with schizophrenia had higher suicide rates for all methods than did the general population. Suicide method differed based on sex. Patients with SUDs exhibit a high SMR for each suicide method and warrant intensive clinical attention.

     

A comprehensive meta-analysis of the risk of suicide in eating disorders

Preti A, Rocchi MBL, Sisti D, Camboni MV, Miotto P. A comprehensive meta‐analysis of the risk of suicide in eating disorders. Objective: Past meta‐analyses on suicide in eating disorders included few available studies. Method: PubMed/Medline search for papers including sample n ≥ 40 and follow‐up ≥5 years: 40 studies on anorexia nervosa (AN), 16 studies on bulimia nervosa (BN), and three studies on binge eating disorder (BED) were included. Results: Of 16 342 patients with AN, 245 suicides occurred over a mean follow‐up of 11.1 years (suicide rate = 0.124 per 100 person‐years). Standardized mortality ratio (SMR) was 31.0 (Poisson 95% CI = 21.0–44.0); a clear decrease in suicide risk over time was observed in recent decades. Of 1768 patients with BN, four suicides occurred over a mean follow‐up of 7.5 years (suicide rate = 0.030 per 100 person‐years): SMR was 7.5 (1.6–11.6). No suicide occurred among 246 patients with BED (mean follow‐up = 5.3 years). Conclusion: AN and BN share many risk factors for suicide: the factors causing lower suicide rates per person‐year in BN compared to AN should be investigated.     

Suicide after discharge from psychiatric inpatient care: a case-control study in Hong Kong

OBJECTIVE: To identify the risk period and the risk factors for suicide in Chinese psychiatric patients after discharge from inpatient psychiatric treatment. The nature of psychiatric aftercare provided to these patients was also explored. METHOD: A case control study with 73 patients who were discharged from a large psychiatric unit in Hong Kong between January 1996 and December 1999 and had received coroners' verdict of suicide or undetermined death within the same period. Controls were 73 surviving patients discharged from the same unit. They were individually matched for sex, age, psychiatric diagnosis, and date of discharge. RESULTS: Post-discharge clustering of suicides was observed among the cases. Nearly 80% of them died within 1 year of discharge. The most common principal diagnosis among the cases was schizophrenia and related psychotic disorders. Multivariate analysis showed that suicide was associated with: unemployment (OR = 12.2, 95% CI = 2.1 - 70.4), past suicidal attempts (OR = 3.4, 95% CI = 1.2 - 9.6), maternal mental illness (OR = 13.4, 95% CI = 1.0 - 170.0), and suicidal ideation or attempt before the last admission (OR = 5.0, 95% CI = 1.4 - 18.0). The psychiatric aftercare received by cases and controls were generally similar. However, cases were more likely to have had contact with health care services in the last week before death (OR = 4.0, 95% CI = 1.3 - 11.9). CONCLUSIONS: Suicidal risk is high in Chinese psychiatric patients soon after discharge. They share some common risk factors for suicide identified in Western studies but several differences are evident: the predominance of schizophrenia in the suicides; the lower prevalence of substance abuse and comorbidity; the low proportion of patients living alone; and the increased clinical contact before death but the less suicidal intent expressed in Chinese patients. It is necessary to consider these socio-cultural factors in assessment of suicidal risk and implementation of suicide prevention strategies in Chinese psychiatric patients.     

Risk factors of suicide in inpatients and recently discharged patients with affective disorders. A case-control study

ObjectivePatients with affective disorders are at high risk of suicide, especially during inpatient treatment and during the first year after discharge.MethodsA blinded case-control design was used. The study included a total national sample of patients with affective disorder admitted during the period from January 1, 1994 to December 31, 1995, who died because of suicide, either during admission or shortly after discharge.ResultsA history of suicide attempt was a significant risk factor (IRR 4.9; 95% CI 2.1–11.6). Loss of job during the year prior to the index admission was associated with an increase in suicide risk (IRR: 2.9; 95% CI 1.2–7.5). Clinical improvement during the index admission (IRR: 0.3; 95% CI 0.1–0.7), and treatment with antidepressant drugs at the censoring date (IRR: 0.3; 95% CI 0.1–0.7) were associated with a decrease in suicide risk.ConclusionImproved treatment may be a key factor in suicide prevention in patients during, and shortly after hospitalisation with affective disorders. Also, there is a need to be especially aware of suicide risk in patients with little or no improvement at discharge.     

A comparison of suicides in psychiatric in-patients,after discharge and in not recently hospitalized individuals

ObjectiveTime of in-patient treatment and the first weeks after hospital discharge have repeatedly been described as periods of increased suicide risk. This study compared demographic, clinical and suicide related factors between in-patient, post-discharge and not recently hospitalized suicides.MethodsSuicide data from the Tyrol Suicide Register were linked with registers of three psychiatric hospitals in the state of Tyrol, Austria. Suicide cases then were categorized as in-patient suicides, post-discharge suicides (suicide within 12 weeks after discharge) or never/not within 12 weeks before death hospitalized suicides. Data were collected between 2004 and 2011.ResultsOf the total of 711 cases, 30 were in-patient, 89 post-discharge and 592 not recently hospitalized suicides. The three groups differed with regard to male-to-female ratio (lower in both hospitalized groups), marital status, suicide method used (jumping in in-patients, hanging in not recently hospitalized suicides), history of attempted suicide and suicide threats (highest in in-patients) and whether suicides had been in psychiatric or general practitioner treatment shortly before death. In most variables with significant differences there was a gradual increase/decrease with post-discharge suicides taking the middle place between the two other groups.ConclusionsThe three suicide populations differed in a number of variables. Varying factors appear to influence suicide risk and choice of method differently in in-patient, post-discharge and not hospitalized suicides.     

Fictitious Twins,Factitious Illness

Abstract

This study characterizes those patients of an urban VA Medical Center (VAMC) who had committed suicide. A cause-of-death search of the 1,075 veterans from the VAMC's case rolls who died during 1998 was conducted. For confirmed and suspected suicides, a chart review was conducted, noting psychiatric history and recent contact with the VAMC. Nineteen patients were either confirmed or suspected suicides. Few of these patients had made recent contact with the VAMC, although the majority of them had received psychiatric services from the VA at some time. The proportion of deaths due to suicide was similar in African American and White patients. Rates of suicide were elevated, primarily because of the high proportion of patients receiving psychiatric treatment. Elderly suicides were less likely to have had psychiatric services or previous psychiatric diagnoses than were younger suicides. Patients with past contact with psychiatric services may be especially at risk of suicide, particularly as contact with these services diminishes. Elderly patients in medical settings with undiagnosed or undertreated psychiatric disorders are also likely to have elevated risk for suicide. These findings demonstrate the importance of acknowledging that risk factors for suicide are specific to sites or populations; this information can be used in allocating resources for developing site-specific strategies for prevention.     

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.