Suicidal behaviour and intensity of psychiatric care in a region at high risk for suicide

BACKGROUND Suicidal behaviour represents a social and health-related issue of prime importance in both the general and psychiatric population. People with mental illness are at great risk of suicide, but indirect evidence suggests that the treatment of psychiatric disorders may prevent suicide. The aim of our study was to compare the risk of suicide in the population of psychiatric patients with that of the general population in Friuli Venezia-Giulia (FVG).

METHOD We analyzed the suicide rates, based on the official statistical database, relating to the resident population in FVG during the years 1998–1999. The sucide rates (per 100?000 subjects) were standardised by sex and age. The characteristics of suicidal behaviour in subjects who had been in contact with (Community Mental Health Centres) CMHC (n=65) were compared with that of suicidal subjects not in contact (n=237).

RESULTS There was an increase in the suicide phenomenon in the elderly population in FVG over the tested period. The rates were three times higher in males than in females. The rates of patients in contact with CMHC in 1998 and in 1999 were, respectively, 14 and 20 times higher than that of the general population. Most suicidal schizophrenics and 37% of the depressed patients have been previously hospitalised.

CONCLUSION The population of north-eastern Italy is at high risk of suicide compared to other regions. The mortality ratio of psychiatric subjects who commit suicide in our sample is elevated. Since Italian community-oriented services rely less on hospitalisation than in other countries, the fact that about 50% of suicidal psychiatric patients have been previously admitted in a psychiatric ward may indicate that previous hospitalisation is a hierarchic factor related to suicide.     

Suicide,ethnicity and psychiatric in-patient care: A case-control study

Abstract

This study compares patients with controls concerning sociodemographic variables and describes Swedish and foreign-born patients concerning psychiatric disorders. suicide risk. history of attempted suicide, suicide method, number of parasuicides and time from discharge to suicide. It is based on 59 psychiatric in-patients who had committed suicide, of whom 46 were native Swedes and 13 foreign-born, and on a random sample of 630 controls living in the same area of Stockholm, Sweden. There was an excess suicide risk for being foreign-born with a crude odds ratio of 1.94 (CI = 1.01?3.76) in an unconditional logistic regression. In the final model, single living, having a somatic disease and being unemployed were major risk factors for committing suicide. There were no differences between Swedes and those of foreign birth concerning distribution of certain background variables (i.e., suicide risk, diagnoses and quality of care assessed via clinical records). Only 39% of the patients were classified as high risk by the doctor-in-charge at admission. This is significantly lower p<0.001) than the retrospectively rated risk. Planned aftercare was considered as satisfactory for about half of the patients. About two-thirds of the patients did not participate in aftercare or almost immediately discontinued the contact. More attention is necessary in order to motivate the patients to take part in aftercare and there is a need for better co-operation between hospital and out-patient clinics.     

Psychosocial and psychiatric characteristics of suicide completers with psychiatric treatment before death: a psychological autopsy study of 76 cases

Aim: The present study was conducted to examine differences in psychosocial and psychiatric characteristics between suicide completers with and without a history of psychiatric treatment within the year before death, using a psychological autopsy method. Methods: A semi‐structured interview was administered by a psychiatrist and other mental health professionals for the closest bereaved of 76 suicide completers. Results: Suicide completers with a history of psychiatric treatment (n = 38) were significantly younger than those without (n = 38) (P < 0.01), and a significantly higher proportion of cases in the treatment group were estimated to be suffering from schizophrenia. Further, in 57.9% of the treatment group, the fatal suicidal behavior involved overdose with prescribed psychotropic drugs. In addition, female suicide completers in the treatment group were more likely to have a history of self‐harm or non‐fatal suicidal behavior. Conclusion: Many suicide completers who received psychiatric treatment were young adults. It was common for suicide completers to overdose on prescribed drugs as a supplementary means of suicide, and many experienced self‐harming behavior before death. In addition, a higher proportion of the treatment cases suffered from schizophrenia.     

Ulcer, attempted suicide and suicide.

Attempted suicide and suicide have been investigated among 2,619 patients suffering from duodenal ulcer, gastric ulcer and ulcer dyspepsia without ulcer demonstrable by x-ray. There was no difference in the percentage of attempted suicides and suicides among the three ulcer groups or between the sexes. Within well-defined periods, there was a statistically significant greater excess of attempted suicides among patients operated on than among unoperated patients. The distribution according to psychiatric diagnosis was very similar to the one observed among persons in general in Copenhagen attempting suicide. The number of patients committing suicide exceeded the expected number significantly, for men as well as for women, but there was no difference between patients operated on and unoperated patients. The psychiatric diagnoses of those committing suicide were predominantly neuroses and psychopathy.     

Mortality among persons with a history as psychiatric inpatients with functional psychosis

  Background: An important aim in all psychiatric care should be a reduction of overall mortality. Information on mortality patterns in different types of psychiatric populations is vital for a successful design of treatment strategies and preventive programmes. The present study aims to describe mortality among persons with a history as psychiatric inpatients with functional psychosis. Methods: All psychiatric inpatients, 17,878 men and 23,256 women, registered in the Swedish National Hospital Discharge Registry between 1978 and 1982 with a functional psychosis (ICD-8 = 295–299) as principal diagnosis were followed for mortality during the time period 1983–85. Life tables were constructed and death rates for various types of causes of death were calculated. Results: Compared to the general population, the excess mortality in the study group caused a reduction in life expectancy of 22.1–27.9% (95% CI) among the men and 15.0–21.7% among the women. In the age group 20–49 years, 62% of the excess mortality was caused by suicide. In the age group 50–89 years, only 8% of the excess was suicide, while 52% was caused by cardiovascular disorders. Conclusions: Reduction in mortality rates requires different strategies in different age groups. Even if the suicide rate were reduced to zero, it would only have a marginal influence on the highly elevated mortality among patients in upper middle age and among the elderly. Among the younger patients (<35 years), on the other hand, practically all excess mortality was caused by suicide and accidents. Accepted: 12 April 2000     

Risk of suicide according to the level of psychiatric contact in the older people: Analysis of national health insurance databases in Taiwan

PurposeSuicide in the older people is a serious problem worldwide; however the effect of psychiatric contact on the risk of suicide has not been fully explored. The aim of this study was to investigate the relationship between psychiatric contact and suicide in the older people in Taiwan.MethodsA population-based database was used in this national case–control study. Propensity score matching was used to match older people who did and did not commit suicide from 2010 to 2012 by calendar year, gender, age, and area of residence. The level of psychiatric contact in the preceding year was classified as “no psychiatric contact,” “only outpatient psychiatric contact,” “psychiatric emergency room contact,” or “psychiatric hospital admission”. Conditional logistic regression analysis was used to assess associations between variables and the risk of suicide.ResultsA total of 2528 older people committed suicide from 2010 to 2012, with a crude suicide mortality rate of 3.37/10,000. Compared to those who had no psychiatric contact in the preceding year, the adjusted odds ratios of suicide were 10.15 (95% CI = 5.8–17.7) for those who had psychiatric emergency room contact, 6.57 (95% CI = 3.7–11.6) for those who had psychiatric hospital admissions, and 3.64 (95% CI = 3.0–4.4) for those with only outpatient psychiatric contact. The risk of suicide was higher in those who had depression (OR = 3.49, 95% CI = 2.2–5.4) and bipolar disorder (OR = 1.98, 95% CI = 1.1–3.6). Patients with cancer were associated with suicide (OR = 8.96, 95% CI = 5.6–14.4).ConclusionsThe positive association with suicide and the level of psychiatric contact in the preceding year in older people indicated that the health personnel need to do a better job in determining possible risk for older people who had psychiatric contact, especially in emergency visit or psychiatric admission. A systematic approach to quality improvement in these settings is both available and necessary. Careful discharge planning and safe transitions of care to outpatient services are required for suicide prevention of high-risk patients after discharge.     

Suicide, Ethnicity and Psychiatric In-Patient Care: A Case-Control Study

This study compares patients with controls concerning sociodemographicvariables and describes Swedish and foreign-born patients concerningpsychiatric disorders, suicide risk, history of attempted suicide, suicidemethod, number of parasuicides and time from discharge to suicide. It isbased on 59 psychiatric in-patients who had committed suicide, of whom 46were native Swedes and 13 foreign-born, and on a random sample of 630controls living in the same area of Stockholm, Sweden. There was an excesssuicide risk for being foreign-born with a crude odds ratio of 1.94 (CI = 1.01 – 3.76) in an unconditional logisticregression. In the final model, single living, having a somatic disease andbeing unemployed were major risk factors for committing suicide. There wereno differences between Swedes and those of foreign birth concerningdistribution of certain background variables (i.e., suicide risk, diagnosesand quality of care assessed via clinical records). Only 39% of thepatients were classified as high risk by the doctor-in-charge at admission.This is significantly lower (p < 0.001) than theretrospectively rated risk. Planned aftercare was considered as satisfactoryfor about half of the patients. About two-thirds of the patients did notparticipate in aftercare or almost immediately discontinued the contact.More attention is necessary in order to motivate the patients to take partin aftercare and there is a need for better co-operation between hospitaland out-patient clinics.     

Suicides among 523 persons in a Swedish county with and without contact with psychiatric care

Among 523 (350 males, 173 females) suicides in 1977-1984, subjects who had had contact with psychiatric care (PC) (63%) were compared with those who had never had such contact (NPC) (37%). The male:female ratios in the PC and NPC groups were 1.6 and 3.0, respectively. Intoxication with drugs and or alcohol was the main method of suicide among the PC subjects, and hanging and intoxication with carbon monoxide predominated among subjects of the NPC group. High percentages of divorces and widows/widowers were characteristic of both groups. Among men and women of the PC group the age groups in which the highest mean suicide rates per 100,000 were found were 45-54 and 55-64 years respectively. The corresponding age groups in the NPC group were greater than or equal to 75 and greater than or equal to 70 years. In the PC group the number of admissions to psychiatric hospitals was more than three in 55% of the subjects and more than eight in 25%. Seventy-three percent had had psychiatric contact within 6 months before the suicide. About 40% in each group had had depressive syndromes. Somatic disease of relevance to the suicides was found among 10% of the PC subjects and 20% of the NPC. About 1/4 of the subjects in both groups had expressed serious suicidal intent shortly before the suicide. The importance of information and education about suicide problems among personnel and relatives is underlined.     

Changes in institutional psychiatric care and suicidal behaviour: a follow-up study of inpatient suicide attempters in Bærum, Norway

Background

During the past decades, extensive reformatory changes in institutional psychiatric care have been implemented in Norway.

Aims

The objective of the present study was to investigate whether these changes have resulted in shortened length of psychiatric hospital stays for suicide attempters. Further, to examine if length of hospital stay and time period in which the patients received treatment were related to the risk of a repeated suicide attempt and/or committing suicide.

Methods

All cases of suicide attempters hospitalised between 1984 and 2006 in the municipality of Bærum, a suburb outside Oslo, were examined. The period of observation was further subdivided in two time intervals on the basis of the de-institutionalisation of psychiatric care, which started to plateau in 1996.

Results

Among 1,574 patients consecutively admitted to the local general hospital after a suicide attempt, 330 were admitted to inpatient psychiatric care. Patients admitted in the period 1996–2006 had significantly shorter hospital stays than patients in the preceding period 1984–1995 (Log Rank P < 0.001). Neither the time period of treatment variable nor the length of hospital stay variable was significantly associated with the risk of a repeated suicide attempt or suicide.

Conclusions

Psychiatric de-institutionalisation appears as not having affected suicide attempt repetition. It is possible that reduced length of hospital stay has been compensated by improved mental health care in general and extended outpatient services in particular.     

Mortality in long-stay patients from psychiatric hospitals in Italy

Background: Mortality in psychiatric patients both from natural and non-natural causes was reported to be markedly higher than in the general population. The effect of the psychiatric hospital (PH) closure process on mortality has nonetheless seldom been investigated. We studied mortality in a cohort of PH patients, taking into account the closure process in Italy. Methods: A total of 2915 patients from 12 PH were described in the period 1994–1996 and followed up until June 2000, and discharges and deaths were registered. Standardized mortality ratios (SMR) for natural and non-natural causes were computed on the basis of regional death rates. Results: Observed deaths were 714 vs. 291.2 expected. The all-causes SMR was 2.47 in males and 2.43 in females. The SMR was 26.92 in males and 13.75 in females for psychiatric causes, 6.84 and 7.89 for undefined causes, 9.57 and 7.27 for pneumonia, 6.38 and 7.78 for chronic obstructive respiratory disease, and 1.27 and 1.58 for ischemic heart disease. No excess was observed for all cancers in males, but the SMR was 1.50 for lung cancer in males, 2.30 for breast cancer and 1.48 for all neoplasms in females. SMR for suicide was 3.85 in males and 2.73 in females. Most SMR were higher at younger age, although the rate of absolute excess deaths was greater above age 60. The SMR for all causes was 2.66 before discharge from PH, and 2.09 after discharge. Conclusions: Mortality remained high after leaving the PH, but no increase was associated to the PH closure. Accepted: 5 February 2003 Correspondence to Barbara D‘Avanzo     

Factors predictive of referral to psychiatric hospital among general hospital psychiatric consultations

The aim of this paper was to explore the factors necessitating psychiatric hospital care in a Finnish multi-centre study of general hospital in-patients referred for psychiatric consultation. The study group consisted of 1251 patients referred to psychiatric hospital (n= 181) and a comparison group (n= 1070) consisting of subjects who were not referred. Differences between groups were studied by univariate analysis. Logistic regression analysis was used both to assess the factors contributing to referral to psychiatric hospital and to create predictive models. The validity of the models was analysed by means of receiver operating characteristic (ROC) curves in an independent sample. Psychiatric hospital care during the previous 5 years was associated with a 3.7-fold (odds ratio) increased risk of hospitalization. A diagnosis of psychosis was associated with a 2.9-fold increased risk, and attempted suicide as a reason for consultation was associated with a 2.1-fold increased risk. Not being married doubled the risk, and the odds ratio was also high in cases of poor psychosocial functioning (as assessed by Global Assessment of Functioning (GAF) score). The predictive model differentiated reasonably well between those patients who were hospitalized and the other patients. In conclusion, this multi-centre study of factors predictive of referral to psychiatric hospital among general hospital patients revealed that the most important determinants were previous psychiatric care, diagnosis of psychosis or severe depression, attempted suicide, being unmarried, and poor psychosocial functioning as assessed by GAF score.     

Survival analysis of suicide risk after attempted suicide

Survival analysis of suicide risk by sex and age after attempted suicide was studied in a cohort of 1573 suicide attempters referred to the psychiatric emergency room at the Karolinska Hospital from 1981 to 1988. The time course of suicide risk and the overall prognosis after attempted suicide and, in particular, the possible usefulness of sex and age as risk factors for the prediction of suicide risk after attempted suicide was analyzed. Nearly two thirds of the sample were women and most of the suicide attempters were young (in their twenties and thirties), and the median age was 35 years. The overall mortality after a 5-year mean observation period after attempted suicide was 11%, and the suicide mortality was 6 %. The suicide risk after attempted suicide among men (8.3%) was nearly twice the female suicide risk (4.3%). Age as a possible suicide risk factor was analyzed for each sex separately by median split subgrouping. It was concluded that both older and younger male suicide attempters are at high risk of suicide (7% and 10% respectively), and older women are at higher risk than younger (6%, vs 2%). The suicide risk is particularly high during the first year after the suicide attempt. The high suicide risk group of young adult male suicide attempters is one of the main feasible targets of psychiatric intervention research programs on suicidal behavior. Suicide among young men is a major cause of years of life lost.     

Inpatient suicide on a general hospital psychiatric ward: Does experience with high risk patients help to prevent suicides?

Abstract

The suicide rate on a general hospital psychiatric ward taking care of highly suicidal patients was 3.2/1000 admissions over a 11-year period. This figure was lower than the suicide rate of a psychiatric hospital in the same city. Although the number of admissions increased during the period, concurrently a statistically significant decrease in suicide rate took place. The authors conclude that accretion of experience on the treatment of suicidal patients and application of adequate physical safety measures helped in suicide prevention on the ward. It seems that a voluntary general hospital psychiatric ward can safely take care of non-psychotic suicidal patients.     

Male suicides and alcohol consumption in the former USSR

A significant decline (34.5%) in the suicide rate occurred in 1984–1988 throughout the USSR. The decline was observed shortly after the introduction of strict restrictions on the sale of alcohol. We tested the hypothesis that the restrictive alcohol policy in the first years of perestroika (June 1985) caused the fall in suicide rates in the former USSR. Data on alcohol consumption, violent death caused by external injury and poisoning (n= 916,315), death due to accidental alcohol poisoning (n= 77,837), suicide (n= 192,305) and death undetermined whether accidentally or purposely (n= 54,253) were analyzed for all former Soviet republics for 1984, 1986, 1988 and 1990. Men were chosen for the analysis, since men are more prone to abuse alcohol than women. Regression analysis with alcohol consumption as the independent variable and suicide rates and violent death rates as dependent variables shows that suicide and alcohol consumption were positively correlated as were violent death and alcohol consumption. In the republics with high alcohol consumption (Slavic and Baltic), suicide rates were also high. In the Caucasian republics, low alcohol consumption was associated with low suicide rates. For most republics, alcohol seems to explain more than 50% of suicides. Alcohol also has considerable explanatory value for violent death. Thus, a restrictive alcohol policy might be a way to reduce suicide and violent death.     

Excess mortality of suicide attempters

  Background: Excessive mortality of suicide attempters has emerged from many follow-up studies. Completed suicide is the main cause of excess deaths, but the increased risk of deaths from other unnatural and natural causes is also of major public health concern. We lack follow-up studies of the different causes of death in cohorts of suicide attempters. The present study aimed to determine the mortality by suicide and other causes of death and to investigate risk factors. Methods: This mean 5.3-year follow-up study was based on an unselected cohort of suicide attempts by both violent and non-violent methods, treated in hospitals in a well-defined urban catchment area in Helsinki. In total, 2782 patients aged 15 years and over admitted to the emergency rooms after suicide attempt between 1989 and 1996 were included in the follow-up analysis. Standardised mortality ratios (SMR) for suicide, disease, accident, homicide, and undetermined death were calculated. Results: Mortality from all causes was 15 times higher than that expected among men and nine times higher in women. SMRs in men were 5402 (95% CI 4339–6412) for suicide, 2480 (95% CI 925–4835) for homicide, and 11,139 (95% CI 6884–16,680) for undetermined cause, and for women 7682 (95% CI 5423–9585), 3763 (95% CI 52–5880) and 15,681 (95% CI 6894-22,294), respectively. Fifteen percent of all suicide attempters died during the average 5.3-year follow-up of the index attempt. Deaths from suicide accounted for 37% of all excess deaths in men and 44% in women. The mortality ratio was highest during the 1st follow-up year. The total number of lost years of life among the 413 suicide attempters who died during follow-up was 13,883. The risk factors for all causes of death were male sex, single, retirement, drug overdose as a method, an index attempt not involving alcohol, and a repeated attempt. Conclusion: A suicide attempt indicates a severe risk of premature death, and suicide is the main cause of excess deaths. However, it appears that concentrating efficient treatment only on the most suicidal patients could prevent no more than two of five premature deaths. More effort is therefore needed to prevent the excess mortality of suicide attempters by also addressing causes of death other than suicide. Accepted: 27 October 2000     

Causative factors as cues for addressing the rapid increase in suicide in Mie Prefecture, Japan: comparison of trends between 1996-2002 and 1989-1995

The number of suicides in Japan has increased from approximately 22 000 per year from 1988 to 1997 to >30 000 per year since 1998. Likewise, the number of suicides has been increasing in Mie Prefecture. The purpose of the present study was to examine the incidence of and circumstances surrounding all suicide cases during 1996-2002 in Mie Prefecture and to compare the data with those from 1989 to 1995. In Mie Prefecture, the age-specific suicide rate during the second 7-year period included marked increases among men aged 50-59 and 60-69 years. Among women, the age-specific suicide rate increased with age during both 7-year periods. During the second period, psychiatric disorders as causative factors increased in all generations. They were especially important for women of the younger generation, whereas economic problems were the most common causative factor among men aged 40-64. Physical illness as a causative factor in suicide was high among the elderly, but among the other age groups this factor trailed behind economic difficulties for men and psychiatric disorders for women. To prevent suicide, social cooperation as well as a plenitude of visiting nurses and psychiatric care is required, and early detection and treatment are also important.     

Psycho-social determinants for psychiatric hospitalisation for neurotic disorders in women

Background: Much has been written about the determinants of psychiatric hospitalisation, chiefly for psychotic patients in an emergency. This paper reports the results of a comparative study between in-patients and pathological subjects from the general population. The aim of this work is to evidence the psycho-social determinants of hospitalisation in a psychiatric department for neurotic disorders. Methods: This study was conducted on a socially fairly privileged population which was, therefore, also fairly homogeneous. The subjects from the two groups were assessed clinically using standardised instruments both for diagnosis (SCAN) and for psycho-social variables (Stressful Life Events: LEDS; Social Support and Self-esteem: Pearlin checklist; care itinerary). Results: Following the analysis of frequency and a multivariate logistic regression analysis, four risk factors for hospitalisation for neurotic disorders were evidenced, including: severity of neurotic disorders, taking a long time to consult a specialist after first onset of anxiety disorders, poor social support, and having experienced one or more provoking agents (Brown and Harris methodology) in the year previous to hospitalisation. Conclusion: The severity of the mental pathology is largely responsible for hospitalisation in neurotic patients as it is in psychotic patients, but it is not the only determinant for hospitalisation. Accepted: 1 December 2002