The spectrum of suicidal ideation in Great Britain: comparisons across a 16-74 years age range

BACKGROUND: Previous studies have examined suicidal ideation in older populations and emphasized the strong association with the presence of psychiatric disorder. However, associations with the presence of psychiatric disorder across the age range are unclear. Representative epidemiological estimates are needed. METHOD: In a national survey of psychiatric morbidity in Great Britain, 8580 randomly selected adults were interviewed. Three questions were asked to assess suicidal ideation, and psychiatric disorder was identified using the revised Clinical Interview Schedule (CIS-R). RESULTS: Suicidal ideation was up to three times commoner in younger adults than in those aged 55-74 years but the odds of depression in those with suicidal thoughts was significantly greater in the older age group (p<0.01). Tiredness with life (p<0.01) and thoughts of death (p<0.01) were also more strongly associated with depression in the older age group. Other major associations of suicidal ideation for all ages were: smaller social support group, being divorced or separated, poor self-rated general health, and limitations in activities of daily living (ADL). Being single was an important factor for younger age groups, and widowhood for older people. Life events were also important in younger people, but not in those aged 55-74 years. CONCLUSIONS: Suicidal thoughts and death wishes are comparatively more unusual in older people; however, they are more likely to be associated with clinical depression. In terms of suicide prevention this study emphasizes the importance of improving rates of recognition and treatment of depression in older people.     

北京地区40家综合医院住院病人自杀意念和自杀未遂的调查

目的:了解北京地区综合医院住院病人自杀意念、自杀未遂的出现率及其危险因素。方法:采用自制抑郁筛选量表在随机抽取的北京40家各级综合医院中调查了2914例年龄>15岁的住院病人,了解他们自杀意念、自杀未遂发生情况及相关因素,并通过多因素logistic模型发现其危险因素。结果:2914例患者中,187人(6·42%;95%CI为5·58%~7·64%)有过自杀意念,其危险因素排列为:近一年感到绝望的频率高(OR=9·2,95%CI为6·5~12·9)、亲属有过自杀行为(4·3,2·3~8·3)、调查当时有重性抑郁发作(2·7,1·7~4·3)、熟人有过自杀行为(2·0,1·3~2·9)、年龄<55岁(1·7,1·2~2·3)、女性(1·5,1·1~2·1)。2914例患者中,25人(0·86%;95%CI为0·56%~1·26%)有过自杀未遂,其危险因素排列为:目前有重性抑郁发作(OR=5·6,95%CI为2·1~15·1)、亲属有过自杀行为(5·1,1·4~18·9)、近一年感到绝望频率高(4·7,1·9~11·9)、年龄<55岁(3·6,1·4~9·3)、女性(3·6,1·4~9·3)。结论:伴有抑郁症状的综合医院住院病人应视为自杀高危人群,需投入更多的关注。根据其自杀意念、自杀未遂的危险因素,应在综合医院制定和执行有针对性的自杀预防计划。     

Psychomotor retardation in elderly depressed patients

BACKGROUND: Up to 70% of older people who commit suicide consult a general practitioner (GP) in the month prior to their death. The purpose of this study was to identify the clinical and demographic characteristics of older adults who are contemplating suicide and are in contact with a GP. METHODS: We utilised a cross-sectional study to investigate the association between suicidal ideation and clinical/demographic variables of 504 consecutive patients aged 60 years or over, attending 1 of 54 randomly selected Western Australian GPs. Prior to their medical consultation, patients completed a self-report questionnaire, which included questions about suicidal ideation (Depressive Symptom Inventory-Suicidality Subscale, DSI-SS), demographic factors, lifestyle factors, physical health and mental health, including depression (Center for Epidemiologic Studies-Depression Scale, CES-D). RESULTS: Within our sample of older patients, 6.3% acknowledged current suicidal ideation. Multivariate analyses indicated that current suicidal ideation was strongly associated with being depressed at least occasionally during the previous week (OR=7.3, 95% CI=2.3-23.0), CES-D scores of 16 points or greater (OR=3.6, 95% CI=1.0-12.1), and a prior history of attempted suicide (OR=15.5, 95% CI=4.0-60.6). Limitations: Our results and conclusions are limited to suicidal ideation, and may not apply to suicidal behaviour. CONCLUSIONS: Depressive symptomatology is strongly associated with suicidal ideation in later life. Strategies that enhance GPs' identification and treatment of affective illness in older patients should have the greatest impact on suicide rates within this age group.     

Suicide prevention in late life: directions for science and practice

Suicide among the elderly is a critical public health problem, yet there remains limited information on risk factors to target due to the few number of controlled studies that could help isolate and focus on the most potent risk factors. We suggest that because there are no proven, effective interventions showing reduced suicidal behaviors in older adults, the best current approach is to improve detection and treatment of later-life depression. This effort may be especially effective in primary care settings, where the majority of our nation's elderly seek and receive their mental health care. We review approaches to assessment and treatment of later life depression that seem most relevant for later life suicide prevention. Testing and determining whether these treatment approaches are effective is an immediate goal on the path to advancing the science and practice of late-life suicide prevention.     

Psychiatric and social aspects of suicidal behaviour in prisons

BACKGROUND: Suicidal behaviour and completed suicide are serious problems within British prisons, leading to significant morbidity and mortality, and are the focus of major efforts towards their prevention. AIM: To explore the demographic, social and psychiatric correlates of suicidal behaviour in prisons in England and Wales and their relationship with health service use; and to develop a combined psychosocial model of risk. METHOD: This report analyses the prevalence of suicidal ideation and suicide attempts in the ONS National Prison Survey, and their association with the presence of psychiatric disorders, personality disorder, substance abuse and social risk factors. These data were compared with data from the second national survey of psychiatric morbidity in adults living at home. In both surveys, a two-phase interviewing procedure was used, covering general health, health service use, assessment of psychiatric disorders, life events, social supports, suicidal behaviour, activities of daily living, sociodemographic data, substance abuse and intelligence. RESULTS: Suicidal thoughts and suicide attempts were commoner in prisons than in the general population and these were significantly associated with higher rates of psychosis, neurosis and personality disorder in prisons. In addition, demographic and factors such as being young, single, white, leaving school early and experiencing poor social support and significant social adversity were important risk factors for suicidal thoughts. Crucially, there was no separate category of people at suicidal risk who did not have psychiatric disorders. CONCLUSIONS: The high rates of suicidal behaviour in prisons cannot be addressed without adequate attention to the high rates of psychiatric disorder and vulnerability factors in prisoners.     

Developing psychological perspectives of suicidal behaviour and risk in people with a diagnosis of schizophrenia: we know they kill themselves but do we understand why?

People with a diagnosis of schizophrenia are at increased risk of suicidal behaviour yet little is understood of the psychological underpinnings of this vulnerability. The biopsychosocial 'Cry of Pain' model [Williams, J.M.G. (1997). Cry of pain. Harmondsworth: Penguin.] provides a broad framework from which to understand suicidal behaviour. However, the utility of the model in relation to suicide in schizophrenia has not yet been explored. This was the primary goal of this paper. Six components of the 'Cry of Pain' model were identified and evaluated with respect to whether they contributed to i. common transdiagnostic factors underlying suicide, ii. factors relating to co-morbid depression which account for suicidal behaviour, or iii. factors which are specific to schizophrenia and underlie suicide risk. The potential for applying the model to clinical management of suicide in schizophrenia is illustrated.     

Risk factors and life processes associated with the onset of suicidal behaviour during adolescence and early adulthood

BACKGROUND: This study examined associations between childhood circumstances, adolescent mental health and life events, and the development of suicidal behaviour in young people aged between 15 and 21 years. METHOD: Data were gathered over the course of a 21-year longitudinal study of a birth cohort of 1265 children born in New Zealand. The measures collected included: (1) patterns of suicidal behaviour (ideation, attempt) (15-21 years); (2) social background, family functioning, parental and individual adjustment during childhood (0-16 years); and (3) time dynamics of mental health and stressful life events during adolescence and early adulthood (15-21 years). RESULTS: By the age of 21 years, 28.8% of the sample reported having thought about killing themselves and 7.5% reported having made a suicide attempt. The childhood profile of those at greatest risk of suicidal behaviour was that of a young person reared in a family environment characterized by socio-economic adversity, marital disruption, poor parent-child attachment and exposure to sexual abuse, and who as a young adolescent showed high rates of neuroticism and novelty seeking. With the exception of the socio-economic and personality measures, the effects of childhood factors were largely mediated by mental health problems and exposure to stressful life events during adolescence and early adulthood. Mental health problems including depression, anxiety disorders, substance use disorder, and to some extent conduct disorder, in addition to exposure to adverse life events, were significantly associated with the onset of suicidal behaviours. CONCLUSIONS: Findings support a life course model of the aetiology of suicidal behaviour in which risk of developing suicidal behaviour depends on accumulative exposure to a series of social, family, personality and mental health factors.     

Suicidal behaviour among primary-care patients with depressive disorders

BACKGROUND: Most national suicide prevention strategies set improved detection and management of depression in primary health care into a central position. However, suicidal behaviour among primary-care patients with depressive disorders has been seldom investigated. METHOD: In the Vantaa Primary Care Depression Study, a total of 1119 primary-care patients in the City of Vantaa, Finland, aged 20 to 69 years, were screened for depression with the Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaire. Depressive disorders were diagnosed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), and the 137 patients with depressive disorder were included in the study. Suicidal behaviour was investigated cross-sectionally and retrospectively in three time-frames: current, current depressive episode, and lifetime. Current suicidal ideation was measured with the Scale for Suicidal Ideation (SSI), and previous ideation and suicide attempts were evaluated based on interviews plus medical and psychiatric records. RESULTS: Within their lifetimes, 37% (51/137) of the patients had seriously considered suicide and 17% (23/137) attempted it. Lifetime suicidal behaviour was independently and strongly predicted by psychiatric treatment history and co-morbid personality disorder, and suicidal behaviour within the current episode was predicted most effectively by severity of depression. CONCLUSIONS: Based on these findings and their convergence with studies of completed suicides, prevention of suicidal behaviour in primary care should probably focus more on high-risk subgroups of depressed patients, including those with moderate to severe major depressive disorder, personality disorder or a history of psychiatric care. Recognition of suicidal behaviour should be improved. The complex psychopathology of these patients in primary care needs to be considered in targeting preventive efforts.     

Socio-economic and psychological correlates of suicidality among Hong Kong working-age adults: results from a population-based survey

BACKGROUND: The global toll of suicide is estimated to be one million lives per year, which exceeded the number of deaths by homicide and war combined. A key step to suicide prevention is to prevent less serious suicidal behaviour to preclude more lethal outcomes. Although 61% of the world's suicides take place in Asia and the suicide rates among middle age groups have been increasing since the economic crisis in many Asian countries, population-based studies of suicidal behaviour among working-age adults in non-western communities are scarce. METHOD: Data from a population-based survey with 2015 participants were used to estimate the prevalence of suicidal ideation and behaviour among the working-age population in Hong Kong, and to study the associated socio-economic and psychological correlates. We focused particularly on potential modulating factors between life-event-related factors and suicidal ideation. RESULTS: Six per cent of the Hong Kong population aged 20-59 years considered suicide in the past year, while 1.4% attempted suicide. Hopelessness, reasons for living, and reluctance to seek help from family and friends had direct association with past-year suicidal ideation. Reasons for living were found to moderate the effect of perceived stress on suicidal ideation. CONCLUSIONS: Suicidality is a multi-faceted problem that calls for a multi-sectored, multi-layered approach to prevention. Prevention programmes can work on modulating factors such as reasons for living to reduce suicidal risk in working-age adults.     

Suicide risk in schizophrenia: Explanatory models and clinical implications,The Schematic Appraisal Model of Suicide (SAMS)

Purpose . The objective of this paper was to evaluate the Cry of Pain model of suicide behaviour as applied to psychosis and to derive theoretically driven guidelines for prevention. Suicide risk in psychotic patients is a serious but poorly understood clinical and social problem. There is a dearth of psychological models to explain suicidal behaviour and to guide effective preventative clinical interventions. Understanding suicidal behaviour in psychosis may be facilitated by utilizing models from depression. The ‘Cry of Pain’ model of suicide is founded on an evolutionary approach to understanding suicidal behaviour in depression. Methods . The model was critically evaluated and relevant literature reviewed. Results . Although strengths of the model were identified, lack of clarity regarding the concepts of defeat, entrapment, and lack of rescue appeared to limit its theoretical and clinical utility. We suggest a modification to this model which replaces concepts of defeat, entrapment, and lack of rescue with a four‐stage appraisal process in conjunction with information‐processing biases and suicidal schema. Conclusions . Methods of testing this model are suggested and guidelines for a clinical intervention (Cognitive Behavioural Suicide Prevention for Psychosis; CBSPp) are outlined.     

Suicidal behaviour in adolescence and subsequent mental health outcomes in young adulthood

BACKGROUND: The aim of this study was to examine the linkages between suicidal ideation and attempt in adolescence and subsequent suicidal behaviours and mental health in young adulthood. METHOD: Data were gathered during the course of a 25-year longitudinal study of a birth cohort of 1265 New Zealand children. The information collected included: (a) measures of suicidal thoughts and attempts in adolescence (< 18 years); (b) measures of suicidal ideation, suicide attempt, major depression, anxiety disorders, and substance use disorders in young adulthood (18-25 years); and (c) measures of childhood and family background, individual characteristics, and mental disorders in adolescence. RESULTS: After statistical adjustment for confounding factors, suicide attempt in adolescence was associated with increased risks of subsequent suicidal ideation (OR 5.7) suicide attempt (OR 17.8) and major depression (OR 1.5). Those reporting suicidal ideation without suicide attempt showed moderate increases in risks of later suicidal ideation (OR 2.5), suicide attempt (OR 2.0) and major depression (OR 1.6). In addition, there was evidence of an interactive relationship in which suicidal behaviour in adolescence was associated with increased risks of later substance use disorders in females but not males. CONCLUSIONS: Young people reporting suicidal ideation or making a suicide attempt are an at-risk population for subsequent suicidal behaviour and depression. Further research is needed into the reasons for suicidal adolescent females being at greater risk of later substance use disorder.     

"Near-fatal" deliberate self-harm: characteristics, prevention and implications for the prevention of suicide

BACKGROUND: There have been few studies of the most serious cases of deliberate self-harm (DSH). These cases represent an important clinical problem. They may also be suitable as a "proxy" for suicide in research studies. METHODS: We developed a definition of "near-fatal" deliberate self-harm (NFDSH) and identified all cases attending accident and emergency departments in an urban area during an 18-month period. We compared them to less severe DSH on social and clinical characteristics, and examined their initial clinical management. We compared their age and gender profile with that of completed suicides. NFDSH cases who agreed to be interviewed were asked about their experiences of seeking help and their views on prevention of suicide. RESULTS: 158 cases were identified, 8% of all DSH. The most common method of self-harm was self-poisoning. The most common psychiatric diagnosis was depression. Compared to less severe DSH, near-fatal cases had higher rates of several social and clinical risk factors for suicide and showed evidence of greater suicidal intent. Forty-one percent were allowed home following assessment. Most admissions lasted 2 days or less. The age and gender profile was closer to that of suicide than in DSH generally. Few subjects agreed to be interviewed; those who did described poor previous experiences of services. LIMITATIONS: We did not assess each case of DSH individually but applied a workable definition of NFDSH. Firm conclusions cannot be drawn from the qualitative part of the study because of the low rate of agreement to interview. CONCLUSIONS: NFDSH is an important clinical phenomenon associated with indicators of high suicide risk. This high risk is frequently not reflected in clinical management. Further studies of NFDSH could contribute to what is known about suicide prevention but the reluctance of NFDSH subjects to be interviewed may be a difficulty for future research.     

Suicide and attempted suicide among older adults in Western Australia

BACKGROUND: Suicide rates are high in later life. Risk factors include male sex and depressive illness. This study investigated the relationship between suicidal behaviour and contact with mental health services among the elderly in Western Australia. METHODS: Record linkage was used to obtain records of hospital admissions and mental health service contacts for all suicide attempts and deaths in the period 1980-95. Standardized incidence ratios were calculated for the elderly, general population and people with mental health service contacts. Cox regression was used to evaluated potential risk factors for elderly people who were in contact with mental health services. RESULTS: People over 60 years of age accounted for 15% of suicides and 4.6% of attempted suicides. Suicide rates were 3.3 times higher in males and 4.4 times higher in females when compared to the general population of elderly people. For attempted suicide, the rate was 5.8 times higher in males and 6.6 times higher in females with prior contact with mental health services. Highest risk of suicide was found in patients with diagnoses of affective psychoses (RR = 3.7), adjustment reaction (RR = 3.2) or depressive disorder (RR = 2.8). The diagnosis of cancer was associated with decreased risk of suicide (RR = 3.6) and attempted suicide (RR = 1.9). CONCLUSIONS: Suicide rates are high among the elderly in Western Australia. Suicide is significantly associated with the diagnosis of mood disorder. Suicide attempts are less common, and are associated most strongly with mood and personality disorders. The decreased risk of self-harm behaviour among patients with cancer warrants further investigation.     

抑郁症自杀行为的相关危险因素临床分析

目的　研究抑郁症自杀行为的危险因素 ,为预防自杀提供依据。方法　按 CCMD— 3诊断标准收集 2 1 1例住院的抑郁症患者 ,采用多因素 Logistic回归分析与抑郁症自杀行为有关的危险因素。结果　抑郁症自杀未遂 68例 (3 2 .2 % ) ,自杀与绝望 (相对危险度 RR=9.3 1 0 )、负性生活事件 (RR=3 .844)、自杀家族史 (RR=3 .62 7)、妄想 (RR=3 .783 )及自责 (RR= 2 .985 )呈正相关 (P均 <0 .0 1 )。结论　绝望、负性生活事件、自杀家族史、妄想及自责是抑郁症患者自杀的危险因素。     

Suicide Prevention in Older Adults

Older adults have high rates of suicide in the United States and worldwide; rates vary markedly by gender, race, and ethnicity. Ceropsychology practice guidelines (e.g., American Psychological Association [APA], 2004 ) indicate the need for assessment and treatment practices specific to older adults, as the phenomenology of mental disorders and psychotherapeutic change processes may shift across the lifespan. Inadequacies in the available knowledge base and in the education and training of clinicians have slowed progress in suicide research and hindered the development of a healthcare workforce that is deeply dedicated to suicide prevention. Inadequate knowledge stems from inattention to demographic differences, definitional imprecision and conceptual conflation, lack of research focus on older adults, and the exclusion of at-risk patients from clinical trials. The near absence of rigorous training and education in suicidology among clinical psychologists amplifies these problems. This article also reviews the empirical literature on suicide risk, noting in particular the roles of mood disorders, suicidal ideation and behavior, adjustment to life events, lack of social integration, personality traits, and access to lethal means. Suggestions are offered for improving risk assessment, the treatment of at-risk patients, and the development of prevention programs. Implications for training and education in clinical psychology are briefly discussed, and directions for future research are offered.     

Suicidal behaviour during different phases of bipolar disorder

BACKGROUND: There are no previous studies comparing the prevalence and risk factors for suicidal behaviour during different phases of bipolar disorder. METHODS: In the Jorvi Bipolar Study (JoBS), 1630 psychiatric in- and outpatients were screened for bipolar disorders with the Mood Disorder Questionnaire. Using SCID I and II interviews, 191 patients were diagnosed with bipolar disorders (90 bipolar I, 101 bipolar II). Suicidal ideation was measured using the Scale for Suicidal Ideation (SSI). Prevalence and risk factors for ideation and attempts during different phases (depressive, mixed, depressive mixed and hypomanic/manic phases) were investigated. RESULTS: There were marked differences between phases regarding suicide attempts and level of suicidal ideation. Hopelessness predicted suicidal behaviour during the depressive phase, whereas a subjective rating of severity of depression and younger age predicted suicide attempts during mixed phases. LIMITATIONS: The relatively small sample size in some phases. CONCLUSIONS: Suicidal behaviour varied markedly between different phases of BD. Suicide attempts and suicidal ideation were related to phases which are associated with depressive aspects of the illness. Hopelessness and severity of depression were key indicators of risk in all phases.     

Vulnerability and resiliency to suicidal behaviours in young people

BACKGROUND: We aimed to examine factors that influence vulnerability/resiliency of depressed young people to suicidal ideation and suicide attempt. METHOD: Data were gathered during a 21-year longitudinal study of a birth cohort of 1,265 New Zealand young people. Measures included: suicide attempt; suicidal ideation; major depression; childhood, family, individual and peer factors. RESULTS: Young people who developed major depression had increased rates of suicidal ideation (OR = 54: 95% CI 4.5-6.6) and suicide attempt (OR = 12.1; 95% CI 7.9-18.5). However, the majority of depressed young people did not develop suicidal ideation or make suicide attempts, suggesting that additional factors influence vulnerability or resiliency to suicidal responses. Factors influencing resiliency/vulnerability to suicidal responses included: family history of suicide; childhood sexual abuse; neuroticism; novelty seeking; self-esteem; peer affiliations; and school achievement. These factors operated in the same way to influence vulnerability/resiliency among those depressed and those not depressed. CONCLUSIONS: Vulnerability/resiliency to suicidal responses among those depressed (and those not depressed) is influenced by an accumulation of factors including: family history of suicide, childhood sexual abuse, personality factors, peer affiliations and school success. Positive configurations of these factors confer increased resiliency, whereas negative configurations increase vulnerability.     

Suicidal ideation and behaviour in the aftermath of marital separation: Gender differences

BackgroundThe limited studies on the consequences of the separation process on suicidal behaviour seem to indicate that separated people are at increased risk of suicide.AimsThe current study aims to compare suicidality immediately after the separation among males and females, and to analyse possible differences in predictors of serious suicidal ideation.MethodSeparated males and females who had contacted relationship counselling services, help-line services, and a variety of support and self-help groups were asked to participate in the study. Participants were required to be 18 years old or older, and have separated from their married/de facto partner within the previous 18 months but not yet divorced. For categorial variables odds ratios with 95% CI and for continuing variables t-tests were calculated. Multinomial logistic regression was applied to estimate the independent contribution of significant predictors.ResultsSeparated males (n = 228) were at an increased risk of developing suicidality during the separation process compared to separated females (n = 142), even after adjusting for age, education, employment and children with the separated partner. The psycho-social risk factors identified in the development of serious suicidal ideation were mental health problems (during the previous year), history of suicide attempts and internalised shame. For separated males, significant predictors also included lower education, separation-related shame and stress from legal negotiations, especially about property/financial issues.ConclusionsThe findings provide a better understanding of suicidal behaviours in the aftermath of marital or de facto separation. This knowledge could be used in the implementation of future suicide prevention strategies in people who are going through the process of a marital/de facto separation.     

Prevention of suicide and attempted suicide in Denmark. Epidemiological studies of suicide and intervention studies in selected risk groups

The suicide rates in Denmark have been declining during the last two decades. The decline was relatively larger among women than among men. All age groups experienced a decline except the very young with stable rates and the very old with increasing rates. The Universal, Selective, Indicated (USI) model recommended by Institute of Medicine was used as a framework for the thesis. Universal preventive interventions are directed toward the entire population; selective interventions are directed toward individuals who are at greater risk for suicidal behaviour; and indicated preventions are targeted at individuals who have already begun self-destructive behaviour. At the universal level, a review was carried out to highlight the association between availability of methods for suicide and suicide rate. There were mostly studies of firearms, and the conclusion of the review was that there was clear indication of restricted access to lethal means was associated with decline in suicide with that specific method, and in many cases also with overall suicide mortality. Restricting access is especially important for methods with high case fatality rate. Our own study indicated a beneficial effect on suicide rates of restrictions in access to barbiturates, dextropropoxyphen, domestic gas and car exhaust with high content of carbon monoxide. Although a range of other factors in the society might also be of importance, it was concluded that restrictions in access to dangerous means for suicide were likely to play an important role in reducing suicide rates in Denmark, especially for women. At the selective level, there are several important risk groups such as psychiatric patients, persons with alcohol and drug abuse, persons with newly diagnosed severe physical illness, all who previously attempted suicide, and groups of homeless, institutionalized, prisoners and other socially excluded persons. The thesis focused on homeless persons and psychiatric patients, especially patients with schizophrenia and related disorders. The thesis contains a review of the risk of suicide in homeless. In all the studies included, increased suicide mortality was found, and in the studies that evaluated suicide risk in different age groups, the excess suicide mortality was most dominant in younger age groups. Our own study revealed an increased risk of suicide, and in univariate analysis, significant predictors for suicide were found to be associated with shortest stay in hostel less than 11 days and more than one stay during one year. The thesis also contains a review of the risk of suicide in first-episode patients with schizophrenia, and it was concluded on the basis of the identified studies that long-term risk of suicide was not 10 percent as previously accepted, but lower. Risk factors for suicide among patients with schizophrenia were evaluated in case control studies, in nested case control studies, and in prospective studies. The following risk factors were the most important and frequently observed predictors: male gender, young age, short duration of illness, many admissions during last year, current inpatient, short time since discharge, previous and recent suicide attempt, co-morbid depression, drug abuse, poor compliance with medication, poor adherence to treatment, high IQ, and suicidal ideations. The results of analyses of psychotic symptoms as risk factor for suicide were contradictory, but a recent meta-analysis concluded that both hallucinations and delusions seemed to be protective; however, there was a non-significant tendency that command hallucinations were associated with higher suicide risk. Prevention of suicide in schizophrenia must especially focus on improving assessment of risk of suicide during inpatient treatment and the first week after discharge, and special attention must be paid to patients with one or more of the identified risk factors. There is a need for large randomised clinical trials evaluating the effect on suicide and suicide attempt of psychosocial and pharmacological treatment in schizophrenia. In our own study, we did not find any effect of integrated treatment on attempted suicide, but there was an effect on hopelessness and a trend toward lower prevalence of depression among patients in the integrated treatment. There were four suicides and one probable suicide (drowning) in standard treatment and one suicide in integrated treatment at two-year follow-up, but the study did not have sufficient power to detect these differences in proportion to who committed suicide; more than one thousand patients should have been in each treatment condition in order for these differences in proportion to be significant. At the indicated prevention level, a literature review was carried out regarding risk of suicide attempt and suicide in short-term, medium-term and long-term follow-up of persons who attempted suicide. It was concluded that the risk of repetition in short- and medium-term follow-up studies was approximately 16 percent, with lower risk among "first-evers" compared to repeaters. There was a large variation in repetition rate. The proportion who committed suicide in medium-term follow-up studies was 2.8 percent and in long-term follow-up studies was 3.5 percent (weighted mean) with clearly higher proportions in the Nordic studies than in the studies from UK. Risk factors for attempted suicide were previous suicide attempt, alcohol and drug abuse, depression, schizophrenia, previous inpatient treatment, self-discharge before evaluation, sociopathy, unemployment, frequent change of address, hostility, and living alone. Several of the predictors are overlapping and most of them were already identified in early studies of factors predictive of repetition of suicide attempt. Predictors of suicide were male gender, increasing age, previous suicide attempt, serious suicide attempt, alcohol and substance abuse, somatic disease, mental illness, and planning of suicide attempt, high suicidal intent score, violent suicide attempt or suicide attempt with severe lethality, and ongoing or previous psychiatric treatment. In our follow-up study from Bispebjerg Hospital, we found that the risk of suicide during a ten-year follow-up period among patients admitted in 1980 after self-poisoning was 30 times greater than in the general population. We also found increased mortality by all other causes of death. Predictors of suicide were several previous suicide attempts, living alone and increasing age. There are not many randomised clinical trials of psychosocial interventions aiming to reduce risk of repetition among suicide attempters. A Cochrane review concluded that evidence was lacking to indicate the most effective forms of treatment for deliberate self-harm patients. A recent randomised controlled trial showed a positive influence of cognitive behavioural therapy on repetition rate. Our own quasi-experimental study of effectiveness of two weeks' inpatient treatment in a special unit of young persons who had severe suicidal thoughts or who had attempted suicide showed that risk of repetition was reduced in the intervention group, and that the intervention group obtained a significantly greater improvement in Beck's Depression Inventory, Hopelessness Scale, Rosenberg Self-Esteem Scale and CAGE-score. The study of emergency outreach indicates that there are many persons in the community that experience a suicidal crisis, and that this group is an important target group for psychiatric emergency outreach. In our study of registration and referral practice in Copenhagen Hospital Cooperation, we conclude that not all suicide attempts were registered as such in the National Patient Register - in fact, only 37 percent. It must be concluded that the quality of the Danish Patient Register must be improved with regard to registration of suicide attempt. We found that psychiatric evaluation was planned in relation to almost all suicide attempts, but that it must be recommended to pay attention to escorting patients to psychiatric emergency in order to ensure that the patient actually attends the planned consultation. We found that patients who were referred after psychiatric evaluation to psychiatric treatment at outpatient facilities only received the planned treatment in approximately two-thirds of the cases; therefore, like Hawton et al. [Hawton et al., 1998; Hawton et al., 1999], we recommend that outpatient facilities adopt an assertive approach to patients who have attempted suicide. Danish suicide research is strong, primarily due to the possibilities for linking complete national registers providing detailed data and large sample sizes for suicide research, which is so far unique for the Nordic countries. This, combined with skilful use of epidemiological methods, had resulted in a remarkable series of papers highlighting risk of suicide in different risk groups, risk factors and protective factors. This activity must continue. In this work it is important to be aware of limitations in naturalistic studies such as the risk of interchanging cause and effect and the necessity to carry out control for confounders. Meta-analysis is a strong tool for summing up results of previous research. Meta-analyses can be used in reporting the evidence for effectiveness of interventions, but also for determining risk or identifying risk factors. A meta-analysis of risk factors of repetition of suicide attempt has not been carried out, and the quality of the identified studies did not allow a formal meta-analysis. Large randomised clinical trials examining the effectiveness of interventions on reducing rate of suicide attempt and suicide should have high priority. Suicide is a major public health problem and should be given high priority with regard to prevention and research. (ABSTRACT TRUNCATED)     

Incidence of suicide ideation and attempts in adults: the 13-year follow-up of a community sample in Baltimore, Maryland.

BACKGROUND: Utilizing a prospectively designed community sample, we set out to estimate the rate of newly-incident suicidal ideation and attempts (non-fatal suicide behaviour) in a community sample, to evaluate antecedent sociodemographic characteristics and psychiatric disorders, and to assess use of mental health services in relation to non-fatal suicide behaviour. METHOD: Prospectively-gathered data was utilized from 3481 continuing participants in the 13-year follow-up of the Baltimore sample of the NIMH Epidemiologic Catchment Area survey interviewed in 1981, 1982 and 1993/6. RESULTS: The incidence of suicide attempts was estimated at 148.8 per 100,000 person-years and ideation at 419.9 per 100,000 person-years. Persons in the youngest age group, in the lowest socioeconomic status, and previously married persons were at increased risk for non-fatal suicide behaviour during the follow-up interval. Persons who reported suicidal ideation at baseline were more likely to report having attempted suicide at follow-up (RR = 6.09, 95% CI 2.58-14.36). Psychiatric disorders, especially depression and substance abuse, were associated with new-onset of non-fatal suicidal behaviour. While persons who reported newly-incident suicidal behaviour were more likely to report use of mental health services, few said that suicidal ideation or attempts were the reason for the visits. CONCLUSIONS: Suicidal ideation is a common and important antecedent to suicide attempts and deserves more attention in community and general medical settings.