Depression and suicide in epileptic victims: a population-based study of suicide victims during the years 1988-2002 in northern Finland

Patients with epilepsy are known to have comorbid affective disorders and a higher risk for suicide compared with the general population. Epilepsy, depression, and suicidal behavior have been shown to have common pathogenic mechanisms in their etiology. We evaluated the association between epilepsy, suicidal behavior, and depression by using the comprehensive database of all suicides (n=1877) committed in northern Finland during the years 1988-2002 with information on all hospital-treated somatic and psychiatric disorders. Hospital-treated epilepsy occurred in 1.3% of the victims. Compared with other suicide victims, those with epilepsy were more often female, were older, and had significantly more often suffered from depression. Epilepsy was first diagnosed 8.8 (3.9-11.6) years before suicide, and depression, about 1 year after epilepsy diagnosis. Interictal depression among patients with chronic epilepsy is often classified as atypical or chronic depression, or it can mimic a dysthymic disorder. Therefore, diagnosis and treatment of depression among patients with epilepsy constitute a great challenge in clinical practice.     

Characteristics of suicide among diabetes patients: A population based study of suicide victims in Northern Finland

ObjectiveRecent case reports of insulin suicides have raised the need to study in detail the suicides among diabetes patients.MethodsThe data consisted of 2489 suicides (2030 men, 459 women) in Northern Finland during 1988 to 2010. The suicide victims with hospital-treated type 1 (n = 27) or type 2 diabetes (n = 51) were compared with those without diabetes (n = 2411).ResultsOf all suicide victims, 3.1% had diabetes (34.6% type 1 and 65.4% type 2 diabetes). 24.0% of victims with type 2 diabetes were under the influence of alcohol when they died from suicide, while the proportion was 44.4% in type 1 diabetes and 46.6% in victims without diabetes (P = 0.007). Compared to those with type 2 diabetes or without diabetes, victims with type 1 diabetes had suffered more commonly from depression (44.4%, 23.5%, 19.9%, respectively) (P = 0.006) and chosen self-poisoning as suicide method (48.1%, 31.4%, and 18.0%) (P < 0.001). In victims with type 1 diabetes insulin as a suicide method covered half of the self-poisoning cases, while the proportion in type 2 diabetes was 13%.ConclusionWe suggest that physicians who treat diabetes patients should evaluate co-occurring depression and substance abuse, both of which are major risk factors of suicide.     

Family history of suicide among suicide victims

OBJECTIVE: The aim was to compare the rates of suicide in family members of suicide victims and comparison subjects who died of other causes. METHOD: The Swedish cause of death register identified all suicides in subjects born between 1949 and 1969 (N=8,396). The comparison group comprised persons of the same age who died of other causes (N=7,568). First-degree relatives of the suicide victims (N=33,173) and comparison subjects (N=28,945) were identified. RESULTS: Among families of the suicide victims there were 287 suicides, representing 9.4% of all deaths in family members. Among comparison families there were 120 suicides, 4.6% of all deaths. The difference was significant. Previous psychiatric care and suicide in a family member predicted suicide in the logistic regression model. CONCLUSIONS: The rate of suicide was twice as high in families of suicide victims as in comparison families. A family history of suicide predicted suicide independent of severe mental disorder.     

Association between physical illnesses and depressive symptoms requiring hospitalization in suicide victims

We examined an association between a history of hospital-treated depression and physical diseases in 1877 suicide victims from Northern Finland. Information on physical diseases and depression of victims was extracted from the Finnish Hospital Discharge Registers. Of suicide victims, 31% of female and 16% of male victims had a lifetime history of depression. When compared with victims without any lifetime hospital-treated physical illnesses, a history of depression was shown to associate with the diseases of the nervous, circulatory, respiratory, and musculoskeletal systems in the group of symptoms and signs, injuries and poisonings, and infectious diseases among male victims. Respectively, in female victims, an increased prevalence of depression was seen in endocrine, nutritional and metabolic diseases, diseases of the nervous, circulatory, genitourinary, skin and subcutaneous tissue, and musculoskeletal systems, and with injuries and poisonings, pregnancy-related problems and infectious diseases. This study is the first to evaluate comorbidity between physical illnesses and depression over the lifetime in suicide victims; earlier studies reported findings in living patients from epidemiological or clinical populations. Since depression can affect quality of life in severely ill patients, targeting depression in patients with chronic illness may assist in decreasing suicide rates.     

Determinants of psychiatric hospitalization after attempted suicide

OBJECTIVE: This study investigated the characteristics of suicide attempters referred to psychiatric hospitals and the factors affecting such referral. METHOD: All 1198 consecutive suicide attempters treated in general hospital emergency rooms in Helsinki during a 12-month period were identified. Data on all health care contacts 1 year before the index attempt and on referrals to psychiatric hospitals after the attempt were gathered. RESULTS: We found that a quarter of patients were referred to psychiatric hospitals as inpatients after index suicide attempts. Factors predicting referral to psychiatric hospitals, compared to nonreferral, were older age, psychotic disorder, mood disorder, lack of alcohol consumption preceding the attempt, somatic illness, suicide attempt on a weekday, previous psychiatric treatment, psychiatric consultation and the hospital treating the suicide attempt. CONCLUSION: Although the clinical characteristics of patients attempting suicide are a major determinant of whether they are subsequently referred to psychiatric hospitals, the treatment practices of emergency room hospitals also influence treatment decisions.     

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.     

Elderly suicide in Finland

Suicide mortality among the elderly is high in most Western countries. We investigated the characteristics of suicide victims 65 years or older in a nationwide psychological autopsy study, the research phase of the National Suicide Prevention Project in Finland. This study population included all completed suicides (N = 1,397, of whom 211 were 65 years or older) that occurred in Finland during a 12-month research period in 1987-1988. The elderly suicide victims were found to have used violent suicide methods more often than the young. Although almost 70% of the elderly persons who had committed suicide had been in contact with health care services during the month before their death, their suicidal intentions were rarely communicated in these contacts. They had been referred to psychiatric services less often than the young, and only 8% had received adequate antidepressive medication. The fact that most elderly suicides have contact with health care services during their final month suggests a potential for suicide prevention. However, the major obstacle to this is the poor recognition of mental disorders and suicidal ideation among the elderly.     

Sex, timing, and depression among suicide victims with schizophrenia

BACKGROUND: Schizophrenia and depression by themselves and especially in combination with each other are known to be important risk factors of suicide. An increased risk of suicide has also been reported for the period immediately after a psychiatric patient's discharge from the hospital. However, to the best of our knowledge, it remains unknown whether survival times differ between suicide victims with schizophrenia concomitantly with and those without depression. OBJECTIVE: This study aimed to examine survival times from the discharge of last hospital treatment (irrespective of the kind of illness) to the day of death in suicide victims with schizophrenia with or without concomitant depression. MATERIAL AND METHOD: A 16-year database of all suicides (1535 males, 342 females) committed during the years 1988-2003 in the province of Oulu in northern Finland, and information available from the national hospital discharge registers formed the basis of this study. RESULTS: In male suicide victims with schizophrenia, the median survival time after final hospitalization was approximately 1 day in those with a history of depression and 90 days in those without depression (P = .005). The corresponding times for females were 50 and 24 days, respectively (P = .396). Using Cox regression analysis after adjusting for confounders, we noticed a statistically significant difference in survival times from last hospitalization to suicide between depressive and nondepressive male patients with schizophrenia (hazard ratio, 1.80; 95% confidence interval, 1.04-3.11), but not females (hazard ratio, 0.72; 95% confidence interval, 0.34-1.53). CONCLUSION: Concomitant depression was markedly linked with shorter survival time in male suicide victims with schizophrenia after last hospitalization. Psychiatric inpatient facilities appear to be in a key position to establish suicide prevention programs for patients with schizophrenia, especially those with depression.     

Psychiatric effects of exposure to suicide among the friends and acquaintances of adolescent suicide victims.

The friends and acquaintances (N = 58) of 10 adolescent suicide victims were interviewed 6 months after the death of the victims, and the rates of psychiatric disorders that had onset after the death were compared with the 6-month incidence of psychopathology in 58 demographically and psychiatrically matched unexposed controls. The exposed group showed higher rates of any new onset major depressive disorder, but the rate of incident suicide attempts was the same in both groups. The median onset of incident depression among the exposed group was within the first month after exposure, and the majority of those exposed youth with incident depression were still depressed at interview 6 months after the death. Adolescent friends and acquaintances of suicide victims experience considerable psychiatric morbidity subsequent to exposure to suicide, most consistent with pathological grief.     

Serotonergic mechanisms in brains of suicide victims

Serotonergic mechanisms have been investigated in postmortem brain samples from controls and suicide victims. The concentrations of 5-hydroxytryptamine (serotonin; 5-HT) and 5-hydroxyindoleacetic acid (5-HIAA) were determined in occipital cortex and hippocampus and the high-affinity binding of ligands to the 5-HT₁, 5-HT₁ and imipramine-binding sites was assessed in frontal cortex, occipital cortex and hippocampus. The only significant difference between the two groups was a modest increase in 5-HIAA levels in the hippocampus of suicide victims. There was no evidence to suggest that those suicide victims with a clinical history of depression represented a subgroup with altered metabolite levels or binding values. The storage conditions of the samples were not related to the metabolite levels or binding values. There was, however, a significant positive correlation between [³H]imipramine binding and age in some brain regions. The results do not provide any evidence of gross alterations in 5-HT mechanisms in suicide or depression.     

Seasonal variation in suicide occurrence in Finland

The aim of this study was to investigate the age-, gender- and suicide method-related seasonality of suicide occurrence by using the largest database examined so far (n=21 279). The Chi-square test for multinomials was used as the overall measure of deviation. The monthly observed and expected numbers of suicides were calculated and classified by year, month, gender, age groups and suicide methods. To identify the statistically significant peak and trough months, the ratio of observed numbers of suicides to expected numbers with 95% confidence intervals was calculated. For males, there was a suicide peak from April to July, while for females the distribution was bimodal (with peaks in May and October). In elderly people there was a significant excess in the number of suicides in autumn, and the troughs were deeper in winter. For violent suicides there was a unimodal spring peak, but for non-violent suicides the distribution was bimodal. The results indicate that suicides among elderly subjects, as well as non-violent suicides, occur significantly more often during autumn than would be expected.     

GABA concentrations in forebrain areas of suicide victims

Concentrations of GABA and seven other amino acids, including the neurotransmitters or neuromodulators taurine, glycine, aspartate, and glutamate, were determined in postmortem brain samples from suicide victims and normal controls. The five brain areas (caudate nucleus, nucleus accumbens, frontal cortex, amygdala, and hypothalamus) contained very similar concentrations of the amino acids in both groups. The only significant difference between the groups was a low glutamine concentration in the hypothalamus of suicide victims. Even when the data were adjusted for differences in tryptophan concentration, a putative biochemical index for agonal and postmortem changes of brain tissue, no new differences emerged in the concentrations of neuroactive amino acids between suicide victims and control subjects.     

Increased adrenal weight in victims of violent suicide

Adrenal weight was significantly higher in 16 victims of violent suicide than in 10 subjects who died suddenly from other causes. Since approximately half of suicide victims are depressed, these results support an association between depression and hypertrophy of the adrenal cortex.     

Brain GABAB binding sites in depressed suicide victims

Binding sites for gamma-aminobutyric acid, type B (GABAB), were measured in post-mortem brain samples (frontal cortex, temporal cortex, and hippocampus) from a group of suicide victims and a group of sex- and age-matched controls. Retrospective psychiatric diagnosis was performed, and only suicide victims with clear evidence of depression in the absence of symptoms of other psychiatric or neurological disorders were studied. There were no significant differences between depressed suicides and controls in the number or affinity of GABAB binding sites in the frontal or temporal cortex and no difference in GABAB binding (measured at two concentrations) in the hippocampus. Thirteen of the depressed suicides had not been prescribed antidepressant drugs recently, and none were found in their blood at postmortem. The number of GABAB binding sites in the frontal and temporal cortex and GABAB binding in the hippocampus did not differ significantly between these drug-free suicides and matched controls. The Kd was higher, however, in the temporal cortex of the drug-free suicides than in the controls. A significant negative correlation was found between age and the number of GABAB binding sites in the temporal cortex (on the basis of pooled data from suicides and controls). These results indicate that GABAB binding sites are unaltered in the brains of depressed suicide victims.     

中国北方城乡两地居民自杀意念、自杀未遂的调查

目的:了解中国北方城乡两地居民自杀意念、自杀未遂的发生率,以及性别之间、城乡之间的差异。方法:采用分层抽样的方法随机抽取北京市区10个居委会和河北武安农村10个村、年龄≥18岁人群共1 000人(城市和农村各500人),实际调查1 007人(城市503人,农村504人);采用自制"公众对自杀的态度问卷"对被试逐项进行调查。结果:被调查的1 007人中,有36人近1年出现过自杀意念,在性别、城乡之间差异无统计学意义(χ2=0.07,χ2=0.11;P均0.05);92人曾经有过自杀意念,在性别之间差异无统计学意义(χ2=0.11,P0.05),但农村显著多于城市(χ2=7.88,P0.05);有6人近1年出现过自杀未遂,18人曾经有过自杀未遂,在性别(χ2=0.72,χ2=0.27)、城乡之间(χ2=0.00,χ2=2.20)差异无统计学意义(P均0.05)。1 007人中有49人的亲属在过去任何时候有过自杀意念,城市显著多于农村(χ2=6.24,P0.05);20人的亲属有过自杀未遂,25人的亲属自杀死亡,城乡之间差异无统计学意义(χ2=0.82,χ2=0.38;P均0.05)。结论:中国北方城乡两地居民自杀意念、自杀未遂的发生率均相对较高,制定相应的自杀预防计划是亟待解决的问题。     

Variables associated with hospitalization decisions by emergency psychiatrists after a patient's suicide attempt

OBJECTIVE: This study explored the factors psychiatrists considered in deciding on hospitalization for a large sample of suicide attempters in the emergency department of a general hospital in Madrid, Spain, between 1996 and 1998. METHODS: Psychiatrists assessed 509 patients who had attempted suicide; 196 of these (39 percent) were hospitalized in the psychiatric unit, and 313 (61 percent) were discharged from the emergency department. The assessment included Beck's Suicidal Intent Scale (SIS) and a checklist of 47 clinical variables. RESULTS: Of the 32 clinical variables significantly associated with hospitalization that were introduced in a logistic regression model, 11 remained significant. Six variables were associated with an increased odds of hospitalization: intention to repeat the attempt, plan to use a lethal method, low psychosocial functioning before the suicide attempt, previous psychiatric hospitalization, a suicide attempt in the past year, and planning that nobody would try to save their life after they had attempted suicide. Five variables decreased the odds: a realistic perspective on the future after the attempt, relief that the attempt was not effective, availability of a method to kill oneself (that was not used), belief that the attempt would influence others, and family support. Models based on the SIS total score and individual SIS items had lower specificity and sensitivity. CONCLUSIONS: Psychiatrists appear to rely on patients' self-report in deciding on hospitalization rather than focus on demographic, diagnostic, or psychosocial issues. If the findings of this study were replicated in other hospital settings, the implication would be that the guidelines for assessing suicide attempts need to encourage thorough and detailed assessment of the attempt and the future plans.     

Reductions in postdischarge suicide after deinstitutionalization and decentralization: a nationwide register study in Finland

OBJECTIVE: This study analyzed trends in suicides occurring after a psychiatric hospitalization during more than a decade of significant structural changes in mental health services in Finland-that is, deinstitutionalization, downsizing of inpatient care, and decentralization. METHODS: Retrospective register data on completed suicides and psychiatric inpatient treatments were collected for the periods 1985-1991 and 1995-2001, representing service provision before and after significant structural changes. The data were used to produce an estimate for a change in postdischarge suicide risk. RESULTS: In both periods, a fifth of suicide victims had been psychiatrically hospitalized within the preceding year. Among persons hospitalized, the risk of suicide was greater in 1985-1991 than in 1995-2001 for both one week after discharge (risk ratio [RR]=1.50, 95% confidence interval [CI]=1.38-1.62) and one year after discharge (RR=1.25, CI=1.19-1.30). When types of disorders were analyzed separately, the relative risk of suicide one year postdischarge for those hospitalized in the earlier period was greater for patients with schizophrenia (RR=1.26, CI=1.17-1.36) and patients with affective disorders (RR=1.60, CI=1.48-1.73). In parallel with general development of inpatient psychiatric services, in 1995-2001 the inpatient treatment periods preceding suicides were significantly shorter (a mean+/-SD of 45+/-340 days in 1995-2001, compared with a mean of 98+/-558 days in 1985-1991), the number of individual patients treated in the hospital for schizophrenia spectrum disorders was lower (26% compared with 36%), and the number treated for affective disorders was higher (45% compared with 35%). CONCLUSIONS: The restructuring and downsizing of mental health services was not associated with any increase in suicides immediately (one week) or one year postdischarge. Instead, the risk of these suicides decreased significantly between the two time periods among several diagnostic categories. Although the role of psychiatric hospitalization in general may have changed over time, patients who are hospitalized now may be less suicidal after discharge. Our results indicate, in terms of postdischarge suicides, that the downsizing of psychiatric hospitals has been a success. However, there is still a substantial need for better recognition of suicidal risk among psychiatric patients.