Comorbid substance use reduces the health care contacts of suicide attempters with schizophrenia spectrum or mood disorders

Utilization of health care services has been found to differ between psychiatric disorders. However, the pattern of health care contacts among suicide attempters with mental disorders is not known. This study systematically investigated the pattern of health care contacts among suicide attempters with schizophrenia spectrum versus mood disorders with or without comorbid substance use disorders both before and after attempted suicide. All consecutive medically treated suicide attempters in Helsinki from January 15, 1997, to January 14, 1998, were identified (n = 1,198). Data were gathered on all their health care contacts within the 12 months before and after the index attempt. Whereas the clear majority of all suicide attempters with schizophrenia spectrum or mood disorders had a treatment contact during the 30 days following the attempt, half of those with pure substance use disorders were without any contact with health care. Comorbid substance use made treatment less likely after attempted suicide among both psychiatric disorder groups; those with schizophrenia spectrum and comorbid substance use disorders were seven times more often left without aftercare recommendation than those without substance use comorbidity. Comorbid substance use disorders among suicide attempters with schizophrenia spectrum disorders decrease the likelihood of active aftercare, despite high suicide risk.     

Deliberate self-poisoning: treatment follow-up of repeaters and nonrepeaters.

Since 1986 psychiatrists and social workers of the Lund Suicide Research Center have investigated subjects admitted to the medical intensive care unit after a suicide attempt. Fifty-nine of 79 deliberate self-poisoners were interviewed 12 months after a suicide attempt. Twenty-one had previously been interviewed 6 months after the index suicide attempt. We obtained minor information on 8 subjects. Two patients had committed suicide. Sixteen subjects (27%) of those who were interviewed showed repeated suicidal behavior (repeaters) during the 1-year follow-up, and their psychiatric diagnoses at the index attempt were most commonly alcohol abuse and dysthymia (DSM-III, Axis I). Compared with nonrepeaters, repeaters had more often made previous suicide attempts, their index attempt was less serious and they were more often in psychiatric treatment at index. At follow-up, repeaters more often than nonrepeaters expressed the need for professional mental health support. Two-thirds of the patients were in treatment at follow-up. About half had remained in continuous treatment and most in psychiatric care for more than 1 year. Repeated self-poisoning occurred despite ongoing treatment. In view of the fact that numerous suicide attempters obviously remain in treatment for several years, we suggest further development and evaluation of long-term treatment strategies.     

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.     

Elderly suicide attempters with depression are often diagnosed only after the attempt

OBJECTIVE: No previous study has comprehensively investigated the pattern of health care contacts among elderly subjects attempting suicide. The present study compared elderly suicide attempters with younger attempters, before and after attempted suicide, in terms of health care contacts, clinical diagnoses of mental disorders, and characteristics predicting lack of treatment contact after the index attempt. METHODS: All consecutive 1198 suicide attempters treated in hospital emergency rooms in Helsinki, Finland, from 15.1.1997 to 14.1.1998 were identified and divided into two age groups: (1) elderly suicide attempters aged 60 years or more (n = 81) and (2) suicide attempters aged under 60 years (n = 1117). RESULTS: During the final 12 months before the attempt, the majority of elderly suicide attempters had a contact with primary health care, but their mood disorders were likely to have remained undiagnosed before the index attempt. In primary health care, only 4% had been diagnosed with a mood disorder before the attempt, but 57% after (p < 0.001). After the suicide attempt, most elderly suicide attempters were referred for aftercare, two thirds having contact with psychiatric care. CONCLUSIONS: For purposes of preventing suicidal behaviour, screening for depression, plus further education on recognition, diagnosis and treatment of mood disorders among the elderly in primary health care setting are needed.     

Treatment of suicide attempters prior to hospital admission

OBJECTIVE: Numerous authors have reported serious shortcomings in the treatment of suicidal patients. This study examined the treatment suicide attempters admitted to a psychiatric hospital in Switzerland had received prior to the suicide attempt. METHOD: Thirty-one patients were admitted to this hospital within a year, representing 36 suicide attempts, which corresponds to 6.5% of the annual admission number. Three of these patients were admitted twice, and one patient was admitted three times. Information on previous treatment was collected in personal interviews and included medication, and its dosage, at 1 month and 2 weeks prior to the suicide attempt, and whether the patient had received psychotherapy. In addition, details of the psychosocial event and the means of the suicide attempt were recorded. RESULTS: Twenty-one patients had been prescribed psychotropic drugs in 24 events, but only in 17 events concerning 15 patients, antidepressants were prescribed prior to hospitalisation. Antipsychotics and benzodiazepines were prescribed in 6 and 21 events, respectively (including 8 events with hypnotics). None of the patients was treated with lithium. In 19 events, 16 patients had received psychotherapy prior to admission. In 32 events, psychotropic drugs were used for the suicide attempt. CONCLUSION: The findings confirm the undertreatment of patients attempting suicide reported by other authors. In spite of the majority of patients being under psychiatric care, no adequate pharmacotherapy had been prescribed particularly for depressed patients.     

Structured disposition planning for adolescent suicide attempters in a general hospital: Preliminary findings on short-term outcome

Abstract

Adolescent suicide attempters are often noncompliant with outpatient psychotherapy and drop out of treatment much more quickly than non-suicidal adolescents. In this study, 23 adolescents received medical treatment and a standard psychiatric evaluation in an Emergency Department following a suicide attempt. In addition, all subjects and their parents received a psychotherapy compliance enhancement intervention which included a verbal agreement between the adolescent and parent/guardian to attend at least four psychotherapy sessions. After discharge from the hospital, each subject received three phone interviews over an 8 week period using a problem solving approach around two key areas: suicidal ideation and psychotherapy compliance. Compared to a three month follow-up of 78 subjects (which did not include an experimental intervention), conducted at the same hospital, the experimental intervention resulted in fewer outpatient psychotherapy ‘no shows' (9% vs. 18%) and a trend toward greater number of sessions attended (5.5 vs. 3.9). There were no re-attempts in the experimental group as compared to 9% in the comparison group. Results are promising and a randomized intervention trial appears indicated.     

Patients' evaluation of their psychiatric consultation after attempted suicide

Few studies have previously investigated patients' evaluation of their psychiatric consultation after attempted suicide. The aim of the present study was to examine the patients' view of their psychiatric consultation after a suicide attempt. Of a systematic sample of 114 suicide attempters in Helsinki, 73 subjects were referred to psychiatric consultation at an emergency room or department, and 53 of these evaluated the consultation received. Half of these suicide attempters considered their psychiatric consultation had occurred too soon after the attempt. Those whose prior attitude toward the consultation was indifferent had higher Hopelessness Scale (HS) and Beck Depression Inventory (BDI) scores than those who were positive. Psychiatric assessment should not take place before the patient has recovered from toxic effects caused by any overdose attempt. Suicide attempters with severe depression and hopelessness are likely to be those most indifferent to the prospect of psychiatric consultation. The presence of severe depression or hopelessness should not deter active evaluation and treatment.     

Suicide attempts among veterans seeking treatment for pathological gambling

BACKGROUND: There is little information in the scientific literature regarding the suicide attempts of pathological gamblers, even though studies of problem gamblers have found that completed suicide, suicide attempts, and suicidal ideation are common outcomes related to gambling behavior. There has been no attempt in previous studies to identify the contributions of comorbid conditions, such as substance abuse, to the suicide attempts of pathological gamblers. METHOD: A retrospective chart review was completed for all consecutive admissions (N = 114) to the Gambling Treatment Program of the Louis Stokes VA Medical Center over a 12-month period (September 2000-September 2001). All subjects met DSM-IV criteria for pathological gambling. Relevant information was obtained from the admission history and physical examination, as well as a variety of self-report questionnaires and structured instruments. RESULTS: Forty-five patients (39.5%) reported that they had made a suicide attempt at some time in their lives. The most common method was overdose. Sixty-four percent of attempters reported that their most recent attempt was related to gambling. Forty-two percent of gamblers with a history of alcohol dependence and 58.8% of those with a history of drug dependence had a history of suicide attempts. Mean impulsivity scores differentiated suicide attempters from nonattempters among gamblers with a history of drug and/or alcohol dependence. Severity of psychiatric symptoms and family problems on admission was related to a history of suicide attempts. CONCLUSION: Pathological gamblers have high rates of attempted suicide. They are highly impulsive and suffer from high rates of comorbid psychiatric conditions as well as social disruptions. A combination of these risk factors very likely contributes to their potential for suicidal behavior.     

Health care contacts before and after attempted suicide

Objective The prevalence and timing of contact with health care predicting and after a suicide attempt are not well known. This study systematically investigated the pattern of all health care contacts both before and after attempted suicide. Methods All consecutive 1,198 suicide attempters treated in hospital emergency rooms in Helsinki during a 12-month period were identified. Data were gathered on all health care contacts 1 year before and after the index attempt. Results The vast majority of the suicide attempters had contact with health care during the 12 months before and after the index attempt. However, half were without a treatment contact during the final 30 days before the index attempt and one-third in the 30 days following the attempt. Suicide attempters who were not referred to aftercare, did not suffer from a previously recognised major mental disorder, were male, or made non-violent attempts were less likely to be receiving treatment after the attempt. Conclusion Although most suicide attempters have contact with health care within the year before and after the parasuicide, far fewer actually have a treatment contact at the time of the attempt. Accepted: 20 September 2001     

The treatment received by substance-dependent male and female suicide victims

Within a nation-wide psychological autopsy study we investigated use of treatment services and recognition of substance abuse problems among male and female substance-dependent suicide victims. Although during their final month half of the male subjects and two-thirds of the female subjects contacted health care services, in only one-sixth and one-third of cases, respectively, were substance abuse problems currently recognized. During their final year, 37% of the males and 67% of the females received psychiatric care. This was associated with Axis-I comorbid disorders among males, with lower socio-economic status and abuse of prescribed drugs among females, and with previous suicide attempts among both sexes. Due to their high psychiatric morbidity and tendency to have contacts with psychiatric services, the recognition, treatment and follow-up of subjects with substance use disorders in psychiatric care would appear to be of major importance for suicide prevention.     

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.     

Attempted suicide and psychiatric consultation.

This study investigated the differences in clinical characteristics between suicide attempters referred or not referred to psychiatric consultation after a suicide attempt and factors affecting such referral to psychiatric aftercare after attempted suicide. All 1198 consecutive suicide attempters treated in hospital emergency rooms in Helsinki during a 12-month period were identified. Data were gathered on any psychiatric consultation after the attempt and on all health care contacts 1 year before and after the index attempt. We found that half of the suicide attempters who were not referred to psychiatric consultation were without any aftercare recommendation and treatment contact soon after their attempt. Factors predicting referral to psychiatric consultation were age, psychotic disorder, lack of substance use disorder and, most strongly, the hospital where the suicide attempt was treated. Although the characteristics of a patient attempting suicide do play a role in determining whether a psychiatric consultation will take place or not, the most important factor is the consultation practices of the particular hospital. This in turn influences the probability of adequate aftercare.     

Factors associated with referral to mental health services among suicide attempters visiting emergency centers of general hospitals in Korea: does history of suicide attempts predict referral?

Objective

This study examined whether a history of past suicide attempts was a critical factor for referral to mental health services among suicide attempters visiting emergency centers of general hospitals in Korea.

Method

In this cross-sectional study, a resident of emergency medicine at each emergency center interviewed 310 suicide attempters visiting five tertiary general hospitals located in Seoul, using standardized questionnaires, during 7 months in 2007. We examined associations between suicide attempt history and referral to mental health services via multiple logistic regressions.

Results

Subjects' rate of referral to mental health services was 47.3%. When we controlled for participant age, time of arrival at the emergency center, psychiatric treatment history, use of alcohol, suicide attempt lethality and subjective expectation to suicide attempts, past suicide attempts did not predict referral to mental health services (odds ratio=1.74; 95% confidence interval .88-3.43).

Conclusion

Psychiatric interventions for suicide reattempters visiting emergency centers are important for preventing suicide, but providers have not considered suicide attempt history as a critical factor for referral to mental health services. Therefore, we suggest that more effort is needed to systemize psychiatric interventions for suicide reattempters at emergency centers in Korea.     

Hopelessness,impulsiveness and intent among suicide attempters with major depression,alcohol dependence,or both

The present study examined differences in hopelessness, impulsiveness and suicide intent between suicide attempters with either major depression or alcohol dependence, comorbid major depression and alcohol dependence, and those without these disorders. A sample of 114 patients from consecutive cases of attempted suicide referred to a general hospital in Helsinki was interviewed and diagnosed according to DSM-III-R. Suicide intent was measured by the Beck Suicide Intent Scale (SIS) and hopelessness was assessed by the Beck Hopelessness Scale (HS). Impulsiveness of the suicide attempt was measured by two items of the SIS. Suicide attempters with major depression without comorbid alcohol dependence had higher suicide intent and lower impulsiveness than attempters with non-depressive alcohol dependence. Suicide attempts may differ between subjects with major depression, alcoholism or both disorders in terms of impulsiveness and suicide intent.     

Is assessing for borderline personality disorder useful in the referral after a suicide attempt?

BACKGROUND: Management of suicide attempters accounts for 10% of the psychiatric activity in the emergency room. In this population, the prevalence of borderline personality disorder (BPD) is high (10 - 55%). These patients present poorer psychosocial outcome and more frequent suicide attempts repetitions. However, the utility of the assessment of BPD in the referral to a specific treatment plan has not been yet studied. OBJECTIVE: To examine the association between the assessment of a diagnosis of BPD after a suicide attempt and the referral from the emergency room to a specific treatment plan. HYPOTHESIS: Suicide attempters with BPD, according to clinicians diagnosis, differ in terms of severity from those without more risk factors of suicide attempt repetitions and poorer psychosocial functioning, and in psychiatric referral from the emergency room. METHOD: Our case-control study took place during 10 months in the Geneva general hospital. We continuously enrolled patients admitted to the emergency room for deliberate self poisoning and separated them into two groups (BPD and control) according to the clinician's diagnosis. Data from medical records were systemically and anonymously gathered. We compared BPD patients' socio-demographic and clinical characteristics, as well as psychiatric referral, with the control group. RESULTS: Of the 478 subjects admitted to the emergency room for deliberate self-poisoning, 99 (22.6%) were diagnosed BPD by clinicians. Compared to controls, they were more frequently female (OR=3.9) and living alone (OR=3.8) and more often resorted to psychiatric care (OR=2.9), notably to emergency care (OR=3.8). Past history of suicide attempt was also more frequent (OR=1.9) as was the use of neuroleptics in the attempt (OR=2.7). No difference was detected in terms of psychiatric referral after emergency room care. CONCLUSION: Even if borderline personality disorder in suicide attempters is associated with more severity criteria, it is not associated with a referral to a specific treatment plan.     

乡村严重自杀未遂者的特征

目的了解乡村严重自杀未遂者的特征并通过比较乡村与非乡村严重自杀未遂者的特征来深入了解2组人群是否相对独立,为制定自杀预防及干预措施提供依据。方法用自制调查表对1所市级、3所县级综合医院诊治的326例严重自杀未遂者进行包括精神科检查在内的2-3小时的调查。结果278例乡村严重自杀未遂者平均年龄(32±13)岁,平均接受正规学校教育(5±3)年,女性占74%,现婚74%,14%有自杀未遂既往史,88%服用农药或鼠药自杀未遂,39%有精神障碍(主要是重性抑郁障碍),13%自杀前曾因心理问题寻求帮助,家庭纠纷和情绪低落是前两位重要的自杀原因。与48例非乡村自杀未遂者相比,乡村组受教育年限短,家庭经济状况差,男性、自杀前一直在工作或学习者、服农药自杀者所占比例高,经历的负性生活事件少,慢性心理压力小(P均小于0.05)。2组在年龄、婚姻状况、自杀意图强度、急性应激强度、自杀前1个月的生命质量、家庭关系、精神疾病患病率等方面的差异无统计学显著性。结论乡村与非乡村严重自杀未遂者的不同特征提示:即使是同样的自杀预防措施,在农村与城镇实施的模式和侧重点应不同。     

Mental health care for adults with suicide ideation

OBJECTIVE: To estimate mental health and substance abuse services use for adults with and without suicide ideation. METHOD: 2000-2001 follow-up of respondents to a nationally representative survey. Measures include self-reports of suicide ideation, specialty and primary care mental health services use, past year counseling, psychotropic medications and perceived need. RESULTS: The percentage of respondents who reported suicide ideation was 3.6%; 74% of them had a probable psychiatric disorder for which effective treatments exist. Nearly half of those with suicide ideation did not perceive a need for care, including some who received care. Of those with suicide ideation and a probable disorder, almost 40% received no treatment. Of those with suicide ideation who perceived a need for alcohol, drug or mental health (ADM) care, almost 40% received no care or inadequate care. In a multivariate model, having a probable psychiatric disorder, perceived need and being white were associated with increased likelihood of treatment use, among persons with suicide ideation. CONCLUSIONS: Many adults with suicide ideation do not perceive a need for care or receive treatment in the same year. Even among those perceiving a need for care, many experience difficulties in obtaining it. It is critical to understand barriers to treatments for this high-risk group.     

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

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

The Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior: Study rationale,methodology, and baseline sample characteristics of a long-term,large-scale,multi-center,prospective, naturalistic,observational cohort study

BackgroundThe Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior (K-COMPASS) study is a prospective, naturalistic, observational cohort study, aiming to identify predictors of suicide attempt and suicide characteristics in the Korean suicidal population. The findings intend to contribute to a thorough understanding of suicidal phenomena and development of suicide prevention guidelines. The present cross-section study examines the study rationale, methodology, and baseline characteristics of the participants.MethodsParticipants were enrolled via the hospital and community gateways, establishing the hospital-based cohort (HC) and community-based cohort (CC), respectively. Baseline assessment was conducted on sociodemographic, clinical, diagnostic, and psychopathological aspects. The Columbia-Suicide Severity Rating Scale was used to investigate suicidality.ResultsA total of 800 suicidal people aged 15 years or older were enrolled from 8 university hospitals and 8 community mental health welfare centers (CMHWCs), among whom 480 (60%) were suicidal ideators and 320 (40%) were attempters. The ideators comprised 207 CC and 273 HC participants, whereas the attempters, 34 CC and 286 HC participants. Despite their lower severity in some measures, including suicidal ideation, compared with their HC counterparts, the CC participants within each group of ideators or attempters presented clinically significant psychopathology. Moreover, alcohol use problems and past suicide attempt were more likely to be found in CC participants. Only 11.1% to 21.6% of the participants in each of the four groups (defined by the cohorts and the ideators/attempters) were on any type of psychiatric treatment.ConclusionsSuicidal visitors to CMHWCs need to be as closely monitored as suicidal patients in university hospitals, especially considering their association with problem drinking and past suicide attempt. A cautious assumption is that the high suicide rate in Korea might be partly attributable to the low proportion of patients receiving psychiatric services.