Suicide among women: a critical review

Despite increasing attention to suicide as a preventable outcome associated with mood disorders, little attention has been given to the risk factors for suicide among women. In this paper, we: 1) review the current literature regarding risk factors for suicide among women; 2) address the theories regarding risk and protective factors for women; 3) integrate the findings into a practical assessment of women's risk of suicide in clinical settings; and 4) consider avenues for future research.     

Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study.

CONTEXT: Suicide is a leading cause of death in the United States, but identifying persons at risk is difficult. Thus, the US surgeon general has made suicide prevention a national priority. An expanding body of research suggests that childhood trauma and adverse experiences can lead to a variety of negative health outcomes, including attempted suicide among adolescents and adults. OBJECTIVE: To examine the relationship between the risk of suicide attempts and adverse childhood experiences and the number of such experiences (adverse childhood experiences [ACE] score). DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of 17 337 adult health maintenance organization members (54% female; mean [SD] age, 57 [15.3] years) who attended a primary care clinic in San Diego, Calif, within a 3-year period (1995-1997) and completed a survey about childhood abuse and household dysfunction, suicide attempts (including age at first attempt), and multiple other health-related issues. MAIN OUTCOME MEASURE: Self-reported suicide attempts, compared by number of adverse childhood experiences, including emotional, physical, and sexual abuse; household substance abuse, mental illness, and incarceration; and parental domestic violence, separation, or divorce. RESULTS: The lifetime prevalence of having at least 1 suicide attempt was 3.8%. Adverse childhood experiences in any category increased the risk of attempted suicide 2- to 5-fold. The ACE score had a strong, graded relationship to attempted suicide during childhood/adolescence and adulthood (P<.001). Compared with persons with no such experiences (prevalence of attempted suicide, 1.1%), the adjusted odds ratio of ever attempting suicide among persons with 7 or more experiences (35.2%) was 31.1 (95% confidence interval, 20.6-47.1). Adjustment for illicit drug use, depressed affect, and self-reported alcoholism reduced the strength of the relationship between the ACE score and suicide attempts, suggesting partial mediation of the adverse childhood experience-suicide attempt relationship by these factors. The population-attributable risk fractions for 1 or more experiences were 67%, 64%, and 80% for lifetime, adult, and childhood/adolescent suicide attempts, respectively. CONCLUSIONS: A powerful graded relationship exists between adverse childhood experiences and risk of attempted suicide throughout the life span. Alcoholism, depressed affect, and illicit drug use, which are strongly associated with such experiences, appear to partially mediate this relationship. Because estimates of the attributable risk fraction caused by these experiences were large, prevention of these experiences and the treatment of persons affected by them may lead to progress in suicide prevention.     

Risk of suicide among persons with AIDS. A national assessment.

OBJECTIVE--We sought to describe the rate, risk, trends, methods, and distribution of suicide among persons with the acquired immunodeficiency syndrome (AIDS) in the United States. DESIGN--We used National Center for Health Statistics multiple-cause mortality data from 1987 through 1989 to identify suicides among persons with AIDS (PWAs) and public-access AIDS surveillance data to determine person-years of observation of PWAs. PATIENTS--Residents of the United States with death certificates indicating suicide. MAIN OUTCOME MEASURE--Death certificates indicating both AIDS and suicide. RESULTS--In 1987 through 1989, a total of 165 suicides among PWAs occurred in 45 states and the District of Columbia. All but one case were male. Among males the rate was 165 per 100,000 person-years of observation, 7.4-fold higher than among demographically similar men in the general population. Self-poisoning with drugs was both the most common method (35%) and the method with the highest standardized mortality ratio (35). Suicide risk for PWAs decreased significantly (P < .05) from 1987 to 1989. CONCLUSION--Persons with AIDS have an increased risk of suicide, and assessment of such risk should be a standard practice in their care. These assessments should be carefully considered when potentially lethal medications are prescribed. The declining trend in suicide rates between 1987 and 1989 is encouraging; possible causes include emerging therapies for human immunodeficiency virus/AIDS, better psychiatric care for these patients, and lessened social stigma against PWAs.     

Prevention of suicide.

We reviewed the epidemiologic features of suicide in Canada and evaluated suicide prevention programs. Three groups were found to be at increased risk for suicide: men aged 70 years or more, women aged 65 to 69 and men aged 20 to 24. The other groups, in decreasing order of risk, were the mentally ill, people who have attempted suicide, those with a life-threatening illness, native people, people with a family history of suicide and prisoners. Studies that evaluated suicide prevention programs showed that none significantly reduced the incidence of suicide; however, the studies were found to be methodologically inadequate or used noncomparable systems of data collection. On the basis of our findings we recommend that primary care physicians routinely evaluate suicide risk among patients in high-risk groups and that intervention include counselling, follow-up and, if necessary, referral to a psychiatrist. Close follow-up is recommended for newly discharged psychiatric patients and those who recently attempted suicide.     

Self-harm: 2. Deliberate nonfatal self-harm.

The incidence of deliberate acts of self-harm, such as drug overdoses, has greatly increased in the past two decades. The term "suicide attempt" is really a misnomer. For most people who harm themselves the primary motivation is rarely to die. As well, there are many differences between self-harm patients and patients who have committed suicide. The former tend to be characterologically disturbed and socially disadvantaged. Intervention narrowly focused on suicide prevention will lead to lengthy hospital stays in high-risk cases and ineffective treatment for most self-harm patients, who tend not to comply with outpatient treatment. Crisis-oriented intervention with a brief hospital stay in all cases of self-harm may provide more effective assessment and management.     

The presence and accessibility of firearms in the homes of adolescent suicides. A case-control study.

OBJECTIVE--The presence of guns in the home, the type of gun, and the method of storage were all hypothesized to be associated with risk for adolescent suicide. DESIGN--Case-control study. SUBJECTS--The case group consisted of 47 adolescent suicide victims. The two psychiatric inpatient control groups were 47 suicide attempters and 47 never-suicidal psychiatric controls, frequency-matched to the suicide victims on age, gender, and county of origin. SETTING--The cases were a consecutive community sample, whereas the inpatients were drawn from a university psychiatric hospital. MAIN OUTCOME MEASURE--Odds of the presence of guns in the home of suicide victims (cases) relative to controls. RESULTS--Guns were twice as likely to be found in the homes of suicide victims as in the homes of attempters (adjusted odds ratio, 2.1; 95% confidence interval, 1.2 to 3.7) or psychiatric controls (adjusted odds ratio, 2.2; 95% confidence interval, 1.4 to 3.5). Handguns were not associated with suicide to any statistically significantly greater extent than long guns. There was no difference in the methods of storage of firearms among the three groups, so that even guns stored locked, or separate from ammunition, were associated with suicide by firearms. CONCLUSIONS--The availability of guns in the home, independent of firearms type or method of storage, appears to increase the risk for suicide among adolescents. Physicians should make a clear and firm recommendation that firearms be removed from the homes of adolescents judged to be at suicidal risk.     

A Systematic Literature Review of Technologies for Suicidal Behavior Prevention

Suicide is the second cause of death in young people. The use of technologies as tools facilitates the detection of individuals at risk of suicide thus allowing early intervention and efficacy. Suicide can be prevented in many cases. Technology can help people at risk of suicide and their families. It could prevent situations of risk of suicide with the technological evolution that is increasing. This work is a systematic review of research papers published in the last ten years on technology for suicide prevention. In September 2017, the consultation was carried out in the scientific databases PubMed, ScienceDirect, PsycINFO, The Cochrane Library and Google Scholar. A general search was conducted with the terms “prevention” AND “suicide” AND "technology. More specific searches included technologies such as "Web”, “mobile”, “social networks”, and others terms related to technologies. The number of articles found following the methodology proposed was 90, but only 30 are focused on the objective of this work. Most of them were Web technologies (51.61%), mobile solutions (22.58%), social networks (12.90%), machine learning (3.23%) and other technologies (9.68%). According to the results obtained, although there are technological solutions that help the prevention of suicide, much remains to be done in this field. Collaboration among technologists, psychiatrists, patients, and family members is key to advancing the development of new technology-based solutions that can help save lives.     

大学生危险行为的流行病学调查

目的 了解大学生危险行为的流行病学特征及其相关因素，以便更好地预防和控制大学生危险行为的发生。方法 按照分层整群抽样方法，随机抽取1100名大学生，由统一培训合格的调查员以无记名方式对苏州市大学生危险行为进行现场问卷调查。结果 危险行为在大学生中普遍存在，吸烟率为37％，饮酒率为86．5％，有9．6％的学生考虑过自杀，有4．9％的学生曾经有过性行为。结论 应高度重视大学生危险行为的现状并从多方面来预防和控制大学生危险行为的发生。     

四所综合医院自杀未遂者自杀意念调查

目的了解沈阳市综合医院急诊室自杀未遂者自杀意念的发生率以及自杀意念的风险因素。方法采用自伤情况问卷、贝克自杀意念量表和美国精神障碍与统计手册第4版病人版(DSM-Ⅳ)轴Ⅰ障碍临床定式检查为调查和诊断工具,对在沈阳市4所三级综合医院急诊室同一时段内诊治的自杀未遂者进行调查,并通过对239例完整的调查资料进行Logistic分析筛查出自杀意念的危险因素。结果自杀意念终生发生率是69.46%(95%CI:60.25%～79.25%),多因素分析显示自杀意念的最重要危险因素为近1周有绝望感(OR=2.88)、有现患精神障碍(OR=2.78)、为解脱痛苦(OR=2.29)。结论综合医院急诊室自杀未遂者有较高的自杀意念发生率,应及时对其识别并评估他们仍存在的自杀意念风险因素,同时需要对他们采取针对性干预措施以防止其再次发生自杀行为。     

Depression in adolescence: new developments

Depression in adolescence is under-recognized although its associated burden of illness is very high. Some frequent associations with depression in this age group are under-achievement, poor lifestyle choices including substance abuse, and a high risk of the persistence of the illness into adulthood There is also an increased risk of mortality related to suicide and harmful lifestyles. For depression in adolescents to be reduced, there needs to be strong collaboration among health professions, adolescents and their caregivers. Non-mental health clinicians must expand their role and become better prepared to recognize, prevent and treat depression in this age-group. Greater public awareness must also be achieved so that adolescents and their caregivers can seek help early.     

长沙市艾滋病患者自杀意念的社会心理因素调查

目的：了解长沙市艾滋病患者的自杀意念率及其影响因素，为降低艾滋病患者自杀意念制定科学依据。 方法：采用自制的人口学量表、Zung氏抑郁量表、Zung氏焦虑量表及贝克自杀意念量表中文版对长沙市某专科医院 的504名就诊或住院的艾滋病患者进行匿名现场问卷调查。结果：长沙市艾滋病患者最近1周、最严重时及终身自杀 意念率分别为13.9%，26.6%和27.2%。同性恋(OR=4.79，2.66，2.37)及有过自杀未遂史(OR=8.56，5.63，5.56)是最近1 周、最严重、终身3种自杀意念的危险因素。焦虑是最严重时(OR=3.28)及终身(OR=3.05)自杀意念的危险因素，抑郁 是最近1周有自杀意念(OR=4.97)的危险因素。结论：长沙市同性恋艾滋病患者为存在自杀意念的高危人群，而有过 自杀未遂史则为高危因素。     

Men's health: what's a GP to do?

Men are at highest risk of cardiovascular disease, chronic lung disease, some cancers, suicide and transport-related injury. An anticipatory approach to men's health in general practice should assess risk for these conditions and offer effective interventions, either to prevent them or manage them early. This requires attention to the barriers, not only to men accessing general practice, but also to appropriate assessment and management, especially among disadvantaged groups.     

中国大学生自杀死亡接触状况及其在生活事件与自杀风险之间的调节效应

目的了解中国大学生自杀死亡接触流行现况及其与自杀风险的关系,检验自杀死亡接触史在生活事件与自杀风险之间
的调节效应。方法采用自杀行为问卷-修订版（SBQ-R）、青少年生活事件量表（ASLEC）、自编自杀死亡接触及基本情况问卷对
全国6 个地区的8202 名在校大学生进行问卷调查。结果①中国大学生近亲自杀死亡史和熟人自杀死亡史的发生率分别为
3.9%和11.8%;②有近亲自杀死亡史大学生的SBQ-R总分显著高于无近亲自杀死亡史大学生的得分（5.51±2.44 vs 4.68±2.11,
P<0.01）;有熟人自杀死亡史大学生的SBQ-R总分显著高于无熟人自杀死亡史大学生的得分（5.23±2.48 vs 4.64±2.07,P<0.01）;
具有自杀死亡接触史的大学生的自杀意念、自杀计划和自杀未遂行为率显著高于无相应经历者（P<0.05）;③生活事件及其各因
子与自杀风险呈显著正相关（0.11≤r≤0.26,P<0.01）;④近亲自杀死亡史×熟人自杀死亡史交互项、生活事件×近亲自杀死亡史
交互项对自杀风险的作用不显著（P>0.05）,生活事件×熟人自杀死亡史交互项对自杀风险的交互作用具有统计学意义（P<
0.01）,高生活事件水平且具有熟人自杀死亡史者自杀风险相对最高。结论中国大学生的自杀死亡接触史、生活事件与自杀风
险关系密切,有近亲自杀死亡史、熟人自杀史、生活事件水平越高,自杀风险越大;熟人自杀死亡史在生活事件与自杀风险的关
系中存在调节效应。
     

Identifying and managing adverse environmental health effects: 3. Lead exposure

LEAD LEVELS IN NORTH AMERICAN CHILDREN AND ADULTS have declined in the past 3 decades, but lead persists in the environment in lead paint, old plumbing and contaminated soil. There are also a number of occupations and hobbies that carry a high risk of lead exposure. There is no evidence for a threshold below which lead has no adverse health effects. Blood lead levels previously considered safe are now known to cause subtle, chronic health effects. The health effects of lead exposure include developmental neurotoxicity, reproductive dysfunction and toxicity to the kidneys, blood and endocrine systems. Most lead exposures are preventable, and diagnosing lead poisoning is relatively simple compared with diagnosing health effects of exposures to other environmental toxins. Accurate assessment of lead poisoning requires specific knowledge of the sources, high-risk groups and relevant laboratory tests. In this article we review the multiple, systemic toxic effects of lead and provide current information on groups at risk, prevention, diagnosis and clinical treatment. We illustrate how the CH²OPD² mnemonic (Community, Home, Hobbies, Occupation, Personal habits, Diet and Drugs) and specific screening questions are useful tools for physicians to quickly obtain an environmental exposure history and identify patients at high risk of lead exposure. By applying effective primary prevention, case-finding and treatment interventions for lead exposure, both the individual patient and the larger community reap the benefits of better health.     

Suicide in teenagers: assessment, management, and prevention.

Adolescents who kill themselves invariably have an underlying psychiatric disorder. Biological markers are not yet clinically useful for identifying adolescents at risk, and there is a paucity of research data on the effectiveness of behavioral intervention for suicidal teenagers. A case of a 16-year-old scholar and athlete is presented to illustrate how multiple risk factors and a family diathesis often go undetected, resulting in tragic consequences. Psychiatric, familial, genetic, and social risk factors of adolescent suicide are reviewed, and the efficacy of lithium and antidepressant pharmacotherapy in reducing suicide rates is discussed. The importance of screening adolescent patients for depression is emphasized. Although teenage suicide is rare and hard to predict, identifying and treating adolescents at risk is essential to further reduce teenage suicide.     

大学生自杀防控外在管理机制

为了有效预防大学生自杀,高校应当在建立健全大学生自杀防控内在教育机制的基础上,不断加强大学生自杀防控外在管理机制建设,不断完善大学生自杀潜在信息收集处理机制、大学生自杀重点对象跟踪监控机制和大学生自杀明显危险应急干预机制。     

Suicide risk among recently released prisoners in New South Wales, Australia

OBJECTIVE: To determine the risk of suicide and drug overdose death among recently released prisoners. DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study of 85 203 adult offenders who had spent some time in full-time custody in prisons in New South Wales between 1 January 1988 and 31 December 2002. MAIN OUTCOME MEASURES: Association between time after release and risk of suicide and overdose death. RESULTS: Of 844 suicides (795 men, 49 women), 724 (86%) occurred after release. Men had a higher rate of suicide than women both in prison (129 v 56 per 100,000 person-years) and after release (135 v 82 per 100,000 person-years). The suicide rate in men in the 2 weeks after release was 3.87 (95% CI, 2.26-6.65) times higher than the rate after 6 months. Male prisoners admitted to the prison psychiatric hospital had a threefold higher risk than non-admitted men both in prison and after release. No suicides among women were observed in the 2 weeks after release. No increased risk of suicide was observed among Aboriginal Australians in the first 2 weeks after release. Of 1674 deaths due to overdose, 1627 (97%) occurred after release. Drug-related mortality in men was 9.30 (95% CI, 7.80-11.10) times higher, and in women was 6.42 (95% CI, 3.88-10.62) times higher, in the 2 weeks after release than after 6 months. CONCLUSIONS: Prisoners are at a heightened risk of suicide and overdose death in the immediate post-release period. After 6 months post-release, the suicide rate approaches the rate observed in custody.     

The prediction of suicide

The prediction of suicide remains a major challenge for health professionals. Sociodemographic predictors of the risk of suicide lack specificity: factors such as living alone, being unemployed, or having a physical or mental illness are common, separately or in combination, but suicide is rare. Psychiatric conditions, such as depression, alcohol dependence, schizophrenia and personality disorders, are strongly associated with suicide, but most psychiatrically ill patients do not suicide. Most suicidal patients consult a helping agency within a month of their act and, in practice, successful assessment of the risk of suicide and intervention to prevent it depend on gaining an understanding of the individual patient and developing a therapeutic relationship. More research into the biological, psychological and social factors that distinguish suicidal from non-suicidal individuals is needed. We review key studies that have addressed the issue of suicide prediction, outline the clinician's role in evaluating the risk of suicide in the individual, and suggest directions for future research.