Suicide in first- and second-generation immigrants in Sweden A comparative study

Background: Studies of suicide in first-generation immigrants have consistently shown higher rates compared to their country of origin. Little is known about the risk of suicide in second-generation immigrants and intercountry adoptees. The aim of this study was to investigate rates of suicide death in second-generation immigrants and intercountry adoptees in comparison with their parental generation and the majority population. Method: The study was based on multivariate analyses of register data on suicide death during 1990–98 in a Swedish national cohort of 2.7 million residents (10–68 years). Results: Second-generation immigrants tended to have higher odds than the first-generation immigrants compared to the majority population in all six minority groups studied. The Finnish minority had the highest and the Middle Easterners the lowest odds for suicide death in both generations of immigrants. The intercountry adoptees had very high odds for suicide death (adjusted OR: 5.0; 95 % CI 3.5–7.0). Conclusions: Second-generation immigrants are at greater risk for suicide death than their parental generation. Intercountry adoptees should be of particular concern in suicide prevention. Accepted: 10 April 2002     

Childhood Exposure to Caregiver Suicidal Behavior and Risk for Adult Suicide Attempts: Findings from a National Survey

The objective of this study was to investigate the association between exposure to caregiver suicidality and subsequent adult suicide attempt (SA). Data came from the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (n = 34,653). Respondents were asked if they had a caregiver attempt or complete suicide during childhood. Logistic regression examined associations between SA and caregiver suicidality. Compared to individuals with no suicidality, risk for lifetime SA was higher for individuals that were exposed to a SA (15.6%, [OR] = 5.86, 95% [CI] = 4.57–7.51) and for those who experienced a death by suicide (6.1%, [OR] = 2.08, CI = 1.32–3.26]. Associations remained significant after controlling for demographics, Axis I and II disorders and childhood adversity. Individuals with exposure to suicidality are at increased odds for SA.     

ADHD in international adoptees: a national cohort study

Several investigators have reported an increased frequency of attention/hyperactivity symptoms in international adoptees, though population-based studies are lacking. In this national cohort study, we aimed to determine the prevalence of ADHD medication in international adoptees in Sweden, in comparison to the general population. A further purpose was to study gender, age at adoption and region of origin as predictors of ADHD medication in international adoptees. The study population consisted of all Swedish residents born in 1985–2000 with Swedish-born parents, divided into 16,134 adoptees, and a comparison population of 1,326,090. ADHD medications were identified in the Swedish Prescribed Drug Register during 2006. Logistic regression was used to calculate the odds ratios. The rates of ADHD medication were higher in international adoptees than in the comparison population for both boys (5.3 vs. 1.5% for 10–15-year olds) and girls (2.1 vs. 0.3% for 10–15-year olds). International adoptees from all regions of birth more often consumed ADHD medication compared with the majority population, but the age and sex adjusted odds ratios were particularly high for adoptees from Eastern Europe, Middle East/Africa and Latin America. Adjusting for maternal education and single parenthood increased the odds ratios even further. The risk also increased with higher age at adoption. Adoptees from Eastern Europe have a very high risk for ADHD medication. A structured identification and support programme should be tailored for this group. Adoptees from other regions have a more moderately increased risk, which should be communicated to adoptive parents and to professionals who care for adoptees in their clinical practice.     

Familial clustering of suicidal behaviour and psychopathology in young suicide attempters

Introduction Familial clustering of suicidal behaviour and psychopathology has been reported in young suicide attempters. Most of these studies were predominantly carried out in clinical treatment settings and lacked statistical power to assess the independent and modifying influences of own and familial psychopathology and suicidal behaviour. Methods We carried out a population-based record-linkage study with a nested case control design. The 14,440 individuals hospitalised due to suicide attempt (cases) and 144,400 matched controls were born in Sweden between 1968 and 1980 and followed up till December 31, 1999. Results Among the strongest independent familial risk factors for youth suicide attempt were siblings’ (OR 3.4; 2.8–4.1), maternal (OR 2.7; 2.5–3.1) and paternal (OR 1.9; 1.7–2.1) suicide attempt. Other important risk factors were familial personality and substance abuse disorders, maternal schizophrenia, non-affective psychoses and organic disorders and parental neurotic, stress-related and somatoform disorders (1.9–3.2 fold increase), and paternal (OR 1.9; 1.6–2.3) and maternal (OR 1.8; 1.3–2.4) suicide completion. Mental illnesses in index subjects, particularly substance abuse, affective and personality disorders, were the dominant determinants of suicide attempt. Strong interactions were observed between psychopathology in index subjects and familial suicidality. Familial suicide completion had a stronger effect on suicide attempt of earlier onset and on boys. Nearly half (47%) of all suicide attempts could be attributed to familial psychopathology (13%), family suicide attempt (7%) and suicide completion (1%) and own psychopathology (25%). Conclusion Early recognition and adequate treatment of individual mental illness contribute to prevent youth suicide attempts. Children of parents with psychopathology and suicidal behaviour should receive early support and attention. Evaluation of familial suicidal behaviour seems to be vital for suicide risk assessment in young psychiatric inpatients. There appears to be an independent effect of familial suicidal behaviour as well as familial psychopathology on youth suicide attempt beyond the transmission of mental illness.     

Repetition of attempted suicide among teenagers in Europe: frequency, timing and risk factors

Background. Adolescents in many countries show high rates of suicide attempts and repetitions of attempts as a common feature. Attempted suicide is the best predictor of future suicide. Repetition of attempts further increases the risk of suicide. The present study sought to identify patterns and risk factors for repetition of attempts in older teenagers. Methods. Data were collected by uniform procedures in a longitudinal follow-up study in seven European centres participating in the WHO/EURO Multicentre Study on Suicidal Behaviour. Information on attempted suicide in the 15–19-year age group during the period 1989–1995 was analysed. Results. A total of 1,720 attempts by 1,264 individuals over a mean follow-up period of 204 weeks (SD 108.9) were recorded. When life-table analysis was performed, 24 % of the individuals who had previously attempted suicide made another attempt within one year after the index attempt, compared with 6.8 % of the “first-evers”, with no major gender difference. Cox regression analysis revealed that previous attempted suicide (OR 3.3, 95 % CI 2.4–4.4) and use of “hard” methods (OR 1.5, 95 % CI 1.1–2.1) were both significantly associated with repetition of attempted suicide. Stepwise Cox regression analysis showed that a history of previous attempted suicide was the most important independent predictor of repetition (OR 3.2, 95 % CI 2.4–4.4). Conclusion. For young suicide attempters, follow-up and adequate aftercare are very important if repetition and risk of suicide are to be reduced. This applies particularly to those who have already made more than one attempt. Accepted: 19 February 2001     

Avoidable mortality among psychiatric patients

Avoidable mortality is a selection of causes of death considered to be amenable to health care and thereby used as an indicator of the quality of health care. In this study avoidable mortality for more than 30,000 psychiatric patients discharged from any hospital of Stockholm County between 1981 and 1985 has been followed up in the Cause of Death Register for the period 1986–1990. Standardised rate ratios were calculated for different groups of psychiatric disorders compared to the general population of Stockholm County for indicators of avoidable mortality, suicide, other mortality (“unavoidable”) and causes possibly related to treatment with psychotrophic drugs. As expected, the psychiatric patients had the most pronounced elevated risk for suicide, i.e. 6- to 24-fold compared to the general population, and noticeably more elevated for women. It is also noteworthy that the relative mortality risks for diagnoses amenable to medical interventions and potential side-effects of psychotrophic drugs are higher than for other causes of death (“unavoidable”). The relative risks for avoidable mortality were 4.7 for men and 3.8 for women and for diagnoses possibly related to side-effects of psychotrophic drugs, 7.2. The relative risks for “unavoidable” mortality were 3.4 for men and 3.2 for women. The excess avoidable mortality rates for psychiatric patients and the elevated suicide risk, especially for female patients, are warning signals of shortcomings in psychiatric care that warrants further investigation. Accepted: 19 January 1998     

Recommended care for young people (15–19 years) after suicide attempts in certain European countries

Data on recommended care for young people aged 15–19 years after attempted suicide from nine European research centres during the period 1989–1992 were analysed in terms of gender, history of previous suicide attempt and methods used. Altogether 438 suicide attempts made by 353 boys and 1,102 suicide attempts made by 941 girls were included. Analyses of the total data from all centres showed that young people with a history of previous suicide attempt and those using violent methods had significantly higher chance of being recommended aftercare than first-time attempters or those choosing self-poisoning. There were no significant differences of being recommended care between genders. Logistic regression analyses of the material were performed and the results were similar. Both having previous attempted suicide (odds ratio 2.0, 95% CI 1.53–2.61) and using “hard” methods (odds ratio 1.71, 95% CI 1.49–1.96) were significantly associated with increased possibility of being recommended aftercare. When individual centres were analysed, large disparities of recommended care after suicide attempts were found and there were no uniform criteria of recommending care for young suicide attempters in Europe. Accepted: 23 August 1999     

Excess mortality of suicide attempters

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

Risk of suicide attempt and suicide death in patients treated for bipolar disorder

OBJECTIVES: To evaluate demographic and clinical predictors of suicide attempt and suicide death in a population-based sample of people treated for bipolar disorder (BD). METHODS: Computerized records were used to identify 32,360 individuals treated for BD at two large prepaid health plans. Suicide attempts were identified using computerized records of outpatient visit diagnoses and hospital discharge diagnoses. Suicide deaths were identified using state death certificate data. RESULTS: Overall event rates were 1.06 per 1,000 person-years for suicide death, 5.6 per 1,000 person-years for suicide attempt leading to hospitalization, and 13.9 per 1,000 person-years for suicide attempt not leading to hospitalization. Men had a significantly lower rate of suicide attempt [hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.56-0.83] but a higher rate of suicide death (HR 2.70, 95% CI 1.69-4.31). Suicide attempts were significantly more frequent among younger patients, but suicide deaths did not vary significantly by age. Substance use comorbidity was significantly related to risk of suicide attempt (HR 2.53, 95% CI 2.07-3.09) but not to risk of suicide death (HR 1.02, 95% CI 0.54-1.93). Comorbid anxiety disorder was associated with significantly higher risk of both suicide attempt (HR 1.40, 95% CI 1.14-1.72) and suicide death (HR 1.81, 95% CI 1.09-2.99). CONCLUSIONS: Among people treated for BD, risk of suicide death is significantly related to male sex and comorbid anxiety disorder. The predictors of suicide death differ markedly from predictors of suicide attempt.     

Suicide and Marital Status in Italy

Background  Completed suicide has been reported as being linked to marital status, with being unmarried associated with a higher suicide rate as compared with being married or living with a partner. Method  Data were obtained from the Italian Data Base on Mortality, collected by the Italian Census Bureau (ISTAT) and processed by the Italian National Institute of Health-Statistics Unit. The Italian population in the last Italian census (October 2001) was used to estimate age-standardized mortality rates from suicide by marital status (ICD-9 revision: E950–E959) and “natural” causes (ICD-9 revision: 0–280; 320–799). Rate ratios and 95% confidence intervals were calculated using married individuals as a reference. All analyses were conducted separately for men and women and for three different age groups (25–44 years, 45–64 years and 65 years and over) for 2000–2002, the most recent years with data available. Logistic regression analysis was used to compare differences by marital status for suicide versus death from natural causes. Results  Being married appears to be a protective factor for suicide, but the impact of being never-married, divorced/separated or widowed varies with age and gender. It is noteworthy that the differences between married and non-married women were less consistent than those among men, especially for elderly women. The results confirm that the protective impact of marriage is higher for suicide than for natural causes of death, and the comparison between the risks of suicide and natural causes of death reveals that the groups relatively more at risk for suicide are divorced/separated women, divorced/separated men (under the age of 64) and widowed men. Conclusions  Both among men and women, being unmarried, widowed or divorced/separated is associated with a higher suicide rate. This study, however, adds information on suicide mortality in specific age-groups compared to mortality from natural causes of death. Overall, these findings support the notion that marital status may dramatically influence the risk of suicide.     

Suicide and violent death among adolescent suicide attempters

A total of 422 subsequent suicide attempts commited by 362 people 15-19 years old in the Helsinki area in 1973-1982 were investigated to find risk factors for subsequent suicide or violent death. By the end of 1982, 8.7% of 115 boys and 1.2% of 247 girls had died. Eight (2.2%) had committed suicide. The mean annual mortality for suicide and violent death was 20-fold compared with the mortality for suicide and violent death among people 15-19 years old in Finland at that time. The risk ratios of the boys for suicide (2.0) and for violent death (2.4) were greater than that of the girls (0.6 and 0.3 respectively). The risk ratio of psychotic persons for suicide was 4.2 and for violent death 4.1. Seriousness of intent heightened the risk, whereas degree of lethality did not influence it. The people who expressed clear-cut difficulties as a reason for their suicide attempt seemed to have a smaller risk for suicide or violent death than people whose reasons remained unclear. Attempted suicide among boys is a serious symptom for predicting subsequent suicide that should be addressed in suicide prevention.     

Characterization of suicidal depression: A 1 year prospective study

BackgroundSuicidal ideation (SI) is an important risk factor of death by suicide. Recent data suggest that suicidal depression (i.e., moderate to severe depression with SI) could be a specific depression subtype with worse clinical outcomes than nonsuicidal depression (i.e., without SI).MethodsAmong 898 French adult inpatients (67% women, mean age: 41.23 [SD: 14.33]) with unipolar depression, 71.94% had moderate to severe depression (defined using the cut-offs of validated scales: beck depression inventory, clinician-rated 30-item inventory depression symptomatology, and quick inventory of depressive symptomatology) and among them, 63.6% had SI according to the suicidal item (score ≥ 2) of the depression scale they filled in. Clinical features (anxiety, psychological pain, and hopelessness) were assessed at baseline. The occurrence of a suicide attempt (SA) or a suicide event (SE) (i.e., actual, aborted or interrupted SA, or hospitalization for SI) was recorded during the 1-year follow-up. The risk of actual SA and SE was compared between groups with adjusted Cox regression models.ResultsThe risk of actual SA and SE during the follow-up was 2- and 1.8-fold higher, respectively, in patients with suicidal depression, independently of potential cofounders such as history of lifetime SA, age, sex, and baseline depression severity.ConclusionsSuicidal depression is associated with poorer prognosis in terms of actual SA/SE, despite optimal care (i.e., care in a hospital department specialized in the management of suicidal crisis). Specific therapeutic strategies might be needed for these patients.     

Do antidepressants precipitate youth suicide?

The association between treatment with Selective serotonin reuptake inhibitors (SSRIs) and suicide in children and adolescents on the individual and ecological level were examined in a nationwide Danish pharmacoepidemiological register-linkage study including all persons aged 10–17 years treated with antidepressants during the period 1995–1999 (n=2,569) and a randomly selected control population (n=50,000). A tripartite approach was used. In Part 1, changes in youth suicide and use of antidepressants were examined. In Part 2, we made an assessment of youth suicide characteristics. In Part 3, we analysed the relative risk (RR) of suicide according to antidepressant treatment corrected for psychiatric hospital contact to minimize the problem of confounding by indication. The use of SSRIs among children and adolescents increased substantially during the study period, but the suicide rate remained stable (Part 1). Among 42 suicides nationally aged 10–17 years at death, none was treated with SSRIs within 2 weeks prior to suicide (Part 2). There was an increased rate of suicide associated with SSRIs (RR=4.47), however, not quite significant (95% CI: 0.95–20.96), when adjusted for severity of illness (Part 3). Conclusively, we were not able to identify an association between treatment with SSRIs and completed suicide among children and adolescents.     

Suicide victims’ contacts with physicians during the year before death

Suicide victims frequently have had contact with physicians during the last year before death. However, oftentimes suicidal ideation is not reported overtly. This study investigates the course of contact rates of suicide victims with physicians during the year before death. Official suicide data and insurance company data were linked for 317 subjects who had committed suicide between 1998 and 2002. Quarterly contact rates with physicians during the respective last year of life were compared. Contact rates of suicide victims with physicians varied considerably concerning age, gender and physicians’ specialization. Contacts with ‘any physician’ and general practitioners generally increased over the year, most pronounced in men and in those older than 60 years. In contrast to males, female contacts to psychiatrists increased until one quarter before suicide and then dropped significantly shortly before suicide. A pattern of contacting more than one general practitioner per quarter occurred significantly more often in the suicide quarter than during the year before, predominantly in those older than 60 years. Such a ‘doctor shopping’ behavior may reflect an intensified patients’ searching for adequate help. Taking contact behavior changes into account may increase the chance to identify individuals at risk and thus may contribute to suicide prevention.     

Association between physical illness and suicide among the elderly

Background Only a few small studies have explored the association between various physical illnesses and suicide in the elderly and they have produced inconsistent results. Thus, we undertook this larger study to more definitively assess the association between elderly suicide and physical illness. Methods This case-control study compared the proportion with physical illnesses among 822 cases who committed suicide with that among 944 controls who died due to motor vehicle accident at age 55 years or over in Alberta, Canada. Results Compared to the motor vehicle accident deaths, the elderly who committed suicide were more likely to have cancer, ischemic heart disease, chronic pulmonary disease, peptic ulcer, prostatic disorder, depression and other psychiatric illnesses. There was no significant difference in the proportion of cerebrovascular disease and diabetes mellitus between the case and control groups before adjustment of demographic and clinical characteristics. After adjustment of these variables, the elderly with any of the following illnesses were more likely to die by suicide than those without the illness: cancer (adjusted odds ratio [95 % confidence interval]: 1.73 [1.16–2.58]), prostatic disorder (excluding prostatic cancer, 1.70 [1.16–2.49]), chronic pulmonary disease among the married (1.86 [1.22–2.83]), depression (6.70 [4.72–9.50]) or other psychiatric illness (2.16 [1.68–2.76]). There was no evidence that ischemic heart disease, cerebrovascular disease, peptic ulcer and diabetes mellitus might be associated with suicide in the elderly. Conclusions Cancer, prostatic disorder, chronic pulmonary disease among the married and psychiatric illness appear to be associated with suicide among the elderly. Accepted: 17 December 2001     

Sex differences in risk factors for suicide after attempted suicide

Abstract.Aim: This study aims to investigate suicide risk factors after attempted suicide and whether and how these risk factors differ between the sexes.Method: A total of 1052 suicide attempters admitted to the Medical Emergency Inpatient Unit, Lund University Hospital, Sweden were followed up concerning suicide and death from other causes after a median period of 6 years and 5 months. In all, 50 persons committed suicide during follow-up. At the index suicide attempt, socio-demographic data and information about clinical characteristics were gathered in a standardised manner. Risk factors were identified among these data using survival analyses for the whole sample and for each sex separately.Result: Men had a higher frequency of suicide and a greater overall mortality than women. Cox regressions showed that suicide attempt(s) prior to the index attempt and the use of a violent method for the index attempt were risk factors for men only, whereas older age and a high suicidal intent (Beck SIS score) were female ones. Major depression was a risk factor for both sexes.Conclusion: More attention probably needs to be paid to the importance of gender in assessment of suicide risk and treatment of suicide attempters.     

Season–of–birth as a risk factor for the seasonality of suicidal behaviour

Despite implicating the same biological systems, the relationship between suicide seasonality and season–of–birth has not been examined previously. The purpose of this study was to investigate the interaction between season–of–birth and the seasonality of suicidal behaviour. All adult suicides (N = 2923) and deliberate self harm (DSH) hospitalizations (N = 33321) in Western Australia (1970–96) were examined. A variable population at risk approach was used to determine season–of–birth. Seasonality was established by spectral analysis. We found that DSH has a significant season–of–birth (p = 0.047) and seasonality of occurrence, both peaking in spring. Individuals born in the 90 days centred on the peak birth period, however, show no DSH seasonality. In contrast, suicide has no season–of–birth (p = 0.53). We also found a season–of–birth effect among the DSH group that eliminates any seasonality of DSH among the high–risk by birth group. Further work is needed to identify the possible biological and environmental determinants of this interaction.     

Attempted suicide predicts suicide risk in mood disorders

Suicide risk was studied in a sample of 346 mood disorder inpatients, 92 of whom were admitted after a current suicide attempt. The overall suicide mortality after a mean observation period of 6 years was 8%. The potential of attempted suicide to predict suicide risk in hospitalized patients with mood disorders was studied by survival analysis after subgrouping on the basis of whether a current suicide attempt had occurred or not. The suicide risk the first year after attempting suicide was 12% (11/92), compared with 2% (4/254) in the mood disorder subgroup with no current suicide attempt. The long-range suicide risk after a current suicide attempt in depression was 15% (14/92) as compared with 5% (13/254) among those without a current suicide attempt. It is concluded that a current suicide attempt in mood disorder inpatients predicts suicide risk particularly within the first year and should be taken very seriously.