Risk factors of future suicide in suicide attempters – A comparison between suicides and matched survivors

The objective of this study was to find risk factors for suicide by looking for clinical and care/treatment consumption differences between 15 hospitalized suicide attempters, who later committed suicide (“completers”), and 15 suicide attempters who did not (“non-completers”), matched according to sex, age and principal diagnosis. Completers had significantly more often attempted suicide after the index admission. After index, completers had received more psychiatric care and treatment than non-completers. Comorbidity was common in both groups of patients. Personality disorders according to the DSM III-R, axis II, Cluster B, however, tended to be more common in the completer group. Increased comorbidity over time could also be seen to a larger extent in completers. In spite of the matching of principal diagnosis, completers tended to have higher Montgomery–Åsberg Depression Rating Scale ratings than non-completers. They also had significantly higher Suicide Assessment Scale (SUAS) scores. From this study, it is apparent that suicide attempters at risk of future suicide have major and multiple psychiatric problems, which cause difficulties in the care and treatment.     

Psychosocial profile of suicide ideators, attempters and completers in India

The study aims to determine the psychological profile of suicide ideators, attempters and completers in a tertiary care teaching hospital. A total of 260 suicidal ideators, 58 attempters and 55 completers were studied. The majority of ideators, attempters and completers were 26-35 years of age, males (except attempters who were predominantly females), married, literate up to high school, employed (ideators) or housewives (attempters and completers). The suicide ideators, attempters and completers who had a past history of attempt were 6.9%, 24.1% and 18.2% respectively. Family history of attempted suicide or completed suicide was also common among patients suffering from depression. In suicidal ideators, mixed anxiety and depressive disorder was the most common psychiatric diagnosis followed by major depression and schizophrenia. Among suicide attempters, adjustment disorder with depression was the most common diagnosis. The most common method of suicide attempt was organophosphorus compound intake whereas in suicide completers, the most common method in use was hanging. The patients with suicidal ideation or attempt need careful evaluation, early intervention and long term follow up.     

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.     

Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients

The characteristics of adolescent suicide victims (n = 27) were compared with those of a group at high risk for suicide, suicidal psychiatric inpatients (n = 56) who had either seriously considered (n = 18) or actually attempted (n = 38) suicide. The suicide victims and suicidal inpatients showed similarly high rates of affective disorder and family histories of affective disorder, antisocial disorder, and suicide, suggesting that among adolescents there is a continuum of suicidality from ideation to completion. However, four putative risk factors were more prevalent among the suicide victims: (1) diagnosis of bipolar disorder; (2) affective disorder with comorbidity; (3) lack of previous mental health treatment; and (4) availability of firearms in the homes, which taken together accurately classified 81.9% of cases. In addition, suicide completers showed higher suicidal intent than did suicide attempters. These findings suggest a profile of psychiatric patients at high risk for suicide, and the proper identification and treatment of such patients may prevent suicide in high-risk clinical populations.     

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.     

Attempted suicide in elderly Chinese persons: a multi-group, controlled study.

OBJECTIVE: Attempted suicide in later life is under-researched despite its public health significance. In this study, the authors delineated the characteristics of elderly suicide attempters in a representative Chinese sample by comparing them with suicide completers and comparison subjects age 65 years or over who were randomly selected from the community. METHODS: There were 224 subjects in this study: 66 suicide attempters, 67 suicide completers, and 91 comparison subjects from the community. Using a case-control design and standardized measuring instruments, authors examined the risk and protective factors associated with attempted suicide, making direct comparisons with the community-comparison subjects and suicide completers. RESULTS: A current diagnosis of major depression was associated with a nearly 60-fold increased risk for attempted suicide, and a population attributable risk (PAR) of 67%. Other risk factors included past suicide attempts, poorer function of self-care, arthritis, and specific personality dispositions, particularly low Conscientiousness. Co-residence with children decreased risk. Although the profiles of suicide attempters and completers were similar, they could be distinguished by suicide intent, recent life events (particularly hospitalization), functional competence, religious denomination, and personality characteristics. CONCLUSIONS: A high degree of clinical vigilance and multidisciplinary collaboration are required in the management of elderly suicide attempters. The treatment of depression should form a crucial part of the prevention program. Features that distinguish suicide completers from suicide attempters may also carry implications for the secondary prevention of suicide in elderly persons.     

Treatment received by alcohol-dependent suicide attempters

The purpose of this study was to examine the clinical features of alcohol-dependent suicide attempters and the treatment they received before and after the index attempt. A total of 47 subjects with current DSM-III-R alcohol dependence were identified from a systematic sample of 114 suicide attempters in Helsinki. All of them were comprehensively interviewed after the attempt, and the treatment they had received was established from psychiatric and other health-care records and follow-up interviews. Most had a history of psychiatric (83%) or substance abuse (83%) treatment. During the final month before the attempt, half of the subjects (51%) had been treated by health care services; 11% had received disulfiram-treatment and 6% had received psychotherapy. Subjects complied with recommended aftercare more often when they had been actively referred. After 1 month, 64% were being treated by health care services. However, only 14% were receiving disulfiram-treatment and 9% were receiving psychotherapy. These findings suggest that the quality and activity of treatment offered to suicide attempters with alcohol dependence should be improved.     

CSF 5-HIAA, suicide intent and hopelessness in the prediction of early suicide in male high-risk suicide attempters

OBJECTIVE: To study the predictive value of the Beck Suicide Intent Scale (SIS), the Beck Hopelessness Scale (BHS) and of 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid for future early suicide in a group of high-risk male suicide attempters. METHOD: Fifteen consecutive male suicide attempters admitted to a psychiatric ward at the Karolinska Hospital, who were not receiving any treatment with antidepressants were diagnosed according to DSM-III, assessed with SIS and BHS and submitted to lumbar puncture. All patients were followed up for cause of death. RESULTS: Five early suicides (within 2 years) were identified. Mean cerebrospinal fluid (CSF) 5-HIAA differed between suicides and survivors. Low CSF 5-HIAA was identified in those who committed early suicide. Neither the Suicide Intent Score nor the Hopelessness Score distinguished suicides from survivors. CONCLUSION: In high suicide risk hospitalized male psychiatric patients CSF 5-HIAA may be a better predictor of early suicide after attempted suicide than SIS or BHS.     

Suicidal intent and psychiatric symptoms among inpatient suicide attempters

The objective of this study was to investigate associations between suicidal intent and psychiatric symptoms, and to study the usefulness of the Suicidal Intent Scale (SIS) and the Comprehensive Psychopathological Rating Scale (CPRS) for suicide risk assessment in an inpatient population. One hundred and ninety-six suicide attempters, of whom 15 eventually committed suicide, were admitted to a psychiatric ward. They were assessed by means of the SIS and the CPRS. Cox regression analyses were performed in order to adjust the relationships between the individual CPRS subscales and suicide for age and gender. The patients who later completed suicide had higher scores on the CPRS than the patients who did not complete suicide. We found no associations between symptoms and suicidal intent. The severity of psychopathology, in terms of high CPRS scores, shows a stronger association with future suicide than the level of suicidal intent (SIS) among inpatient suicide attempters. Suicidal intent is evidently scored regardless of psychiatric symptoms.     

Personality, parental rearing behaviour and parental loss in attempted suicide: a comparative study

Thirty psychiatric patients (aged 18-29) who had attempted suicide were compared with 2 matched control groups, one consisting of nonsuicidal psychiatric patients and the other of normal subjects, for personality patterns, parental rearing practices and personal loss before the age of 15. The instruments used were the Eysenck Personality Questionnaire (EPQ), the Lazare-Klerman-Armor Trait Scale (LKAS), the Narcissistic Personality Inventory (NPI) and the Own Memories of Child-Rearing Experiences (EMBU). Patients admitted for suicide attempts differed significantly from normals on several personality dimensions, whereas suicide attempters did not have personality characteristics that made them substantially different from nonsuicidal psychiatric controls. The suicide attempters had experienced significantly more negative and less positive parental rearing factors than normals, but no difference was found between suicidal and nonsuicidal patients for own memories of parental rearing patterns. Parental loss due to divorce had occurred significantly more often among suicide attempters than among both nonsuicidal psychiatric patients and normals.     

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.     

The dexamethasone suppression test and completed suicide

The present study was undertaken to further explore the relationship between the dexamethasone suppression test (DST) and suicide. Depressed inpatients who had undergone the DST at index admission and later committed suicide (n = 13) were matched for age, gender, diagnosis, and type of DST (1 mg, 2 mg) with depressed inpatients from the same hospital and study time period to form 2 groups: a suicide attempter group (n = 25) and a nonattempter group (n = 28). The suicide completers group had significantly higher 1600 postdexamethasone cortisol levels than the suicide attempters group and a significantly higher 1600 rate of DST nonsuppression compared with the suicide attempter + nonattempter combined group. Although the rate of DST nonsuppression did not differ between the suicide attempter and nonattempter groups, serious attempters had significantly higher 1600 cortisol levels and a statistically higher proportion of patients who completed suicide than nonserious attempters.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Comorbidity of axis I and axis II disorders in patients who attempted suicide

OBJECTIVE: The authors compared the characteristics of suicide attempters with and without comorbid psychiatric and personality disorders to identify factors that explain the high suicide risk associated with psychiatric comorbidity. METHOD: A representative group of 111 patients who had attempted suicide (72 female and 39 male) was assessed for psychiatric and personality disorders according to ICD-10 criteria. The characteristics of patients with both types of disorder were compared with those of patients without comorbid disorders. A semistructured interview schedule and standardized questionnaires were used to investigate patients' background characteristics, the circumstances of the suicide attempts, psychological characteristics, and outcome after 12-20 months. RESULTS: Comorbidity of psychiatric and personality disorders was present in 49 patients (44%). More patients with comorbid disorders had made previous suicide attempts (N=41 [84%] versus N=28 [45%]) and repeated attempts during the follow-up period (N=25 [51%] versus N=9 [15%]). Differences in precipitants and motives for the index episode were also found: patients with comorbid disorders were more depressed and hopeless, reported more episodes of aggression, were more impulsive, and had lower self-esteem and poorer problem-solving skills. Differences in self-esteem and problem-solving skills distinguished between the groups in a stepwise discriminant function analysis. More of the patients with comorbid disorders reported not being loved by their parents and parental suicidal behavior. CONCLUSIONS: Suicide attempters with comorbid psychiatric and personality disorders show marked differences from those without both of these disorders. Comorbidity may contribute to greater suicide risk. Some of the characteristics of patients with comorbid disorders pose major clinical challenges that should be addressed in an effort to reduce suicide risk.     

Low serum cholesterol in violent but not in non-violent suicide attempters

Many previous studies have suggested that low or lowered serum cholesterol levels may increase the risk of mortality not due to somatic disease: principally, suicide and violent death. Because violent death is rare, some studies have investigated afterwards the relation between cholesterol levels and either suicide attempts in psychiatric populations or violence in criminally violent populations. However, none of these studies have compared cholesterol levels in violent and non-violent suicide attempters. The blood of 25 consecutive drug-free patients following a violent suicide attempt and of 27 patients following a non-violent suicide attempt by drug overdose was drawn in the 24 h following admission. Patients with a diagnosis of alcohol abuse and with cholesterol-lowering therapy were excluded. Age, sex, body mass index, psychiatric diagnosis and the physical conditions of the suicide attempt were investigated. Thirty-two healthy subjects were used as a control group. There were no differences between the groups in age, frequency of psychiatric diagnoses or body mass index. There was more women in the group of non-violent suicide attempters than in that of violent suicide attempters (P<0.001). In analyses controlling for sex and age, the serum cholesterol concentration was 30% lower (F(2,82)=15.8; P<0.0001) in the group of violent suicide attempters (147+/-54 mg/dl) than in the group of non-violent suicide attempters (209+/-38 mg/dl) or control subjects (213+/-46 mg/dl). Our results showed that low serum cholesterol level is associated with the violence of the suicide attempt and not with the suicide attempt itself. Further investigations are necessary to determine the usefulness of this easily accessible parameter as a potential risk indicator for violent acts such as violent suicidal behavior in susceptible individuals.     

P11 (S100A10) as a potential biomarker of psychiatric patients at risk of suicide

Although suicide represents 1.8% of the global burden of disease, there are few objective assays for suicide risk. Being associated with depressive disorders, which have a high risk of suicide, the proteins P11, P2RX7, and S100β may be biomarkers for a suicidal disposition. We measured levels of p11 and P2RX7 mRNA in peripheral blood mononuclear cells (PBMCs) of 26 psychiatric patients (11 suicide attempters, 15 suicide non-attempters) with post-traumatic stress disorder (PTSD) and major depressive disorder (MDD), and 14 normal controls, using quantitative real-time PCR. We also conducted a meta-analysis of microarray data of p11, P2RX7 and S100β from post-mortem prefrontal cortex (PFC) of patients who committed suicide (n = 56) and non-suicide controls (n = 61). We found that PBMC p11 mRNA levels were significantly lower in suicide attempters and higher in suicide non-attempters, when compared to normal controls. The PFC p11 mRNA levels in suicide completers were also lower than non-suicide controls (adjusted p = 0.007). Unlike p11, PBMC P2RX7 mRNA levels were significantly lower than normal controls in all patients including suicide attempters, suicide non-attempters, and suicide completers. In addition, levels of S100β in PFC did not differ between suicide completers and non-suicide controls. These results suggest that PBMC p11 mRNA levels may be a potential adjunctive biomarker for the assessment of suicide risk in mental disorders and warrants a larger translational study to determine its clinical utility.     

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.     

Severity of personality disorders and suicide attempt

Objective: Severity of personality disorders (PDs) may be more useful in estimating suicide risk than the diagnosis of specific PDs. We hypothesized that suicide attempters with severe PD would present more attempts and attempts of greater severity/lethality. Method: Four hundred and forty‐six suicide attempters were assessed. PD diagnosis was made using the International Personality Disorder Questionnaire – Screening Questionnaire. PDs were classified using Tyrer and Johnson’s classification of severity (no PD, simple PD, diffuse PD). Severity/lethality of attempts was measured with the Suicide Intent Scale, Risk‐Rescue Rating Scale and Lethality Rating Scale. Results: Attempters with severe (diffuse) PD had more attempts than the other groups. After controlling for age and gender, this difference remained significant only for the younger age group and women. There was no relationship between severity of PDs and severity/lethality of attempts. Conclusion: Younger female attempters with severe PD are prone to repeated attempts. However, the severity of PD was not related to the severity/lethality of suicide attempts.     

Comparison of completed and attempted suicide in Akita, Japan

To determine the factors underlying suicide in Akita prefecture, a questionnaire survey was conducted among members of the Akita Prefectural Medical Association (APMA), regarding suicide cases they attended. During the investigation period (1 July 2001-30 June 2002), the total number of suicide cases was 243 (138 completed, 105 attempted). Significant differences were identified between completed and attempted suicide groups in terms of gender, age distribution, and suicidal methods. Specifically, in the completed suicide group, the number of male completers exceeded that of female completers, the number of middle-aged or elderly completers was high, and the majority of completed suicide cases involved hanging as the suicide method. Conversely, in the attempted suicide group, the number of female attempters exceeded that of male attempters, younger attempters were frequent, hanging was rare, and drug overdose or cutting was common. In addition, the number of cases involving a history of previous suicide attempts was significantly higher in the attempted suicide group than in the completed suicide group. The results of the present study support the concept that the completed and attempted suicide groups are essentially of a different nature. Furthermore, the number of cases involving a history of previous suicide attempts was found to be significantly lower in the completed suicide group than in the attempted suicide group. This result indicates the difficulty in decreasing the number of completed suicides by simply providing intervention and care for individuals who have attempted suicide.     

Fatal and non-fatal suicidal behavior in Israeli adolescent males

The objective of this study is examine the similarities and differences between adolescent suicide completers, adolescents with non-fatal suicidal symptoms, and non-suicidal psychiatric controls in an epidemiologic sample. Using the central Israeli military medical registry, 214 18-21 year old males from the same national service cohort were identified, consisting of 43 consecutive completed suicides and 171 consecutive central psychiatric clinic outpatients presenting with near-fatal suicide attempts, serious suicide attempts, para-suicidal gestures, threats, ideation, or other non-suicidal complaints. Systematic pre-induction and service data were available for all subjects, with detailed postmortem inquest data for suicides. Systematic clinical data, including the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS), Hamilton Depression Scale, and Eysenck Personality Inventory were obtained on all clinic subjects. Major depression was present in half of completers, near-lethal attempters, and ideators, but absent in the other clinic groups, whose commonest diagnosis was adjustment disorder. Depression scores increased across groups with increasing intent; ideators also had high scores. Completers and near-lethal attempters had higher I.Q. and medical fitness ratings and were in more demanding assignments than other groups. Prior attempts were commonest in completers, near-lethal attempters, and gesturers. Disciplinary history, ethnicity, family intactness, immigrant status, and Eysenck Personality Inventory scores did not differentiate the groups. The findings may not be generalizable to female adolescents or to other countries or time periods. The findings thus point to contrasts, as well as similarities, between groups of adolescents with different types of suicidal symptoms.