Impulsivity in anxiety disorder patients: is it related to comorbid cyclothymia?

Objective

The relationship between anxiety and impulsivity is controversial and not well explored. In a previous study we compared impulsivity, measured by different rating tools, in patients with anxiety disorders vs. healthy controls. In the same sample we now explore the influence of comorbid soft bipolar spectrum disorders on the relationship between anxiety disorders and impulsivity.

Method

A sample including 47 subjects with anxiety disorder(s) and 45 control subjects matched for demographic, educational and work characteristics underwent a diagnostic evaluation by the Mini Neuropsychiatric Interview (MINI); a symptomatological evaluation by the Bech-Rafaelsen Depression and Mania Scale (BRDMS), the State-Trait Anxiety Inventory (STAI), the Hypomania Check List (HCL-32) and the Clinical Global Impression (CGI); a temperamental and personological evaluation by the Questionnaire for the Affective and Anxious Temperament Evaluation of Memphis, Pisa, Paris and San Diego—Modified (TEMPS-M), the Separation Anxiety Symptoms Inventory (SASI), the Interpersonal Sensitivity Symptoms Inventory (ISSI); and, finally, a psychometric and a neuro-cognitive evaluation of impulsivity by the Barratt Impulsiveness Scale (BIS) and the Immediate and Delayed Memory Task (IMT/DMT). The initial sample of patients with anxiety disorders was then subdivided into two subgroups depending on the presence of comorbid cyclothymia (Cyclo+, n = 26 and Cyclo−, n = 21). For the diagnosis of cyclothymic disorder, we used both the DSM-IV-TR criteria and also a modified threshold for hypomania with a duration of 2 days. We compared symptomatological, temperamental, personological and impulsivity measures in Cyclo+, Cyclo− and controls.

Results

The comparison between Cyclo+, Cyclo− and controls showed that Cyclo+ are the most impulsive subjects in all the investigated measures and are characterized by greatest symptomatological impairment, highest scores in temperamental scales, and highest levels of interpersonal sensitivity and separation anxiety. Cyclo− subjects resulted to be more impulsive compared to controls concerning the retrospective trait measures, but not in the neuro-cognitive test.

Limitations

Correlational cross-sectional study.

Conclusion

In our patients with anxiety disorders, without lifetime comorbidity with major mood episodes, trait and state impulsivity resulted to be greater than in controls. In particular impulsivity was highest in patients with both anxiety disorders and cyclothymia. In anxious-cyclothymic patients also separation anxiety and interpersonal sensitivity were more severe than in anxious patients without cyclothymia and controls. Our findings suggest that impulsivity, rather than being directly related to the presence of the anxiety disorder, could be associated with comorbidity with cyclothymia.     

Implications of abnormal pathology in fulminating colitis on the outcome of surgery

Background

The severe relapse of the diseases in patients with Crohn's disease or ulcerative colitis is associated with high morbidity and mortality. Early prediction for the failure of aggressive medical treatment and consequently, early surgical interference in cases with severe colitis and severe Crohn's colitis are supposed to be effective means for reducing these high rates.

Methods

Patients who presented at the Accident & Emergency Department with severe colitis and severe Crohn's colitis and on whom emergency colectomy was operated were identified and they formed the basis of this study.

Results

Patients (n = 34) with acute fulminating colitis and their condition required emergency colectomy were seen over a period of 5 years.A strategy of early detection of cases of toxic dilatation and/or perforation proved efficient in reducing morbidity and mortality in cases of severe colitis.The mortality in the presented series was zero and the morbidity occurred mainly in such cases that presented with fulminant distal colitis, which was complicated by proximal faecal loading.

Conclusion

Diagnosis of proximal faecal loading in cases with fulminant colitis is likely to be an indication for surgery. Further studies are required for confirming this conclusion.     

Understanding responses to government health recommendations: public perceptions of government advice for managing the H1N1 (swine flu) influenza pandemic

Objective

To explore people's beliefs, perceptions, reasoning, and emotional and contextual factors that may influence responses to government recommendations for managing flu pandemics.

Methods

Eleven focus groups were conducted with a purposive sample of 48 participants. Participants were invited to discuss their perceptions of the H1N1 pandemic and government advice on recommended actions for managing the H1N1 pandemic.

Results

Thematic analysis showed that participants were skeptical about the feasibility and appropriateness of government recommendations for managing the H1N1 pandemic. They expressed doubts about self-diagnosis and concerns regarding the perceived effectiveness and costs of recommendations to stay home if unwell and get vaccinated.

Conclusions

Government advice is a specialized form of health communication with members of the public. People engage in an active process of evaluating government advice in terms of its credibility, feasibility and costs. To improve future pandemic preparedness, attempts should be made to elicit and address common doubts and concerns people have about following recommended advice.

Practical implications

This study provides preliminary information on potential concerns and issues that could be addressed in future pandemic communications. Further research is needed to elicit and address the public perspective so that the impact of future pandemics may be reduced.     

Medical students’ self-assessment of performance: Results from three meta-analyses

Objective

Self-assessment is an important component of medical education. Meta-analyses were conducted to better understand accuracy of self-assessment and direction of inaccuracy.

Methods

Three meta-analyses were conducted on results from 35 published articles on medical student self-assessment, one for each of the theoretically distinct ways of measuring accuracy of self-reported ability (correlational, paired comparison, and independent means comparison). Characteristics that potentially influence self-assessment accuracy, including gender, year in medical school, and type of self-assessment, were examined.

Results

Students are moderately able to self-assess performance and are more accurate later in medical school. Students as a whole do not significantly over- or underestimate, but are more likely to overestimate on communication-based, standardized patient encounters than objective, knowledge-based performance measures. Female students underestimate their performance more than male students, but gender analyses are often unreported.

Conclusion

A deeper understanding of the causes and consequences of over- and underestimation is impossible without measurement and reporting of the direction of inaccuracy.

Practice implications

To improve our understanding of self-assessment and increase its effectiveness as a teaching tool, research should report self-assessment as both a correlation and a paired comparison, and conduct analyses of important moderators that can influence self-assessment accuracy.     

Contextual recognition memory deficits in major depression are suppressed by cognitive support at encoding

Objectives

To investigate the effect of cognitive support (an associative orienting instruction at encoding) on contextual memory in depressed patients.

Methods

Seventeen patients (age 20-40 years, 14 women) diagnosed with major depressive disorder (MDD) and 22 healthy controls matched for age, gender and education completed a recognition memory task for item (object) and context (location), with or without an incidental binding cue at encoding. In addition, participants completed the vocabulary subtest of the Wechsler Adult Intelligence Scale (WAIS III) and the Wisconsin Card Sorting Test (WCST). Salivary samples were collected at 7 AM, 4 PM and 10 PM on the day of testing for cortisol and DHEA level measurement.

Results

Depressed patients showed a deficit in contextual memory in the absence of a binding cue but did not differ from healthy controls in item memory or when a binding cue was present. Cortisol and cortisol/DHEA ratios were lower in depressed patients compared to healthy controls and correlated with memory deficits.

Conclusions

Contextual memory deficits in MDD patients can be reduced by providing cognitive support at encoding.     

Resilience mitigates the suicide risk associated with childhood trauma

Objective

We wished to examine whether resilience might be a protective factor in relation to suicidal behavior.

Method

To do this resilience was examined in relation to childhood trauma, a well established risk factor for suicidal behavior, in two samples. In a preliminary sample 20 abstinent substance abuse patients who had attempted suicide were matched for age and their score on the Childhood Trauma Questionnaire (CTQ) with 20 substance abuse patients who had never attempted suicide. The two age and CTQ matched attempter (N = 20) and non-attempter (N = 20) groups were then compared for their scores on the Connor-Davidson Resilience Scale (CD-RISC). In the second sample 166 prisoners who had attempted suicide were matched for age and their scores on the CTQ with 166 prisoners who had never attempted suicide. These two age and CTQ matched attempter (N = 166)and non-attempter (N = 166) groups were similarly compared for their CD-RISC resilience scores.

Results

In the preliminary substance abuse sample, patients who had never attempted suicide (N = 20) had significantly higher mean CD-RISC resilience scores than the age and CTQ matched patients who had attempted suicide (N = 20). Similarly in the prisoner sample, those who had never attempted suicide (N = 166) had significantly higher CD-RISC resilience scores than the age and CTQ matched prisoners who had attempted suicide (N = 166).

Conclusions

The results from these two studies suggest that resilience may be a protective factor mitigating the risk of suicidal behavior associated with childhood trauma.     

Does Attention Deficit Hyperactivity Disorder increase the risk of suicide attempts?

Objective

To determine if Attention Deficit Hyperactivity Disorder (ADHD) is a risk factor for suicide attempts.

Methods

Data were drawn from the National Comorbidity Replication Survey (NCS-R), a nationally representative sample of adults (N = 8098).

Results

Of the 365 adults with current ADHD, 16% attempted suicide. After controlling for the presence of comorbid disorders, logistic regression analyses revealed that the ADHD was not a not a strong predictor of suicide attempts; having one or more comorbid disorders was associated with fourfold to twelvefold elevated risk.

Limitations

The small sample size of respondents with ADHD who attempted suicide significantly reduced the probability of determining which specific comorbid disorders were correlated with parasuicide.

Conclusions

Early treatment of ADHD and comorbidity may reduce the risk of suicide attempts and improve its prognosis.     

Psychological factors associated with the incidence and persistence of suicidal ideation

Background

Suicidal ideation has been identified as both a common antecedent and a significant risk factor for suicide attempt and completed suicide. However, little is known about the incidence and persistence of suicidal ideation in the general population and the associated risk factors.

Methods

A 12-month follow-up survey investigated 997 of the respondents who participated in the baseline territory-wide survey of adult population in Hong Kong. A set of baseline psychological factors was considered as predictors of first onset and persistence of suicidal ideation.

Results

Twelve-month incidence (1.9%) and persistence (6.2%) rates were estimated. Respondents with anxiety and lack of reasons for living were more likely to report a development of suicidal thoughts in the follow-up assessment, while respondents with higher level of average life distress and lower level of hope were at increased risk of continuing to have suicidal thoughts. Depression was found to partially mediate the effect of average life distress on persistent suicidality.

Limitations

Retention rate of the follow-up sample was about 50% only. Assessments of suicidal ideation were based on retrospective reports.

Conclusions

Psychological factors differentially predict first onset and persistence of suicidal ideation. It is of clinical value that depression partially mediated the effect of life distress on persistence of suicidality.     

Exploring the relationship between underlying dimensions of posttraumatic stress disorder and depression in a national, trauma-exposed military sample

Background

Posttraumatic stress disorder (PTSD) and depression are highly comorbid and intercorrelated. Yet little research has examined the underlying processes explaining their interrelationship.

Method

In the present survey study, the investigators assessed the combined symptom structure of PTSD and depression symptoms, to examine shared, underlying psychopathological processes. Participants included 740 Canadian military veterans from a national, epidemiological survey, previously deployed on peacekeeping missions and administered the PTSD Checklist and Center for Epidemiological Studies-Depression Scale (CES-D).

Results

An eight-factor PTSD/depression model fit adequately. In analyses validating the structure, PTSD's dysphoria factor was more related to depressive affect than to several other PTSD and depression factors. Somatic problems were more related to dysphoria than to other PTSD factors.

Limitations

Only military veterans were sampled, and without the use of structured diagnostic interviews.

Conclusions

Results highlight a set of interrelationships that PTSD's dysphoria factor shares with specific depression factors, shedding light on the underlying psychopathology of PTSD that emphasizes dysphoric mood.     

Development of a tool to assess the impact of a brief counseling curriculum: Validation of the Attitudes to Psychological Interventions and Counseling in Primary Care (APIC-PC) survey

Objective

To develop and validate an instrument to assess knowledge and attitudes regarding the use of psychological interventions in primary care.

Methods

A 13-item questionnaire was developed based on literature review and expert panel discussion. Exploratory and confirmatory factor analyses were carried out to test the construct validity of the subscales. Item-scale correlations were used to test the construct validity of the items. Internal reliability was tested by Cronbach's alpha. Responsiveness of the instrument was evaluated by using independent t-test of pre and post program scores.

Results

Exploratory factor analysis extracted four factors: skills and knowledge, confidence to provide counseling, willingness to provide counseling, and curriculum needs. Confirmatory factor analysis demonstrated excellent goodness-of-fit. Item scale correlations confirmed convergent and discriminant validity. Good responsiveness was shown on independent t-test of the pre and post responses.

Conclusions

The Attitudes to Psychological Interventions and Counseling in Primary Care (APIC-PC) survey is a valid and responsive instrument for assessing knowledge and attitudes regarding psychological approaches in patient management (mental health care).

Practice implications

Psycho-social counseling skills training is increasingly being recognised as a valuable component of undergraduate primary care medical education. The APIC-PC is a useful tool for evaluating the impact of such programs.     

Neuroimaging-based markers of bipolar disorder: evidence from two meta-analyses

Background

Bipolar disorder (BD) is often misdiagnosed or tardily detected, leading to inadequate treatment and devastating consequences. The identification of objective biomarkers, such as functional and structural brain abnormalities of BD might improve diagnosis and help elucidate its pathophysiology.

Methods

To identify neurobiological markers of BD, two meta-analyses, one of functional neuroimaging studies related to emotional processing and a second of structural whole-brain neuroimaging studies in BD were conducted in the present study. Conducting a literature search on studies published up to September 2009 we identified 28 studies that were eligible for the meta-analyses: 13 functional magnetic resonance imaging studies, related to emotional processing and 15 structural imaging studies using whole-brain voxel-based morphometry. Only studies comparing patients with bipolar disorder to healthy controls were considered. Data were extracted or converted to a single anatomical reference (Talairach space). The activation likelihood estimation technique was used to assess the voxel-wise correspondence of results between studies.

Results

In patients with BD, decreased activation and diminution of gray matter were identified in a cortical-cognitive brain network that has been associated with the regulation of emotions. By contrast, patients with BD exhibited increased activation in ventral limbic brain regions that mediate the experience of emotions and generation of emotional responses. The present study provides evidence for functional and anatomical alterations in BD in brain networks associated with the experience and regulation of emotions.

Conclusions

These alterations support previously proposed neurobiological models of BD and might represent valid neurobiological markers of the disorder. The specificity of these results to unipolar depression remains to be explored.     

The activity of class I, II, III and IV of alcohol dehydrogenase (ADH) isoenzymes and aldehyde dehydrogenase (ALDH) in the wall of abdominal aortic aneurysms

Objective

Human blood vessels contain a huge amount of alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH), which play a significant role in the metabolism of many biological substances and participate in various metabolic pathways. The aim of this study was the investigation of the differences between the activities of ADH and ALDH in the wall of aortic aneurysm and wall of healthy aorta, that can explain the pathological background of aneurysm development.

Methods

For the measurement of the activity of class I and II ADH isoenzymes and ALDH activity the fluorometric methods was employed. The total ADH activity and activity of class III and IV isoenzymes was measured by the photometric method. The study material consisted of vessels wall samples obtained from 45 abdominal aortic aneurysm.

Results

The activity of the class I ADH isoenzyme was significantly lower in the wall of aortic aneurysm than in healthy aorta. The other tested classes of ADH showed the tendency to lower level of the activity in aneurysm tissue than that in wall of unchanged aorta. The activities of total ADH and ALDH were also not significantly lower in the aneurysms.

Conclusion

The decrease of the activity of class I ADH isoenzymes in the wall of aortic aneurysm may be a factor of some disorders in metabolic pathways with participation of these isoenzymes.     

Hypomania across the binge eating spectrum. A study on hypomanic symptoms in full criteria and sub-threshold binge eating subjects

Backgrounds

Obese subjects affected by binge eating can be distinguished between those showing full criteria Binge Eating Disorder (BED) and those who show binge eating of insufficient frequency to satisfy DSM criteria, or sub-threshold BED (s-BED). The present paper aims to investigate whether subjects with BED full criteria show more hypomanic symptoms than those with s-BED, after controlling for personality variables as potential confounders.

Methods

The Hypomania Checklist (HCL-32), the Beck Depression Inventory (BDI) and the Temperament and Character Inventory (TCI) were administered to 103 obese patients with binge eating.

Results

Full criteria BED subjects were more likely to be female and showed higher HCL-32 scores and lower scores in character dimensions (Self-directedness and Cooperativeness) compared to s-BED subjects. A logistic regression with Eating Disorder Diagnosis as outcome measure (BED or s-BED) revealed that lower Cooperativeness, higher Hypomania scores and female sex predicted having BED full criteria.

Limitations

Further research is necessary to replicate these findings in a larger sample.

Conclusions

Patients with more severe binge eating might be more likely to have a comorbid bipolar spectrum disorder. Hypomanic symptoms should be assessed and mood stabilizing treatment should be considered in these patients.     

Third year medical students perceptions towards learning communication skills: implications for medical education

Objective

To analyze students’ perceptions towards learning communication skills pre-and-post training in a Communication and Clinical Skills Course (CCSC) at a Portuguese Medical School.

Methods

Content analysis was used to describe and systematically analyze the content written by students (n = 215 from a total of 229) in an open-ended survey. In addition, content analysis association rules were used to identify meaning units.

Results

Students’ pre-training definitions of communication skills were not specific; their post-training definitions were more precise and elaborated. Students perceived communications skills in Medicine as important (61%), but recommended that teaching methodologies (52%) be restructured. There appeared to be no connection between criticism of teaching skills performance and perceptions of the other aspects of the course.

Conclusion

Students’ experiences at CCSC are associated with their perceptions of communications skills learning. Content analysis associations indicated that these perceptions are influenced by context.

Practice implications

Improvement of curricula, teaching and assessment methods, and investment in faculty development are likely to foster positive perceptions towards learning communication skills in these students.     

Interaction of 5-HTTLPR genotype and unipolar major depression in the emergence of aggressive/hostile traits

Objective

The 5-HTTLPR polymorphism has been associated both with depression and aggression/hostility. The multidirectional association between depression, aggression and the s allele may be important, since all these phenomena are related to suicidal behavior. Our aim was to investigate the association between 5-HTTLPR and aggressive/hostile traits in depressed patients and controls.

Methods

137 depressive and 118 control women completed the Buss-Durkee Hostility Inventory and were genotyped for 5-HTTLPR. BDHI scores in the different groups were investigated by Generalized Linear Model Analysis. Association between dependent and independent variables in the model was tested by the likelihood ratio Chi-square statistic.

Results

Diagnosis and genotype showed a significant association with several aggressive/hostile traits. Interaction of the two main effects was also significant in case of several subscales. Post hoc analyses indicated a significant association between BDHI subscales and s allele only in the depressed group.

Limitation

Only women were studied and since gender differences are present both in aggressive behavior and putatively in the behavioral effects of 5-HTTLPR genotype, our findings pertain only to females.

Conclusion

Our results indicate a robust relationship between aggression/hostility and 5-HTTLPR genotype, but this association is more marked in the presence of depression. The presence of the s allele thus not only contributes to a higher risk of depression, but in depressives also leads to higher aggression/hostility. Our results have important implications for suicide research, since the s allele is associated with violent suicide, and this association may be mediated through the emergence of increased aggression/hostility in depressed patients carrying the s allele.     

Methodological reflections on body-mind intervention studies with cancer patients

Objective

Methodological reflection on the content, results and limitations of three body-mind intervention studies with cancer patients (CPs) in order to improve the quality of studies on body-mind interventions and to raise the potential value for CPs.

Methods

A secondary analysis of a study on haptotherapy and two studies applying relaxing face massage, using a variety of well-being effect measures. Six methodological themes are discussed: (1) drop-out; (2) characteristics of participating patients, (3) participation of patients in other complementary interventions; (4) satisfaction of participants; (5) effects of the three interventions, and (6) role of response shift.

Results

The three interventions showed limited effects after controlling for relevant confounding factors. They are mainly the small sample sizes, the low intensity of the intervention, the possible inadequate measure moments and the use of other CAM that may be responsible for the absence of effects.

Conclusions

Body-mind interventions require more methodological reflections to develop attractive and effective interventions for CPs. Attention needs to be paid to measuring short term effects, practically fitting research designs, and response shift.

Practice implications

Interventions should be intensive, repeated and not too short. The implementation of interventions requires attention to several organizational factors in the health care.     

Unpredicted gender preference of obstetricians and gynecologists by Muslim Israeli-Arab women

Objectives

To investigate the gender preference of Muslim Israeli-Arab women regarding obstetricians/gynecologists, and identify other features that affect their choice.

Methods

The study included 167 responders to an anonymous questionnaire.

Results

Around one-half of the responders had no gender preference regarding family physicians, but most (76.6%) preferred a female gynecologist. Likewise, most responders preferred pelvic examinations (85.6%) and pregnancy follow-up (77.8%) by female gynecologists. Additionally, 61.7% preferred consulting female physicians for major obstetrical and gynecological (OB/GYN) problems. The reasons for female preference were embarrassment (67.7%), feeling comfortable with female gynecologists (80.8%) and the notion that female gynecologists are more gentle (68.3%). The three most important factors which affected actual selection, however, were experience (83.8%), knowledge (70.1%) and ability (50.3%), rather than physician gender (29.3%). Multivariate analysis revealed that other qualities and importance of background variables of the gynecologist were independent predictors of gender preference.

Conclusions

Although Muslim Arab-Israeli women express gender bias regarding their preference for gynecologists/obstetricians, personal and professional skills are considered to be more important factors when it comes to actually making a choice.

Practice implication

We suggest that the ideal obstetrician/gynecologist for these women would be female, though skilled, knowledgeable, and experienced male would be appropriate.     

Context awareness in health care: a review

Background

Health care systems will integrate new computing paradigms in the coming years. Context-awareness computing is a research field which often refers to health care as an interesting and rich area of application.

Aim

Through a survey of the research literature, we intended to derive an objective view of the actual dynamism of context awareness in health care, and to identify strengths and weaknesses in this field.

Methods

After discussing definitions of context, we proposed a simple framework to analyse and characterize the use of context through three main axes. We then focused on context-awareness computing and reported on the main teams working in this area. We described some of the context-awareness projects in health care. A deeper analysis of the hospital-based projects demonstrated the gap between recommendations expressed for modelling context awareness and the actual use in a prototype. Finally, we identified pitfalls encountered in this area of research.

Results

A number of opportunities remain for this evolving field of research. We found relatively few groups with such a specific focus. As yet there is no consensus as to the most appropriate models or attributes to include in context awareness. We conclude that a greater understanding of which aspects of context are important in a health care setting is required; the inherent sociotechnical nature of context-aware applications in health care; and the need to draw on a number of disciplines to conduct this research.     

Determinants of different types of medication non-adherence in cholesterol lowering and asthma maintenance medications: a theoretical approach

Objective

To quantify and compare the determinants of different types of medication non-adherence in cholesterol lowering and asthma maintenance medications using a theoretical approach.

Methods

Study design was online cross sectional survey. A conceptual framework was developed using Andersen's Behavioral Model and Leventhal's Common Sense Model to understand the determinants of medication non-adherence. Regression analyses were used to test the models for predicting non-adherence.

Results

The models based on Andersen's Behavioral Model and Leventhal's Common Sense Model were significant. While predisposing factors such as treatment convenience and beliefs in medications were significant in cholesterol lowering medications, need factors such as illness perceptions and disease severity were significant in asthma maintenance medications. Among the enabling factors, self efficacy was a significant predictor in both cholesterol lowering and asthma maintenance medications.

Conclusion

Different determinants explained different types of non-adherence and suggest the need to consider different types of non-adherence for different medications as well as different determinants for each type of non-adherence.

Practice implications

Identifying determinants of different types of non-adherence can help health care professionals develop targeted interventions which can be more successful than the current model of single and generalized interventions to reduce non-adherence.     

Predictors of suicide relative to other deaths in patients with suicide attempts and suicide ideation: a 30-year prospective study

Background

Although there is a large literature that prospectively examines predictors of suicide, low base rates of suicide and imprecision of measurement hinder definitive conclusions from being drawn.

Method

This study examined predictors of suicide relative to other types of death in a sample of 297 patients who had been hospitalized for suicide ideation or a suicide attempt between 1970 and 1975 and who were confirmed dead in 2005. Many predictors were measured using well-validated assessment instruments.

Results

Fifty-five patients had died by suicide. Univariate predictors of an increased risk for eventual suicide included younger age, completion of at least a high school degree, a diagnosis of a psychotic disorder, taking active precautions against discovery during the attempt, and a non-zero score on the suicide item of the Beck Depression Inventory, whereas African American ethnicity was associated with a decreased risk of eventual suicide. Variables that remained significant in a multivariate analysis included younger age, African American ethnicity, and taking active precautions against discovery during the attempt. Risk factors did not vary as a function of whether eventual suicide occurred less than or more than five years after the initial evaluation or by attempter v. ideator status.

Limitations

Despite the attempt to maximize statistical power by following a high-risk sample for 30 years, the number of deaths by suicide was still relatively low.

Conclusions

Taking active precautions against discovery of a suicide attempt has the potential to be an important predictor of eventual suicide and should be assessed by clinicians. Future prospective studies should assess predictors at multiple time points to gain a richer clinical picture of the circumstances surrounding deaths by suicide.