Deceptive examinees who committed suicide: report of two cases

Deceptive behavior by neuropsychological examinees does not preclude the presence of significant psychopathology. To illustrate this fact we present two cases. Case 1 had a diagnosis of factitious disorder and clear evidence on neurological and neuropsychological exams of exaggeration. Case 2 had a somatoform disorder and provided a deceptive social history. Long after the neuropsychological evaluations, both persons committed suicide. These cases provide anecdotal evidence that deceptive behavior does not preclude the presence of serious psychopathology, and that deceptive behavior and self-destructive behavior sometimes coincide.     

A case control study on psychopharmacotherapy before suicide committed by 61 psychiatric inpatients

OBJECTIVE AND METHOD: The pharmacotherapy of 61 suicide victims (0.24 % of 27,078 admissions from January 1, 1980 to December 31, 1999) was compared to that of a control group matched for age, gender and diagnosis at the time of discharge. RESULTS: Both groups were also comparable regarding stay in hospital, history of psychiatric disease, and frequency of hospitalisations during the year preceding the index evaluation. Multiple but not single suicide attempts were significantly more frequent in patients who were later to complete the suicide than in controls. Schizophrenia (ICD-9, ICD-10) was the most frequent diagnosis among suicide victims (44.3 %). Affective psychosis (ICD-9, ICD-10) bore the highest relative risk (0.8 %). 50 % of the schizophrenic patients in the suicide group had been continuously treated with full-dose tricyclic antidepressants. The CPZ-equivalents in the patients treated with antipsychotics were not of discriminating value. Four of 27 schizophrenic patients in the suicide group had been off neuroleptics for ten days or more; this was never observed among the controls. Lorazepam applied in 40% of the schizophrenic and in 25 % of the affective psychosis suicide victims had more often been withdrawn or reduced during the ten days preceding suicide than among controls. No schizophrenic suicide victims but five controls had been on mood stabilisers. The use of antipsychotics (classical and atypical) and a recent change in tricyclic drug or drug dose were more frequent in suicide victims with affective psychosis. Lithium had been given to one patient, but it had also been administered to six controls; this difference is significant. CONCLUSION: Mood stabilisers, especially lithium, should be considered more often in patients with previous suicide attempt(s). When changing antidepressants in affective psychosis, benzodiazepines might be given more deliberate consideration. Patients in all diagnostic categories should be closely guided by means of intensified psychotherapeutic interventions while undergoing a benzodiazepine reduction. The treatment of patients suffering from schizophrenia with full-dose tricyclic regimens should be considered as possibly enhancing the acute suicide risk in some individuals.     

Development of a screening instrument for heavy users of psychiatric inpatient services

Patients who show an above-average utilization of medical care are described as "heavy users". Heavy utilization of psychiatric inpatient care could be reduced by well directed community based services. Heavy users should, therefore, be identified at the beginning of a period of heavy service consumption. For this reason, a screening instrument (SPSI) was developed. Six predictors of heavy utilization of inpatient care were included as items in the SPSI. Weighting of items and examination of the instrument were carried out with a sample of 184 schizophrenia patients, whose utilization of inpatient care was recorded prospectively over a period of 30 months. 83 percent of heavy users and 85 percent of ordinary users were correctly identified with the SPSI test at a cutoff score of - 6.7. The SPSI is a short questionnaire which could be used without special rater training in psychiatric care in order to offer identified heavy users well directed community based services, which are less costly than inpatient care, but at least just as appropriate for the special needs of these patients.     

Selection of patients who attempted suicide for psychiatric consultation.

A total of 1018 self-poisoned patients were treated during one year (1983) at the emergency room of Helsinki University Central Hospital for 1207 suicide attempts; 46% were left without psychiatric consultation. Women were consulted more frequently than men. Patients with previous psychiatric treatment were referred more often for psychiatric consultation. The use of alcohol was more frequently present in suicide attempts that did not lead to psychiatric consultation. Somatic seriousness was also less severe in this group. It was assumed that those left without consultation were not in mortal danger. There were no differences in the suicide mortality of these 2 groups during a 5-year follow-up.     

Clinical characteristics of adolescent psychiatric inpatients who have attempted suicide

 The clinical characteristics of 191 adolescent inpatients were examined in relation to frequency of previous suicide attempts, predictors of suicide attempts prior to hospitalization, and lifetime suicide attempts. Overall, more than 50% of the adolescent inpatients had attempted suicide during their lifetime, and of these more than half (58%) had made more than one attempt. Approximately half of the suicide attempters had made a serious attempt prior to hospitalization. Girls reported higher levels of depressive symptoms and suicidal ideation than boys, in addition to having attempted suicide prior to hospitalization (33%) or during lifetime (37%) more often than the boys (13% and 26%, respectively). Although about two thirds of the adolescent inpatients reported that they had received some help after a suicide attempt, approximately half of the repeaters had not received any help. The results of multivariate analyses showed that suicide attempts made prior to hospitalization were predicted by depressive symptom levels and a clinical diagnosis of depressive disorder, whereas frequency of lifetime suicide attempts was predicted by suicidal ideation levels and having a family member or a friend who had attempted (or committed) suicide. The high prevalence of lifetime and repeated suicide attempts among the psychiatric inpatients underscores the importance of identifying risk factors in the clinical evaluation of adolescent suicide attempters. Accepted: 1 April 1998     

Demographic and clinical profiles of patients who make multiple visits to psychiatric emergency services

OBJECTIVE: The study identified clinical and sociodemographic characteristics of patients making multiple visits to a psychiatric emergency service. METHODS: Information was obtained for patients visiting a hospital psychiatric emergency service in Montreal from 1985 to 2000. Profiles were determined for four groups: one visit, two visits, three to ten visits, and 11 or more visits. To determine whether the profile for those with 11 or more visits was generalizable, data for patients visiting the main site and three other such services from 2002 to 2004 were similarly analyzed. RESULTS: At the main study site (1985 to 2000), patients with single visits accounted for 36% of the 29,569 visits. The 292 patients with 11 or more visits accounted for almost 21% of total visits. Timing of the visit-time of day and day of the week-did not differentiate between groups. However, time itself was important in identifying patients with 11 or more visits: use of 30-month observation periods resulted in identification of only 8% of this group. Patients with 11 or more visits were more likely to be diagnosed as having schizophrenia and as having a comorbid diagnosis and were generally younger at the index visit and more economically impaired than those in the other groups. Overall, and at two of the three other sites, schizophrenia was overrepresented in the highest user group. CONCLUSIONS: Most visits to the psychiatric emergency service were made by frequent users who had distinctive profiles, which are potentially useful for developing clinical strategies to reduce the impact of this patient group on this service.     

First contact with psychiatric services: who leaves and who remains

ObjectiveThe objective of this study was to obtain information on patients in their first contact with community mental health departments in the south of Italy, particularly on dropout patients leaving care without a previous agreement.MethodA 3-month cohort of 265 “first-contact” psychiatric patients assisted at four different community mental health centers (CMHCs) was examined and followed up at 6 months.ResultsThe overall dropout rate after 6 months was 38.7%; it was higher for patients receiving pharmacological therapy alone and for patients seeking help on their own initiative, whereas physician-referred patients showed a lower dropout rate. More severely ill patients, as evaluated by physicians, showed dropout rates lower than those of patients “rating” themselves as severely ill.ConclusionsTo lower dropout rates in CMHC settings, physicians should be provided with more concrete support in the patient selection and referral process. Greater focus should be placed on patients' motivational aspects and on their perceptions of their own symptom severity, as well as on the risks of dispensing “easy” solutions such as pharmacological therapy alone.     

Prevalence of cocaine use among residents of New York City who committed suicide during a one-year period.

OBJECTIVE: In the mid-1980s the form of cocaine called "crack" became widely available in New York City. The authors sought to determine the prevalence of cocaine metabolites detected at autopsy in persons who committed suicide in New York City during this period. METHOD: Individual reviews of the autopsy and toxicological records of all persons under the age of 61 who had committed suicide in the city during a 1-year period were conducted to determine demographic characteristics, suicide methods, and cocaine and alcohol use at the time of death. RESULTS: In one of every five cases studied, the person who committed suicide had used cocaine within days of his or her death. The prevalence of cocaine use among young Hispanic males who committed suicide was 45%. Persons who were young, black, or Hispanic and who had used alcohol immediately before the fatal injury were most likely to have been recent cocaine users. After controlling for demographic variables and ethanol use, the investigators found that individuals who committed suicide with firearms were twice as likely to have used cocaine as those who used other methods. CONCLUSIONS: In contrast to the results of regional and household surveys during this period, which suggested that the current prevalence of cocaine use in New York City was 3%-5%, these results suggest a high prevalence of cocaine use in the days immediately preceding death by young persons who commit suicide. Additional studies are needed to determine how cocaine may act as a risk factor for suicide.     

Attitudes of psychiatric nursing personnel towards patients who have attempted suicide

The aim of this study was to examine the attitudes towards suicidal patients of a group of psychiatric nursing personnel (n=197) and to establish a baseline of attitudinal measures against which the effects of a subsequent educational programme can be assessed. A scale, known as the Understanding of Suicide Attempt Patient Scale (USP Scale) was developed for this purpose. The reliability of the scale was satisfactory, and its correlation with visual analogue scale (VAS) scores based on clinical vignettes suggests that it has validity. Women tended to be more sympathetic than men, and older personnel were more favourably disposed than the younger nurses. Differences between personnel working in different settings were found, which might be explained by differences in the frequency of contact with suicide-prone patients, more frequent exposure being associated with more positive attitudes.     

精神分裂症患者住院期间自杀自伤行为研究

目的了解精神分裂症患者住院期间自杀自伤行为的检出率和特征,比较住院期间有自杀自伤行为和无自杀自伤行为的精神分裂症患者的临床特征,探讨预测和防范精神分裂症患者住院期间发生自杀自伤行为的策略。方法采用自行设计的一般情况调查表、简明精神病评定量表(BPRS)、汉密尔顿抑郁量表17项版(HAMD-17)、临床疗效总评量表(CGIS)对197例连续住院的精神分裂症患者的自杀自伤行为进行研究,将在住院期间有自杀自伤行为的39例患者(自杀自伤行为组)与158例无自杀自伤行为的患者(无自杀自伤行为组)进行比较。结果 1精神分裂症患者住院期间的自杀自伤行为检出率为19.80%;2自杀自伤行为组在无职业、经济状况差、社会支持差、入院前2周内有明显应激事件、有物质滥用或依赖、有精神病家族史、既往有自杀未遂史、自杀自伤行为时有幻觉或妄想、分裂症偏执型等与无自杀自伤行为组比较,差异有统计学意义(P0.05或0.01),Logistic回归分析显示,经济状况差、入院前2周内有明显应激事件、既往有自杀未遂史是住院期间发生自杀行为的危险因素;3入院时、住院第2、4周末两组BPRS总评分、HAMD-17总评分比较差异均有统计学意义(P0.01),住院第2周末,两组CGI评分差异有统计学意义(P0.01)。结论精神分裂症患者住院期间的自杀自伤行为检出率较高,应高度重视,并重点关注经济状况较差、入院前2周内有明显应激事件、既往有自杀未遂史和HAMD-17高分的患者。     

The psychiatric clinical specialist''s impact on psychiatric emergency services

Psychiatric emergency services have evolved into more comprehensive programs during the past two decades. With this evolution other disciplines have gained access to the services and integrated their expertise and philosophy into the daily care of patients. Nursing has been an integral part of this process and contributed its perspective in nursing care. This paper outlines the development of psychiatric emergency services with a special emphasis on the contribution of nursing specialists who have developed their role within the psychiatric emergency service.

What has been unique about the nursing contribution is the attention to individualizing patient care and modifying treatment approaches to meet the patients' needs and interests in psychiatric treatment. Additionally, nursing has complemented the physician's role by developing expertise in assessment that is both psychologically and biologically oriented. Nursing's future contribution to psychiatric emergency services should address mechanisms for tracking patients who enter the psychiatric emergency service system with an emphasis on linkage with other programs or resolution of the crisis episode.     

Association between changes in psychiatric services and increases in suicide rates

Summary The purpose of the study is to discover whether there is an association between changes in the psychiatric services offered by the largest psychiatric hospital in Iceland during the period 1955–1978 and changes in the rate of suicide. Marked changes occurred in the services after 1965. The rate of suicide in the patient population was significantly higher during 1965–1978 than during 1955–1964. It is concluded that the changes in the psychiatric services are associated with an increase in the rate of suicide and that this increase may to some extent be a side effect of therapeutic methods introduced after 1965. The conclusion is thought to imply the necessity for further evaluation of those therapeutic methods as applied in the hospital and increasing the application of measures for the prevention of suicide.     

Identifying and tracking “heavy users” of acute psychiatric inpatient services

This study explores the extent and consistency of heavy use of acute psychiatric inpatient services among Medicaid recipients across five years and four sites. Approximately 35% of inpatient service users account for approximately 75% of the dollars spent on inpatient services across place and time. Heavy users are distinct from non-heavy users in being comprise of more children and adolescents, in being disproportionately white, and in having more severe disabilities. The study findings are discussed in the context of the planning of appropriate services for this patient subgroup.     

Mortality and suicide rates of involuntarily committed patients

The mortality and suicide rates for involuntarily committed patients in Denmark are presented. Two cohorts of psychiatric patients committed to a mental hospital from January 1, 1971 to December 31, 1975 (8322 people) and January 1, 1981 to December 31, 1985 (5253 people) have been followed. The standard mortality rate (SMR) in relation to the total Danish population were 4.9 (4.5–5.4) and 5.2 (4.7–5.8), respectively, for the two cohorts, during the first year after involuntarily commitment to a mental hospital. During the same period, the SMR for suicide among the committed patients were 44.9 (37.1–53.9) and 30.9 (24.2–38.9), respectively. The crude suicide rates among the committed patients during the first year after the commitment were 14.3 and 14.0, respectively, per 1000 years, unchanged between the cohorts. Short length of stay in hospital (< 14 days), a nonpsychotic main diagnosis, male sex, and age 35 years or more were equally related to high risk of suicide in the 1971 cohort as evaluated to proportional hazard methods (Cox regression), and short length of stay and commitment on the danger indication provided the most information in relation to high suicidal risk in the 1981 cohort. Methodological problems and the reasons for the results are discussed.