The suicide risk of discharged psychiatric patients

BACKGROUND: The suicide risk of psychiatric patients fluctuated along the course of their illness and was found to be high in the immediate post-discharge period in some settings. The epidemiology and psychiatric services for the suicide population in Hong Kong have differed from those of the West (i.e., low youth suicide rate, high elderly suicide rate, high female/male ratio, and heavily government-subsidized psychiatric service). This study examined the suicide rates within a year of discharge from psychiatric inpatient care in Hong Kong. METHOD: Discharges from all psychiatric hospitals or psychiatric wards in general hospitals in Hong Kong from 1997 through 1999 were followed up for suicides (ICD-9, E950-E959) and "undetermined" causes of deaths (E980-E989) by record linkage with the Coroner's Court until their deaths or Dec. 31, 2000. The suicide rates (/1000 person-years at risk) and standardized mortality ratios (SMRs; assigning a value of 1 to the same age- and sex-specific suicide rates in the general population) were calculated. RESULTS: 21,921 patients (aged over 15 years) were discharged from psychiatric hospitals from 1997 through 1999. Two hundred eighty patients committed suicide within 1 year of discharge; 85 suicides (30%) occurred within 28 days after discharge. The SMRs for suicide in the first 28 days after discharge were 178 (95% CI = 132 to 235) for females and 113 (95% CI = 86 to 147) for males. These rates were 4.0 (95% CI = 2.7 to 5.6) times higher for females and 4.6 (95% CI = 3.2 to 6.3) times higher for males than the rate in the rest of the year. Young adults had higher SMRs than the elderly. No specific diagnoses had higher suicidal risk than others. Calculations including undetermined causes of deaths (N = 53) gave similar results. CONCLUSION: The immediate post-discharge period carries a high risk of suicide for psychiatric patients. The high-risk groups are young adults and females. No diagnosis appears to carry a particularly high risk.     

'Theory of mind' in violent and nonviolent patients with paranoid schizophrenia

The role of mentalizing abilities (or theory of mind) and empathic abilities in violent behavior were studied in 24 hospitalized males with paranoid schizophrenia (ICD-10). Patients were divided into violent and nonviolent groups based on their history of committing violent acts against others. To examine these abilities, patients heard a series of 12 short scenarios depicting social situations followed by questions that require making mental state or empathic inferencing. Our results show that violent patients have more difficulties than nonviolent patients in tasks involving empathic inferencing, and better abilities in inferring cognitive-mental states in others. In addition, violence seems to be associated with a history of alcohol and drug abuse, young age, and the hostility component of the Brief Psychiatric Rating Scale. Logistic regression analyses suggest that violence is associated with the combination of hostility towards others, good mentalizing abilities and poor empathy. These results are discussed in light of recent theories on violent behavior in psychiatric populations.     

Correlates of suicide and violence risk 1: the suicide risk measure

A measure of suicide risk was developed using items reported to discriminate suicidal patients from controls in various studies. The new self-report scale was administered to 82 outpatients, 157 inpatients, and 83 college students. Using total scores, significant differences were found between the college sample and the two patient samples. The scale also discriminated between patients who reported one or more past suicide attempts and those who reported none. An independent cross-validation showed that half of the items continued to discriminate between patient and control groups. Sensitivity and specificity estimates were also determined. The test does not attempt to predict a specific rare event, i.e., suicide. It attempts to describe the degree to which a given individual reveals a set of characteristics that are similar to a suicide prototype.     

有无凶杀行为的精神分裂症患者智测结果比较

目的 探讨有凶杀行为与无凶杀行为的精神分裂症患者之间的认知差异.方法 对有凶杀行为的精神分裂症组(39例)、无凶杀行为的精神分裂症组(32例)及正常对照组(38例)进行韦氏成人智力测验,并比较三组间测验分数的差异.结果 除相似性分量表评分外,有凶杀行为的精神分裂症组与无凶杀行为的精神分裂症组其它各分量表评分和智商均显著低于正常对照组;有凶杀行为的精神分裂症组相似性分量表评分和言语智商均显著低于无凶杀行为的精神分裂症组.结论 精神分裂症患者存在认知缺损,且有凶杀行为和无凶杀行为的精神分裂症患者之间亦存在某种程度的认知差异.     

Behavioral treatment of violent psychiatric patients

This article reviewed major accelerative and decelerative behavioral treatments for aggressive and destructive behavior in psychiatric patients. Accelerative procedures supplant antagonistic behavior by teaching adaptive skills, and by strengthening competing responses; they are realized in token economies, social skills training, differential reinforcement of other behavior, and activity programming. Current decelerative procedures reduce violent behavior by decreasing reinforcement accessible to the patient following violent acts; they are exemplified by social extinction, response cost, time out from reinforcement, overcorrection, and contingent restraint. All behavioral interventions are applied within a philosophic framework that emphasizes observable behavior, measurement of treatment effects, and restructure of the social and physical environment to improve patients' response patterns. This approach extends beyond a problem-oriented model and presents proven techniques for developing and maintaining patients' adaptive functioning.     

Correlates of suicide risk in juvenile detainees and adolescent inpatients

OBJECTIVE: To compare correlates of risk for suicidal behavior in juvenile detainees with those in another high-risk group, adolescent psychiatric inpatients. METHOD: Eighty-one adolescents in a short-term juvenile detention center were contrasted with a matched group of 81 adolescent psychiatric inpatients on a clinical assessment battery of established instruments including a measure for risk of suicidal behavior. RESULTS: Juvenile detainees and adolescent psychiatric inpatients reported similar levels of distress on measures of suicide risk, depression, impulsivity, and drug abuse. After controlling for depression, impulsivity and drug abuse remained significantly associated with suicide risk scores in the juvenile detention group, but did not in the psychiatric contrast group. For depressed female inpatients, hopelessness added significantly to the prediction of suicide risk scores. CONCLUSIONS: Correlates of risk for suicidal behavior in juvenile detainees may differ from those in other high-risk groups. Results suggest that it may be helpful to examine impulsivity and history of drug abuse when assessing suicide risk for detained adolescents. Further study of juvenile detainees as a separate high-risk group is warranted to better determine the nature and extent of risk.     

Neuromyelitis optica: suicide risk and psychiatric comorbidities

Journal of Neurology -     

Violent and nonviolent suicide attempts--a controlled Rorschach study

Rorschach records from 20 patients who had made active, violent suicide attempts were compared with records from 20 patients who had taken drug overdoses and 20 psychiatric control patients who had not made a suicide attempt. Ego function ratings showed that violent attempters were more paranoid than both other groups and less able to cope with conflict situations, to handle dysphoric affect and to differentiate between reality and imagination. Violent attempters had lower level of cognitive maturity than controls and tended to produce fabulized combination responses, suggesting cognitive slippage, and distorted human content responses, indicating pathological object relationships. Nonviolent attempters did not differ from controls. Six patients, all from the violent attempt group, completed suicide within a follow-up period of 4 years. Compared with the survivors, they were less tolerant of dysphoric affect and showed more pronounced decline of developmental level within cards. Completers could be identified on the Rorschach at 55% sensitivity and 93% specificity.     

Depression type and depression severity in relation to risk of violent suicide attempt

Low levels of cerebrospinal fluid 5-hydroxyindoleacetic acid and a blunted thyroid-stimulating hormone response to thyrotropin-releasing hormone have been reported in depressed patients--in particular in those who have made violent suicide attempts. There are at least two conceivable explanations for these findings: The biological abnormalities relate to (1) disturbed aggression regulation or to (2) disturbed mood regulation (either type or severity). The second alternative presupposes that violent suicide attempts occur differentially in a particular depression type or differentially in severe depression. This study demonstrated that violent suicide attempts are "depression-specific," i.e., they relate to a particular depressive syndrome, that of vital depression, but not to the severity factor. Therefore, it is impossible to decide whether the biological abnormalities in depressed, violent suicide attempters relate to a particular type of mood disorder or to a distorted regulation of aggression.     

Effect of psychopharmacotherapy on suicide risk in psychiatric inpatients

A retrospective analysis of the psychopharmacotherapy of 25 inpatients who had committed suicide and the same number of matched control subjects was carried out comparing the quality and doses of medication. Two statistically significant differences between the groups considering the medication were found. The suicide group had lower neuroleptic doses and they more often used benzodiazepine medication than the control group. The presence of depression was documented in the hospital charts more frequently in the suicides, but no differences were observed between the groups in the amount of antidepressant medication used.     

Violence and suicide risk assessment in the psychiatric emergency room

Structured clinical rating scales covering 10 areas related to suicide and violence were constructed for use in a psychiatric emergency room (ER). Ninety-five ER patients were evaluated with the scales, 50 of whom were discharged after the visit and 45 of whom were admitted to the inpatient psychiatric wards of the hospital. The admitted patients were found to differ significantly from the discharged patients on every one of the 10 scales. Scores on the scales were also found to predict suicide precautions on the wards, harrassment of other patients as assessed from nursing notes, and indicators of violence on the wards. The scales were also found to have high internal reliability and high sensitivity and specificity. They appear to be helpful to clinicians in identifying patients in need of hospitalization and may also serve as limited predictors of hospital functioning.     

Children's trauma and adjustment reactions to violent and nonviolent war experiences

OBJECTIVE: According to most studies, more than half of children exposed to war meet criteria for posttraumatic stress disorder (PTSD). Although we know that children are adversely affected by atrocities of war, we do not know which specific war events are associated with children's stress reactions. For example, it is unclear whether differences exist in response to violent versus nonviolent war-trauma experiences. This study examined the relationship of violent and nonviolent war experiences to children's trauma reactions and adjustment in a group of children from Bosnia. METHOD: During the 1994 siege in Sarajevo, 791 children aged 6 to 16 years participated in a study of trauma experience and response, in which assessment questionnaires (Impact of Event Scale, PTSD Reaction Index, Children's Depression Inventory, Child Behavior Checklist, and War Experience Questionnaire) were completed by children and their teachers. RESULTS: In this sample 41% had clinically significant PTSD symptoms. Children were adversely affected by exposure to both violent and nonviolent war-traumas. An additive effect of trauma exposure on trauma reactions was also found. However, many war experiences were not associated with children's adjustment and trauma reactions. CONCLUSIONS: Additive effects of violence and deprivations during war may overwhelm the coping skills of children and leave them vulnerable to externalizing and internalizing adjustment difficulties and symptoms of PTSD.     

Higher hopelessness and suicide risk predict lower self-deception among psychiatric patients and non-clinical individuals

The present study was designed to explore psychopathological correlates of self-deception in clinical and nonclinical individuals to ascertain whether self-deception was associated with higher hopelessness, a proxy of suicide risk. The patients were 58 consecutive psychiatric patients (30 men, 28 women) admitted to the Sant'Andrea Hospital's psychiatric ward in Rome. Controls were composed of a sample recruited from the general population (62 men and 80 women). All the participants completed the Beck Hopelessness Scale (BHS), and the Balanced Inventory of Desirable Responding-6 Form 40A (BIDR). More than 55% of the patients had BHS scores of 9 or higher indicating severe hopelessness, while only 32% of the control subjects reported scores of 9 or higher on the BHS (p < .01). Subjects with BHS scores of 9 or higher (compared to subjects with lower scores) had lower scores on the self-deceptive enhancement dimension of the BIDR, and were also more likely to be unemployed or retired. Self-deception may be a coping response to stressful live events. Disruption of such coping mechanism may indeed increase suicide risk as individuals do not want to face self-awareness and get close to a highly negative self.     

Correlates of life satisfaction among psychiatric patients

The aim of this study was to examine the sociodemographic and clinical variables associated with life satisfaction in psychiatric patients. The study population consisted of out-patients and in-patients (n= 1204) treated at the Department of Psychiatry of Kuopio University Hospital in North Savo, Finland, during May 1993. Sociodemographic, psychosocial and clinical correlates of life satisfaction were examined by means of two different questionnaires, one directed at patients and the other directed at the staff. Life satisfaction was assessed by means of a separate scale based on four questions. Patients with schizophrenia were less dissatisfied than patients with other disorders. The strongest correlates of dissatisfaction were depression and poor social support. Other factors relating to dissatisfaction in multiple regression analysis were self-rated health and poor financial circumstances. A psychosomatic reaction tendency or degree of psychosocial functioning at the time of the study was not independently related to life satisfaction. Psychiatric patients who are dissatisfied should be evaluated both for depression and for effectiveness of their social network.     

Bidirectional associations between perceived parental support for violent and nonviolent responses and early adolescent aggressive and effective nonviolent behaviors

The current study examined bidirectional relations between early adolescents' perceptions of parental support for violent and nonviolent responses to conflict and their aggressive and effective nonviolent behaviors six months later. Data was collected across the sixth and seventh grades for 520 adolescents at three middle schools in the southeastern United States. At baseline, participants were ages 10–14 (M = 11.29). Longitudinal path models showed that perceived parental support for violent responses was negatively associated with effective nonviolent behaviors and positively associated with aggressive behaviors across sixth and seventh grades. Across seventh grade, reciprocal negative relations were found between perceived parental support of nonviolent responses and aggressive behaviors. Effective nonviolent behaviors were positively associated with perceived parental support for nonviolent responses. Study implications include the importance of adolescent perceptions of parental support of violent and nonviolent responses in influencing early adolescents' effective nonviolent and aggressive behavior.