Suicide in psychiatric patients. A prospective study of 67 cases without initial signs of severe depression or alcoholism

All cases from the county, who were subjected to post-mortem examination at the Department of Forensic Medicine, University of Lund with a diagnosis of suicide during 1949-1984, were compared with the inpatient register at the Department of Psychiatry, University Hospital, Lund during 1949-1969. During these years all patients were rated at discharge with a multidimensional schedule. All patients with initial ratings of severe depression/melancholia and alcoholism were analyzed separately and excluded from the present sample. The ratings of the suicide cases were compared with those of 8,046 other inpatients. There were 67 suicide cases, 36 men and 31 women. The suicide cases had higher frequencies of the item easily led/dependent/immature personality (34% versus 18%) and of attempted suicides (19% versus 8%). There were no differences in ratings of symptoms as slight depression and anxiety or of situational factors. Attempted suicide was related to suicides early in the course, while easily led/dependent/immature was not so related. At the time of the suicide there was a higher frequency of never married and a lower frequency of married subjects in the present series compared with suicides in severe depression/melancholia and alcoholism.     

Suidical ideation in severe depression

Suicidal ideation and communication were investigated for 89 suicide victims with a primary severe depression and matched controls. The selection of patients was based on multiaxial ratings of all hospitalised patients between 1956 and 1969. A blind record evaluation was performed, including scores on Beck's Scale for Suicidal Ideation and additional items apart from that scale. There was no relation between high scores on the Beck's scale and completed suicide. In the male group, suicidal ideation “beyond one's own will” was related to suicide. Female suicides that had made an attempt showed higher suicidal ideation than female suicides who had not. A substantial minority of the women (22%) committed suicide without showing any previous intent. Only 5% of the male suicides had shown no previous intent to commit suicide. Received: 4 December 1998 / Accepted: 8 February 2000     

Risk factors for suicide in melancholia A case-record evaluation of 89 suicides and their controls

Eighty-nine inpatients with a primary severe depression and melancholia who had committed suicide were investigated. They were admitted to the Department of Psychiatry, Lund, Sweden between 1956–1969 and died before 1984. Matched controls were selected. Case records were evaluated at index admission to find suicidal risk factors in melancholia. Prospective ratings were compared. Women committing suicide had higher scores than their controls on the items unmarried, non-compliance and suicide attempt but lower ratings on disharmonic childhood and non-severe physical disease. Men committing suicide had higher scores on the items heredity for psychosis and a brittle or sensitive personality. For the latter item suicide was related to life-weariness. Suicide attempt was related to acute onset and lack of psychomotor retardation. Two suicidal processes were proposed for men: one related to aggression and one not. Social factors seem less important in the prediction of suicide in melancholia than in depression in general.     

The occurrence of suicide in severe depression related to the months of the year and the days of the week

The purpose of the present study was to investigate the distribution of suicide during the months of the year and the days of the week in severe depression. A total of 1206 in-patients rated at discharge from the Department of Psychiatry, Lund, Sweden, on a multiaxial diagnostic schedule received the diagnosis severe depression/melancholia between 1956 to 1969. When followed up to 1998, a total of 114 depressed patients had taken their own life. Out of these, 98 patients appeared to have a primary depression. The monthly distribution of suicides showed a significant peak in October/November for men (41 % of all male suicides). No correlation with the onset of depression could be detected. Furthermore, there was a preponderance of suicide on Sundays for both sexes (31 % of all suicides). Received: 28 March 2001 / Accepted: 29 November 2001     

Late mortality in severe depression

OBJECTIVE: To assess late mortality among psychiatric in-patients with severe depression/melancholia. METHOD: 1,206 in-patients rated at discharge on a multidimensional diagnostic schedule had received the diagnosis severe depression/ melancholia between 1956 and 1969. A first follow-up was made in 1984. The present follow-up constitutes 675 survivors 15-42 years after the first admission. They were followed-up by means of the general population register and local parish registers to January 1st 1998. RESULTS: At this second follow-up another 279 patients were deceased, standardized mortality ratio 1.3, indicating a continuous increased mortality late in the course of depression. Eleven suicides (4%) were included, eight men and three women, which was less than the 22% found in the first investigation. Male patients showed a higher suicide rate than female patients late in the course. CONCLUSION: The general mortality and suicide rate remain increased late in the course.     

Attempted-suicide trends in Stockholm County, Sweden, 1975-1985

A total of 22,961 admissions, representing 19,127 individuals, diagnosed as certain or undetermined attempted suicide were registered in the computer medical information system in Stockholm County for the study period 1975-1985. Two different statistical regression models were used to describe the trends of attempted suicide and undetermined attempted suicide. A simple linear ordinary least squares model generally performed better at describing the observed rates in sex- and age-specific rates of attempted suicide when the diagnosis of attempted suicide was certain. Significantly increasing attempted-suicide trends for men over 35 and women over 45 as well as for all ages pooled for both men and women were found. Undetermined attempted suicides were described better by a quadratic model than by the linear model. Women 35-44 and 65-85 years old and men 25-54 years old were found to have an increasing initial phase followed by a leveling out in the rates around 1980-1982, with weak evidence that the rate might even be slowly decreasing. Comparing earlier findings of decreasing rates in completed suicides for all ages, and findings in this study of increasing attempted-suicide trends during the same period, we believe that improved somatic and psychiatric treatment of attempted-suicide patients may partly account for the decreased rates of completed suicides.     

Om religiøse problemer hos psykiatriske patienter

Wasserman D. Decreasing suicide rates in Stockholm County, Sweden.

Trends in suicide frequency were explored for men and women in different age groups in Stockholm County during the 11-year period 1975–1985. Linear regression analysis of the demographically age-adjusted incidence of suicide yielded a statistically significant decrease in the number of suicides for both sexes, when all ages were pooled. When different age groups were analysed, a significant decrease was noted for both men and women in the 15- to 24-year age group and for men in the 55- to 64-year age group. Women in Stockholm County showed greater mortality from suicide than women throughout Sweden, The male to female ratio for Stockholm County was 1.6, compared with 2.4 for the whole of Sweden. Statistically significant decreases were also noted for undetermined suicides for women in the 45- to 54-year age group and when all age groups were pooled, and for men in the 15- to 24-year and 35- to 44-year age groups. The possibility that this decrease in suicide frequency is due to the diminished consumption of alcohol and psychopharmaca in Stockholm County is discussed.     

Gender-related changes in suicide rates and methods in Eastern Finland from 1988 to 1997

The first aim of the study was to investigate the changes in regional suicide rates for the province of Kuopio, Eastern Finland, from 1988 to1997 and compare rates with those for the whole Finland. The second aim was to investigate gender-related changes in suicide rates and methods during the study period. Altogether, 777 suicides were examined. Between 1988 and 1997, regional male suicide mortality decreased, approaching the mean national level, which was rising during the same interval. From 1992 to 1997, there was a rise in regional suicide mortality, which coincided with a decrease at the national level. Female suicide rates in Eastern Finland also initially decreased, but thereafter remained variable and slightly higher than the national level. Gender-related differences in suicide mortality diminished. The initial difference between genders in mean age (49.5 years in women, 41.8 years in men) disappeared towards the end of the study period (47.0 years in women, 45.2 years in men). The decline in mean ages of women was mostly due to change in urban suicides, whereas the increase in the mean age of men was caused by change in rural suicides. Among men, the relative proportion of self-poisoning suicides rose significantly. The divergent development of suicide rates from the province of Kuopio and the entire nation may reflect differences in the development of social structures in rural Eastern Finland compared to more densely populated parts of the country. Gender differences and local variation in suicide mortality should be taken into account when assessing and developing further suicide prevention strategies.     

Gender-related changes in suicide rates and methods in Eastern Finland from 1988 to 1997

The first aim of the study was to investigate the changes in regional suicide rates for the province of Kuopio, Eastern Finland, from 1988 to 1997 and compare rates with those for the whole Finland. The second aim was to investigate gender-related changes in suicide rates and methods during the study period. Altogether, 777 suicides were examined. Between 1988 and 1997, regional male suicide mortality decreased, approaching the mean national level, which was rising during the same interval. From 1992 to 1997, there was a rise in regional suicide mortality, which coincided with a decrease at the national level. Female suicide rates in Eastern Finland also initially decreased, but thereafter remained variable and slightly higher than the national level. Gender-related differences in suicide mortality diminished. The initial difference between genders in mean age (49.5 years in women, 41.8 years in men) disappeared towards the end of the study period (47.0 years in women, 45.2 years in men). The decline in mean ages of women was mostly due to change in urban suicides, whereas the increase in the mean age of men was caused by change in rural suicides. Among men, the relative proportion of self-poisoning suicides rose significantly. The divergent development of suicide rates from the province of Kuopio and the entire nation may reflect differences in the development of social structures in rural Eastern Finland compared to more densely populated parts of the country. Gender differences and local variation in suicide mortality should be taken into account when assessing and developing further suicide prevention strategies.     

Mortality among psychiatric patients

The mortality of all patients seen at the Department of Psychiatry, the General Hospital in Lund, Sweden during 1962 was studied for the years 1962–1968. The number of deaths was 260. The expected number of deaths in a corresponding sample of the general population was 159. The mortality was significantly increased in both men and women. The ratio between observed and expected mortality was highest in the younger age groups. The overmortality was due mainly to an increased number of suicides, accidents and nervous and circulatory diseases in the men and suicide and cancer in women. The patients who died were compared with a randomized subsample of psychiatric patients sill alive at the end of the observation time. The items chosen for comparison were social and medical factors previously found to be related to mortality. The purpose was to try to recognize high risk groups within the psychiatric population. Divorced persons were more common among those who died than among controls, and more males who died were living along, unemployed or invalid pensioners. Mortality seemed to be independent of type of care in 1962 in terms of hospitalization and out-patient contact. Differences found in psychiatric services by those who had died and controls before and after 1962 were of low significance. The one outstanding psychiatric diagnosis among those who died was the organic brain syndrome. Alcoholism was more common among men who died accidental deaths compared with controls. More than 50% of the patients who committed suicide had previously attempted suicide. A high proportion of those who died were hospitalized in somatic wards and sent to the psychiatric out-patient department for psychiatric assessment. Common reasons for referral were recently attempted suicide and pain, often of unknown origin.     

Aspects of the Suicidal Career in Severe Depression: A Comparison Between Attempts in Suicides and Controls

Suicide attempts in the long term course of illness were investigated in 89 suicides with a primary severe depression/melancholia and in matched controls. Multiaxial ratings at index admission between 1956 and 1969 enabled the selection of patients. These patients were tracked to January 1, 1984. A blind record evaluation was performed. Suicide attempts were more common among suicides than controls. General characteristics of attempts, such as severity, the use of a violent method, and repetition did not differentiate suicides from controls. Rather, there were differences in the pattern of suicide attempts. In suicides, only, re-attempts were related to number of episodes of mood disorder. Controls more often made re-attempts after a stressful life event. Serious attempts occurred early in the course of suicide attempts in female suicides, in contrast to controls. There was a correlation between the occurrence of a suicide attempt and completed suicide among male unipolar patients and female bipolar patients.     

“The psychological skeleton in the closet”: mortality after a sibling’s suicide

Purpose

To study the association between loss of an adult sibling due to suicide and mortality from various causes up to 18 years after bereavement.

Methods

We conducted a follow-up study between 1981 and 2002, based on register data representing the total population of Swedes aged 25–64 years (n = 1,748,069).

Results

An elevated mortality rate from all causes was found among men (RR 1.26; 95 % CI: 1.14–1.40) and women (1.27; 1.11–1.45) who had experienced a sibling’s suicide. The standardized rate ratio of suicide of bereaved to non-bereaved persons was 2.46 (1.86–3.24) among men and 3.25 (2.28–4.65) among women. We also found some indications of an interrelation between sibling suicide and subsequent deaths from external causes other than suicide in men (1.77; 1.34–2.34) and deaths from cardiovascular disease in women (1.37; 0.99–1.91). An elevated all-cause mortality rate was found after the first year of bereavement in men, while bereaved women experienced higher mortality rates during the first 2 years and after 5 years of bereavement.

Conclusions

Our study provides support for adverse health effects among survivors associated with sibling loss due to suicide. Sibling suicides were primarily associated with suicide in bereaved survivors, although there was an increased mortality rate from discordant causes, which strengthens the possibility that the observed associations might not be entirely due to shared genetic causes.     

Hospitalization for suicide attempt and completed suicide: epidemiological features in a managed care population

BACKGROUND: Understanding factors that contribute to high suicide risk holds important implications for prevention. We aimed to examine the sociodemographic and medical predictors of attempted suicide (severe enough to require hospitalization) and of completed suicide in a large population-based sample from a health maintenance organization (HMO) in northern California, USA. METHOD: We designed a cohort study, including 87,257 women and 70,570 men aged 15 through 89 years old at baseline (in 1977-1985) with follow-up for hospitalizations and mortality through the end of 1993. RESULTS: After a median of 10 years, 169 first hospitalizations for attempted suicide (111 among women, 58 among men) and 319 completed suicides (101 among women, 218 among men) were identified. There was a greater incidence of hospitalization for suicide attempt in women than in men and, conversely, a greater incidence of completed suicide in men than in women. The predominant methods of attempted and completed suicides were ingestion of psychotropic agents and use of firearms, respectively. In gender-specific multivariate analysis of hospitalization for suicide attempt, statistically significant associations were seen for age 15-24 years (women), 65-89 years (men), white race (women), 12th grade or less education (both genders), technical/business school education (men), never being married (men), history of emotional problems (both genders), history of family problems (women), history of job problems (men) and presence of one or more comorbidities (men). The independent predictors of completed suicide were: age 15-24 years (both genders), Asian race (women), Caucasian race (both genders), never being married (both genders), being separated/divorced (women), prior inpatient hospitalization for suicide attempt (both genders) and history of emotional problems (both genders). CONCLUSION: These findings could help health professionals be more effective in the prevention of suicide morbidity and mortality.     

Women,Femininity, Indirect and Direct Self-Destructiveness. A Review

The aim of this work was to review results of research into direct and indirect self-destructiveness in women. Studied projects covered two populations: individuals who attempted suicide and individuals who did not attempt suicide. The Chronic Self-Destructiveness Scale and Bem Sex Role Inventory were used. Intensity of indirect self-destructiveness is lower in women. A probable explanation of the gender paradox in suicides may be the hypothesis that suicides attempted by men more often end in death as men display stronger indirect self-destructiveness. Masculinity and male sex are factors that predispose to indirect self-destructiveness, while femininity and female sex are factors protecting against it. Gender schema opposite to biological sex is significant to intensity of indirect self-destructiveness.     

Suicide in severe depression related to treatment

The objective of the present study was to assess the association between depressive characteristics and completed suicide despite adequate antidepressant therapy in severe depression and to investigate the frequency of lethal antidepressant overdoses. A record evaluation of 98 suicide victims with a primary severe depression had been performed. These had been admitted to the Department of Psychiatry, Lund University Hospital between 1956 and 1969 and followed up to 1998. Psychomotor retardation was related to completed suicide after ECT. The estimated frequency of lethal intoxication with antidepressants was low: 3% of the suicides.     

Mortality in major affective disorder: relationship to subtype of depression

A total of 219 inpatients with a DSM-III diagnosis of major depression, 150 women and 69 men, were followed prospectively for 3–10 years and mortality was recorded. The patients were previous participants in psychopharmacological multicenter trials, which were carried out for the purpose of comparing the antidepressant effect of newer 5-HT reuptake inhibitors with that of the tricyclic antidepressant drug, clomipramine. The study comprised patients with a total Hamilton Rating Scale for Depression score of ≥ 18 and/or a Hamilton subscale score of ≥ 9. Diagnostic classification according to the Newcastle I Scale in endogenous and nonendogenous depression was performed. The observed mortality was significantly greater than that expected. The increased mortality was essentially due to suicides and mainly found among women. Patients scored as nonendogenously depressed had a significantly higher suicide rate than endogenously depressed patients. The excess number of suicides in the nonendogenous group largely occurred within the first year of observation. No association was found between response to the antidepressant treatment in the trial and the suicide risk in the first 3 years of observation.     

High Early Suicide Risk in Elderly Patients After Self-Poisoning

This article reports the findings of a follow-up study of suicide mortality in elderly patients after an index episode of self-poisoning. A total of 222 consecutive patients (143 female) aged 65 years or older (mean age 76.5 years; range 65–100) presenting at the emergency department of the Karolinska University Hospital after self-poisoning during 1994–2000, were followed up for the cause of death by January 1, 2006. Survival analysis was applied to study suicide and death risk. Of the 15 suicides, 13 (87%) occurred during the first year after the index episode of self-poisoning (cumulative suicide risk 6.2%). The risk of dying of all causes during the first year was increased fourfold. Self-poisoning in both elderly men and women is associated with high early suicide risk.     

Causative factors as cues for addressing the rapid increase in suicide in Mie Prefecture, Japan: comparison of trends between 1996-2002 and 1989-1995

The number of suicides in Japan has increased from approximately 22 000 per year from 1988 to 1997 to >30 000 per year since 1998. Likewise, the number of suicides has been increasing in Mie Prefecture. The purpose of the present study was to examine the incidence of and circumstances surrounding all suicide cases during 1996-2002 in Mie Prefecture and to compare the data with those from 1989 to 1995. In Mie Prefecture, the age-specific suicide rate during the second 7-year period included marked increases among men aged 50-59 and 60-69 years. Among women, the age-specific suicide rate increased with age during both 7-year periods. During the second period, psychiatric disorders as causative factors increased in all generations. They were especially important for women of the younger generation, whereas economic problems were the most common causative factor among men aged 40-64. Physical illness as a causative factor in suicide was high among the elderly, but among the other age groups this factor trailed behind economic difficulties for men and psychiatric disorders for women. To prevent suicide, social cooperation as well as a plenitude of visiting nurses and psychiatric care is required, and early detection and treatment are also important.     

Temperaments in completed suicides: Are they different from those in suicide attempters and controls?

BackgroundTemperaments in completed suicides have never been assessed whereas there is substantial research on temperaments in attempted suicides and psychiatric patients.MethodsThe significant others of 18 completed suicides participated in this study in order to provide an assessment of temperaments, hopelessness, depression and the suicide risk of their loved ones. The data were compared with data from 244 psychiatric patients of whom 83 had attempted suicide in the previous month. The following instruments were used: the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto questionnaire (TEMPS-A), the Beck Hopelessness Scale (BHS), the Gotland Scale for Male Depression (GSMD), and the Mini International Neuropsychiatric Interview (MINI) module for assessing suicide risk.ResultsIndividuals who died by suicide more frequently had scores of 9 or higher on the BHS and higher MINI suicide risk scores compared with patients with mood disorders who had not attempted suicide in the previous month. Completed suicides also had lower scores on the TEMPS-A Cyclothymia and Anxiety scales and on the MINI suicide risk scale than mood disorder patients with a recent suicide attempt.LimitationsProxy assessment of variables through survivors can result in underestimation of psychiatric morbidity and other parameters investigated, and limits the generalization of our resultsConclusionsOur study adds information about temperamental subtypes and other variables in completed suicides and points to their difference from attempted suicides and non-suicidal psychiatric patients.     

Ante- and perinatal circumstances and risk of attempted suicides and suicides in offspring: the Northern Finland birth cohort 1966 study

Purpose

To investigate those ante- and perinatal circumstances preceding suicide attempts and suicides, which have so far not been studied intensively.

Methods

Examination of the Northern Finland Birth Cohort 1966 (n?=?10,742), originally based on antenatal questionnaire data and now followed up from mid-pregnancy to age 39, to ascertain psychiatric disorders in the parents and offspring and suicides or attempted suicides in the offspring using nationwide registers.

Results

A total of 121 suicide attempts (57 males) and 69 suicides (56 males) had occurred. Previously unstudied antenatal factors (maternal depressed mood and smoking, unwanted pregnancy) were not related to these after adjustment. Psychiatric disorders in the parents and offspring were the risk factors in both genders. When adjusted for these, the statistically significant risk factors among males were a single-parent family for suicide attempts (OR 3.71, 95% CI 1.62–8.50) and grand multiparity for suicides (OR 2.67, 95% CI 1.15–6.18). When a psychiatric disorder in females was included among possible risk factors for suicide attempts, it alone remained significant (OR 15.55, 8.78–27.53).

Conclusions

A single-parent family was a risk factor for attempted suicides and grand multiparity for suicides in male offspring even after adjusting for other ante- and perinatal circumstances and mental disorders in the parents and offspring. Mothers’ antenatal depressed mood and smoking and unwanted pregnancy did not increase the risk of suicide, which is a novel finding.