Is seasonality of suicides stronger in victims with hospital-treated atopic disorders?

The aim of the present study was to test whether the seasonal distribution of suicides differed between atopic and non-atopic suicide victims. A cross-sectional comparison of the semi-annual and seasonal distribution of suicides was made by using a 13-year database of all suicides (1296 males, 289 females) committed during the years 1988-2000 in the province of Oulu in Northern Finland. During the first half of the year, the proportion of suicides among atopic patients was significantly higher than that linked with non-atopic patients. Of all atopic patients, 72% committed suicide during the first and 28% during the second half of the year. Suicides among victims without any atopic disorders followed a uniform seasonal distribution throughout the year (50 vs. 50%). The exacerbation of an atopic disorder may increase the risk of suicide in spring; something that should be taken note of in clinical work.     

Reductions in postdischarge suicide after deinstitutionalization and decentralization: a nationwide register study in Finland

OBJECTIVE: This study analyzed trends in suicides occurring after a psychiatric hospitalization during more than a decade of significant structural changes in mental health services in Finland-that is, deinstitutionalization, downsizing of inpatient care, and decentralization. METHODS: Retrospective register data on completed suicides and psychiatric inpatient treatments were collected for the periods 1985-1991 and 1995-2001, representing service provision before and after significant structural changes. The data were used to produce an estimate for a change in postdischarge suicide risk. RESULTS: In both periods, a fifth of suicide victims had been psychiatrically hospitalized within the preceding year. Among persons hospitalized, the risk of suicide was greater in 1985-1991 than in 1995-2001 for both one week after discharge (risk ratio [RR]=1.50, 95% confidence interval [CI]=1.38-1.62) and one year after discharge (RR=1.25, CI=1.19-1.30). When types of disorders were analyzed separately, the relative risk of suicide one year postdischarge for those hospitalized in the earlier period was greater for patients with schizophrenia (RR=1.26, CI=1.17-1.36) and patients with affective disorders (RR=1.60, CI=1.48-1.73). In parallel with general development of inpatient psychiatric services, in 1995-2001 the inpatient treatment periods preceding suicides were significantly shorter (a mean+/-SD of 45+/-340 days in 1995-2001, compared with a mean of 98+/-558 days in 1985-1991), the number of individual patients treated in the hospital for schizophrenia spectrum disorders was lower (26% compared with 36%), and the number treated for affective disorders was higher (45% compared with 35%). CONCLUSIONS: The restructuring and downsizing of mental health services was not associated with any increase in suicides immediately (one week) or one year postdischarge. Instead, the risk of these suicides decreased significantly between the two time periods among several diagnostic categories. Although the role of psychiatric hospitalization in general may have changed over time, patients who are hospitalized now may be less suicidal after discharge. Our results indicate, in terms of postdischarge suicides, that the downsizing of psychiatric hospitals has been a success. However, there is still a substantial need for better recognition of suicidal risk among psychiatric patients.     

Adolescent suicide: endpoint of long-term difficulties.

Characteristics of adolescent suicide victims (N = 53) were investigated in a nationwide study of suicides in Finland. The data were collected through interviews with the victims' parents and attending health care personnel and from official records. Four victims in 10 had shown antisocial behavior. One-third of the adolescents had previous suicide attempts, and 6 in 10 were known to have verbalized their suicidal thoughts. One-third of the victims had been in contact with a psychiatric care system. The results suggest that most adolescent suicides are an endpoint of long-term difficulties, and all suicidal tendencies among adolescents should be taken seriously.     

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.     

General hospital suicides--a psychological autopsy study in Finland

Although both severe medical disorders and mental disorders are established risk factors for suicide, it is not known if patients who commit suicide in general hospitals differ from others. This study investigated current mental disorders and other clinical characteristics among general hospital suicide victims and compared them with other suicide victims in an unselected nationwide population. Drawing on data from a psychological autopsy study of all suicides (N = 1397) in Finland during one year, all suicides committed by patients in a general hospital setting were identified. Retrospective DSM-III-R consensus diagnoses were assigned and general hospital suicide victims were compared with other suicide completers in terms of clinical characteristics. Twenty-six general hospital suicide victims, 1.9% of all suicides, were identified. Subjects who completed suicide during general hospital treatment were older and used more violent suicide methods than other suicide victims. One or more diagnoses of psychiatric (Axis I) disorders were assigned for 88% of the general hospital suicide victims. Overall, the most prevalent disorder was major depression, which was more common among the general hospital suicide victims, even when age was controlled for. The findings of this study suggest that most people who commit suicide during a spell of general hospital treatment suffer from current mental disorder, as do suicide victims in general. The recognition and treatment of major depression in particular should be improved in order to prevent suicide in general hospitals.     

Cocaine and alcohol use preceding suicide in African American and white adolescents

The goal of this investigation was to determine whether cocaine and ethanol use was a differentiating factor between African American and white teenage suicide victims. This is a retrospective analysis of medical examiner's records of all completed suicides in Fulton County, GA from 01/1989 to 12/2003, and included 1296 cases. There were 79 suicide victims aged 19 and younger during the study interval, and of this group, 49 (62%) were African American, 26 (33%) were white, and 4 (5%) other race, compared to adults (20 years) where 28.5% were African American, 68.6% white and 2.9% other race (chi(2)=42.678, d.f.=2, p<0.0001). Of the black teenaged victims, 82.2% had no cocaine or alcohol detected at autopsy, while 41.7% of the white victims were positive for one or both substance (chi(2)=4.633, d.f.=1, p=0.04). Only 8.9% of the black teenage suicide victims had used cocaine prior to death compared to 28% of the whites (chi(2)=4.432; d.f.=1; p<0.04). The suicide rate (suicide/100,000/year) for black teens was 5.48 compared to 4.16 for whites, but the rate of cocaine positive teen suicides was 1.12 for whites and 0.45 for blacks. The pattern of cocaine use changes dramatically in the adult group, with 27% of African American suicide victims compared to 7.7% of whites being positive (chi(2)=73.272; d.f.=1; p<0.001). Use of intoxicating substances does differentiate teenage suicide victims, as only a small proportion of black teenagers had used cocaine or alcohol prior to death compared to almost half of all whites.     

Influence of method on seasonal distribution of attempted suicides in italy

To verify if attempted suicides follow different seasonal distributions according to the method chosen, we studied the Italian monthly distribution of admissions for attempted suicide in the period 1984-1995 according to gender and age, distinguishing between non-violent (ICD 950-952) and violent (ICD 953-958) attempted suicides. The effect of temperature was also taken into account. A clear asymmetry in seasonal distribution of events can be observed in the oldest age groups in both genders, with a peak in warmer months. Only male attempted suicides by violent methods show a clear asymmetry in seasonal distribution, with a peak in spring months and a trough in autumn months. Spectral analysis, more accurate in detecting seasonal rhythms than analyses that only compare monthly seasonal means, identifies a circannual rhythm for violent suicides in both genders. The seasonal components of total variance in attempted suicides account for 16.5 and 12.4%, respectively, of violent male and female attempted suicides. Among males, a significant (p < 0.05) 4 cycles/year pattern is seen alongside the more relevant (89.4%, p < 0.01) 1 cycle/year distribution. Among females, aside from the 1 cycle/year distribution (63.3%, p < 0.01) noted, a 6 cycles/year pattern is found to contribute significantly (16.9%, p < 0.05) to the seasonal component of variance. A clear relationship with temperature indicators is noted among males: higher temperatures positively correlate with attempted suicides, whereas cooler temperatures seem to exert a protective action. Female attempts show a less evident correlation with indicators of temperature. Sample composition by age and gender and the lack of distinction between methods of attempted suicide may have obscured the seasonal component of some classes of attempted suicide in previous studies. The circannual rhythm found in this study of violent attempted suicide in relation to climate seasonal change confirms the importance of taking chronobiological variables into account in the evaluation of patients at risk of suicide.     

Suicide after discharge from psychiatric inpatient care: a case-control study in Hong Kong

OBJECTIVE: To identify the risk period and the risk factors for suicide in Chinese psychiatric patients after discharge from inpatient psychiatric treatment. The nature of psychiatric aftercare provided to these patients was also explored. METHOD: A case control study with 73 patients who were discharged from a large psychiatric unit in Hong Kong between January 1996 and December 1999 and had received coroners' verdict of suicide or undetermined death within the same period. Controls were 73 surviving patients discharged from the same unit. They were individually matched for sex, age, psychiatric diagnosis, and date of discharge. RESULTS: Post-discharge clustering of suicides was observed among the cases. Nearly 80% of them died within 1 year of discharge. The most common principal diagnosis among the cases was schizophrenia and related psychotic disorders. Multivariate analysis showed that suicide was associated with: unemployment (OR = 12.2, 95% CI = 2.1 - 70.4), past suicidal attempts (OR = 3.4, 95% CI = 1.2 - 9.6), maternal mental illness (OR = 13.4, 95% CI = 1.0 - 170.0), and suicidal ideation or attempt before the last admission (OR = 5.0, 95% CI = 1.4 - 18.0). The psychiatric aftercare received by cases and controls were generally similar. However, cases were more likely to have had contact with health care services in the last week before death (OR = 4.0, 95% CI = 1.3 - 11.9). CONCLUSIONS: Suicidal risk is high in Chinese psychiatric patients soon after discharge. They share some common risk factors for suicide identified in Western studies but several differences are evident: the predominance of schizophrenia in the suicides; the lower prevalence of substance abuse and comorbidity; the low proportion of patients living alone; and the increased clinical contact before death but the less suicidal intent expressed in Chinese patients. It is necessary to consider these socio-cultural factors in assessment of suicidal risk and implementation of suicide prevention strategies in Chinese psychiatric patients.     

Suicide among Children and Adolescents: Data from Çukurova,Turkey

The purpose of this study was to investigate the general properties of suicide among children and adolescents in our region, and to evaluate the results in the light of the literature. The autopsy records of the morgue of the Adana branch of the Turkish Forensic Medicine Council were investigated retrospectively. Focus of the study was shaped by suicide cases in children and adolescents (under 18) between the years of 1997–2005. All of the cases were analyzed with regard to age, sex, method of suicide, and year. The childhood and adolescent (0–18 years) deaths comprised 24.4% (n: 1390) of all medico-legal autopsy cases (n: 6808). The origin of death in 186 (13.4%) cases involving victims younger than 18 years of age was suicide. The majority of suicide cases (62.9% n: 117) were females. Adolescents of 16–18 years of age constituted the overwhelming majority (70.43% n: 131) of all childhood suicides. Mean age was 16.13. The most frequent method of suicide was shooting in males, and poisoning in females. However, hanging was the most frequent method (34.41% n: 64) overall.     

An association between month of birth and method of suicide

Abstract

Background. A statistically significant association between season of birth and suicidal behaviour has been reported. However, the effect of month of birth on the choice of suicide method is yet to be established. Aim. This study examines the association between commonly used methods of suicide and season of birth using data on suicide collected over a 21-year period in England, Wales and Scotland. The sample size available, in excess of 52,000 suicides, greatly exceeds all previous studies in this field. Method. Data on suicides registered between 1979 and 2000® were obtained from the Office for National Statistics (ONS) for England and Wales, and the General Register Office (GRO) for Scotland. Our analyses include all suicides [ICD 9 codes; E950– E959] and undetermined injury deaths [E980–E989], reported between 1979 and 2000 in England, Wales and Scotland for persons born between 1941 and 1966. We used Poisson and negative binomial generalised linear models (GLMs) with seasonal harmonic components. Results. Adjusting for the year of birth, the model predicts that the average increase in risk of suicide between the trough (October) and the peak (May) of the seasonal component is 17.9% (95% CI= 13–33%). For males the estimated increase in risk was 15% (95% CI 5–22%) and for females 27% (95% CI 8–47%). The effect of month of birth on suicide applied to all commonly used methods, with the exception of suicide by burning (SBB) with a significant increase of 16% (95% CI 2–37%) in people born in January compared to other methods. Conclusion. Our results replicate our earlier finding of an association between season of birth and suicide incidence. Birth rates of persons who kill themselves show a disproportionate excess in spring compared to other months. The unexpected observed finding in suicide by burning (SBB) may represent the effect of latitude and warrants further examination. Seasonality of birth in suicide may enhance our understanding of some biological aspects in its aetiology and give directions for future research.     

A unique monthly distribution of suicide and parasuicide through firearms among Israeli soldiers

The monthly distribution of completed suicide and parasuicide by Israeli soldiers was analyzed during the 7-year period of 1984–1990. Although parasuicide in general showed a constant incidence throughout the year, the monthly rate of suicide as well as parasuicide through firearms varied during the year in a similar way. The seasonal pattern of completed suicides, the vast majority of which occur with firearms, was correlated with the seasonal pattern of parasuicides through firearms. The combined variability of the two seasonal patterns was found to be significantly different from a pattern of a constant monthly incidence with a peak in December and a nadir in October. The monthly incidence of suicide and parasuicide through firearms was found to be negatively correlated with the duration of the daily photoperiod, when the latter was phase-advanced by 1–2 months. This unique pattern of seasonal incidence of suicide and parasuicide through firearms is different from most of the patterns reported in the Northern Hemisphere.     

Suicide notes in adolescence

Suicide rates for adolescents have shown a substantial increase over the past 30 years, but there is little information regarding the clinical status of adolescents who end their lives. In the adult literature, one avenue to understanding the psychologic condition immediately prior to the self-destructive act has been the study of suicide notes, and the present study constitutes the first systematic investigation of notes left by children or adolescents. Records of death were examined in the Office of the Coroner, City of Montreal, and all suicides between ages 10 and 20 were identified for the years 1978 to 1982. Seventeen individuals who left notes were identified, comprising 10% of the population of suicides. Suicides who left notes did not differ from the total group in age and sex distribution but were more likely to choose shooting as a method. The content of the notes was studied in terms of 11 variables which had proven characteristic of suicide notes in the adult literature, and the results were compared to those reported for adults. In general, our results support a psychoanalytic perspective which understands suicide as resulting from an ambivalent attachment to an object, loss of the object, internalization, and the direction of aggression against the self. Cases appeared to fall into two clusters. Older adolescents were more concrete, left specific instructions, did not address the note, did not give a reason for the act, and tended to choose intoxication as a method.(ABSTRACT TRUNCATED AT 250 WORDS)     

Psychiatric diagnoses in 3275 suicides: a meta-analysis

Background

It is well known that most suicide cases meet criteria for a psychiatric disorder. However, rates of specific disorders vary considerably between studies and little information is known about gender and geographic differences. This study provides overall rates of total and specific psychiatric disorders in suicide completers and presents evidence supporting gender and geographic differences in their relative proportion.

Methods

We carried out a review of studies in which psychological autopsy studies of suicide completers were performed. Studies were identified by means of MEDLINE database searches and by scanning the reference list of relevant publications. Twenty-three variables were defined, 16 of which evaluating psychiatric disorders. Mantel-Haenszel Weighted Odds Ratios were estimated for these 16 outcome variables.

Results

Twenty-seven studies comprising 3275 suicides were included, of which, 87.3% (SD 10.0%) had been diagnosed with a mental disorder prior to their death. There were major gender differences. Diagnoses of substance-related problems (OR = 3.58; 95% CI: 2.78–4.61), personality disorders (OR = 2.01; 95% CI: 1.38–2.95) and childhood disorders (OR = 4.95; 95% CI: 2.69–9.31) were more common among male suicides, whereas affective disorders (OR = 0.66; 95% CI: 0.53–0.83), including depressive disorders (OR = 0.53; 95% CI: 0.42–0.68) were less common among males. Geographical differences are also likely to be present in the relative proportion of psychiatric diagnoses among suicides.

Conclusions

Although psychopathology clearly mediates suicide risk, gender and geographical differences seem to exist in the relative proportion of the specific psychiatric disorders found among suicide completers.

     

Glutamatergic deficits and parvalbumin-containing inhibitory neurons in the prefrontal cortex in schizophrenia

Background

Clinician training deficits and a low and declining autopsy rate adversely impact the quality of death certificates in the United States. Self-report and records data for the general population indicate that proximate mental and physical health of minority suicides was at least as poor as that of white suicides.

Methods

This cross-sectional mortality study uses data from Multiple Cause-of-Death (MCOD) public use files for 1999–2003 to describe and evaluate comorbidity among black, Hispanic, and white suicides. Unintentional injury decedents are the referent for multivariate analyses.

Results

One or more mentions of comorbid psychopathology are documented on the death certificates of 8% of white male suicides compared to 4% and 3% of black and Hispanic counterparts, respectively. Corresponding female figures are 10%, 8%, and 6%. Racial-ethnic discrepancies in the prevalence of comorbid physical disease are more attenuated. Cross-validation with National Violent Death Reporting System data reveals high relative underenumeration of comorbid depression/mood disorders and high relative overenumeration of schizophrenia on the death certificates of both minorities. In all three racial-ethnic groups, suicide is positively associated with depression/mood disorders [whites: adjusted odds ratio (AOR) = 31.9, 95% CI = 29.80–34.13; blacks: AOR = 60.9, 95% CI = 42.80–86.63; Hispanics: AOR = 34.7, 95% CI = 23.36–51.62] and schizophrenia [whites: AOR = 2.4, 95% CI = 2.07–2.86; blacks: AOR = 4.2, 95% CI = 2.73–6.37; Hispanics: AOR = 4.1, 95% CI = 2.01–8.22]. Suicide is positively associated with cancer in whites [AOR = 1.8, 95% CI = 1.69–1.93] and blacks [AOR = 1.8, 95% CI = 1.36–2.48], but not with HIV or alcohol and other substance use disorders in any group under review.

Conclusion

The multivariate analyses indicate high consistency in predicting suicide-associated comorbidities across racial-ethnic groups using MCOD data. However, low prevalence of documented comorbid psychopathology in suicides, and concomitant racial-ethnic discrepancies underscore the need for training in death certification, and routinization and standardization of timely psychological autopsies in all cases of suicide, suspected suicide, and other traumatic deaths of equivocal cause.     

Family history of suicide among suicide victims

OBJECTIVE: The aim was to compare the rates of suicide in family members of suicide victims and comparison subjects who died of other causes. METHOD: The Swedish cause of death register identified all suicides in subjects born between 1949 and 1969 (N=8,396). The comparison group comprised persons of the same age who died of other causes (N=7,568). First-degree relatives of the suicide victims (N=33,173) and comparison subjects (N=28,945) were identified. RESULTS: Among families of the suicide victims there were 287 suicides, representing 9.4% of all deaths in family members. Among comparison families there were 120 suicides, 4.6% of all deaths. The difference was significant. Previous psychiatric care and suicide in a family member predicted suicide in the logistic regression model. CONCLUSIONS: The rate of suicide was twice as high in families of suicide victims as in comparison families. A family history of suicide predicted suicide independent of severe mental disorder.     

Risk factors for suicide in the immediate post-discharge period

BACKGROUND: Suicide risk is highest in the first few months following psychiatric in-patient care. Most data on post-discharge suicides have come from Western countries. Many studies collected cases of suicide over a long post-discharge period and did not focus on this high-risk period. This study aims to describe the characteristics and examine the risk factors of suicides occurring in the immediate post-discharge period in Hong Kong. METHODS: A case-control study based on discharged patients from all psychiatric hospitals/units in Hong Kong in 1997-1999. Suicides occurring within 60 days of discharge from psychiatric hospitals (N = 97) were ascertained by record linkage with Coroner's court data. Controls were matched for age, gender, diagnoses, discharge hospitals, and dates of discharge. Possible risk factors were extracted from in- and out-patient records, and were identified by conditional logistic regression. RESULTS: The commonest diagnosis and suicide method were schizophrenia and falling from a height, respectively. There were no significant case-control differences in the drug treatment received. Risk factors for suicides were: previous deliberate self-harm (OR = 2.3, 95% CI = 1.07-5.05), admission for deliberate self-harm (OR = 3.2, 95% CI = 1.3-7.8), compulsory admission (OR = 3.1, 95% CI = 1.1-8.7), living alone (OR = 5.8, 95% CI = 1.4-23), work stresses (OR = 5.4, 95% CI = 1.5-18) and being out of contact (OR = 7.9, 95% CI = 1.87-33). The overall number of risk factors had greater screening efficacy for suicide than any single factor. CONCLUSIONS: Vulnerable (previous suicidality) and uncooperative (compulsory admission and out of contact) patients who live alone and are exposed to work stresses are prone to immediate post-discharge suicide. Thorough treatment of the circumstances leading to the index admissions, management of work stresses, improved engagement in follow-up care and systematic assessment of suicide risk are indicated.     

Recent life events and their role in suicide as seen by the spouses.

The occurrence of recent life events during the last 3 months and their significance in the suicide process as subjectively perceived by the surviving partners were studied among a subpopulation of suicide victims (n = 400) who had a spouse or a cohabitant as the informant. This subpopulation was drawn from a total suicide population (n = 1397) of 1 year in Finland. According to the partners' reports, life events during the last 3 months were reported in 85% of the suicides. Job problems (33%), family discord (32%) and somatic illness (29%) were most commonly reported. More male than female victims had experienced recent life events, and the mean number of events was higher among men than among women. There were differences between single life events in terms of how often the partners perceived them as precipitants of suicide. Separation was seen as the most critical event: in 68% of suicides with reported separation during the last 3 months the partner also rated it as a precipitant, followed by somatic illness in 57%, family discord in 44%, financial trouble in 44%, unemployment in 34%, death in 29%, job problems in 19% and illness in family in 14%.     

Mental disorders and suicide prevention

Abstract In the research phase of the National Suicide Prevention Project, all suicides ( n = 1397) in Finland between March 1987 and April 1988 were examined retrospectively using the psychological autopsy method. Careful retrospective diagnostic evaluation of the victims according to DSM-III-R criteria was done by weighing and integrating all available information. A series of studies addressing the mental disorders among suicide victims, the treatment received before death and the life events is now reviewed.
Among a random sample of suicide victims from the nationwide suicide population, at least one psychiatric diagnosis was made for 93% of the victims. The most prevalent disorders were depressive syndromes (66%) and alcohol dependence/abuse (43%). The prevalence of major depression was higher among women than among men. Major depression as the principal diagnosis was more common among the elderly suicides. Among adolescent victims, depressive syndromes were also the most prevalent disorders. Adjustment disorders were common (25%) among male adolescent suicides. The majority of suicide victims of all ages suffered from comorbid mental disorders.
Among suicide victims who had had contact with a health carer before death, inadequacy of treatment for mental disorders seems to have been common. Of the major depressive victims only 3% were found to have received adequate psychopharmacological treatment, and only 7% received weekly psychotherapy by a trained therapist.
The analysis of the massive database collected in the research phase of the National Suicide Prevention Project in Finland is still ongoing, and the implications of the findings for suicide prevention will be refined during the research process. The necessity to improve recognition and treatment for comorbid depressive disorders in all age groups seems evident already.