Depressed patients who suicide at their first attempt have had few admissions

A prior suicide attempt is generally considered to be an indicator of increased future suicide risk. However, approximately 50% of psychiatric patients who commit suicide have made no previous suicide attempt. Thus, an effort was made to detect other predictors of future suicide risk in this group. The records of 100 psychiatric patient suicides were examined. Patients who completed suicide at their first attempt (n = 57) were compared with patients who suicided after a previous attempt (n = 43). There were no significant differences between the two groups on any of the sociodemographic or clinical variables examined. However, patients with a primary psychiatric diagnosis of an effective disorder who committed suicide at their first attempt had had significantly less admissions than depressed patients who committed suicide after a previous attempt. The clinical implication is that the absence of many prior admissions in a depressed patient is not an indicator of low suicide risk.     

Risk factors for suicide: a questionnaire survey by psychiatrists in Fukuoka Prefecture]

In our previous study, we demonstrated a preliminary questionnaire survey to psychiatrists from university hospitals, psychiatric hospitals, psychiatric clinics, and departments of psychiatry in general hospitals in Fukuoka Prefecture. In that study, 324 psychiatric patients who committed suicide between January 1, 1998 and December 31, 2001 were ascertained. In the present study, we have recruited matched control patients from the same clinics/hospitals and further demonstrated a secondary questionnaire survey to the psychiatrists in order to reveal the various risk factors for suicide suggested by the literature. Associations between completed suicide and possible risk factors were examined in 192 completed suicide psychiatric patients and 356 non-suicidal psychiatric patients (controls). Significant association was found for history of admission to psychiatric hospitals, history of suicide attempts, history of substance abuse, cluster B personality disorders, and hopelessness in our sample. In male samples, history of suicide attempts, cluster B personality disorders, recent loss, and hopelessness were significantly associated with suicide. In females, history of admission to psychiatric hospitals, history of suicide attempts, and hopelessness were significant.     

Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients

Large M, Smith G, Sharma S, Nielssen O, Singh SP. Systematic review and meta‐analysis of the clinical factors associated with the suicide of psychiatric in‐patients. Objective: To estimate the strength of the associations between the suicide of psychiatric in‐patients and demographic, historical, symptomatic, diagnostic and treatment factors. Method: A systematic review and meta‐analysis of controlled studies of the suicide of psychiatric in‐patients including suicides while on approved or unapproved leave. Results: Factors that were significantly associated with in‐patient suicide included a history of deliberate self‐harm, hopelessness, feelings of guilt or inadequacy, depressed mood, suicidal ideas and a family history of suicide. Patients suffering from both schizophrenia and depressed mood appeared to be at particular risk. The association between suicidal ideas and in‐patient suicide was weak and did not reach statistical significance after a quantitative correction for publication bias. A high‐risk categorization as defined by a combination of retrospectively determined individual risk factors was strongly statistically associated with in‐patient suicide (OR = 10.9), with a sensitivity of 64% and a specificity of 85%. Conclusion: Despite the apparently strong association between high‐risk categorization and subsequent suicide, the low base rate of in‐patient suicide means that predictive value of a high‐risk categorization is below 2%. The development of safer hospital environments and improved systems of care are more likely to reduce the suicide of psychiatric in‐patients than risk assessment.     

Suicide and violence in patients with major psychiatric disorders

The relationship between violence directed at the self and violence directed at others has intrigued psychiatrists for several decades. The goal of this study was to examine the relationship between suicide and violence against others in patients with major psychiatric disorders and to compare psychiatric symptoms associated with suicide in violent and non-violent patients. Subjects included physically assaultive psychiatric inpatients and a nonviolent comparison group. Physical and verbal assaults were recorded prospectively for 4 weeks. History of suicide attempts was obtained through chart review and patient interviews. The Brief Psychiatric Rating Scale was administered at the end of the 4 weeks by raters who were blind to both suicidal and violent behavior. The suicide attempters did not differ from the non-attempters on any measure of violent behavior or hostility. Suicide attempts were not accompanied by different symptoms in violent and non-violent patients; however, violence and suicide attempts were accompanied by dissimilar psychiatric symptoms. The physically assaultive patients presented with more severe positive psychotic symptoms than the non-assaultive patients. The suicide attempters, on the other hand, did not differ from non-attempters on psychotic symptoms, but presented with more severe depression and anxiety. The relationship between these symptoms and suicide attempts was noteworthy in its temporal stability, as most of the patients had attempted suicide many years prior to this study.     

Long-term follow-up after severe suicide attempt by multiple blunt trauma.

OBJECTIVE: After parasuicide there is a high risk of reattempts. However, it seems that patients who survived severe suicidal trauma recover well. Therefore, the outcome of patients with severe multiple blunt trauma as a result of a suicide attempt was investigated with respect to psychiatric and somatic health, quality of life (QOL) and suicide reattempt rates. METHODS: Patients who underwent a suicide attempt were isolated from a prospectively collected sample of trauma patients from a level I University Trauma Centre. Follow-up examination was performed 6.1 +/- 3 years after the trauma. A physical and psychiatric examination was performed, using established psychiatric scales. RESULTS: Twelve percent of severely injured patients were identified as suicide attempters (male/female: 37/28, mean age 38 +/- 18 years, mean Injury Severity Score (ISS) 40 +/- 15 points). A psychiatric diagnosis was present in 90% at the time of the suicide attempt. Twenty-one patients died during the hospital stay (32%) and six subjects died thereafter, none due to suicide. Thirty-five individuals were eligible for examination. None of them had reattempted suicide. Seventeen (48%) had good outcomes reflected by absent or ambulatory psychiatric treatment, employment, normal psychiatric findings and good psychosocial ability. An indeterminate outcome was determined in 24%. Predictive variables for an adverse outcome (10 patients, 28%) were found to be a diagnosis of schizophrenia, continued psychiatric treatment and being without employment. CONCLUSION: Despite the seriousness of the suicide attempt, survivors recovered well in about half the cases with no further suicide attempt in any patient. An early psychiatric consultation already on the Intensive Care Unit (ICU) is recommended.     

Relatives of psychiatric inpatients--do physical violence and suicide attempts of patients influence family burden and participation in care?

A common concern of psychiatric patients' relatives is that patients might be a danger to themselves or others. The aim of this study was to investigate family burden and relatives' participation in care in relation to physical violence towards others and suicide attempts by psychiatric inpatients before admission. Information concerning violence and suicide attempts by the patients prior to admission was collected from the medical records of 155 acutely voluntarily and involuntarily admitted psychiatric inpatients. Relatives were interviewed a month after admission, using a semi-structured questionnaire. Violence towards other persons and suicide attempts were recorded in 16% and 17% of the cases, respectively. There were no differences between relatives of patients who had been violent and other relatives regarding burden and participation in care. Relatives of patients with suicide attempts more often stated they had been prevented from having own company, worried about suicide attempts by the patient, had mental health problems of their own, and had own need for care and support. It was concluded that violence of acutely admitted psychiatric patients, targeted at other people, was not associated with burden of family, but the results corroborate the need for psychiatric services to involve and support relatives of psychiatric patients with suicidal behaviour.     

Ictal and psychiatric aspects of suicide in epileptic patients.

OBJECTIVE: To evaluate the ictal and psychiatric aspects underlying the high risk of suicide among epileptic patients. METHOD: We surveyed the records of 1611 epileptic patients seen in a neurology clinic during an eight-year period, found four who died by suicide, and characterized their ictal and psychiatric features. RESULTS: All four epileptic patients had partial complex seizures and temporal lobe foci. Two had an associated paranoid schizophrenia with suicidal ideation, and good or improving seizure control at the time of their deaths. Another patient killed himself during a brief psychotic episode associated with increasing epileptiform discharges. The fourth patient had ictal depression and committed suicide during a flurry of partial complex seizures. CONCLUSIONS: These findings suggest that the high suicide rate among epileptic patients has a greater association with psychotic behaviors and psychic auras than with major depression or the psychosocial burden of being epileptic. We further review other reported risk factors for suicide in epilepsy.     

Correlates of risk of suicide in violent and nonviolent psychiatric patients

OBJECTIVE: This study was designed to identify variables that correlate with the risk of suicide in two patient groups that differ mainly in their level of expressed aggression. METHOD: Twenty-eight psychiatric patients with a history of violent behavior who were in a forensic psychiatric facility were tested and compared to 28 psychiatric inpatients without a history of violence who were admitted to a large municipal hospital. Measures used included a battery of self-report questionnaires, with acceptable reliability and validity, that provided indices of risk of suicide, risk of violence, impulsivity, anger, anxiety, and various mood states. RESULTS: The two groups, matched on demographic variables and overall risk of suicide, differed significantly on the measured risk of violence. The two groups showed similar patterns of correlations between risk of suicide and such variables as risk of violence, anger, fear, state and trait anxiety, lack of impulse control, suspiciousness, and rebelliousness. They differed in the correlation between suicide risk and depression. In the nonviolent patients there was a high correlation between risk of suicide and sadness; in the violent patients there was no correlation between these variables. CONCLUSIONS: The low correlation between sadness and risk of suicide in the violent patients, and the low prevalence of affective disorder diagnoses in these patients compared to other patients, suggests that suicidal risk should be managed differently in highly violent patients than in others.     

Suicide in psychiatric patients in Denmark, 1971-81. I. Demographic and diagnostic description

Data concerning all suicide cases in Denmark with a psychiatric history (1971-81) were compiled through computer record linkage between central registers. Cases of suicide during and up to 1 year after inpatient hospitalization were investigated. 21% of the suicides took place while the patient was still hospitalized. The overall suicide rates increased slightly faster than in the population without recent psychiatric hospitalization. There were few suicides in the groups over 65 and under 25 years of age. A sharp relative increase in suicide mortality in the provincial and particularly rural populations was noted. Approximately half of the patients were psychotic, mainly with major affective disorder. The percentage of patients with neurosis or personality disorder decreased. 37% of the men and 18% of the women were diagnosed as substance abusers. Fairly consistently, approximately 10% of the suicide victims were characterized by affective reactions or no psychiatric illness.     

Completed suicide among psychiatric in‐patients with depression in an Australian mental hospital

Up to 45% of completed psychiatric in‐patient suicides have a diagnosis of depression. Twenty‐two completed psychiatric in‐patient suicides with depression, over a 21‐year period, in a large psychiatric hospital in Melbourne, Australia, were examined. The characteristics, including demographic and clinical data, for the completed suicides with depression were compared with a comparison group of ‘alive’ in‐patients with depression. Completed suicide among psychiatric in‐patients with depression was associated with male sex, suicidal thoughts during admission, and fluctuating suicidal ideation or continuous absence of suicidal ideation. Over 40% of completed suicides occurred whilst on approved leave and over 20% after absconding from the hospital. Violent methods (including jumping in front of trains, trams and road traffic, jumping of buildings, hanging and drowning) were used in over 65% of completed suicides. Psychiatric units should be developed away from readily available methods of suicide. In‐patients with suicidal thoughts during the admission and unstable suicidal ideation should be carefully observed to avoid absconding and suicide, and should be carefully assessed prior to granting of leave. Copyright © 2000 Whurr Publishers Ltd.     

A clinical study of suicidal behavior in schizophrenic patients]

117 subjects admitted to the Department of Emergency and Critical Care Medicine at Sapporo City General Hospital due to suicide attempts between June 1983 and August 1986 were studied. Various aspects of attempted suicide and successful suicide in patients with schizophrenia were compared with those same aspects in patients with other psychiatric conditions. Similarly, 30 patients with schizophrenia who attempted suicide between January 1975 and December 1989 while inpatients or discharged outpatients in the Department of Neuro-Psychiatry at Sapporo City General Hospital were also examined. 1) In both the transverse study in the Department of Emergency and Critical Care Medicine and the longitudinal study in the Department of Neuro-Psychiatry at Sapporo City General Hospital, suicidal behavior in patients with schizophrenia increased significantly over a 5 year period after the onset of the disease. 2) Schizophrenic patients used more lethal methods for suicide (such as a direct and violent injury to the body) than did other psychiatric patients. With regards to body injury method, there was no difference between schizophrenics and other psychiatric patients between the ages of 20 and 30, though significantly more schizophrenics between the ages of 30 and 50 chose a violent body injury method. 3) Schizophrenics attempted suicide more often at any other place out of their houses than did other psychiatric patients (depressives, neurotics, etc.) and normal subjects. The difference between schizophrenics and other psychiatric patients was particularly distinct between the ages of 30 and 50. 4) Most schizophrenic patients who attempted suicide were in an exacerbated period of the illness. Interviews immediately after suicide attempts revealed that most patients attempted suicide against their will, moved by delusional and hallucinatory experiences. It is therefore presumed that most suicide in schizophrenics, even though seemingly unexpected or impulsive, is actually provoked by rapid fluctuation of the psychosis. 5) Positive symptoms reported at the time of attempted suicide included delusion of persecution, imperious auditory hallucinations, hypochondriacal delusions, and delusion of guilt. The abnormal experience which induced suicide attempts generally consisted of delusional perceptions regarding an inability to recover health, hallucinatory commands, and acute self-disruption generated by experiences such as sudden delusional ideas. These drove the patients toward suicide. 6) Most suicide attempts were within several days or several hours of abrupt symptom exacerbation. It is noteworthy that these attempts were clustered within limited periods of time. Overt suicidal tendencies continued for several months, suggesting that there is a period in which suicide may be easily induced.(ABSTRACT TRUNCATED AT 400 WORDS)     

Treatment of suicide attempters prior to hospital admission

OBJECTIVE: Numerous authors have reported serious shortcomings in the treatment of suicidal patients. This study examined the treatment suicide attempters admitted to a psychiatric hospital in Switzerland had received prior to the suicide attempt. METHOD: Thirty-one patients were admitted to this hospital within a year, representing 36 suicide attempts, which corresponds to 6.5% of the annual admission number. Three of these patients were admitted twice, and one patient was admitted three times. Information on previous treatment was collected in personal interviews and included medication, and its dosage, at 1 month and 2 weeks prior to the suicide attempt, and whether the patient had received psychotherapy. In addition, details of the psychosocial event and the means of the suicide attempt were recorded. RESULTS: Twenty-one patients had been prescribed psychotropic drugs in 24 events, but only in 17 events concerning 15 patients, antidepressants were prescribed prior to hospitalisation. Antipsychotics and benzodiazepines were prescribed in 6 and 21 events, respectively (including 8 events with hypnotics). None of the patients was treated with lithium. In 19 events, 16 patients had received psychotherapy prior to admission. In 32 events, psychotropic drugs were used for the suicide attempt. CONCLUSION: The findings confirm the undertreatment of patients attempting suicide reported by other authors. In spite of the majority of patients being under psychiatric care, no adequate pharmacotherapy had been prescribed particularly for depressed patients.     

Preventing suicidal behaviour in a general hospital psychiatric service: priorities for programming.

PURPOSE: General hospital psychiatric services are able to provide leadership and coordinate the development of suicide prevention programs for individuals serviced in general hospital settings. We completed this literature review to suggest priorities for programming. METHODS: Our procedure was to update the review by Gunnell and Frankel that guided priorities for Health of the Nation, the national suicide prevention strategy in the UK. We completed a search, using the terms suicide prevention and control, of all English-language research and clinical trials conducted between January 1, 1994, and May 1, 2004. RESULTS: We identified 82 papers. Of these, 48 were excluded and the remaining 34 were grouped by secondary care setting categories. We found no articles on screening tools for predicting risk of suicide, 16 articles on interventions for individuals with suicidal behaviour, 14 articles on the treatment of major psychiatric disorders, 1 article and 1 published abstract on discharge from hospital, and 2 articles on reducing access to means. CONCLUSIONS: Based on a review of each category, we make several program and policy recommendations, including regularly updating clinical assessment skills, using guidelines for assessment of patients following a suicide attempt, assessing the risk of suicide 24 to 48 hours before discharge from hospital, and incorporating education about reducing access to means into routine psychiatric care.     

Obésité et bypass gastrique,impact sur la qualité de vie et le risque suicidaire : revue de la littérature

In the last few years, the flourishing number of surgery for morbid obesity induces a growing interest in the short, medium and long-term consequences of the operative procedures. Both massive overweight and its surgical treatment such as gastric bypass can influence the mental health of patients and have an impact on their risk of suicide and suicide rates. Indeed, the suicide rate after the surgical treatment of obesity is increased; although medical literature is prolific on the subject of quality of life after gastric bypass surgery, less is known about the causes of postoperative suicide. There are few theories that allow discussion or hypothesis making and among these none can explain alone the excess of preventable deaths. This raises many questions about the management of candidates for gastric bypass: Is it possible to improve preoperative screening of patient's compliance? Should psychiatric follow-up become compulsory after surgery? It appears obvious from the current literature that suicide rates are higher among gastric bypass patients than the general population. It is reasonable to assume that this finding is related to the psychological difficulties experienced by patients, the impact on their quality of life and social functioning, on emotional and on a professional level. The intervention and massive weight loss can often destabilize an already precarious balance. It seems necessary to strengthen the psychiatric treatment of candidates for bariatric surgery and discuss the value of mandatory postoperative follow-up, as well as to promote patient compliance. Bariatric surgery patients with a history of psychiatric comorbidities should benefit from strict preoperative consultations and appropriate medication in order to rigorously balance their condition before surgery. Postoperative measures should include monitoring of high-risk populations such as patients with psychiatric comorbidity, as well as considering couple psychotherapy or support groups for patients and their relatives.     

Psychosocial risk factors associated with suicide attempts and violence among psychiatric inpatients

OBJECTIVES: To better understand the relationship between suicidal behavior and violence directed toward others among patients with major psychiatric disorders, this study examined how suicide attempts and violent behaviors were associated with various psychosocial problems. METHODS: Participants were inpatients in two psychiatric state hospitals. They included 216 inpatients who had physically assaulted another patient or a staff member and a comparison group of 81 inpatients who had not assaulted anyone. History of suicide attempts and historical information about various risk factors for violence and suicide were obtained through chart review and patient interviews. RESULTS: Patients in the violent group did not differ from those in the nonviolent group in whether they had attempted suicide. Suicide attempts and violence were associated with different historical variables. Suicide attempts were associated with a history of head trauma, harsh parental discipline, and parental psychopathology. Violence against others was associated with having a history of school truancy and foster home placement. CONCLUSIONS: Among inpatients with major psychiatric disorders, violence and suicide attempts were not related to each other and were associated with dissimilar psychosocial risk factors.     

Deliberate self-harm before psychiatric admission and risk of suicide: survival in a Danish national cohort

Purpose

Psychiatric illness and deliberate self-harm (DSH) are major risk factors of suicide. In largely 15 % of psychiatric admissions in Denmark, the patient had an episode of DSH within the last year before admission. This study examined the survival and predictors of suicide in a suicidal high-risk cohort consisting of hospitalized psychiatric patients with recent DSH.

Methods

This national prospective register-based study examined all hospitalized psychiatric patients who self-harmed within a year before admission. All admitted patients, in the time period 1998–2006, were followed and survival analyses techniques were used to identify predictors of suicide.

Results

The study population consisted of 17,257 patients; 520 (3 %) died by suicide during follow-up; 50 % of the suicides occurred within a year from the index admission. A rate of 1,645 suicides per 100,000 person–years in the first year after psychiatric admission was found. Adjusted analyses showed that a higher degree of education, having DSH within a month before psychiatric admission and contact with a private psychiatrist increased the risk of suicide.

Conclusions

Psychiatric hospitalized patients with recent DSH revealed high suicide rates, even during hospitalization. When discharging psychiatric patients with recent DSH careful arrangement of follow-up treatment in the outpatient setting is recommendable.     

五-羟色胺2A受体基因A1438G多态性与精神疾病患者自杀未遂的关联性研究

目的 探讨五-羟色胺2A(5-HT2A)受体基因A1438G多态性与精神疾病患者的自杀未遂之间的关系。方法 共有52例有自杀未遂的精神疾病患者和64例无自杀的精神疾病患者及63例正常人入组研究。所有入组者按常规方法提取DNA,用限制性片段长度多态性方法分析5-HT2A受体基因的多态性。结果 自杀未遂组的A1438G多态性位点的G等位基因频率(0.52)高于正常对照组(0.39)x2=3.91,P<0.05。自杀未遂组与正常对照组间的基因型分布的差异也有显著性(x2=6.12,P<0.05)。结论 精神疾病患者的自杀未遂与5-HT2A受体基因的A1438G多态性有关,G等住基因可能是自杀行为的危险因素。     

Completed suicide in psychiatric inpatients and former inpatients. A comparative study

A total of 49 psychiatric inpatient suicides were compared with 53 former psychiatric inpatients who had committed suicide within one year after their discharge. Significant differences were found in the diagnostic distribution of both groups, especially the predominance of schizophrenics among inpatient suicides, and of alcoholics and drug abusers among suicides of former inpatients. Furthermore, some other important differences between the groups emerged that bore practical implications. In different diagnostic groups suicide occurs for different reasons and based on different psychosocial backgrounds. In the investigation of suicide in psychiatric patients, homogeneity of the population studied in terms of patient status should be strived for.