Predictors of adolescent suicide attempts: a nationally representative longitudinal study of Norwegian adolescents

OBJECTIVE: To investigate the risk and protective factors for previous and future suicide attempts among adolescents. METHOD: A representative sample of high school students (N = 9,679) in grades 7 through 12 (aged 12-20 years) were followed from 1992 to 1994. Response rate was 97% at initial testing and 80% at follow-up. Measures of psychiatric symptoms (depressed mood, eating problems, conduct problems), substance use, self-worth, pubertal timing, social network, and social integration were included. RESULTS: A total of 8.2% had ever attempted suicide and 2.7% reported an attempt during the 2-year study period. Logistic regression analysis showed that future attempts were predicted by previous attempt, female gender, young age, perceived early pubertal development (stronger among girls), suicidal ideation, alcohol intoxication, not living with both parents, and poor self-worth. CONCLUSIONS: The importance that the clinician ask about previous suicidal behaviors is underscored. Early pubertal timing (particularly among girls), loss of self-worth, and alcohol intoxication may serve as risk factors for future suicide attempts.     

Natural history of affective disorders: Comorbidity as a predictor of suicide attempts

OBJECT: Comorbidity of psychiatric illnesses and substance misuse can lead to an increase in suicide attempts. METHOD: Retrospective data collection from case notes of 81 consecutive admissions to an acute psychiatric ward. Previous diagnoses, substance misuse and suicidal attempts were all examined. RESULTS: The rate of suicide attempts among all groups was 40.7%. Alcohol abuse or use of illegal drugs was reported in 69.7% of suicide attempters. More than half of the patients (66.7%) overconsumed alcohol. CONCLUSION: Clinical implication of the effect of comorbidity on suicidal behaviour and length of stay are discussed.     

Suicidality among Norwegian youth: Review of research on risk factors and interventions

Background and Aim: Published research on suicidality among Norwegian youth and publications describing interventions were summarized in order to access the current status of knowledge building via empirical research. Method: A systematic Medline search identified 29 studies on risk factors on the entire spectrum of suicidal phenomena from self-harm without suicidal ideation to completed suicide with the mean age at/under 25 years. A specialist Norwegian journal, Suicidologi, was searched for additional matter, especially interventions. Result: Most studies focussed on psychological and psychiatric risk factors of attempted suicide. Other suicidal phenomena, psychosocial and societal risk factors, and impact of interventions were hardly studied. Depression, previous suicidal behaviour, alcohol use and non-intact parental unit were consistent significant risk factors found in suicide and attempted suicide studies. Conclusion: Supporting non-intact parental units and the maintenance of intact parental units along with early detection and management of suicide attempts, depression and alcohol use should be targeted as suicide prevention interventions among adolescents.     

Risk factors associated with suicide attempt in young French people

Demographic data, personal and familial characteristics, as well as DSM-III-R-based psychiatric diagnoses were collected in 369 adolescents and young adults aged between 15 and 29 years, referred to an Emergency Department for psychological problems. In total, 60% of them were suicide attempters. Separations before the age of 12 years and depression in the family emerged as the main features distinguishing the suicidal group from the psychiatric control group. Fifty per cent of suicide attempters were repeaters. Fostering during childhood, suicide attempts and depression in the family were found to be risk factors for repeated self-attempts. These results support the view that significant levels of dysfunction, together with increased psychiatric morbidity, especially suicidal behaviour, characterize the families of young self-attempters.     

Risk of repetition of suicide attempt, suicide or all deaths after an episode of attempted suicide: a register-based survival analysis

OBJECTIVE: This study was undertaken in order to estimate the incidence of repetition of suicide attempt, suicide and all deaths, and to analyse the influence of psychiatric illness and socio-demographic factors on these. METHOD: The study is a Danish register-based survival analysis that retrieved personal data on socio-economic, psychiatric and mortality conditions from various registers. Hazards were estimated using Cox regression with a time-dependence covariate. Suicide-attempters (2.614) and non-attempters (39.210)were analysed being matched by gender, age and place of residence. RESULTS: The average follow-up period for suicide-attempters was 3.88 years, during which 271 (10.37%) of them died. By comparison, death occurred four times more often among suicide-attempters than among non-attempters. Suicide was far more common among attempters (61, 2.33%) than among non-attempters (16, 0.04%). A proportion of the attempters (31.33%) repeated their attempt within the follow-up period. The most reliable predictors for suicide and death were repetition, suicide attempt method and treatment for mental illness. The most reliable predictors for repetition were age, gender and mental illness. DISCUSSION: Individuals with a history of suicide attempts form a well-defined high-risk group for suicide, and are in need of treatment immediately after the episode. Somatic and psychiatric staff must be informed about the risk factors for subsequent suicidal behaviour after an episode of attempted suicide. Furthermore, departments that are in contact with suicidal individuals need action plans to ensure that all such individuals are discharged to proper treatment immediately after the suicide attempt.     

Suicidal behaviour and intensity of psychiatric care in a region at high risk for suicide

BACKGROUND Suicidal behaviour represents a social and health-related issue of prime importance in both the general and psychiatric population. People with mental illness are at great risk of suicide, but indirect evidence suggests that the treatment of psychiatric disorders may prevent suicide. The aim of our study was to compare the risk of suicide in the population of psychiatric patients with that of the general population in Friuli Venezia-Giulia (FVG).

METHOD We analyzed the suicide rates, based on the official statistical database, relating to the resident population in FVG during the years 1998–1999. The sucide rates (per 100?000 subjects) were standardised by sex and age. The characteristics of suicidal behaviour in subjects who had been in contact with (Community Mental Health Centres) CMHC (n=65) were compared with that of suicidal subjects not in contact (n=237).

RESULTS There was an increase in the suicide phenomenon in the elderly population in FVG over the tested period. The rates were three times higher in males than in females. The rates of patients in contact with CMHC in 1998 and in 1999 were, respectively, 14 and 20 times higher than that of the general population. Most suicidal schizophrenics and 37% of the depressed patients have been previously hospitalised.

CONCLUSION The population of north-eastern Italy is at high risk of suicide compared to other regions. The mortality ratio of psychiatric subjects who commit suicide in our sample is elevated. Since Italian community-oriented services rely less on hospitalisation than in other countries, the fact that about 50% of suicidal psychiatric patients have been previously admitted in a psychiatric ward may indicate that previous hospitalisation is a hierarchic factor related to suicide.     

Younger onset of depression is associated with greater suicidal intent

BACKGROUND: Age of onset of major depression seems to be dropping in Western nations. Early onset usually predicts a more serious illness with a relatively poor prognosis. Since depression is associated with suicide, this begs the question of whether early onset of depression is associated with the degree of intent of suicidal behaviour, and whether this relationship differs according to gender. METHODS: Relevant responses from 9,282 residents of the United States were drawn from a nationally representative community survey conducted in 2001 through 2003 using the W.H.O. version of the Composite International Diagnostic Interview. The primary outcome measure was the retrospectively determined age of first major depressive episode. RESULTS: Younger age of onset for depression was associated with higher levels of suicidal intent, irrespective of age at the time of interview. A significant interaction between level of intent and age at interview appeared to be accounted for by the later onset among those in the eldest cohort who reported an absence of suicidal behaviour. The influence of suicidal intent on onset of depression was greater for women than for men. CONCLUSIONS: The earlier the age of first symptoms of major depressive episode, the higher the degree of suicidal intent, irrespective of age at interview and gender, although the more pronounced trend for women suggests a greater sensitivity to underlying factors that may involve depression and lead to suicide risk.     

Suicide after deliberate self-harm: a 4-year cohort study

OBJECTIVE: The purposes of this study were to estimate suicide rates up to 4 years after a deliberate self-harm episode, to investigate time-period effects on the suicide rate over the follow-up period, and to examine potential sociodemographic and clinical predictors of suicide within this cohort. METHOD: This prospective cohort study included 7,968 deliberate self-harm attendees at the emergency departments of four hospital trusts in the neighboring cities of Manchester and Salford, in northwest England, between September 1, 1997, and August 31, 2001. Suicide rates and standardized mortality ratios (SMRs) for the cohort were calculated. Potential risk factors were investigated by using Cox's proportional hazards models. RESULTS: Sixty suicides occurred in the cohort during the follow-up period. An approximately 30-fold increase in risk of suicide, compared with the general population, was observed for the whole cohort. The SMR was substantially higher for female patients than for male patients. Suicide rates were highest within the first 6 months after the index self-harm episode. The independent predictors of subsequent suicide were avoiding discovery at the time of self-harm, not living with a close relative, previous psychiatric treatment, self-mutilation, alcohol misuse, and physical health problems. CONCLUSIONS: The results highlight the importance in a suicide prevention strategy of early intervention after an episode of self-harm. Treatment should include attention to physical illness, alcohol problems, and living circumstances. Self-harm appears to confer a particularly high risk of suicide in female patients.     

Attempted suicide among young people: risk factors in a prospective register based study of Danish children born in 1966

OBJECTIVE: In order to prevent suicidal behaviour among adolescents and young adults it would be valuable to know if altering the conditions of their upbringing could reduce their suicidal behaviour. The study surveys possible risk factors. METHOD: Population-based registers covering children born in Denmark in 1966 at the age span of 14-27 years and their parents for: health, education, family dissolution, suicidal behaviour, substance abuse, criminality and unemployment. A discrete-time proportional hazard modelling was used to analyse the longitudinal observations. RESULTS: First-time suicide attempts were associated with parental psychiatric disorder, suicidal behaviour, violence, child abuse and neglect. Increased risks were also found among adolescents and young adults who suffered from psychiatric disorder or physical handicap, had been legally imprisoned, were addicted to drugs, or without graduation, vocational training or employment. CONCLUSION: Stigmatization, social exclusion, and mental disorders in the adolescents or young adults and parents increased risks for attempted suicide.     

Gender differences in adolescents and young adults with suicidal behaviour.

OBJECTIVE: Gender differences in prevalence rates of suicide attempts and suicidal thoughts as well as in risk factors for suicide attempts such as traumatic events and mental disorders were investigated in a random sample of 3021 adolescents aged 14-24 years. METHOD: The M-CIDI (Composite International Diagnostic Interview) was used to survey suicidal behaviour, DSM-IV lifetime diagnoses and traumatic events. RESULTS: The female suicide attempters showed suicidal thoughts and suicide attempts significantly more often, and suicide attempts at a much younger age than the males. Furthermore, the females experienced sexual abuse much more often, and suffered significantly more often from anxiety disorders. The male suicide attempters showed higher rates of alcohol disorders and financial problems. CONCLUSION: A higher rate of anxiety in female suicide attempters results probably as a consequence of sexual abuse, which in turn makes them more vulnerable than males for attempting suicide between the age of 14-17.     

Suicidal ideation and suicide attempts in homeless mentally ill persons

BACKGROUND: Despite reports of high rates of suicidal behavior among mentally ill homeless persons, it remains unknown whether the well-established suicide risks of increased age and comorbid psychiatric and substance abuse disorders ("dual diagnosis") documented in the general population are also markers for increased suicide risk among homeless persons. METHODS: Data from a multi-site outreach program (ACCESS) (N = 7,224) were used to investigate whether rates of serious suicidal ideation and recent suicide attempts varied with the age and substance abuse diagnosis(es) (drug abuse and/or alcohol abuse disorders) among homeless mentally ill clients. RESULTS: The prevalence of 30-day suicidal ideation and suicide attempts (37.5 % and 7.9 %, respectively) was extremely high. Although the risk of serious suicidal ideation and suicide attempts was greater among the younger compared with the older homeless mentally ill clients, risks were not significantly increased by co-morbid alcohol and/or drug abuse. However, a significant interaction between age and co-morbid substance abuse was observed showing that among older clients but not younger clients, those with drug and alcohol abuse were at significantly greater risk of suicidal ideation than those without substance use problems, controlling for confounding factors. CONCLUSION: Efforts to prevent suicide should recognize that among homeless people with mental illness, young-middle-aged (30- to 39-year-old) clients are at greatest risk of suicidal behavior. Among older clients the presence of both drug and alcohol abuse significantly increases suicide risk. These patterns are of special importance because they are quite different from those that are well documented in non-homeless populations.     

Suicidal ideation and attempts among psychiatric patients with major depressive disorder

BACKGROUND: Few studies have investigated risk factors for suicidal ideation and attempts, or possible variations in them, among representative samples of psychiatric patients with major depressive disorder. METHOD: As part of the Vantaa Depression Study in Vantaa, Finland, 269 patients with DSM-IV major depressive disorder (MDD), diagnosed by interview using semistructured World Health Organization Schedules for Clinical Assessment in Neuropsychiatry, version 2.0, and Structured Clinical Interview for DSM-III-R Personality Disorders, were thoroughly investigated. Information was gathered on patients' levels of depression, anxiety, hopelessness, perceived social support, social and occupational functioning, and alcohol use. Suicidal behavior was assessed by interviews, including the Scale for Suicidal Ideation, and by information from psychiatric records. Data were gathered from Feb. 1, 1997, to May 31, 1998. RESULTS: During the current MDD episode, 58% of all patients had experienced suicidal ideation; among the 15% of the total who had attempted suicide, almost all (95%) had also had suicidal ideation. In nominal regression models predicting suicidal ideation, hopelessness, alcohol dependence or abuse, low level of social and occupational functioning, and poor perceived social support were found to be significant (p < .05) independent risk factors. High severity of depression and current alcohol dependence or abuse in particular, but also younger age and low level of social and occupational functioning, predicted suicide attempt. CONCLUSION: Suicidal ideation is prevalent and appears to be a precondition for suicide attempts among psychiatric patients with MDD. The risk factors for suicidal ideation and attempts locate in several clinical and psychosocial domains. While these risk factors largely overlap, the overall level of psychopathology of suicide attempters is higher compared with that in patients with ideation, and substance use disorders and severity of depression may be of particular importance in predicting suicide attempts.     

Suicides among 523 persons in a Swedish county with and without contact with psychiatric care

Among 523 (350 males, 173 females) suicides in 1977-1984, subjects who had had contact with psychiatric care (PC) (63%) were compared with those who had never had such contact (NPC) (37%). The male:female ratios in the PC and NPC groups were 1.6 and 3.0, respectively. Intoxication with drugs and or alcohol was the main method of suicide among the PC subjects, and hanging and intoxication with carbon monoxide predominated among subjects of the NPC group. High percentages of divorces and widows/widowers were characteristic of both groups. Among men and women of the PC group the age groups in which the highest mean suicide rates per 100,000 were found were 45-54 and 55-64 years respectively. The corresponding age groups in the NPC group were greater than or equal to 75 and greater than or equal to 70 years. In the PC group the number of admissions to psychiatric hospitals was more than three in 55% of the subjects and more than eight in 25%. Seventy-three percent had had psychiatric contact within 6 months before the suicide. About 40% in each group had had depressive syndromes. Somatic disease of relevance to the suicides was found among 10% of the PC subjects and 20% of the NPC. About 1/4 of the subjects in both groups had expressed serious suicidal intent shortly before the suicide. The importance of information and education about suicide problems among personnel and relatives is underlined.     

Suicidal ideation and attempts in bipolar I and II disorders

OBJECTIVE: Few studies have investigated the prevalence of and risk factors for suicidal ideation and attempts among representative samples of psychiatric patients with bipolar I and II disorders. METHOD: In the Jorvi Bipolar Study (JoBS), psychiatric inpatients and outpatients were screened for bipolar disorders with the Mood Disorder Questionnaire from January 1, 2002, to February 28, 2003. According to Structured Clinical Interviews for DSM-IV Axis I and II Disorders, 191 patients were diagnosed with bipolar disorders (bipolar I, N = 90; bipolar II, N = 101). Suicidal ideation was measured using the Scale for Suicidal Ideation. Prevalence of and risk factors for ideation and attempts were investigated. RESULTS: During the current episode, 39 (20%) of the patients had attempted suicide and 116 (61%) had suicidal ideation; all attempters also reported ideation. During their lifetime, 80% of patients (N = 152) had had suicidal behavior and 51% (N = 98) had attempted suicide. In nominal regression models, severity of depressive episode and hopelessness were independent risk factors for suicidal ideation, and hopelessness, comorbid personality disorder, and previous suicide attempt were independent risk factors for suicide attempts. There were no differences in prevalence of suicidal behavior between bipolar I and II disorder; the risk factors were overlapping but not identical. CONCLUSION: Over their lifetime, the vast majority (80%) of psychiatric patients with bipolar disorders have either suicidal ideation or ideation plus suicide attempts. Depression and hopelessness, comorbidity, and preceding suicidal behavior are key indicators of risk. The prevalence of suicidal behavior in bipolar I and II disorders is similar, but the risk factors for it may differ somewhat between the two.     

Survival analysis of suicide risk after attempted suicide

Survival analysis of suicide risk by sex and age after attempted suicide was studied in a cohort of 1573 suicide attempters referred to the psychiatric emergency room at the Karolinska Hospital from 1981 to 1988. The time course of suicide risk and the overall prognosis after attempted suicide and, in particular, the possible usefulness of sex and age as risk factors for the prediction of suicide risk after attempted suicide was analyzed. Nearly two thirds of the sample were women and most of the suicide attempters were young (in their twenties and thirties), and the median age was 35 years. The overall mortality after a 5-year mean observation period after attempted suicide was 11%, and the suicide mortality was 6 %. The suicide risk after attempted suicide among men (8.3%) was nearly twice the female suicide risk (4.3%). Age as a possible suicide risk factor was analyzed for each sex separately by median split subgrouping. It was concluded that both older and younger male suicide attempters are at high risk of suicide (7% and 10% respectively), and older women are at higher risk than younger (6%, vs 2%). The suicide risk is particularly high during the first year after the suicide attempt. The high suicide risk group of young adult male suicide attempters is one of the main feasible targets of psychiatric intervention research programs on suicidal behavior. Suicide among young men is a major cause of years of life lost.     

The associations between health risk behaviours and suicidal ideation and attempts in a nationally representative sample of young adolescents.

OBJECTIVE: To examine associations between health risk behaviours and suicidal ideation and attempts in Canadian adolescents aged 12 to 13 years. Young adolescents think about and attempt suicide. However, most existing research on suicide has been conducted on individuals aged 15 years and older. METHOD: The present study examined a nationally representative Canadian sample of adolescents aged 12 to 13 years (n=2090). Health risk behaviours included disruptive (shoplifting, physical fighting, damaging property, fighting with a weapon, carrying a knife, and gambling), sexual (petting below the waist and sexual intercourse), and substance use behaviours (smoking cigarettes, consuming alcohol, marijuana or hash, and glue or solvents). Unadjusted and adjusted (for all significant health risk behaviour and psychiatric symptoms) models were tested. RESULTS: All health risk behaviours were common among male and female adolescents. In unadjusted models, almost all health risk behaviours were associated with suicidal ideation and attempts among adolescent boys. In adjusted models, only damaging property, sexual intercourse, and smoking cigarettes remained statistically associated with suicidal ideation, while smoking cigarettes and using marijuana or hash remained statistically associated with suicide attempts among adolescent boys. All health risk behaviours were statistically associated with suicidal ideation and attempts among female adolescents in unadjusted models. In adjusted models, only carrying a knife remained statistically associated with suicidal ideation, while shoplifting and gambling remained statistically associated with suicide attempts among adolescent girls. CONCLUSIONS: Health risk behaviours among young adolescents are associated with suicidal ideation and attempts among young adolescents. Recognizing health risk behaviours among young adolescents may be one means of understanding who among them is at increased risk of suicidality.     

Nicotine use in suicides: a case-control study.

PURPOSE: Despite of higher rates of substance-related disorders in psychiatric patients and suicides than in the general population, there is no clear specificity to the relationship between nicotine use and other psychiatric disorders for suicide risk. METHODS: One hundred and sixty-three suicides (mean age 49.8 +/- 19.3 years; 64.4% males; using psychological autopsy method) and 396 control persons (mean age 51.6 +/- 17.0 years; 55.8% males) were assessed with a standardised semi-structured interview including SCID-I and SCID-II (for DSM-IV). Suicides and controls were compared in terms of nicotine consumption and psychiatric disorders. Logistic regression was used to evaluate the interactions of tobacco consumption with psychiatric disorders. RESULTS: Suicides were significantly more often current smokers and heavy users of cigarettes (> 20 cigarettes per day; P < 0.001, each). Alcohol dependence, other axis I disorders than substance-related disorders, and cluster B personality disorder(s) remained independent predictors for suicide in both genders, current nicotine consumption only in men (OR = 2.6, 95% CI 1.3-5.2). DISCUSSION AND CONCLUSIONS: In males, but not in females, nicotine consumption contributed to risk of completed suicide after control for psychiatric disorders and has to be considered as independent risk factor for suicide.     

Core features of suicide. Gender,age, alcohol and other putative risk factors in a low-incidence population

The aim of the study was to elucidate some supposed core features of suicide through a study of suicide in a low-incidence population. The material covered all suicides and undetermined deaths 1945–2004 in the Faroe Islands (a low-incidence population) and the study made use of all available information. Results showed that suicide rate had been low since the Second World War. However, there was an increase throughout the 1970s and 1980s. Supposed core features of suicide, such as gender, marital status, former psychiatric admittance, former suicidal behaviour, alcohol and method preference were confirmed. Others were not, such as an increasing rate with old age. In diagnostics, the role of psychiatric disorders was confirmed, but so was a substantial role of “no disorder”. Increase period revealed a high proportion of cases with alcohol involved and a substantial part included males, in age groups 25–64 years, unmarried, divorced and alcohol intoxicated. The main conclusion was that a low-incidence population of suicide population confirmed some supposed core features of the suicide phenomenon. Others, related to age and psychiatric disorders, were only partially confirmed. In periods of increase, the most vulnerable were the young and middle-aged males, unmarried, divorced, and alcohol played a crucial role.     

Genetics of suicide: an overview

Risk for suicide may have heritable contributions. Evidence supporting this hypothesis includes strong and consistent findings from more than 20 controlled family studies indicating nearly 5-fold greater relative risk of suicidal acts among relatives of index cases with suicidal behavior compared to relatives of nonsuicidal controls. Relative risk was greater for completed suicide than for attempts. Contributions of genetic instead of environmental factors are indicated by a higher average concordance for suicidal behavior among co-twins of suicidal identical twins compared to fraternal twins or to relatives of other suicidal subjects, in at least seven studies. Three studies indicate significantly greater suicidal risk, particularly for completed suicide, among biological versus adoptive relatives of suicidal or mentally ill persons adopted early in life. Molecular genetics studies have searched inconclusively for associations of suicidal behavior with genes mainly for proteins required for central serotonergic neurotransmission. Complex interactions of environmental with heritable risk and protective factors for suicide and psychiatric illnesses or vulnerability traits are suspected, but specific intervening mechanisms remain elusive. Familial or genetic risks for psychiatric factors strongly associated with suicide, such as major affective illnesses and alcohol abuse, as well as impulsive or aggressive traits, have not consistently been separated from suicidal risk itself.