Epidemiology of completed suicides in Singapore for 2001 and 2002

This study provides an analysis of 640 completed suicide cases in Singapore for the years 2001 and 2002, compared to previous years and in relation to demographic and socioeconomic factors, as well as to the characteristics of a subgroup of suicide victims with prior psychiatric illness. There was little change in the suicide pattern over the 2 years studied compared to previous years. The sex ratio was constant at 1.5. Population-adjusted ratios were 1 for Chinese, 0.5 for Malays, and >1 for both Indians and other ethnic groups. Falling from heights ranked first in terms of method adopted for both years. A disproportionately higher number of suicides were recorded for the 25-34 and the > or =75-year-old age groups. A total of 47 (17.2%) in 2001 and 74 (20.2%) in 2002 of the cases had a history of prior psychiatric illness, with psychotic disorders being the most common diagnostic category. There was also a statistically significant correlation between unemployment and incidence rates. Although the overall rate of elderly suicides had gone down since the 1990s, prevention strategy should focus on the elderly as this rate is still about 3-4 times the national average.     

Caring Letters Project: a military suicide-prevention pilot program

Background: The Caring Letters Project (CLP) is a suicide prevention program that involves sending brief caring letters to discharged inpatients following psychiatric hospitalization. Several studies suggest that repeatedly sending caring messages may reduce suicides and suicide attempts in high-risk populations. Aims: The aims of this study were to (1) evaluate feasibility of use in the military setting, (2) explore trends toward reduction of psychiatric rehospitalizations, (3) assess preference for and test e-mail correspondence, and (4) identify best practices and gather data to inform a randomized controlled study. Methods: A total of 110 psychiatric inpatients at a military treatment facility consented, were interviewed, and then received personalized handwritten letters or e-mails at regular intervals following discharge. Data collected included demographics, clinical characteristics, preference for e-mail versus postal mail, rates of undeliverable and return correspondence, rehospitalizations, and adverse events requiring safety procedures. Results: A total of 436 letters and e-mails have been sent to date. Most participants indicated preference for e-mail versus postal mail. Fifteen participants were readmitted for treatment compared to 20 patients in usual care. Twenty participants sent responses and all were positive statements about the program. There were no adverse events. Conclusions: This program is feasible for use at a military treatment facility. A randomized controlled trial is needed to determine whether the intervention can reduce suicide rates among military and veteran populations.     

Seasonality in suicide: a study of farming suicides in England and Wales

Seasonality in suicide rates has long been reported. Spring peaks in suicide deaths have been positively correlated with the proportion of the workforce engaged in agriculture. Some studies have indicated that suicides using violent methods are more likely to show seasonality. Recent research has suggested that seasonal patterns have diminished. This study examined deaths in male farmers, an occupational group which might be expected to be more vulnerable to seasonal influences because of the nature of their work and the relatively high proportion of farmers using violent methods for suicide. Data on suicides between 1982 and 1999 by males in England and Wales aged 15 years and over were provided by the Office for National Statistics. Seasonal patterns of suicide in farmers and nonfarmers were examined by nonparametric tests and harmonic analysis. No significant seasonal variation was found for farmers. For nonfarmers, although a chi-square test showed significant variation in monthly distribution, this was not found when a harmonic analysis was applied. There was no significant difference in the variation of violent suicides throughout the year. This study reinforces recent findings that seasonal variation in suicide appears to be diminishing, even in an occupational group where this might be expected.     

Suicidal behavior in a young offender population

Young offenders have numerous problems, including increased psychopathology, housing, and psycho-social stresses and increased rates of substance abuse. The current study investigated the contribution that substance use might make to a particularly vulnerable group of young people. Of the 300 young people approached for the study, 23.7% reported a prior suicide attempt. For this group, the most significant predictors of a prior suicide attempt were negative affect, prior exposure to violence, and housing stress. Life-time substance-use variables were most predictive of the number of suicide attempts a young person might make. Self-reported lethality (the expectation that on the last attempt the young person expected to die) was not strongly predicted by any variable. The research identifies the important role that dynamic risk factors (such as mood, substance use, and psychosocial stressors) play in increasing the risk of self-harm for young offenders, and raises the need to provide for more comprehensive discharge planning and support in order to manage these needs.     

Peer suicide prevention in a prison

Suicide rates among inmate populations in prisons are considerably higher than in the general population. Suicide prevention is a common need among penal institutions around the world. Traditional approaches involving only correctional staff in suicide prevention efforts have proven to have their limitations. The involvement of inmates in peer prevention efforts seems to be a reasonable alternative approach. This study examines such a program, called SAMS in the Pen, operated jointly between the prison and the Samaritans of Southern Alberta. This service, the first of its kind in Canada, involved inmate volunteers, known as SAMS, who were trained in listening skills, suicide prevention, and risk assessment. Data was collected for the research from volunteers, correctional staff, general inmate population, and professional staff. However, given the low absolute number in the one institution where the study was carried out, statistical analyses were not practical. As with any new service, the SAMS in the Pen experienced some developmental problems but was perceived to be a worthwhile service to both inmates and staff of the prison.     

Suicide and other external-cause mortality statistics in Ireland: a comparison of registration and occurrence data

There are two sets of annual mortality statistics released by the Central Statistics Office (CSO) in Ireland, one based on deaths registered in the particular year and the other based on the deaths that occurred in that year. We compared the registration and occurrence figures for suicide and for other deaths by an external cause for the years 1987-2003. The occurrence figures were, on average, 6% higher than the registration figures. There was evidence that the extent of the discrepancy increased over the study period, reaching almost 20% in recent years. The findings suggest that caution needs to be taken in the media reporting of registration figures for suicide and other external causes of death in Ireland and in the interpretation of these figures by health professionals.     

Adolescent self-poisoning: a cohort study of subsequent suicide and premature deaths

Previous self-harm has been identified as a risk factor for subsequent suicide by adolescents. The objective of the study was to identify further risk factors for subsequent premature death and suicide in a population of adolescents presenting with self-poisoning. A longitudinal cohort design using data-linkage of consecutive adolescent patients presenting to the Hunter Area Toxicology Service, a regional toxicology service for Newcastle, Australia, with the National Death Index of the Australian Institute of Health and Welfare was used. A total of 441 adolescents aged 10 to 19 years presented with self-poisoning over 5 years from January 1991 to December 1995, with follow-up to March 2001. There were 14 deaths total, eight of which were likely suicides. There was a 22-fold increase in suicide rate for males and a 14-fold increase for females compared with age-normalized population rates. Adjusted hazard ratios (95% CI) forpremature death were male gender 3.77 (1.11-12.78), nonaffective psychotic disorders 16.3 (3.83-69.34) and the mental illnesses of childhood 6.12 (1.68-22.23). There was a similar pattern for suicide: Male gender, nonaffective psychotic disorders, and the mental illnesses of childhood confer greater risk for subsequent suicide or premature death in this population.     

Social modeling in the transmission of suicidality

Evidence from twin, adoption, and family studies suggests that there is strong aggregation of suicidal behaviors in some families. By comparison, the role of social modeling through peers has yet to be convincingly established. This paper uses data from four large studies (the WHO/EURO Multicentre Study on Suicidal Behaviour, the WHO/SUPRE-MISS, the CASE study, and the Queensland Suicide Register) to compare the effects of exposure to fatal and nonfatal suicidal behavior in family members and nonfamilial associates on the subsequent suicidal behavior of male and female respondents of different ages. Across all studies, we found that prior suicidal behaviors among respondents' social groups were more important predictors of suicidal behavior in the respondents themselves than previous research had indicated. Community-based suicide attempters in the WHO SUPRE-MISS had higher rates of exposure to prior suicide in nonfamilial associates than in family members. In an adolescent population, exposure to prior fatal suicidal behavior did not predict deliberate self-harm when exposure to nonfatal suicidal behavior (both familial and social) were controlled for, but exposure to nonfatal suicidal behaviors in family and friends was predictive of deliberate self-harm and suicide ideation, even after controlling for exposure to fatal suicidal behavior. The potential impact of "containment" of information regarding suicidal behaviors as a prevention initiative is discussed, in light of information behavior principles of social marketing.     

Risk assessment and suicide prevention in primary care

General practitioners (GPs) are assumed to occupy an important position in the prevention of suicide through the introduction of risk assessment techniques commonly used in psychiatric practice. Despite this theoretical role for primary care services, it remains unclear how frequently GPs implement risk assessment in patients who may be vulnerable to suicide. To address this, a retrospective survey of probable suicides was conducted within a primary care setting utilizing a questionnaire of GPs who had experienced a patient suicide and was augmented by hospital and coroners' records. 85% of questionnaires were returned and 61 deaths were adjudged as suicides during the year long census period. 75% of suicides were male and 54% were aged under 35.28% were in contact with psychiatric services prior to death, although 60% had some diagnosis of mental disorder. GPs had little knowledge of a patient's life circumstances in up to half of cases. Recording of risk assessment occurred in 38% of subjects, was positively associated with prior psychiatric contact (p = 0.001) but negatively associated with presence of physical illness (p = 0.004), older patient age (p = 0.04), and GPs length in practice (p = 0.05). One GP felt their suicide case was preventable. The low rate of risk assessment and limited knowledge of patient lifestyle point to the need for active engagement of GPs in future suicide prevention strategies and should influence the content of training programs in primary care.     

Suicide rates and mental health services in modern China

Suicide rates in China have in the past been reported to be very low for a variety of historical and political reasons. In recent years, however, the reported suicide rates in China have increased alarmingly among certain age groups. This article reviews reports of the national rural suicide rates in China for 1992, gathered from the Annal of Chinese Public Health, which has previously never been reported publicly. The highest suicide rates occur in the rural areas and among young women and men over 60 years. These data reveal that suicide in China may have some unique characteristic associated with a variety of socio-cultural variables, such as traditional culture, social class, economic status, health care levels, and interpersonal problems. The author shows that lack of mental health services in rural areas in China may be considered one of associated reasons to the high rural suicide rate in China.     

Socioeconomic change and suicide: a time-series study from the Republic of Ireland

This ecological study examined the association between seven socioeconomic indicators (GDP, unemployment rate, female labor force participation rate, alcohol expenditure, marriage rate, percentage of births outside of marriage, and indictable crime rate) and total, male, and female rates of suicide and suicide plus undetermined death in Ireland during the period 1968-2000. Analysis of the data expressed as absolute values showed highly significant associations between the socioeconomic indicators and the total, male, and female suicide rates. However, these associations were explained by the strongly trended data. The trended nature of the data was removed by using year-to-year differences. Analysis of the first-differenced data showed that none of the socioeconomic indicators was associated with the total, male, or female suicide rates with the exception of indictable crime, which had a significant independent effect on the female suicide rate (coefficient = 2.0, p < .01) but not on suicide plus undetermined death. This study highlights the need to use econometric methods in time-trend analyses, the lack of age-sex specific exposure data in this area, and the challenge of understanding trends in suicide in their socioeconomic context.     

Unemployment and suicidal behavior in a New Zealand birth cohort: a fixed effects regression analysis

This study examined the association between exposure to unemployment and suicidal behaviors (suicidal ideation and attempted suicide) in a birth cohort of New Zealand young adults using fixed-effects logistic and Poisson regression models. Data were gathered on unemployment and suicidal behaviors at annual periods from ages 16-25 years. At all ages increasing exposure to unemployment was associated with increased risks of suicidal ideation (p < .0001) and number of suicide attempts (p < .0001). Following adjustment for fixed effects and time-dynamic covariates, associations between unemployment and suicidal ideation reduced to marginal significance (p < .10), while the association between unemployment and suicide attempts was not statistically significant (p > .10). After adjustment, those experiencing 6 or more months of unemployment in a given year had odds of suicidal ideation that were 1.43 (95% CI: .96 to 2.16) times higher, and rates of suicide attempts that were 1.72 (95% CI: .89 to 3.32) times higher, than those who were not exposed to unemployment. Although unemployment was associated with moderate increases in risks of suicidal behaviors, much of this association was explained by confounding factors.     

County council politicians' attitudes toward suicide and suicide prevention: a qualitative cross-cultural study

The purpose of the present study was to compare county council politicians' attitudes toward suicide and suicide prevention in five European countries. A questionnaire was distributed and here the responses to the open-ended questions are analyzed qualitatively. Considerable differences were found in what the politicians in the five countries believed to be the most important causes of suicide and how suicide can be prevented. There were also differences in to what degree the politicians revealed a judgmental attitude toward suicide, which seemed to be related to the magnitude of the problem in the respective countries. A certain implicit inconsistency in the logic directing the politicians' responses was found when their views on causes to suicide and suicide prevention strategies were compared. The responses indicate a need for increased consciousness and knowledge about suicide and suicide prevention among politicians in all the five countries. This is important since they are responsible for initiating and funding suicide preventive efforts.     

One-hundred cases of suicide in Budapest: a case-controlled psychological autopsy study

The authors performed a case-controlled psychological autopsy study of 100 successive suicides in Budapest, examining the presence of major depression, alcohol, and drug and/or medicament dependency/ abuse according to DSM-IV. The presence of somatic diseases, psychosocial stress, oppressive experiences, and interpersonal relationship disorders within the period of 1 month previous to death was also examined. The control group of 100 people who died of natural causes was identical with the suicide group in respect of number, sex, and age. RESULTS: Among those committing suicide, psychosocial stress, oppressive experiences, and interpersonal relationship disorders were much more frequent and behavioral changes occurred more often in the weeks preceding death compared to the control group. A single suicide attempt during one's life span did not prove to be predictive for a later fatal action, but multiple attempts did. Major depression was diagnosed in 36% of the cases in the suicide group and 17% in the control group. Half of major-depressed suicides (18 persons) and almost all in the control group (16 persons) suffered from reactive (secondary) major depression as a result of somatic disease. Severe alcoholism was found in 33% of the suicide cases and in 44% of the control group. Drug and/or medicament consumption (misuse and/or abuse) occurred in 14% and 8% of the cases, respectively. The data emphasize again that alcoholism seems to be one of the most serious problems in Hungary both in psychological and somatic illnesses.     

War Crimes in the Armed Conflict in Pakistan

Research on the characteristics of suicide bombers is reviewed. Contrary to previous commentary, it is suggested that suicide bombers may share personality traits (such as the "authoritarian personality") that psychological profiles of suicide bombers might be feasible, and that the suicide bombers may be characterized by the risk factors that increase the probability of suicide.‐     

The most common method of suicide in Tehran 2000-2004: implications for prevention

The likelihood of completing suicide depends to some extent on knowledge of effective means and also on the availability and/or acceptability of such methods. Since studying suicide methods may have an implication for prevention, the focus of this study was on the most favored method of suicide in Tehran, Iran. The study uses confirmed suicide data provided by the Beheshet Zahra Organization (BZO), which gathers all mortality data within Tehran and enters them into a computerized database, from which the relevant information for all the recorded suicide cases during the year 2000 to 2004 were obtained and analyzed. There were 703 cases of suicide (632 males and 71 females) in the BZO database, with a sex ratio of 8.9. The mean (standard deviation) of age at suicide for those who chose hanging and for those who have chosen other methods of suicide were 33.93 (14.2) and 34.60 (13.4) years, respectively. Hanging was the method favored by 572 (85.9%) of cases. Use of hanging was higher in females (61, 85.9%) than in males (511, 80.9%), and higher among the married (304, 53.6%) than among singles (268, 46.4%). The high proportion of persons using hanging as a method of suicide in Tehran may reflect the fact that this method is more acceptable and/or easily available and/or less likely to be misclassified as accidental or undetermined death. The prevention of such suicides is extremely difficult in the general population. Therefore, it is suggested that, to prevent suicide by hangings, the authorities should focus on the causal factors of suicide rather than on the acceptability and/or the availability of this method.     

Motor vehicle exhaust gas suicide in Victoria, Australia 1998-2002

Motor vehicle exhaust gas suicide (MVEGS) is the second most frequent method of suicide in Victoria, Australia. It is a highly lethal method of suicide with 1.5 deaths for every hospital admission. Australian regulations require all vehicles manufactured since 1998 to have a maximum carbon monoxide exhaust emission level of 2.1 g/km, reduced from the previous level of 9.6 g/km. Information surrounding all Victorian MVEGS between 1998-2002 was analyzed to determine whether suicides occurred in vehicles with the lower emission levels. Between 1998-2002, 607 suicides by this means were recorded while just 393 hospital admissions were recorded for the same period. Mean carboxyhaemoglobin levels were significantly lower in fatalities using vehicles manufactured from 1998, however suicide still occurred in these vehicles (n = 25). The extent to which the new regulations contributed to the relatively low rate of suicide in vehicles less than 5 years old compared to their frequency in the fleet remains unknown. Based on international experience and the age of the Victorian vehicle fleet, it may take well over a decade until substantial decreases in MVEGS are observed in the absence of active preventive measures.     

Elevated rates of suicidal behavior in gay, lesbian, and bisexual youth

Both clinical and epidemiological literature point to elevated rates of suicidal behaviors in gay, lesbian, and bisexual youth (GLBY). Recent North American and New Zealand studies of large populations (especially the US Youth Risk Behavior Surveys from several states) indicate that gay, lesbian, and bisexual adolescents (males in particular) can have rates of serious suicide attempts at least four times those of apparently heterosexual youth. There are various reasons why this figure is likely to be an underestimate. Reasons for these elevated rates of suicidal behavior include a climate of homophobic persecution in schools, and sometimes in family and community--values and actions that stigmatize homosexuality and that the youth who has not yet "come out" has to endure in silence.     

Preventing elderly suicide through primary care by community-based screening for depression in rural Japan

Depression is a major cause of suicide among the elderly. Few previous community-based interventions against depression have reduced the suicide rate. This study aims to evaluate outcomes of a community-based program to prevent suicide among the elderly using a quasi-experimental design with a neighboring reference group. The program, including depression screening with follow-up and health education through primary care and public health nursing, was implemented for 10 years in Matsudai town, a rural area of Japan (population 6,015; suicide rate per 10(5) [65-year-olds] for males 290.6, and for females 361.3). Changes in the suicide risk were estimated by the incidence rate ratio (IRR). The female risk of completing suicide in the intervention area was reduced by 70% (age-adjusted IRR: 0.30; 95% CI: 0.14-0.67), while there was no change in the risk for males in the intervention area nor for males or females in the reference area (Kawanishi town: population 9,425; elderly suicide rate for males 212.2, females 151.9). A ratio of the female IRR in the intervention area to that in its prefecture was also estimated at 0.45 (95% CI: 0.19-0.97), showing that the reduction of suicide risk in the intervention area was greater than the historical trend. A community intervention against suicide using management of depression with nonpsychiatric, primary health care would be effective for elderly females, but not males.     

Reaching suicidal people with media campaigns: new challenges for a new century

Five variables were investigated in the evaluation of Suicide Prevention Weeks (SPW) held in 1999, 2000, and 2001 in Québec, Canada: exposure to the campaign, previous suicide ideation, knowledge, attitudes, and intentions. After the year 2000 campaign, a telephone survey conducted on a representative sample of 1020 men revealed that only those actually exposed to the SPW had gained more knowledge of suicide facts and resources. However, the SPW did not influence attitudes or intentions to seek help. Results are not surprising, considering the low intensity of the campaign, especially in the media. Campaigns aimed at changing suicidal behaviors must be intensive.