Familial study of suicidal behavior among adolescents in Slovenia

The number of adolescents who attempt or complete suicide is increasing. Risk factors range from mental disorders, to problems at school, family problems, or difficulties in establishing relationships. A further important, and too often underestimated, risk factor for adolescent suicide is the presence of suicidal behavior in the adolescent's family. We investigated 184 high school adolescents in a region in Slovenia with a high suicide rate (30/100,000/year). They were questioned by means of an anonymous questionnaire about the presence of suicidal behavior in their relatives and about the presence of suicidal thoughts, plans, and acts in themselves. The results revealed that 13% of the adolescents studied had a relative who had attempted suicide and a further 9% of the adolescents had lost a relative due to suicide. About half of all females and almost a third of males had had suicidal thoughts (differences between sexes were statistically significant: chi2 = 6.13; p < .01). Attempted suicide among relatives was positively correlated with the presence of suicidal plans among adolescents (phi = 0.15; p < .05). This correlation proved to be even stronger and statistically more significant in men when we split the sample by gender. All variables (suicidal thoughts, suicidal plans, and suicide attempts) in the adolescent males positively correlated with attempted suicide among their relatives ((phi = 0.28, p < .01; phi) = 0.26, p < .05; phi = 0.34, p < .01; respectively). Our results speak in favor of a higher risk of suicidal behavior among adolescents with suicidal behavior in their families.     

Child and adolescent survivors of suicide

Suicide in a family is distressing for each and every member. Children and adolescents bereaved by suicide are known to be more at risk of suffering from a variety of psychiatric problems, especially affective disorders. A group of children and adolescents who experienced a suicidal death in the family were assessed for psychiatric problems as well as for social adjustment. The findings suggest that the bereaved children and adolescents are at elevated risk for major depressive disorder, posttraumatic stress disorder, and impaired social adjustment.     

Child and adolescent suicide deaths in New Mexico, 1990-1994

The suicide death rate in New Mexico is consistently higher than the national rate. Among adolescents, suicide is the third leading cause of death nationally, but in New Mexico it is the second leading cause of death. This study describes the pattern of adolescent suicide deaths in New Mexico. We conducted a retrospective review of all medical examiner autopsies for adolescent suicides (ages 20 years and younger) in New Mexico from 1990-1994. Records were reviewed for demographics and possible contributing factors such as depression, previous attempts, and alcohol and drug use. We identified 184 suicide deaths among children and adolescents ages 9-20 years for an overall rate of 12.9 per 100,000. Our rates for ages 5-9 years (0.2), 10-14 years (3.8), and 15-19 years (22.3) are over twice the U. S. rates. Suicide deaths resulted primarily from firearms (67%), hanging (16%), poisoning (6%), inhalation (4%), and other methods (7%). Method varied by ethnicity (p = .01) and gender (p = .03); males and non-Hispanic Whites were overrepresented among firearm deaths. Firearm ownership was known in 60 (48%) of the firearm deaths. Of these, 53% of the firearms belonged to a family member, 25% to the decedent, and 22% to a friend. Over one-third of decedents (41%) experienced mental disorders, primarily depressed mood and clinical depression. Previous suicide attempts were noted for 15% of the decedents. Some 50% of the decedents had alcohol or drugs present at the time of death; among American Indians/Alaska Natives, 74% had drugs or alcohol present (p = .003). Targeted interventions are needed to reduce adolescent suicide in New Mexico. We suggest raising awareness about acute and chronic contributing factors to suicide; training physicians to look for behavioral manifestations of depression; and involving physicians, teachers, and youth activity leaders in efforts to limit firearm accessibility, such as advising parents to remove firearms from their households.     

Deliberate self-harm patients who discharge themselves from the general hospital without adequate psychosocial assessment

Deliberate self-harm patients who leave the acute hospital environment before the completion of psychiatric assessment have an increased risk of subsequent self-harm. We considered the available data on 50 premature self-discharges identified prospectively in a general hospital with a well-developed integrated-care pathway for self-harm patients, and compared them to a control group. The self-discharge group was found to be more likely to have attempted self-poisoning without alcohol intoxication or other forms or combinations of self-harm, and an absence of identifiable previous self-harm or prior contact with local specialist psychiatric services. The two groups showed no difference in age, sex, or area of residence based on community mental health team sectors. It is proposed that these findings indicate hypotheses for further studies of why people leave the hospital without adequate assessment, and how service design could be improved in order to help them.     

Suicidal ideation and suicide attempts among Australian adults

Too little is known about suicidal thoughts and behaviors at a population level to recommend appropriate preventive strategies. Using data from the Australian National Survey of Mental Health and Wellbeing (NSMHWB), this study examined rates of, and risk factors for, suicidal ideation and suicide attempts. For 10,641 respondents, the 12-month and lifetime cumulative incidence rates of suicidal ideation were 3.4% and 16.0%, respectively; the 12-month and lifetime cumulative incidence rates of suicide attempts were 0.4% and 3.6%, respectively. 12-month ideation was associated with anxiety disorders (relative risk ratio [RRR] = 3.51; population attributable risk percent [PAR%] = 19.6%), affective disorders (RRR = 11.94; PAR% = 38.8%) and substance abuse disorders (RRR = 1.85; PAR% = 6.1%). Attempts in the past 12 months were also associated with anxiety disorders (RRR = 7.06; PAR% = 37.0%), affective disorders (RRR = 12.24; PAR% = 39.5%), and substance abuse disorders (RRR = 2.09; PAR% = 7.7%). Age, marital status, and disability were associated with ideation; marital status and employment status with attempts. Approximately 12% of ideators in the sample progressed to making an attempt; employment status was the only significant predictor. Reducing suicidal ideation and attempts requires a multi-faceted approach that targets those with mental illness but also adopts population-based strategies that address other factors, such as unemployment.     

Suicide risk in outpatients with specific mood and anxiety disorders

The present study examined the relationships between specific anxiety, mood disorders, levels of hopelessness, and suicide ideation. The sample consisted of 606 outpatients recruited from several psychiatric settings. It was found that dysthymia was significantly associated with hopelessness. Patients presenting major depressive episode with higher anxiety symptoms had significantly increased scores on the hopelessness scale. Major depressive episode and bipolar disorder, but not dysthymia, were significantly associated with higher levels of suicide ideation. Increased levels of anxiety symptoms in patients with dysthymia were associated with increased levels of suicide ideation, while increased depressive symptoms in patients with specific phobia and generalized anxiety disorder were associated with significantly lower levels of suicide ideation. The findings suggest that depressive disorders, but not anxiety disorders, constitute risk for suicide. Moreover, the differentiation between a depressive and an anxiety disorder as the principal diagnosis, as well as the assessment of anxiety-level symptoms in patients with major depressive episode and dysthymia, seems of special relevance when assessing suicide risk.     

Sati: a type of nonpsychiatric suicide

Sati as an act of ritual suicide has been reported from the Indian subcontinent, especially among the Hindus, for several centuries. Although legally proscribed, these acts occur even now in modern India. The principle behind such acts has been put forward as the principle of good wife. There is little evidence to suggest that women who commit this act suffer from a formal mental illness. Cultural factors and gender role expectations play a significant role in the act and its consequences. Using recent examples, this paper illustrates the cultural factors, which may be seen as contributing to the act of suicide. Other factors embedded in the act also emphasize that not all suicides have underlying psychiatric disorders and clinicians must take social causation into account while preparing any prevention strategies.     

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.     

The media and suicide: a cautionary view

There is now unequivocal statistical evidence of an association between some media portrayals of suicide and further subsequent suicide. However, it is a weak association, and it is probably of far less importance than our need to address basic principles of good mental health management. Rather than prescribe to the media how to report suicide, its potentially positive effects should be addressed.     

Evidence-based prevention strategies of suicide behavior in the world: implications for Slovenia

In this review we consider how Slovenia could consider tackling its high rate of suicide (overall 29 per 100,000, 46 in males, 13 in females). First, we consider the evidence for risk factors that may contribute to Slovenia's high rate of suicide. Second, we describe the interventions to try to reduce the impact of these factors and the evidence for such interventions. We categorize interventions in terms of their operation at either the population level or that of high-risk groups. However, it should be borne in mind that settings often assumed to provide access to population groups, such as general practice and schools, do not reach some people who are likely to be at high risk; for example those who have dropped out of school or who have been excluded from a GP's list. We focus particularly on those for high-risk groups, as a number of East-European countries with high suicide rates such as Slovenia, Hungary, and the Baltic republics are currently considering a shift toward more community-based mental health services. The provision of community mental health services in Slovenia would provide an opportunity to study their impact on the suicide rate. However, we conclude that their development should be accompanied by other initiatives operating at population levels. This multilevel approach acknowledges the complexity of the etiology of suicide, the impossibility of reaching all those at risk through services and the lack of strong evidence for any one intervention.     

Suicide on the Indian subcontinent

The Indian subcontinent comprises eight countries (India, Pakistan, Bangladesh, Nepal, Sri Lanka, Afghanistan, Bhutan, and the Maldives) and a collective population of more than 1.3 billion people. 10% of the world's suicides (more than 100,000 people) take place in just three of these countries, viz. India, Sri Lanka, and Pakistan. There is very little information on suicides from the other four countries. Some differences from suicides in Western countries include the high use of organophosphate insecticides, larger numbers of married women, fewer elderly subjects, and interpersonal relationship problems and life events as important causative factors. There is need for more and better information regarding suicide in the countries of the Indian subcontinent. In particular, studies must address culture-specific risk factors associated with suicide in these countries. The prevention of this important public health problem in an area of the world with myriad socio-economic problems, meager resources, and stigmatization of mental illness poses a formidable challenge to mental health professionals, policy makers, and governments of these countries.     

The prevention of suicide in India and the developing world: the need for population-based strategies

Very high rates of suicide have been reported from India and the developing world. However, much of the debate on suicide prevention focuses on individuals, methods, site-specific solutions, or particular suicide prevention strategies. This article argues for population based approaches that focus on improving the general health of populations (e.g., macroeconomic policies that aim for social justice, schemes to meet basic human needs, organizing local support groups within vulnerable sections of society, developing and implementing an essential pesticide list, addressing gender issues, and increasing public awareness through the mass media) rather than medical, psychiatric, and other strategies that target individuals (e.g., treatment of mental illness, counseling, etc.) in order to reduce high suicide rates in India and developing countries. Individual approaches will help people in distress and prevent individuals from committing suicide, but will not reduce population suicide rates.     

The main factors of repetition: review of some results of the Pecs Center in the WHO/EURO Multicentre Study on Suicidal Behaviour

The authors obtained more information about the characteristics of suicide attempters in order to examine the most important differences between those who attempted suicide for the first time (first-evers) and those who had a previous attempt (repeaters). Within the framework of the WHO/EURO Multicentre Study on Suicidal Behaviour in Pecs Center, 1158 cases of parasuicide were collected over 4 years (July 1, 1997-June 30, 2001). In the monitoring sample, 728 (62.9%) parasuicide acts were committed by women and 430 (37.1%) by men, and more than half of the attempters had made a previous attempt In the logistic regression model a higher risk of repetition was found to be related to being divorced (OR 1.84), unemployed or economically inactive (OR 1.45), and without higher education (OR 2.54). In the sample, mental disorders were the most significant risk factor for repeated attempts. The odds ratio was highest (OR 5) for personality disorders. The results may reflect (besides some factors of social destabilization) a higher importance of major mental health problems among repeaters. For this reason, more effective recognition and treatment of the underlying psychiatric and social conditions of suicide attempters has special importance to prevent future suicidal behaviour.     

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.     

Cathartic effect of suicide attempts not limited to depression: a short-term prospective study after deliberate self-poisoning

The cathartic effect of suicide is traditionally defined as the existence of a rapid, significant, and spontaneous decrease in the depressive symptoms of suicide attempters after the act. This study was designed to investigate short-term variations, following a suicide attempt by self-poisoning, of a number of other variables identified as suicidal risk factors: hopelessness, impulsivity, personality traits, and quality of life. Patients hospitalized less than 24 hours after a deliberate (moderate) overdose were presented with the Montgomery-Asberg Depression and Impulsivity Rating Scales, Hopelessness scale, MMPI and World Health Organization's Quality of Life questionnaire (abbreviated versions). They were also asked to complete the same scales and questionnaires 8 days after discharge. The study involved 39 patients, the average interval between initial and follow-up assessment being 13.5 days. All the scores improved significantly, with the exception of quality of life and three out of the eight personality traits. This finding emphasizes the fact that improvement is not limited to depressive symptoms and enables us to identify the relative importance of each studied variable as a risk factor for attempted suicide. The limitations of the study are discussed as well as in particular the nongeneralizability of the sample and setting.     

Assessing suicide risk in cluster C personality disorders

The aim of the study was to assess suicide risk in psychiatric outpatients with specific cluster C personality disorders (avoidant, dependent, and obsessive-compulsive). A sample of 142 psychiatric outpatients was used for the study. The sample was composed of 87 outpatients meeting diagnostic criteria for a personality disorder and 53 psychiatric outpatients meeting criteria for an axis I disorder only. The results showed that dependent, but not avoidant or obsessive-compulsive, personality disorders, as well as the clusters A and B personality disorders, were significantly associated with suicide attempts. This association remained significant after controlling for both a lifetime depressive disorder and severity of depression for the cluster A and the cluster B personality disorders, but not for dependent personality disorder. The results underline the importance of assessing suicide risk in patients with cluster A and cluster B personality disorders, while the assessment of suicide risk in patients with cluster C personality disorders seems to be irrelevant as long as assessment of a comorbid depressive disorder is appropriately conducted.     

Coping with youth suicide and overdose: one community's efforts to investigate, intervene, and prevent suicide contagion

From 2000-2005, Somerville, MA, experienced a number of youth overdoses and suicides. The community response followed CDC recommendations for contagion containment. A community coalition, Somerville Cares About Prevention, became a pivotal convener of community partners and a local research organization, the Institute for Community Health, provided needed expertise in surveillance and analysis. Mayoral leadership provided the impetus for action while community activists connected those at risk with mental health resources. Using a variety of data sources (including death certificates, youth risk surveys, 911 call data, and hospital discharges) overdose and suicide activity were monitored. Rates of suicide and overdose for 10-24-year-olds were higher than in previous years. Using case investigation methods, the majority of suicide victims were found to be linked through common peer groups and substance abuse. Subsequent community action steps included: a community-based trauma response team, improved media relationships, focus groups for suicide survivors, and prevention trainings to community stakeholders. Youth suicide and overdose activity subsided in May of 2005. The community partnerships were critical elements for developing a response to this public health crisis. This collaborative approach to suicide contagion used existing resources and provides important lessons learned for other communities facing similar circumstances.     

A pilot study of the suicide victim's last contact with a health professional

Suicide victims frequently have contact with health care professionals in the months before death. The primary aims of this pilot psychological autopsy study were to determine the feasibility of undertaking a full study and to describe the characteristics of the last health care professional contacts with suicide victims aged > 34 years. We interviewed the informants of 52 suicides. Interviews were obtained from 37 health care professionals who had contact with 28 of the suicides during the 3 months before death. The primary reasons for the last contact with the health care professional were mental health (62%), physical health (22%), and social (14%). 87% of health care professional contacts occurred within 1 month of death. Symptoms of depression were noted in 49% of health care professional contacts. Consensus psychological autopsy diagnoses of depression were made in 64% of suicide victims. Overall suicide risk was assessed by 38% of health care professionals during their last contact. This was more likely to occur when the deceased presented as depressed, was aged < 60 years or seen by a psychiatrist. None was assessed to be suicidal. The family informants regarded nine of the suicide victims to have been suicidal before death but informed a health care professional in only one third of the cases. Critical information that might have altered the management is not often accessed from family members.     

Predicting suicidal risk in a cohort of depressed children and adolescents

Background: In children and adolescents with a depressive disorder, predicting who will also go on to exhibit suicide-related behaviors (SRBs), including suicide attempt or self-harm, is a key challenge facing clinicians. Aims: To investigate the relative contributions of depressive disorder severity, hopelessness, family dysfunction, and perceived social support to the risk of suicide-related behaviors. Methods: This was a cross-sectional study of a group of 10-16-year-olds with major depressive disorders and dysthymic disorder. Results: Child-rated depressive disorder symptom severity emerged as the greatest predictor of risk. Hopelessness and family dysfunction were also significant predictors of SRBs. In combination these variables were strong predictors, accounting for 66% of the variance. This is a cross-sectional study design, rather than longitudinal, therefore risk prediction over time was not possible. Conclusions: Understanding the child and adolescents depressive disorder symptom severity from their perspective, their level of hopelessness, as well as their family context is critical in understanding the risk of SRBs. These findings may help to provide direction for targeted interventions to address these clinical risk factors.