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.     

The protective role of parental involvement in adolescent suicide

This study of 2,722 adolescents aged 14-18 years explored whether parental involvement can protect against adolescent suicide attempts. Compared to their counterparts suicide attempters were more likely to have been in trouble with the police, to report lower levels of parental interest and academic motivation, and to report suicidal ideation and using alcohol or an illegal drug when they feel stressed. They were also less likely to reside with both parents. The association between parental involvement and suicidal behaviour was not stronger for sons than for daughters or for adolescents who had experienced family disruption than for those who grew up in two-parent families.     

Newspaper reporting of suicide cases in Hong Kong

This study addresses the concerns over newspapers' reporting of suicide cases in Hong Kong, SAR (Special Administrative Region), using the WHO guidelines on the reporting of suicide news as a reference for comparison. We compared the official suicide information extracted from the Coroner's Court for the year 2000 with newspaper reports on suicides taken from five major Chinese local newspapers, which accounted for about 80% of the total circulation in Hong Kong. The type of newspaper reporting on suicides was also examined. Newspapers tended to report on those suicide victims who suffered relationship problems, whereas those who had family problems were significantly underreported. Among the suicides reported in the newspapers, 6.2% were found on the front page and the majority of the reports were presented pictorially. The reporting of suicides was selective and the coverage was incomplete, with student suicides reported excessively. The method of reporting for Hong Kong newspapers was not in line with the recommendations of the WHO or international best practices on presenting suicide news. For this reason we recommend a partnership approach with active participation from the media on suicide prevention so that communication professionals can proactively participate in suicide prevention work more effectively.     

Outcome of suicidal ideation and behavior in a young, help-seeking population over a 2-year period

Suicidal behavior is associated with negative outcomes, including completed suicide. This study examined the prevalence of suicidal behavior in a sample of referrals to a youth psychiatric service and investigated the stability of suicidality over 2 years. Of the 140 people (mean age 17.8) who were referred to a youth psychiatric service, 82 who were accepted for treatment (RA group) and 58 who were not accepted (RNA group) were assessed; 57% reported considering suicide and 39% reported attempting suicide in the 12 months prior to referral. Participants who reported suicidal ideation were significantly more likely than nonsuicidal participants to have multiple Axis I diagnoses and lower levels of functioning. At the 2-year follow-up there was a significant reduction in suicidality in the RA group, but not in the RNA group. In conclusion, suicidality is prevalent among young people referred to psychiatric services. Even brief contact with services results in a reduction in suicidality over 2 years.     

A Historical Analysis of Mass Casualty Bombers

Over the past two decades repeated attempts have been made to identify the next "new" form of terrorism, but all have come up short. Modern terrorism is not about the next trend, but is--and long has been--characterized by mass casualty bombers (defined as those terrorist groups that have killed 25 or more people in a bombing attack). When compared to other "new" terrorists, mass casualty bombers are more prolific than state-sponsored terrorists, more deadly than suicide terrorists, more identifiable than religious terrorists, and more plausible than CBRN terrorists. Mass casualty bombers have long presented the greatest terrorist threat to international peace and security and will likely continue to do so in the future.     

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.     

How did Tarasoff affect clinical practice?

The Tarasoff decisions of the California Supreme Court in 1974 and 1976 held that psychotherapists could be held liable for failing to protect the victims of their potentially violent patients. Our survey of psychiatrists, psychologists, and social workers in eight metropolitan areas showed that Californians were more likely to have heard of the case, to believe it required warning the likely victim, and actually to issue warnings in such cases than were psychotherapists from other jurisdictions. Therapists were more willing to take steps to protect victims in 1980 than in 1975, but willingness to warn increased more among Californians than among those in other states. We conclude that although Tarasoff has influenced therapists' attitudes and behavior more in California than elsewhere, the case has also affected psychotherapeutic practice nationally.     

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.     

History of childhood abuse and neglect and suicidal behavior at hospital admission

Suicide is a major public health problem. Preventive measures have been sought by identifying risk factors. This study evaluates the association of childhood abuse and neglect with suicidal behavior at the time of psychiatric hospital admission. A total of 120 subjects (72 females; mean age 42.5 +/- 15.6 years old) admitted from August 2006 to July 2007 completed the Childhood Trauma Questionnaire (CTQ) to assess severity of exposure to childhood maltreatment. Thereof 62 (51.6%) patients presented with suicidal behavior at admission. Patients who had attempted suicide had significantly higher CTQ scores. Regression analysis indicated that shorter illness duration and severity of childhood maltreatment were predictors of suicidal behavior at admission. The study showed that inpatients of a psychiatric unit of a general hospital who experienced severe childhood abuse or neglect were significantly more likely to present with suicidal behavior. History of childhood maltreatment should be evaluated as an associated risk factor of suicidal behavior at admission of psychiatric inpatients.     

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.     

Attitudes toward suicide bombing in Pakistan

Although suicide bombing is a historical phenomenon, there has been a recent upsurge in such incidents. In Pakistan, over the last year, more than 1,000 people have been killed in suicide bombing incidents. Assessing the attitudes and perceptions of people toward suicide bombing can help understand some of the root causes of this phenomenon. In this pilot study, we conducted a cross-sectional survey of people (N = 215) in Karachi, Pakistan, to assess their attitudes and perceptions toward suicide bombing. The majority of the respondents condemned suicide bombing and disagreed with the notion that Islam or any other religion supports it. Belonging to the Sunni Muslim sect and strong adherence to religion predicted support for suicide bombing. The majority believed suicide bombing to be a result of religious fundamentalism. Opinion was divided as to whether suicide bombers have an underlying psychiatric illness. Further studies with larger sample sizes are needed to determine the attitudes and perceptions of the Pakistani population regarding this important issue.     

Male and Female Suicide Bombers: Different Sexes,Different Reasons?

This article analyzes the motivations and recruitment of female suicide terrorists. Biographical accounts of 30 female and 30 male suicide terrorists were coded for method of recruitment, motivation for attack, and outcome of attack. A log-linear analysis found that female suicide terrorists were motivated more by Personal events, whereas males were motivated more by Religious/nationalistic factors. Females were equally likely as males to be recruited through peer influence, exploitation, or self promotion, whereas males were more likely to be recruited as a result of religious persuasion. The results highlight the need for continued research into female terrorism.     

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.     

Restoring Choice: The Relationship Between Offense Seriousness,Intervening Time,and Victims’ Responses to the Offer of Restorative Interventions

This study investigates victims’ responses to the offer of involvement in a restorative intervention. It tests the hypotheses that victims’ choices are related to the seriousness of the offense (H1), and that this relationship is moderated by how long after the offense the restorative intervention is offered (H2). A cross-sectional, between-subjects design was used, drawing on data from 256 offenses collected for operational purposes by a restorative justice service. Victims of medium-seriousness offenses were most likely to choose indirect and direct reparation. Intervening time moderated the relationship between seriousness and victim choice: victims of low-seriousness offenses became more likely to choose community reparation with time, victims of medium-seriousness offenses became less likely to choose direct or indirect reparation, and there was no change with time for victims of the most serious offenses. These results suggest nonlinear relationships between seriousness, intervening time, and victim choice. Although more complex and in different directions than anticipated, they lend some support to both hypotheses. The study highlights qualitative differences between types of restorative interventions, points to a significant disparity between victims’ choices and processes the literature suggests are of most benefit, and raises questions regarding when and how restorative interventions should be offered.     

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.     

The content of suicide notes from attempters and completers

A study of the content of suicide notes from attempted suicides and completed suicides was conducted using the Linguistic Inquiry and Word Count (LIWC) text analysis program. Notes from completed suicides had fewer metaphysical references, more future tense verbs, more social references (to others) and more positive emotions than did the notes from attempted suicides. The implications of these results were discussed.     

Sexual Violence Against Marginalized Victims: Choice of Victim or Victim of Choice?

Research shows that sex trade workers and homeless populations are at a high risk of severe violence and homicide. Based on a sample of 229 violent sex offenders, we investigate the differences between sexual crimes committed against marginalized (n = 73) and nonmarginalized victims (n = 156). Findings from logistic regression analyses show that offenders who target marginalized victims are more likely to degrade their victim and use a variety of torture methods. However, offenders who target nonmarginalized victims are more likely to use a weapon, and kill the victim by strangulation. Implications for future research are discussed.     

The privilege and responsibility of suicide prevention

Each year about a million people worldwide take their lives, and a further unknown number, but probably no less than 20 million, attempt suicide. In addition, for every person who engages in suicidal behavior, another five or six will be associated with them in some way, making a conservative total of 100 million people worldwide who are affected each year--and to whom we have some degree of responsibility. There is no one approach to suicide prevention, and probably more so than for any other human condition, we are privileged to be able to collaborate with many different disciplines in our endeavors. However, there is a considerable responsibility to ensure that whatever our own area of expertise and interest may be, we should apply universal principals of objective analysis to these diverse contributions. This is addressed by examining research from four broad areas. First, there are studies that irrevocably bring together the sociological and biological approaches to suicide. Second, there are reports that support the notion of the universality of suicide. Third, despite considerable attention paid to the media, its influence on suicide is very limited. And finally, although there have been pessimistic reviews, there are persuasive data from innovative research designs that have documented that we can prevent suicide.