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.     

Can a theory of suicide predict all "suicides" in the elderly?

Older adults consistently have the highest rates of suicide in most societies. Despite the paucity of studies until recently, research has shown that suicides in later life are best understood as a multidimensional event. An especially neglected area of research is the psychological/psychiatric study of personality factors in the event. This paper outlines one comprehensive model of suicide and then raises the question: Is such a psychiatric/psychological theory applicable to all suicides in the elderly? To address the question, I discuss the case of Sigmund Freud; raise the topic of suicide and/or dignified death in the terminally ill; and examine suicide notes of the both terminally ill and nonterminally ill elderly. I conclude that, indeed, greater study and theory building are needed into the "suicides" of the elderly, including those who are terminally ill.     

Suicide in Japan: present condition and prevention measures

This article introduces the reader to present conditions and suicide prevention measures in Japan. The suicide rate has increased gradually since the early 1990s, reaching a postwar peak in 1998. The number of suicides has remained at about 30,000 every year since 1998. Middle-aged (55-59 years) and elderly men have especially high suicide rates. In 2002, The Council of Learned People on Measures Against Suicides (organized by the Japanese Ministry of Health, Labor, and Welfare) released its report on national suicide prevention strategies. Although national suicide prevention strategies have just begun to be established, some prefectures or regions have undertaken unique suicide prevention measures.     

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.     

Assessment of accuracy of suicide mortality surveillance data in South Africa: investigation in an urban setting

Although it is not a legal requirement in South Africa, medical practitioners determine the manner of injury death for a surveillance system that is currently the only source of epidemiological data on suicide. This study assessed the accuracy of suicide data as recorded in the system using the docket produced from standard medico-legal investigation procedures as the gold standard. It was conducted in one of three cities where the surveillance system had full coverage for the year 2000. In the medico-legal system, one-third of cases could not be tracked, had not been finalized, or had unclear outcomes. For the remaining cases, the sensitivity, specificity, and positive and negative predictive values were generally high, varying somewhat across sex and race groups. Poisoning, jumping, and railway suicides were more likely than other methods to be misclassified, and were more common among females and Whites. The study provides encouraging results regarding the use of medical practitioner expertise for the accurate determination of suicide deaths. However, suicides may still be underestimated in this process given the challenge of tracing disguised suicides and without the careful examination of potential misclassifications of true suicides as unintentional deaths.     

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.     

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.     

Effect of the broadcast of a television documentary about a teenager's suicide in Israel on suicidal behavior and methods

Portrayals of suicide in the media are controversial because they may impact on suicide rates and methods. The aim of this study was to analyze the effect of the broadcast of a television documentary wherein an adolescent girl is interviewed about her suicide plan and subsequently dies by suicide. National suicide rates during the 8 weeks prior to the program and the 4 weeks following it were compared to the same periods in the previous year. There was no significant difference in the rates of completed and attempted suicides before and after the program. There was a shift toward the method used in the film after the broadcast, but it was found to be nonspecific to that year. A significant decrease was noted in the mean age of suicide attempters in the last promotional week prior to the broadcast compared to the previous year (p = .032). These preliminary findings suggest that the repeated televised promotion of a documentary on suicide may raise the risk of suicide in vulnerable populations. Further investigations in bigger populations are needed.     

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.     

A Psychological Re-Examination of Mental Health Problems among the 9/11 Terrorists

ABSTRACT

More than 15 years have passed since the terrorist attacks of 11 September 2001, and a comprehensive re-examination of the 9/11 attackers is now warranted. Research on the psychology of terrorists has evolved dramatically, and there is also new information on some offenders. The present study provides the available psychological and psychiatric evidence on each of the 9/11 pilots, muscle hijackers, and thwarted hijackers who intended to participate in the “planes operation.” Overall, findings suggest that the 9/11 terrorists may have had significantly more mental health problems than previously assumed, and the leaders who planned 9/11 personally approved suicide attackers with prior histories of mental illness. By widely publicizing this information, security officials may be able to more effectively delegitimize suicide terrorism and reduce the number of individuals who would consider funding, supporting, or committing these deadly attacks.     

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.     

Season and suicide: recent findings from Italy

Seasonal asymmetry in yearly suicide occurrence is a long-observed phenomenon in psychiatric, suicidological, and sociological research, and the effects of seasonal factors on suicidal behavior have been the focus of a number of earlier studies. Taking into account limitations of data and methods, these studies have generally favored interpretations based on psychosocial factors. Recent studies have challenged the widely held notion that seasonal effects on suicide are a unitary phenomenon, not influenced by age, gender, or circumstances of the act. In particular, the seasonal occurrence of suicides has been found to differ significantly between the young and the elderly, and differences have also been found between male and female cycles of occurrence. Suicides using violent methods have been shown to follow clearer seasonal patterns than suicides by less violent methods (such as drug or gas poisoning), possibly reflecting the greater impulsive component involved in the choice of a violent lethal means. In this paper, findings from Italy are used to illustrate the clinical implications of studies into the topic of season and suicide, with the aim of developing more effective preventative strategies.     

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.     

Suicide outside of prison settings among males under investigation for sex offenses in Ireland during 1990 to 1999

Thirty-two cases of suicide outside prison were identified among 7008 Irish men under investigation for sexual offenses between 1990 and 1999. Previously this risk category has not been identified. Risk ratios of 1/1644 for those accused of offenses against adults, and 1/24 for those accused of offending against minors, respectively, were estimated based on the conservative estimates found here. The increase in the base rate of suicide in Ireland during the study period is an insufficient explanation. The frequency is comparable to prison suicides for the period, and the population of risk may overlap. The incidence increases over the study period. It outpaces increases in prosecutions and may reflect responses to the changing social environment of these investigations. These men use community psychiatric services that may need to become aware of the increased risk of suicide they pose.     

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.     

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.     

Suicide,gender, and age variations in India. Are women in indian society protected from suicide?

A new set of data concerning the pattern of suicide in India between 1991-1997 are presented. Suicide rates rose over this period despite a small decline in the Indian suicide rate in 1995 and 1996. It was found that between 1995 and 1997 there was a modest fall in the suicide rates among under 29-year-olds of both sexes, and an increase among those 30 years and older. The pattern of suicides in India is bimodal: the incidence of suicides is highest for those in the 30-44-year-old category of both sexes and tends to decline in higher age categories. Suicide rates were nearly equal for young women and men, a contrast with the pattern of suicide sex ratios in eight developed countries.     

Suicidal behavior in the Ukraine, 1988-1998

This report studies the available data concerning suicide rates in the Ukraine and points to the importance of appropriate monitoring of suicides and attempted suicides. It illustrates the necessity of collecting this information and of developing "The Ukrainian National Program on Suicide Prevention." Unfortunately, suicide research and publications about suicide rates were prohibited in the former Soviet Union, so some of the data about suicidal behavior in the Ukraine is incomplete. We used the official suicide death statistics of the Ukraine from the Center of Statistics (Ukrainian Ministry of Health) for the period 1988-1998. The overall rate of suicide in the Ukraine is relatively high. Official statistics in the Ukraine show that there were 29.6 suicides per 100,000 population in 1998. The frequency of completed suicide differs in the various regions of the country, suicides being more frequent in the industrially developed regions and in the rural areas of the country than in the cities. In the western part of the Ukraine the frequency of suicide is relatively low (11.1 per 100,000). Between 1988 and 1997 the suicide rate increased by 57%. In 1998 the suicide rate for women was approximately five times lower than that for men.     

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.     

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.