An Unmatched Case‐Control Study of Nearly Lethal Suicide Attempts in Houston,Texas: Research Methods and Measurements

T his article details the research methods and measurements used in conducting a population‐based, case‐control study of nearly lethal suicide attempts among persons aged 13–34 years, residing in Houston, Texas. From November 1992 to July 1995, we interviewed 153 case subjects presenting at one of three participating hospital emergency departments and used random digit dialing to identify 513 control subjects residing in the same catchment area in which cases were enlisted. Unlike most research in this area, this study was designed to extend our understanding of suicidal behavior and prevention activities beyond identification and treatment of depression and other mental illnesses. We discuss the overall strengths and weaknesses of our study design and conclude that this methodology is well suited for studying rare outcomes such as nearly lethal suicide.     

The Choice of Weapons: A Study of Methods of Suicide by Sex,Race, and Region

ABSTRACT: The relationship of sex, race and region to methods of suicide are used to test the validity of two theories which attempt to explain the choice of methods among suicide victims. The two theories, lethality of intent and differential socialization with firearms, are briefly discussed. Data are collected from official death certificates in five cities during a three year period, 1969 through 1971. The findings provide little support for the lethality of intent theory. Although the differential socialization theory receives partial support, one can argue for a broader sociocultural perspective on methods of suicide which includes location in the social structure as well as regional socialization.     

Examining the impact of psychiatric diagnosis and comorbidity on the medical lethality of adolescent suicide attempts

Specific psychiatric diagnoses and comorbidity patterns were examined to determine if they were related to the medical lethality of suicide attempts among adolescents presenting to an urban general hospital (N=375). Bivariate analysis showed that attempters with substance abuse disorders had higher levels of lethality than attempters without substance abuse. Regression results indicated having depression comorbid with any other diagnosis was not associated with medical lethality. However, having a substance abuse disorder was associated with higher suicide attempt lethality, highlighting the importance of substance abuse as a risk factor for lethal suicide attempts in adolescents. This finding stimulates critical thinking around the understanding of suicidal behavior in youth and the development and implementation of treatment strategies for suicidal adolescents with substance abuse disorders.     

Sex differences in adolescent suicides in Norway, 1990-1992

All suicides in persons under 20 years in Norway in the time period 1990-1992 (99 males, 30 females) were included in a postmortem case-control study with seven controls for each suicide, focusing on gender differences. Few sex differences between the suicide completers were evident, in spite of the difference in suicide rates (M/F rate ratio = 3.0). Females more often attempted suicide (p = .05), more often wrote farewell notes (p = .03), and used less violent suicide methods (ns). The adjusted risk for suicide related to affective disorders (Female OR = 22,1; Male OR = 24.0, both p = .000) and disruptive disorders (female OR = 14,7, ns; male OR = 5.0, p = .002) differed little, as did the effect of frequent use of alcohol or substances (female OR = 0.4, ns; male OR = 0.4, ns).     

Epidemiologic Characteristics and Trends of Fatal Suicides among the Elderly in Taiwan

Taiwan has one of the highest suicide rates in the world, especially among its elderly. The epidemiologic characteristics and trends of the surging elderly suicide rates from 1993 to 2003 are described, with a special emphasis on the risk groups, the methods used in suicide, and their geographical variations. Data on annual mortality for persons over 65 years of age with external cause‐of‐death codes E950–E959 were obtained from the Death Certification data file provided by the Department of Health and used in the analysis. The suicide rate for each 5‐year age group over 65 years old increased during the 11‐year period. Elderly males had the highest suicide rate and experienced an increased rate of 49% during the decade. The average suicide ratio between elderly males and females was about 2:1. Never‐married males had the highest age‐adjusted as well as sex‐ and marital status‐specific suicide rates, and showed an increased rate of 66% over the 11‐year period. Geographical variations in suicide rates were significant, with the lest urbanized eastern Taiwan having a higher rate than other regions. Hanging, strangulation, and suffocation were the most used methods for committing suicide by the elderly, but their use had decreased from 63% to 54% during the decade; but jumping off a building and drowning increased significantly. Variation in suicide rate among months was not significant. With the increase in the elderly suicide rate, more governmental and societal interventions are needed to alleviate this social and human problem.     

Risk for Suicide among Medicaid Beneficiaries

Demographic, diagnostic, and service expenditure characteristics of Florida Medicaid enrollees who died by suicide were investigated. Among persons receiving Medicaid and Supplemental Security Income (SSI), findings indicate the most powerful predictors of suicide were involuntary psychiatric examination, mental health hospitalization, and high mental health service use. Among Medicaid enrollees not receiving SSI, strongest suicide predictors were mental health hospitalization, high expenditures for physical health medications, and involuntary psychiatric examination. Findings suggest reducing involuntary psychiatric examinations and mental health hospitalizations while improving physical health may reduce suicide in the Medicaid population. Comprehensive hospital discharge planning, adherence monitoring with follow‐up care, training mental health providers in assessing suicide lethality, and providing adequate assessment time are all crucial to achieve these objectives.     

Evaluation of a Suicide Prevention Center by Sampling the Population at Risk*

ABSTRACT: At present there are no clear guidelines for assessing the effectiveness of suicide prevention and crisis centers. This report focuses on one readily available source of data, specifically that segment of the population at risk made up of persons admitted to the inpatient service of a mental health center due to depressive and/or suicidal states, including suicide attempts. To determine the role of the suicide prevention center in providing services to this group, 575 persons meeting these criteria were interviewed. The findings included the following: (a) 11 percent had utilized suicide prevention center services, with 59 percent of these experiencing substantial benefit; (b) 20 percent stated they were unaware of the center; (c) 8 percent expressed the view that calling the center would be inappropriate because a suicide attempt was not imminent; and (d) 26 percent indicated an inclination to call the center in the event of subsequent difficulties. Experience suggests that response to a crisis (intervention) as well as response to low lethality callers with “everyday problems” (prevention) constitute valid functions of a suicide prevention and crisis center. Preoccupation with short-term goals, such as reducing the apparent suicide rate, should not dominate the conceptualizing of program evaluation methods.     

Method choice, intent, and gender in completed suicide

Women who commit suicide use less violent methods, such as drugs and carbon monoxide poisoning, than do men, who more often use violent methods such as guns and hanging. Theories that attempt to explain this finding focus on gender differences in suicidal intent, socialization, emotions, interpersonal relationships, orientation and access to methods, and neurobiological factors. Data from a psychological autopsy study were used to test the theory that women who commit suicide use less violent means because they are less intent on dying. Although women were significantly less likely to use a violent method than men, there was no difference in the lethality of their suicidal intent.     

Influence of Religious Factors on Attitudes Towards Suicidal Behaviour in Ghana

The objective of this qualitative study was to understand how religion influences lay persons’ attitudes towards suicide in Ghana. Twenty-seven adults from both rural and urban settings were interviewed. Interpretative phenomenological analysis was used to analyse the data. Results showed that the participants are committed to core and normative religious beliefs and practices they perceived as life preserving. Such an understanding influenced their view of suicidal behaviour as unacceptable. Nevertheless, religion facilitated their willingness to help people during suicidal crisis. Religious commitment theory is used to explain some of the findings of this study. Implications for suicide prevention are discussed.     

Association of suicide rates of elderly persons with fertility rates

A negative correlation between societal suicide rates and social integration has been reported, but rarely specifically examined for suicide rates of the elderly although suicide rates of elderly persons are among the highest. The associations of suicide rates of elderly persons and fertility rates for 81 countries were examined using data from the World Health Organisation and United Nations. Fertility rates were considered a proxy measure for social integration. Multiple regression analysis indicated that suicide rates for males and females in the age bands 65-74 years and 75+ years were independently (negative) correlated with fertility rates. Fertility rates, as a measure of social integration, may interact with, modify and mediate the effect of cultural factors on suicide rates of elderly persons.     

Comparison of the Effects of Telephone Suicide Prevention Help by Volunteers and Professional Paid Staff: Results from Studies in the USA and Quebec,Canada

Research since the 1960s has consistently found that lay volunteers are better at helping suicidal callers than professionals. Yet, professional degrees are increasingly becoming requirements for helpline workers. In our first study, we conducted post hoc comparisons of U.S. helplines with all professional paid staff, all lay volunteers, and a mix of both, using silent monitoring and standardized assessments of 1,431 calls. The volunteer centers more often conducted risk assessments, had more empathy, were more respectful of callers, and had significantly better call outcome ratings. A second study of five Quebec suicide prevention centers used silent monitoring to compare telephone help in 1,206 calls answered by 90 volunteers and 39 paid staff. Results indicate no significant differences between the volunteers and paid employees on outcome variables. However, volunteers and paid staff with over 140 hours of call experience had significantly better outcomes. Unlike the United States, Quebec paid employees were not required to have advanced professional degrees. We conclude from these results and previous research that there is no justification for requiring that suicide prevention helpline workers be mental health professionals. In fact, the evidence to date indicates that professionals may be less effective in providing telephone help to suicidal individuals when compared to trained lay volunteers.     

Suicide as Social Logic

Although suicide is not viewed as a mental disorder per se, it is viewed by many if not most clinicians, researchers, and lay people as a real or natural symptom of depression. It is at least most typically seen as the unfortunate, severe, yet logical end result of a chain of negative self-appraisals, negative events, and hopelessness. Extending an approach articulated by the early French sociologist Gabriel Tarde, in this paper I argue that suicide is merely an idea, albeit a very bad one, having more in common with societal beliefs and norms regarding such things as divorce, abortion, sex, politics, consumer behavior, and fashion. I make a sharp contrast between perturbation and lethality, concepts central to Edwin S. Shneidman's theory of suicide. Evidence supportive of suicide as an idea is discussed based on what we are learning from the study of history and culture, and about contagion/cluster phenomena, media/communication, and choice of method. It is suggested that certain individuals are more vulnerable to incorporate the idea and act of suicide into their concepts of self, based on the same principles by which ideas are spread throughout society. Just as suicide impacts on society, so does society impact on suicide.     

Patterns of Presentation for Attempted Suicide: Analysis of a Cohort of Individuals Who Subsequently Died by Suicide

All suicides and related prior attempts occurring in Northern Ireland over two years were analyzed, focusing on number and timing of attempts, method, and mental health diagnoses. Cases were derived from coroner's records, with 90% subsequently linked to associated general practice records. Of those included, 45% recorded at least one prior attempt (with 59% switching from less to more lethal methods between attempt and suicide). Compared with those recording one attempt, those with 2+  attempts were more likely to have used less lethal methods at the suicide (OR = 2.77: 95% CI = 1.06, 7.23); and those using less lethal methods at the attempts were more likely to persist with these into the suicide (OR = 3.21: 0.79, 13.07). Finally, those with preexisting mental problems were more likely to use less lethal methods in the suicide: severe mental illness (OR = 7.88: 1.58, 39.43); common mental problems (OR = 3.68: 0.83, 16.30); and alcohol/drugs related (OR = 2.02: 0.41, 9.95). This analysis uses readily available data to highlight the persisting use of less lethal methods by visible and vulnerable attempters who eventually complete their suicide. Further analysis of such conditions could allow more effective prevention strategies to be developed.     

Suicide in Batman, southeastern Turkey

The southeastern part of Turkey has comparatively high female suicide rates. We aimed to research social, economic, cultural, and psychiatric reasons of suicides in Batman in a case-controlled psychological autopsy study comparing suicides with matched community controls. The female suicide rate was 9.3 per 100.000 and the female/male ratio was 1.72/1. The suicides most frequently occurred in young females, mean age 20.7. The most frequent method (45%) was hanging. The most frequent stressful life events were health problems and family disruption. High suicide rates among females may be related to negative social status of females living in the region.     

The LSARS-II: Lethality of Suicide Attempt Rating Scale-Updated

The concept of lethality is essential to the assessment of suicide risk; yet operational definitions of lethality for purposes of its measurement have been loose and varied. A number of scaling measures have been published in the literature, with no relative consensus on the best of these. In addition, only a few of these scales have published data on their psychometric properties. Of these, we argue that the best is the Lethality of Suicide Attempt Rating Scale (LSARS; Smith, Conroy, & Ehler, 1984). Presented here is a significantly revised and redesigned listing of drugs and chemicals and lethal ranges of ingestion (in caps, tabs, or ounces) by body weight to update that scale.     

Telephone counseling and crisis intervention: A review

The empirical research pertaining to the effectiveness of telephone counseling and referral systems personnel was critically reviewed. The assessment was organized according to several evaluation strategies that researchers have utilized to evaluate effectiveness. These strategies included, for example, client self-reports, client "shows" versus "no-shows" following referral, data pertaining to suicide rates, counselor ratings of personal effectiveness, and phone workers' ability to offer empathy to clients. It was concluded that discussions of effectiveness should be constrained by a careful consideration of the specific index of efficacy chosen by investigators as well as methodological issues associated with current research in this area. There is reason to believe that the availability of telephone crisis services may be related to reduced suicide rates among young white females. Also, there is a significant need to empirically associate counseling technique and indices of effectiveness with substantive measures of client outcome in future research. Additional topics reviewed include the probable differential effectiveness of lay workers with various presenting problems of clients, and the role that training and maturity seem to play in successful interventions. Guidelines for the use of evaluation techniques which coincide with service goals are also offered.     

An empirical study of seriously disturbed suicidal patients

Aspects of unconscious processes in a group of seriously disturbed psychiatric patients are examined in an effort to predict near-lethal suicide attempts and explore psychoanalytic formulations of suicide. The Rorschach Inkblot Test, the most widely used projective measure in suicide research (Bongar 1991), was chosen for its potential to shed light on specific unconscious processes. Psychic states commonly associated with suicide were measured by psychoanalytic Rorschach analog scales and then subjected to a progression of statistical analyses in order to predict future occurrence and lethality of suicide attempts. On the basis of a priori hypotheses, the authors developed a suicide index comprising four psychoanalytic Rorschach signs that predicted, with considerable accuracy, which patients would later make near-lethal suicide attempts. The best predictors were unconscious processes indicative of penetrating affective overstimulation, disturbance in the capacity to maintain adequate ego boundaries, and depressive affective states characterized by a morbid preoccupation with death and inner decay. These findings provide empirical support for several well-known formulations of the unconscious motivations for suicide.     

MMPI ratings of suicide risk.

Among past attempts to use MMPI data to predict suicidal behavior, there has been a lack of research on the ability of clinicians to identify MMPI profiles of suicidal persons. In this study, the MMPI profiles of 20 male psychiatric patients who committed suicide and the MMPI profiles of 20 male patients who did not attempt or commit suicide were presented to six clinical psychologists with expertise in MMPI interpretation. The clinicians were asked to classify each MMPI profile as coming from a patient who did or did not later commit suicide, and to rate eight variables thought to be relevant to the assessment of suicide risk. Data analysis revealed that the clinicians could not identify suicide and nonsuicide patients from their MMPI profiles. Furthermore, the ratings of the eight suicide variable did not differentiate suicide and nonsuicide patients.     

Preliminary field-testing of a risk estimator for suicide

A 15-item suicide risk estimator, empirically derived from a prospective study of 2,753 suicidal persons, was given a field trial in five clinical settings. Two hundred ninety subjects were included. Volunteer crisis workers needed an average of 4.5 minutes to complete the instrument, and rated its ease of administration 2.5 on a 5-point scale. When compared with clinical ratings, the instrument estimated suicide risk slightly higher than did the interviewers. Scale items that differed from the raters' intuition tended to be omitted more than others. The trial provided valuable information needed to prepare for a large scale evaluation.