Suicide mortality of suicide attempt patients discharged from emergency room, nonsuicidal psychiatric patients discharged from emergency room, admitted suicide attempt patients, and admitted nonsuicidal psychiatric patients

The suicide mortality rate and risk factors for suicide completion of patients who presented to an emergency room (ER) for suicide attempt and were discharged without psychiatric admission, patients who presented to an ER for psychiatric problems other than suicide attempt and were discharged without psychiatric admission, psychiatric inpatients admitted for suicide attempt, and psychiatric inpatients admitted for other reasons were examined. The records of 3,897 patients who were treated at a general hospital in Seoul, Korea, from July 2003 to December 2006 were reviewed. Forty-three of the 3,897 subjects died by suicide during the 2.5-year observation period. Compared to the general Korean population, the suicide mortality rate was 82-fold higher for suicide attempt patients, admitted; 54-fold higher for suicide attempt patients, discharged; 21-fold higher for nonsuicidal patients, admitted; and 11-fold higher for nonsuicidal patients, discharged. In all four groups, diagnosis of a depressive disorder and suicide attempt at presentation were each significant independent risk factors for suicide completion. These results highlight the need for suicide prevention strategies for depressed patients who present to the ER or are admitted to a psychiatric ward after a suicide attempt.     

Risk factors for medically serious suicide attempts: evidence for a psychodynamic formulation of suicidal crisis

This study explored a psychodynamic model for suicide risk by examining risk factors for medically serious suicide attempts, including assessments of affect flooding, negative self-schema / fragmentation, and impaired reality testing, closely approximating Maltsberger's psycho-dynamic formulation of suicide crisis. Baseline risk factors including age, gender, psychiatric symptoms, high-risk behaviors, and the Implicit Risk for Suicide Index (IRSI) were used to detect medically serious suicide attempts monitored for up to a year after the assessment. Twenty-five psychiatric inpatients who made life-threatening suicide attempts after assessment were compared to 25 inpatients and 25 psychotherapy outpatients who made no suicide attempts during follow-up. Statistical analysis revealed that a history of at least one suicide attempt and elevated IRSI scores accounted for 60 percent of the variance in detecting medically serious suicide attempts. Elevated IRSI accurately identified suicide attempt status above and beyond past suicide attempts and other empirically validated risk factors. Results are discussed in light of psychodynamic formulations of suicide risk.     

Suicide attempts and family history of suicide in three psychiatric populations

The influence of a family history of suicide on suicide attempt rate and characteristics in depression, schizophrenia, and opioid dependence was examined. One hundred sixty inpatients with unipolar depression, 160 inpatients with schizophrenia, and 160 opioid-dependent patients were interviewed. Overall, a family history of suicide was associated with a higher risk for suicide attempt, with high-lethality method, with repeated attempts, and with number of attempts, while the interaction between family history and diagnostic group was not significant. Thus, a positive family history of suicide was a risk factor for several suicide attempt characteristics independent of psychiatric diagnosis.     

Assessment of mode of anger expression in adolescent psychiatric inpatients.

Anger can play an important role in depression and suicide risk among adolescents. The present study evaluated internalized and externalized anger in 92 adolescent psychiatric inpatients. Results indicated that adolescents who internalized their anger were more likely to be depressed and to experience feelings of hopelessness. In addition, adolescents who internalized their anger made more serious suicide attempts than did those who externalized their anger. In contrast, adolescents who externalized their anger were more likely to have alcohol-related problems. Thus, different modes of anger expression appear to be related to different manifestations of psychopathology. It was concluded that assessment of mode of anger expression in adolescents may enhance our understanding of suicide and its risk factors.     

Factors of Early Suicide after Discharge: A National Linkage Study for Suicide Victims in Taiwan

Patients recently discharged from psychiatric inpatient care have a higher suicide rate. The study aimed to identify the characteristics associated with early suicide of those patients discharged from psychiatric wards in Taiwan. The results indicated that among 672 suicide victims who died within one year post‐discharge from psychiatric wards in Taiwan between 2000 and 2004, diagnosis of schizophrenia, shorter disease duration, and co‐morbidity with cancer were all significantly associated with suicide occurring within one month of discharge. Clinical diagnosis of psychiatric disorders, recent psychiatric diagnosis, and co‐morbidity with severe physical illnesses should receive special monitoring for potential suicide after discharge.     

Revisiting the association of aggression and suicidal behavior in schizophrenic inpatients

Our study investigated the association of aggression and suicidal behavior in schizophrenic inpatients. Eight thousand nine hundred one admissions for schizophrenia (1998-2007) to a psychiatric university hospital were included. Schizophrenic suicides (n = 7)/suicide attempters (n = 40) were compared to suicides (n = 30)/suicide attempters (n = 186) with other diagnoses and to schizophrenic non-attempters regarding aggression. Logistic regression analysis was performed to explore risk factors for attempted suicide. Schizophrenic suicides/suicide attempters did not differ from other suicides/suicide attempters or from schizophrenic non-attempters with regard to aggression. Risk of inpatient suicide attempt was increased for patients with attempted suicide at admission, high school graduation, and disorganized subtype. Aggression could not be found to be a predictor of attempted suicide. Aggression seems to have a minor role for suicidal behavior in schizophrenia.     

The Relation of Self-Hatred and Suicidality in People With Schizophrenia-Spectrum Symptoms

It is well known that depressive symptoms represent a risk for suicidality in general. It is less clear, however, that general depressive symptoms comprise a definite suicide risk factor for people with schizophrenia. Based on this, as well as on the early writings of E. Bleuler (1911/1987), it was hypothesized that there may be a particular aspect of depressive symptoms that combines with schizophrenia to encourage suicidality. Specifically, schizophrenia may impart to self-concept a quality of self-hatred that encourages suicidality in schizophrenic people. If so, then an index of self-hatred should be more correlated with suicidality among people with schizophrenia-spectrum symptoms than among people with fewer such symptoms. Two studies evaluated this possibility. In Study 1 on 243 suicidal outpatients affiliated with the military, self-hate and suicidality were more correlated among people with schizotypal symptoms than among other patients. In Study 2 on 113 VA psychiatric inpatients, self-hate and suicidality were more correlated among people with a diagnosis of schizophrenia than among patients with a diagnosis of major depression. Study limitations were noted, and it was suggested that self-hatred be a focus of suicide risk assessment in schizophrenic people.     

A case control study of suicide and attempted suicide in older adults

Risk factors for serious suicidal behavior among older adults were examined in a case control study of 53 adults aged 55 and older who died by suicide or made medically serious suicide attempts and who were compared with 269 randomly selected comparison subjects. Multivariate analyses suggested that risk of serious suicidal behavior was elevated among those with current mood disorders (OR = 179, CI = 52.8-607.6), psychiatric hospital admission within the previous year (OR = 24.4, CI = 1.9-318.7), limited social network (OR = 4.5, CI = 1.4-14.6). The predominant role of mood disorders was confirmed by population attributable risk (PAR) estimates (73.6%), suggesting that the improved detection, treatment and management of mood disorders should be the primary focus of suicide prevention strategies for older adults.     

Discerning reported suicide attempts within a youthful offender population

With suicide being the third leading cause of death among young people, early identification of risk is critical, particularly for those involved with the juvenile courts. In this study of court-involved youth (N = 433) in two Midwest counties, logistic regression analysis identified some expected and unexpected findings of important demographic, educational, mental health, child welfare, and juvenile court-related variables that were linked to reported suicide attempts. Some of the expected suicide attempt risk factors for these youth included prior psychiatric hospitalization and related mental health services, residential placement, and diagnoses of depression and alcohol dependence. However, the most unexpected finding was that a court disposition to shelter care (group home) was related to a nearly tenfold increased risk in reported suicide attempt. These findings are of importance to families, mental health professionals, and juvenile court personnel to identify those youth who are most at risk and subsequently provide appropriate interventions to prevent such outcomes.     

Risk Factors of a Suicide Reattempt by Seasonality and the Method of a Previous Suicide Attempt: A Cohort Study in a Japanese Primary Care Hospital

Suicide has a great impact on the individual whose life is lost and the bereaved family members. The risk of a suicide reattempt is particularly high during the first 12 months after a suicide attempt. In this cohort study, risk factors for a suicide reattempt were explored among 291 patients at suicide risk. Clinical and demographic data were collected from a Japanese primary care hospital. Past psychiatric history and multiple diagnoses were associated with suicide reattempts in both genders. Drug overdose, past psychiatric history, and the summer season were linked to suicide reattempts among males. Past psychiatric history and multiple diagnoses were linked to suicide reattempts among females. Appropriate assessment of past psychiatric history, season and method of suicide attempt, gender, and diagnosis may play a role in preventing suicide.     

Drop-in suicide prevention group decreases suicidal ideation among Veterans

This study examined the effectiveness of a weekly, drop-in therapy support group designed for Veterans identified at increased risk for suicide. Veterans were identified as at risk for suicide and referred to the group following hospitalization on the inpatient psychiatric unit after an increase in suicidal ideation (SI), presentation to a provider with SI with a plan, or having made a suicide attempt. An archival chart review was performed on 359 patients who were referred to the Coping, Understanding, Support, and Prevention Group from 2009 through 2011. Documented risk of suicide was collected from the chart including: frequency of inpatient psychiatric hospitalization, visits to the emergency department or mental health walk in clinic for SI, reported SI in clinical notes, consults resulting from calls to the Veteran’s Crisis Line, and assignment or removal of suicide risk behavior flags in the electronic medical record, for a period of 12 months prior to referral to the group and for a period of 12 months after referral to the group. Negative binomial regression models found that Veterans attending the support group showed a significantly greater reduction in frequency of endorsing SI post-referral compared to those who did not attend the group. Results imply that offering Veterans an ongoing therapeutic group format to give and receive support from peers also struggling with suicide risk factors is an effective way to reduce suicide-related thoughts.     

Early suicide following discharge from a psychiatric hospital

Social and clinical risk factors for completed suicide occurring shortly after discharge from a psychiatric hospital were examined in this case-control study. Seventy-seven individuals who received "suicide" or "undetermined death" verdicts at inquest, and who had been previously discharged from psychiatric hospitals in Bradford, U.K., were compared with a control group. A history of deliberate self-harm was significantly associated with early suicides compared with both late suicides and controls. A diagnosis of mood disorder, specifically depression, and longer case-notes were also significantly associated with early suicides compared to controls. This study has implications for risk management of recently discharged psychiatric patients.     

Suicidal behavior in schizophrenia and schizoaffective disorder: examining the role of depression

Understanding the relationship between depression and suicidal behavior among individuals with schizophrenia and schizoaffective disorder can aid assessment and treatment. In this study, 86 individuals with schizophrenia and schizoaffective disorder were assessed for past and current suicidal behavior, depression, hopelessness, and reasons for living. Thirty-four percent reported a history of suicide attempts. Suicidal behavior typically occurred 4.5 years after the onset of psychosis and 7.5 years after the onset of the first major depressive episode for those who had a history of major depression. Depression was frequent among both attempters and non-attempters, but only half of the attempters reported a suicide attempt during an episode of major depression. And almost half of those with depression never made a suicide attempt despite a long history of illness. Although depression is a potential stressor for triggering suicidal behavior in a vulnerable subset of individuals with schizophrenia, schizophrenia research must identify other risk factors for suicidal behavior. Clinicians should remember that even without a depressive episode there is still a significant risk for suicidal behavior in schizophrenia.     

Risk Factors for Attempting Suicide in Heroin Addicts

In order to examine risk factors for attempting suicide in heroin dependent patients, a group of 527 abstinent opiate dependent patients had a psychiatric interview and completed the Childhood Trauma Questionnaire. Patients who had or had never attempted suicide were compared on putative suicide risk factors. It was found that 207 of the 527 heroin abusers (39.3%) had attempted suicide. Attempters were younger; more were female, reported childhood trauma, a family history of suicidal behavior, a history of aggression, treatment with antidepressant medication, and alcohol and cocaine dependence. Logistic regression revealed that a family history of suicidal behavior, alcohol dependence, cocaine dependence, and treatment with antidepressant medication were significant predictors of attempting suicide. These results suggest that attempting suicide is common among opiate dependent patients and that both distal and proximal risk factors may play a role.     

Suicide Attempts and Suicide among Marines: A Decade of Follow‐up

Suicidal behavior among military personnel is of paramount public health importance because of the increased risk of death from suicide in this population. Pre‐ and post‐Marine recruit training risk factors for suicide attempts among current and former Marines were examined in 10 years following recruit training. The characteristics of the subsample of current and former Marines who died by suicide during this time are also described. Stressful and traumatic life events (e.g., childhood physical, sexual, and emotional abuse, sexual harassment during recruit training) and pre‐recruit training suicide attempts emerged as having strong associations with post‐recruit training attempts. Half of those who died by suicide in the 10 years following recruit training endorsed at least one significant life stressor prior to joining the Marines. This study highlights the importance of screening for stressful and potentially traumatic experiences occurring both before and during military service as part of a comprehensive suicide risk assessment in military samples.     

CSF 5-HIAA Predicts Suicide Risk After Attempted Suicide

Suicide risk after attempted suicide, as predicted by cerebrospinal fluid (CSF) monoamine metabolite concentrations, was studied in a sample of 92 psychiatric mood disorder inpatients admitted shortly after attempting suicide. The potential of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the CSF to predict suicide risk within the first year after attempted suicide was studied by means of survival analysis after median split sub-grouping. Eleven patients (12%) committed suicide within 1 year after attempted suicide. Eight of these belonged to the below-the-median (< 87 nM) CSF 5-HIAA subgroup, that is, the suicide risk was 17% as compared with 7% among those with above-the-median CSF 5-HIAA. The cumulative number of survived patient-months during the first year after attempted suicide was significantly lower in the low CSF 5-HIAA subgroup. It was concluded that low CSF 5-HIAA predicts short-range suicide risk after attempted suicide in mood disorder psychiatric inpatients. These findings lend further support to the serotonin hypothesis of suicide risk.     

Characteristics of suicide attempters and nonattempters with schizophrenia in a rural community

In this study, demographic and clinical characteristics of individuals with schizophrenia in a Chinese rural community who had attempted suicide at some time in their lives and those who had not made a suicide attempt were compared. Among individuals with schizophrenia, subjects with (n = 38) and without (n = 472) a lifetime history of suicide attempt were assessed with the Present State Examination. The results indicate that attempters had a significantly younger age, higher level of education, higher rate of lifetime depressed mood and hopelessness, and a larger number of positive symptoms than patients without suicide attempts. The logistic regression models also indicated that hopelessness, the number of positive symptoms and age were the most important predictors. Early interventions focusing on reducing hopelessness and controlling positive symptoms may help reduce the risk of suicide attempts among patients with schizophrenia.     

Schizophrenia and deliberate self-harm: a systematic review of risk factors

Deliberate self-harm (DSH) is a strong predictor of suicide in schizophrenia. The aim of this review was to identify risk factors for DSH in schizophrenia. This systematic review of the international literature examined cohort and case-control studies of patients with schizophrenia or related diagnoses that reported DSH as an outcome. Studies were identified by searching electronic databases and reference lists, and by consulting international experts. Fourteen studies met the eligibility criteria. Of the 29 variables examined by two or more studies, five (past or recent suicidal ideation, previous DSH, past depressive episode, drug abuse or dependence, and higher mean number of psychiatric admissions) were associated with an increased risk of DSH, and one (unemployment) was associated with a reduced risk. Schizophrenic patients with these risk factors need careful follow-up and monitoring, with treatment of any associated comorbid depression or drug abuse. Large, prospective studies of DSH in schizophrenia are needed to further define risk factors and to build on the findings of this review.     

The Gender‐Specific Associations Between Religion/Spirituality and Suicide Risk in a Sample of Austrian Psychiatric Inpatients

Most studies have found religion/spirituality to be protective against suicide risk, with a stronger effect among women. To understand this effect, theories of suicide and clinical samples are needed, but related studies are lacking. We applied two established suicide models in 753 psychiatric inpatients. Religion/spirituality correlated protectively with components of the suicide models, with stronger associations among women. The protective effect emerged especially for the capability aspect of suicide among men and for the motivational aspect among women, suggesting very different causal mechanisms, but this has to be replicated with longitudinal studies.