Suicides in Nunavik: a life course study.

This study reports results of a life course study conducted with Inuit in Nunavik to obtain information on the life adversities and cumulative burden of adversity for three groups: those who died by suicide, those who attempted suicide, and those who experienced suicidal ideation but never attempted. The study involved different levels of collaboration between health authorities, front-line health workers and the research team. Results indicate that substance misuse and relational difficulties are most associated with the burden of adversity for those people who died by suicide, while bullying is most associated with the burden of adversity for those people who have made suicide attempts and those who have never made a suicide attempt. Specifically targeting parent-child relations, substance misuse, and bullying may be an important upstream strategy for reducing future suicidality in Nunavik.

The Role of Adolescence in Development Paths Toward Suicide: Specificities and Shaping of Adversity Trajectories.

Purpose: Adolescence is a key period of transitions in the psychological, cognitive, neurobiological and relational domains, which is associated to high susceptibility to adverse life experiences. However, the way adolescent development alters life paths toward suicide remains unclear. Thereby, we aimed at testing whether and how adolescence interfered with the adversity trajectories of individuals who died by suicide. Methods: In a sample of 303 individuals who died by suicide, longitudinal Burden of Adversity ratings were derived from extensive psychological autopsies and life trajectory narrative interviews conducted with informants. Piecewise Joint Latent Class Models allowed the identification of patterns of adversity trajectories and tested the introduction of breakpoints in life-paths. Classes inferred from the optimal model were compared in terms of socio-demographics, psychopathology, and rate of different adverse life events. Results: The most accurate model derived 2 trajectory patterns with a breakpoint in early adolescence. In the first class (n = 39), the burden of adversity increased steadily from birth to death, which occurred at 23 (SE = 1.29). In the second class (n = 264), where individuals died at 43 years of age (SE = 0.96), the burden of adversity followed a similar trajectory during infancy but stabilized between 10 and 14 years and started to increase again at about 25. Childhood family instability, dependent events, exposure to suicide, intra-family sexual victimization and affective disorders at death were more frequent in class 1. Conclusions: A bifurcation in trajectories between early and late suicides occurs during adolescence. The dynamic pattern of adversity during this period is a key issue to understand the developmental heterogeneity in suicide risk.

Suicide amongst the Inuit of Nunavut: An Exploration of Life Trajectories.

This article reports results of the life trajectories from 92 Inuit who died by suicide, matched for age and gender with 92 living-controls. A proxy-based procedure and semi-structured interviews with informants were conducted to obtain trajectories of developmental events occurring over the life course for suicide and community-matched controls. Results from this research indicate two different trajectories that differentiate the control-group from the suicide-group throughout the life course. Even though the number of suicide attempts are similar between both groups, the suicide-group had a more important burden of adversity, which seemed to create a cascading effect, leading to suicide.

Protective Factors in the Inuit Population of Nunavut: A Comparative Study of People Who Died by Suicide, People Who Attempted Suicide, and People Who Never Attempted Suicide.

Epidemiological data shows an alarming prevalence of suicide in Aboriginal populations around the world. In Canada, the highest rates are found in Inuit communities. In this article, we present the findings of a secondary analysis conducted with data previously collected as part of a larger study of psychological autopsies conducted in Nunavut, Canada. The objective of this secondary analysis was to identify protective factors in the Inuit population of Nunavut by comparing people who died by suicide, people from the general population who attempted suicide, and people from the general population who never attempted suicide. This case-control study included 90 participants, with 30 participants in each group who were paired by birth date, sex, and community. Content analysis was first conducted on the clinical vignettes from the initial study in order to codify the presence of protective variables. Then, inferential analyses were conducted to highlight differences between each group in regards to protection. Findings demonstrated that (a) people with no suicide attempt have more protective variables throughout their lifespan than people who died by suicide and those with suicide attempts within the environmental, social, and individual dimensions; (b) people with suicide attempts significantly differ from the two other groups in regards to the use of services; and (c) protective factors that stem from the environmental dimension show the greatest difference between the three groups, being significantly more present in the group with no suicide attempt. Considering these findings, interventions could focus on enhancing environmental stability in Inuit communities as a suicide prevention strategy.

Evaluation of the Dawson College Shooting Psychological Intervention: Moving Toward a Multimodal Extensive Plan.

In 2006, following the shooting at Dawson College, the authorities implemented an intervention plan. This provided an opportunity to analyze the responses to services offered, and afforded a learning opportunity, which led to the proposal of an extensive multimodal short- and long-term psychological plan for future needs. Both quantitative and qualitative data were gathered 18 months after the event, involving the participation of 948 students and staff. Mental health problems and the perception of services offered after the shooting were investigated, using standardized measures. Second, focus groups and individual interviews were conducted among a subgroup of participants (support team members; teachers and employees; students and parents) and permitted to gather data on services received and services required. Individual report of events, the extent of psychological impact and services offered and received were analyzed in terms of the following dimensions: intervention philosophy, training, ongoing offer of services and finally, detection and outreach. A significant incidence of disorders and a high rate of exacerbation of preexisting mental disorders were observed within the 18 months following the shooting. Postimmediate and short-term intervention appeared adequate, but the long-term collective vision toward community support and availability of mental health services were lacking. Lessons learned from this evaluation and other school shootings suggest that preparedness and long-term community responses are often overlooked. A multimodal extensive plan is proposed based on a theoretical model from which interventions strategies could be drawn.

Systematic services audit of consecutive suicides in New Brunswick: the case for coordinating specialist mental health and addiction services.

OBJECTIVE: To weight the potential of promotion, prevention, and treatment programs to help establish priorities in multipronged suicide prevention strategies. METHODS: Psychological autopsy methods served to collect information on consecutive suicides over 14 months in New Brunswick (n = 102). A panel of researchers, clinicians, provincial planners, and consumers reviewed the cases and applied a systematic needs assessment procedure to establish interventions and services received, unmet needs at the individual level, and programmatic and systemic shortcomings. RESULTS: More than two-thirds of the individuals suffered from a depressive disorder and a similar proportion from substance (essentially alcohol) abuse or dependence; one-half also presented a personality disorder. In the last year, more than one-half had been in contact with a mental health services specialist, but less than 5% had contact with addiction services, though one-third had previous contact in their lifetime. In one-third of the cases, service gaps called for greater coordination and integration of mental health specialists and addiction services within the health care system. In one-half of the cases, system needs were found to be unmet for public awareness efforts aimed at encouraging individuals to consult health and social services professionals, and in terms of training efforts geared to improving detection, treatment, and referral for mental illness, substance-related problems, and suicidal behaviour by primary medical, social, and specialist services. CONCLUSION: This study supports multipronged suicide prevention strategies that should include integrated public promotion, professional development campaigns, and better program coordination. Authorities in New Brunswick have opted to favour the latter strategy component, whose development and application must be evaluated to determine its impact on suicide rates.

Life trajectories and burden of adversity: mapping the developmental profiles of suicide mortality.

BACKGROUND: Little is known about differential suicide profiles across the life trajectory. This study introduces the life-course method in suicide research with the aim of refining the longitudinal and cumulative assessment of psychosocial factors by quantifying accumulation of burden over time in order to delineate distinctive pathways of completed suicide. METHOD: The psychological autopsy method was used to obtain third-party information on consecutive suicides. Life-history calendar analysis served to arrive at an adversity score per 5-year segment that was then cluster-analysed and correlated to define victim profiles. RESULTS: Two distinct life trajectories emerged: (1) individuals who experienced childhood traumas, developmental adversity and little protection were more likely to present concurrent psychiatric and Axis II disorders; and (2) individuals who experienced less adversity but seemed more reactive to later major difficulties. CONCLUSIONS: The life calendar approach presented here in suicide research adds to the identification of life events, distal and recent, previously associated with suicide. It also quantifies the burden of adversity over the life course, defining two distinct profiles that could benefit from distinct targeted preventive intervention.

Suicide cases in New Brunswick from April 2002 to May 2003: the importance of better recognizing substance and mood disorder comorbidity.

OBJECTIVE: To investigate all suicide cases that occurred in New Brunswick in the 14 months spanning April 1, 2002, to May 31, 2003, to determine 6-month and lifetime prevalence rates of psychopathology in the deceased. METHOD: We used 2 psychological autopsy methods: direct proxy-based interviews and medical chart reviews, together with telephone contacts with informants. Consensus DSM-IV diagnoses were formulated by clinical panels on the basis of the Structured Clinical Interviews I and II for DSM-IV complemented by medical charts. RESULTS: Of the 109 suicide deaths identified by the coroner at the time of the study, we were able to investigate 102. At time of death, 65% of the suicide victims had a mood disorder, 59% had a substance-related disorder, and 42% had concurrent mood and substance-related disorders. The lifetime prevalence of substance-related disorders among these suicide victims was 66%. Finally, 52% of the suicide victims presented with a personality disorder; one-half of these were of the cluster B type. CONCLUSIONS: Although treatment of depression has frequently been recognized as the focal point of clinically based suicide-prevention efforts, our results underscore substance-related disorders as a key dimension of completed suicide. Suicide-prevention programs should be designed to address this problem more directly.

STin2 variant and family history of suicide as significant predictors of suicide completion in major depression.

BACKGROUND: Suicide is the most serious outcome of major depression, yet not all depressed patients will commit suicide. Genes, along with other factors, might account for this difference. Serotonergic alterations have been observed in suicide and depression and impulsive-aggressive behaviors. Therefore, we aimed to identify predictors of suicide, considering genetic variation at the serotonin transporter (5-HTT) gene. METHODS: We investigated the 5-HTT gene-linked polymorphic region (5-HTTLPR) and intron 2 (STin2) variants of this gene and their relationship to behavioral and clinical risk factors for suicide in a sample of depressed suicides (n =106) and depressed control subjects (n =152), diagnosed by means of proxy-based interviews. RESULTS: We found a significant association of suicide completion with having at least one copy of the STin2 10 allele [chi(2)(1) = 10.833, p = .002]. No differences were found for the 5-HTTLPR variable number of tandem repeats. After controlling for behavioral and clinical risk factors for suicide, the STin2 variant remained a significant predictor of suicide in major depression when jointly considered with a family history of suicide (odds ratio 5.560, 95% confidence interval 1.057-29.247). CONCLUSIONS: The STin2 locus might account, at least in part, for the observed familial aggregation of suicidal behavior. These results should be further explored in families where clustering of suicidal behavior is observed.

Is violent method of suicide a behavioral marker of lifetime aggression?

OBJECTIVE: The main purpose of this study was to investigate whether the method of suicide is a valid behavioral marker of a lifetime history of aggression. METHOD: The authors applied the psychological autopsy method to investigate 310 individuals who committed suicide. They used structured clinical assessments and personality trait scales in interviews with family members of the deceased. RESULTS: Violent method was associated with a higher level of lifetime aggression and a higher level of impulsivity. In addition, violent method was associated with lifetime substance abuse or dependence and psychotic disorders. Controlling for age, sex, substance disorders, and other major psychopathology, the authors found that lifetime aggression and the interaction between impulsivity and aggressive behavior remained associated with violent method. CONCLUSIONS: These results support the use of violent method of suicide as a behavioral marker of a higher level of lifetime impulsive-aggressive behaviors.

Familial aggregation of suicidal behavior: a family study of male suicide completers from the general population.

OBJECTIVE: This study compared suicidality in families of adult male suicide completers and community comparison subjects. METHOD: Two hundred forty-seven relatives of 25 male suicide completers and 171 relatives of 25 matched comparison subjects were assessed for recurrent risk of suicidal and related behaviors. Analyses were performed on a subgroup of relatives of suicide completers with cluster B personality disorders. RESULTS: Relatives of suicide completers were over 10 times more likely than relatives of comparison subjects to attempt or complete suicide after the authors controlled for psychopathology. Relatives of suicide completers were not more likely to exhibit suicidal ideation but had more severe suicidal ideation than relatives of comparison subjects. These findings were stronger for the suicide completers diagnosed with cluster B personality disorders. CONCLUSIONS: Suicide has a familial component independent of psychopathology that may be mediated by a combination of factors, including more severe suicidal ideation and aggressive behavior.

Psychiatric risk factors for motor vehicle fatalities in young men.

BACKGROUND: Motor vehicle accident (MVA) fatalities are an important cause of death in young men. Psychiatric disorders have been shown to be risk factors for MVA, but only a few studies have investigated MVA fatalities. METHOD: A case-control study was carried out comparing 61 young male MVA fatalities in which the subject was the driver with an equal number of living male subjects matched for age (case by case with no more than 1 year's difference between case subjects and control subjects) with the accident group. We assessed both groups, using structured interviews and psychological autopsies. RESULTS: Our results suggest that cluster B personality disorders (borderline and [or] antisocial) (OR 3.54; 95%CI, 1.38 to 16.01) and substance use disorders in the last 6 months (OR 4.33; 95%CI, 1.42 to 9.25) increased the risk of dying in MVAs. In addition, we observed an age effect, where differences in cluster B personality disorders and substance use disorders in the last 6 months were only significantly more prevalent in case subjects aged 26 years or over, compared with control subjects of the same age. Drivers under age 25 years appeared to be comparable with control subjects on all measures of psychopathology. Finally, this interaction between cluster B personality disorders and age over 26 years was the only significant predictor of car fatalities (adjusted OR 16.25; 95%CI, 1.67 to 158.10). CONCLUSION: Borderline and antisocial personality disorders in which impulsive-aggressive behaviours play a central role and substance use disorders appear to be risk factors for young male deaths in MVAs. Interestingly, this effect seems to be specific to MVA case subjects aged 26 years or over.

Seasonal differences in psychopathology of male suicide completers.

Suicide is known to vary according to season, with peaks in the spring and troughs in the winter. The presence of psychopathology is a significant predictor of suicidality, and it is possible that the seasonal variation of suicide completion may be related to seasonality in the manifestation of psychiatric disorders common to suicide completers. In the current study, we evaluated 115 French-Canadian male suicide completers from the Greater Montreal Area for DSM-IV psychiatric disorders using proxy-based diagnostic interviews. Subjects were assessed for seasonal differences in the prevalence of DSM-IV psychiatric diagnoses just before their deaths. Diagnoses of major depressive disorder (MDD) without comorbid cluster B personality disorders, and schizophrenia were differently distributed between seasons. Most (63.4%) subjects with MDD committed suicide in the spring/summer (P =.038). However, closer examination revealed that depressed suicides with comorbid cluster B personality disorders did not show seasonality, while 83.3% of depressed suicides without comorbid cluster B personality disorders committed suicide in the spring/summer (P =.019). 87.5% of those suicides with schizophrenia committed suicide in the fall/winter (P =.026), and the only suicide with schizophrenia who died in the spring/summer was also the only one without positive symptomology. Our study is limited to male suicide completers, and results should not be generalized to women. We conclude that seasonal variation in suicide manifests itself differently in patients with different psychopathology. These findings indicate that assessment of suicide risk may need to include consideration of possible seasonal effects, depending on psychopathology.

Alpha 2A adrenergic receptor gene and suicide.

Suicide is a complex trait resulting from the interaction of several predisposing factors, among which genes seem to play an important role. Alterations in the noradrenergic system have been observed in postmortem brain studies of suicide victims when compared to controls. The purpose of this study was to test the hypothesis that genetic variants of the alpha(2A) adrenergic receptor gene are implicated in suicide and/or have a modulatory effect on personality traits that are believed to mediate suicidal behavior. We studied a sample of suicides (N=110) and control subjects (N=130) for genetic variation at four loci, including three in the promoter region (g-1800t, c-1291 g and the g-261a) of the alpha(2A) adrenergic receptor gene, and a potentially functional locus, N251K, which leads to an amino acid change (asparagine to lysine). No significant differences were observed at the promoter loci in terms of allelic or genotypic distribution between suicides and controls. However, analysis of the functional polymorphism N251K revealed that the 251 K allele was only present among suicides, though only three suicide cases had this allele, two of which were homozygous. These results are preliminary. If confirmed, they suggest that variation at the alpha(2A) adrenergic receptor gene may play a role in a small proportion of suicide cases.

Investigation of completed suicide and genes involved in cholesterol metabolism.

BACKGROUND: Several lines of evidence support the association between low or lowered levels of serum total cholesterol and suicide. Genetic epidemiological studies suggest that genes predispose to suicide. Given that genes control many aspects of cholesterol biosynthesis and metabolism, one approach through which to explore the putative association between low cholesterol and suicide is through genetic studies. METHODS: We examined the potential role of five genes encoding proteins involved in cholesterol biosynthesis and transport in a total sample of 305 male Caucasian subjects, consisting of 145 suicide completers and 160 controls. We investigated variation in the HMG CoA reductase (HMGCR), 7-dehydrocholesterol reductase (DHCR7), lipoprotein lipase (LPL), low-density lipoprotein receptor (LDLR), and apolipoprotein E (APOE) genes. RESULTS: We were unable to detect significant differences in allele or genotype frequencies between the suicide cases and controls for any of the genes studied. No relationship was found between genotype and impulsivity or aggression as measured using the BIS and BDHI, respectively. LIMITATIONS: The limitations of this study are consistent with the typical limitations inherent in most genetic association studies involving complex behavioral traits. CONCLUSION: Although these genes are unlikely to play a major role in susceptibility to suicide, further studies in a larger sample are necessary to reveal the smaller genetic effects, if present.

Wolfram syndrome and suicide: Evidence for a role of WFS1 in suicidal and impulsive behavior.

There is evidence suggesting that subjects affected with the Wolfram syndrome (WFS) and normal carriers present an increased risk of psychiatric disorders, particularly depression and suicidal behavior. We investigated a possible role of the gene involved in WFS (WFS1) in the neurobiology of suicide and the potential modulatory effect on traits associated to suicidal behavior. Genetic variation at WFS1 (H611R, R456H, and I333V) was investigated in 111 suicide victims and 129 normal controls. Possible effects on psychopathology and behavioral traits were investigated in a subsample of suicide cases (N = 31) for whom phenotyping was carried out by means of structured psychiatric interviews and questionnaires adapted for psychological autopsies. We found a significantly higher frequency of the 611R/611R genotype in suicide completers as compared to controls (chi(2) = 19.21, df=2, P = 0.001). Suicide completers with this genotype had higher scores on measures of impulsivity (t = -3.15, df = 15.3, P = 0.006); novelty seeking (NS) (t = -3.35, df = 13.8, P = 0.005); and conversely, lower scores of persistence (t = 2.4, df = 16.6, P = 0.028). Scores of impulsivity and NS remained higher in subjects with the associated genotype after adjusting for age, gender, and psychopathology. These results suggest a role for WFS1 in the pathophysiology of impulsive suicide, and are consistent with previous clinical reports suggesting an increased risk of suicidal behavior in WFS homozygotes and heterozygotes. However, these findings are preliminary and should be confirmed in independent samples.