The role of depression and use of alcohol and other drugs after partner suicide in the association between suicide bereavement and suicide: cohort study in the Danish population.

BACKGROUND: Although suicide bereavement is associated with suicide and self-harm, evidence regarding mechanisms is lacking. We investigated whether depression and substance use (alcohol and/or other drugs) explain the association between partner suicide bereavement and suicide. METHODS: Linkage of nationwide, longitudinal data from Denmark for the period 1980-2016 facilitated a comparison of 22 668 individuals exposed to bereavement by a partner's suicide with 913 402 individuals bereaved by a partner's death due to other causes. Using causal mediation models, we estimated the degree to which depression and substance use (considered separately) mediated the association between suicide bereavement and suicide. RESULTS: Suicide-bereaved partners were found to have a higher risk of suicide (HRadj = 1.59, 95% CI 1.36-1.86) and of depression (ORadj 1.16, 95% CI 1.09-1.25) when compared to other-bereaved partners, but a lower risk of substance use (ORadj 0.83; 95% CI 0.78-0.88). An increased risk of suicide was found among any bereaved individuals with a depression diagnosis recorded post-bereavement (ORadj 3.92, 95% CI 3.55-4.34). Mediation analysis revealed that depression mediated 2% (1.68%; 95% CI 0.23%-3.14%; p = 0.024) of the association between suicide bereavement and suicide in partners when using bereaved controls. CONCLUSIONS: Depression is a partial mediator of the association between suicide bereavement and suicide. Efforts to prevent and optimize the treatment of depression in suicide-bereaved people could reduce their suicide risk. Our findings might be conservative because we did not include cases of depression diagnosed in primary care. Further work is needed to understand this and other mediators.

Investigating risk of self-harm and suicide on anniversaries after bereavement by suicide and other causes: a Danish population-based self-controlled case series study.

AIMS: To investigate mechanisms of suicide risk in people bereaved by suicide, prompted by observations that bereaved people experience higher levels of distress around dates of emotional significance. We hypothesised that suicide-bereaved first-degree relatives and partners experience an increased risk of self-harm and suicide around dates of (i) anniversaries of the death and (ii) the deceased's birthday, compared with intervening periods. METHODS: We conducted a self-controlled case series study using national register data on all individuals living in Denmark from 1 January 1980 to 31 December 2016 and who were bereaved by the suicide of a first-degree relative or partner (spouse or cohabitee) during that period, and who had the outcome (any episode of self-harm or suicide) within 5 years and 6 weeks of the bereavement. We compared relative incidence of suicidal behaviour in (i) the first 30 days after bereavement and (ii) in the aggregated exposed periods (6 weeks either side of death anniversaries; 6 weeks either side of the deceased's birthdays) to the reference (aggregated unexposed intervening periods). As an indirect comparison, we repeated these models in people bereaved by other causes. RESULTS: We found no evidence of an elevated risk of suicidal behaviour during periods around anniversaries of a death or the deceased's birthdays in people bereaved by suicide (adjusted incidence rate ratio [IRRadj] = 1.00; 95% confidence interval [CI] = 0.87-1.16) or other causes (IRRadj = 1.04; 95% CI = 1.00-1.08) compared with intervening periods. Rates were elevated in the 30 days immediately after bereavement by other causes (IRRadj: 1.95, 95% CI: 1.77-2.22). CONCLUSIONS: Although people bereaved by suicide are at elevated risk of self-harm and suicide, our findings do not suggest that this risk is heightened around emotionally significant anniversaries. Bereavement care should be accessible at all points after a traumatic loss as needs will differ over the grief trajectory.

Proportion of suicides in Denmark attributable to bereavement by the suicide of a first-degree relative or partner: Nested case-control study.

OBJECTIVE: To provide the first estimates of the risk of suicide after bereavement by the suicide of any first-degree relative and the proportion of suicides in Denmark attributable to suicide bereavement. METHODS: We conducted a nationwide nested case-control study defining cases as all Danish-born individuals who died by suicide in Denmark between 01 January 1980 and 31 December 2016 (n = 32,248), age-matched to four living controls. Using three exposure categories (bereavement by the suicide of a relative [parent, offspring, sibling, and spouse/cohabitee]; non-suicide bereavement; no bereavement) and conditional logistic regression adjusted for pre-specified covariates we estimated the odds of exposure to suicide bereavement in cases versus controls. We tested whether associations differed for men and women, estimated the population attributable fraction (PAF) of suicides in our population at risk that could be attributed to a first-degree relative's suicide loss, and estimated the attributable fraction among the exposed (AFe). RESULTS: Suicide bereavement was associated with an increased odds of suicide when compared with no bereavement (ORadj2  = 2.90, 95% CI: 2.46-3.40) or non-suicide bereavement (ORadj2  = 1.48, 95% CI: 1.25-1.74). There was no evidence to support any interaction with sex. PAF (0.69%; 95% CI: 0.62%-0.77%) and AFe (60.12%; 95% CI: 53.19%-66.03%) estimates suggested that in Denmark 0.69% of suicides, and 60% of suicides among suicide-bereaved relatives, could be prevented if it was possible to address all factors increasing suicide risk in suicide-bereaved relatives. CONCLUSION: Suicide bereavement in relatives and partners contributes to at least one in 145 suicides in Denmark.

Using epidemiological evidence to forecast population need for early treatment programmes in mental health: a generalisable Bayesian prediction methodology applied to and validated for first-episode psychosis in England.

Background: Mental health policy makers require evidence-based information to optimise effective care provision based on local need, but tools are unavailable. Aims: To develop and validate a population-level prediction model for need for early intervention in psychosis (EIP) care for first-episode psychosis (FEP) in England up to 2025, based on epidemiological evidence and demographic projections. Method: We used Bayesian Poisson regression to model small-area-level variation in FEP incidence for people aged 16-64 years. We compared six candidate models, validated against observed National Health Service FEP data in 2017. Our best-fitting model predicted annual incidence case-loads for EIP services in England up to 2025, for probable FEP, treatment in EIP services, initial assessment by EIP services and referral to EIP services for 'suspected psychosis'. Forecasts were stratified by gender, age and ethnicity, at national and Clinical Commissioning Group levels. Results: A model with age, gender, ethnicity, small-area-level deprivation, social fragmentation and regional cannabis use provided best fit to observed new FEP cases at national and Clinical Commissioning Group levels in 2017 (predicted 8112, 95% CI 7623-8597; observed 8038, difference of 74 [0.92%]). By 2025, the model forecasted 11 067 new treated cases per annum (95% CI 10383-11740). For every 10 new treated cases, 21 and 23 people would be assessed by and referred to EIP services for suspected psychosis, respectively. Conclusions: Our evidence-based methodology provides an accurate, validated tool to inform clinical provision of EIP services about future population need for care, based on local variation of major social determinants of psychosis.

Trends in method-specific suicide in Brazil from 2000 to 2017.

PURPOSE: Understanding long-term patterns of suicide methods can inform public health policy and prevention strategies. In Brazil, firearm-related policies may be one salient target for suicide prevention. This study describes trends in method-specific suicide at the national and state-levels in Brazil, with a particular focus on firearm-related suicides. METHODS: Brazilian mortality data for suicide and undetermined intent among people aged 10 years and older between 2000 and 2017 were obtained from the National Mortality Information System. We examined national and state-level trends in age-standardised suicide rates for hanging, self-poisoning, firearms, jumping from a high place, other, and unspecified methods. We also compared total rates of mortality from suicide and undetermined intent over the period. Applying Joinpoint regression, we tested changes in trends of firearm-specific suicide rates. RESULTS: The total suicide rate increased between 2000 and 2017. Rates of hanging, self-poisoning by drugs or alcohol and jumping from a high place showed the largest increases, while firearm-specific suicide rates decreased over the study period. Trends in methods of suicide varied by sex and state. CONCLUSION: It is of public health concern that suicide rates in Brazil have risen this millennium. Restricting access to firearms might be an effective approach for reducing firearm-specific suicides, especially in states where firearm availability remains particularly high. Treatment and management of substance misuse may also be an important target for suicide prevention policies. More work is needed to understand the causes of rising suicide rates in Brazil and to improve the mental health of the population.

Association between homicide rates and suicide rates: a countrywide longitudinal analysis of 5507 Brazilian municipalities.

OBJECTIVE: To estimate the association between homicide and suicide rates in Brazilian municipalities over a period of 7 years. DESIGN: We conducted a longitudinal ecological study using annual mortality data from 5507 Brazilian municipalities between 2008 and 2014. Multivariable negative binomial regression models were used to examine the relationship between homicide and suicide rates. Robustness of results was explored using sensitivity analyses to examine the influence of data quality, population size, age and sex on the relationship between homicide and suicide rates. SETTING: A nationwide study of municipality-level data. PARTICIPANTS: Mortality data and corresponding population estimates for municipal populations aged 10 years and older. PRIMARY AND SECONDARY OUTCOME MEASURES: Age-standardised suicide rates per 100 000. RESULTS: Municipal suicide rates were positively associated with municipal homicide rates; after adjusting for socioeconomic and demographic factors, a doubling of the homicide rate was associated with 22% increase in suicide rate (rate ratio=1.22, 95% CI: 1.13 to 1.33). A dose-response effect was observed with 4% increase in suicide rates at the third quintile, 9% at the fourth quintile and 12% at the highest quintile of homicide rates compared with the lowest quintile. The observed effect estimates were robust to sensitivity analyses. CONCLUSIONS: Municipalities with higher homicide rates have higher suicide rates and the relationship between homicide and suicide rates in Brazil exists independently of many sociodemographic and socioeconomic factors. Our results are in line with the hypothesis that changes in homicide rates lead to changes in suicide rates, although a causal association cannot be established from this study. Suicide and homicide rates have increased in Brazil despite increased community mental health support and incarceration, respectively; therefore, new avenues for intervention are needed. The identification of a positive relationship between homicide and suicide rates suggests that population-based interventions to reduce homicide rates may also reduce suicide rates in Brazil.

Prevalence and incidence of clinical outcomes in patients presenting to secondary mental health care with mood instability and sleep disturbance.

BACKGROUND: Mood instability and sleep disturbance are common symptoms in people with mental illness. Both features are clinically important and associated with poorer illness trajectories. We compared clinical outcomes in people presenting to secondary mental health care with mood instability and/or sleep disturbance with outcomes in people without either mood instability or sleep disturbance. METHODS: Data were from electronic health records of 31,391 patients ages 16-65 years presenting to secondary mental health services between 2008 and 2016. Mood instability and sleep disturbance were identified using natural language processing. Prevalence of mood instability and sleep disturbance were estimated at baseline. Incidence rate ratios were estimates for clinical outcomes including psychiatric diagnoses, prescribed medication, and hospitalization within 2-years of presentation in persons with mood instability and/or sleep disturbance compared to individuals without either symptom. RESULTS: Mood instability was present in 9.58%, and sleep disturbance in 26.26% of patients within 1-month of presenting to secondary mental health services. Compared with individuals without either symptom, those with mood instability and sleep disturbance showed significantly increased incidence of prescription of any psychotropic medication (incidence rate ratios [IRR] = 7.04, 95% confidence intervals [CI] 6.53-7.59), and hospitalization (IRR = 5.32, 95% CI 5.32, 4.67-6.07) within 2-years of presentation. Incidence rates of most clinical outcomes were considerably increased among persons with both mood instability and sleep disturbance, relative to persons with only one symptom. CONCLUSIONS: Mood instability and sleep disturbance are present in a wide range of mental disorders, beyond those in which they are conventionally considered to be symptoms. They are associated with poor outcomes, particularly when they occur together. The poor prognosis associated with mood instability and sleep disorder may be, in part, because they are often treated as secondary symptoms. Mood instability and sleep disturbance need better recognition as clinical targets for treatment in their own right.

Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): a retrospective study.

BACKGROUND: Little is known about the relative incidence of fatal and non-fatal self-harm in young people. We estimated the incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England. METHODS: We used national mortality statistics (Jan 1, 2011, to Dec 31, 2013), hospital monitoring data for five hospitals derived from the Multicentre Study of Self-Harm in England (Jan 1, 2011, to Dec 31, 2013), and data from a schools survey (2015) to estimate the incidence of fatal and non-fatal self-harm per 100 000 person-years in adolescents aged 12-17 years in England. We described these incidences in terms of an iceberg model of self-harm. FINDINGS: During 2011-13, 171 adolescents aged 12-17 years died by suicide in England (119 [70%] male and 133 [78%] aged 15-17 years) and 1320 adolescents presented to the study hospitals following non-fatal self-harm (1028 [78%] female and 977 [74%] aged 15-17 years). In 2015, 322 (6%) of 5506 adolescents surveyed reported self-harm in the past year in the community (250 [78%] female and 164 [51%] aged 15-17 years). In 12-14 year olds, for every boy who died by suicide, 109 attended hospital following self-harm and 3067 reported self-harm in the community, whereas for every girl who died by suicide, 1255 attended hospital for self-harm and 21 995 reported self-harm in the community. In 15-17 year olds, for every male suicide, 120 males presented to hospital with self-harm and 838 self-harmed in the community; whereas for every female suicide, 919 females presented to hospital for self-harm and 6406 self-harmed in the community. Hanging or asphyxiation was the most common method of suicide (125 [73%] of 171), self-poisoning was the main reason for presenting to hospital after self-harm (849 [71%] of 1195), and self-cutting was the main method of self-harm used in the community (286 [89%] of 322). INTERPRETATION: Ratios of fatal to non-fatal rates of self-harm differed between males and females and between adolescents aged 12-14 years and 15-17 years, with a particularly large number of females reporting self-harm in the community. Our findings emphasise the need for well resourced community and hospital-based mental health services for adolescents, with greater investment in school-based prevention. FUNDING: UK Department of Health.

Sleep problems and suicide associated with mood instability in the Adult Psychiatric Morbidity Survey, 2007.

OBJECTIVE: Mood instability is common in the general population. Mood instability is a precursor to mental illness and associated with a range of negative health outcomes. Sleep disturbance appears to be closely linked with mood instability. This study assesses the association between mood instability and sleep disturbance and the link with suicidal ideation and behaviour in a general population sample in England. METHOD: The Adult Psychiatric Morbidity Survey, 2007 collected detailed information about mental health symptoms and correlates in a representative sample of adult household residents living in England ( n = 7303). Mood instability was assessed using the Structured Clinical Interview for DSM-IV Axis-II. Sleep problems were defined as sleeping more than usual or less than usual during the past month. Other dependent variables included medication use and suicidal ideation and behaviour (response rate 57%). Generalized linear modelling was used to estimate the prevalence of mood instability and sleep problems. Logistic regression was used to estimate odds ratios. All estimates were weighted. RESULTS: The prevalence of mood instability was 14.7% (95% confidence interval [13.6%, 15.7%]). Sleep problems occurred in 69.8% (95% confidence interval: [66.6%, 73.1%]) of those with mood instability versus 37.6% (95% confidence interval: [36.2%, 39.1%]) of those without mood instability. The use of sedating and non-sedating medications did not influence the association. Sleep problems were significantly associated with suicidal ideation and behaviour even after adjusting for mood instability. CONCLUSION: Sleep problems are highly prevalent in the general population, particularly among those with mood instability. Sleep problems are strongly associated with suicidal ideation and behaviour. Treatments that target risk and maintenance factors that transcend diagnostic boundaries, such as therapies that target sleep disturbance, may be particularly valuable for preventing and addressing complications related to mood instability such as suicide.

Major Depression in Canada: What Has Changed over the Past 10 Years?

OBJECTIVE: Major depressive episodes (MDE) make an important contribution to disease burden in Canada. The epidemiology of MDE in the national population has been examined in 2 mental health surveys, one conducted in 2002 and the other in 2012. Our objective was to compare selected variables from the 2 surveys to determine whether changes have occurred in the prevalence, treatment, and impact of MDE. METHOD: The World Health Organization World Mental Health Composite International Diagnostic Interview was used in both surveys and the MDE module (which was not modified) was scored using the same algorithm. Some variables assessing impact and management of MDE were also identical in the 2 surveys. The analysis was based on frequency estimates and associated 95% confidence intervals. RESULTS: The annual prevalence of MDE was 4.7% (95% CI 4.3% to 5.1%) in 2012, nearly identical to 4.8% (95% CI 4.5% to 5.1%) in 2002. Receipt of potentially adequate treatment (defined as taking an antidepressant or 6 or more visits to a health professional for mental health reasons) increased from 41.3% in 2002 to 52.2% in 2012, mostly due to an increase in respondents reporting 6 or more visits. Use of second generation antipsychotics also increased. There was no evidence of diminishing prevalence or impact (as assessed by symptoms of distress). CONCLUSIONS: There appears to have been an increase in receipt of treatment for people with MDE and a changing pattern of management. However, it was not possible to confirm that the impact of MDE is diminishing as a result.

Exploration of Undertreatment and Patterns of Treatment of Depression in Multiple Sclerosis.

BACKGROUND: Depression is a common comorbid condition with multiple sclerosis (MS). Historically, however, it has been undertreated. Little is known about the characteristics of those who receive, or do not receive, treatment for depression in the MS population. This study evaluated depression treatment in patients with MS, associated patient characteristics, and probable determinants of antidepressant drug use in those with and without depression. METHODS: A total of 152 patients with MS completed questionnaires and the Structured Clinical Interview for DSM-IV-TR (SCID) to determine depression status. Tabular analyses and a binary regression model were used to identify patient characteristics associated with antidepressant drug use. RESULTS: Of participants with major depression according to the SCID, 65% were taking antidepressant medications. With adjustment for successful treatment (antidepressant drug use by those not currently depressed and currently depressed), the prevalence of treated depression increased to 85.7%. Of those receiving treatment for depression, 19% were receiving nonpharmacologic treatment alone, 38% were taking antidepressant drugs only, and 44% were receiving both pharmacologic and nonpharmacologic treatments. Demographic and clinical variables were not statistically significantly associated with antidepressant drug use in those with depression. CONCLUSIONS: A large proportion of participants with depression in MS are now receiving treatment, a change from previous reports. The adequacy of treatment has become a bigger question because many of the treated patients continued to have depressive symptoms. Further research is needed to identify ways to achieve better outcomes for depression.

Descriptive epidemiology of major depressive disorder in Canada in 2012.

OBJECTIVE: The epidemiology of major depressive disorder (MDD) was first described in the Canadian national population in 2002. Updated information is now available from a 2012 survey: the Canadian Community Health Study-Mental Health (CCHS-MH). METHOD: The CCHS-MH employed an adaptation of the World Health Organization World Mental Health Composite International Diagnostic Interview and had a sample of n=25 113. Demographic variables, treatment, comorbidities, suicidal ideation, and perceived stigma were assessed. The analysis estimated adjusted and unadjusted frequencies and prevalence ratios. All estimates incorporated analysis methods to account for complex survey design effects. RESULTS: The past-year prevalence of MDD was 3.9% (95% CI 3.5% to 4.2%). Prevalence was higher in women and in younger age groups. Among respondents with past-year MDD, 63.1% had sought treatment and 33.1% were taking an antidepressant (AD); 4.8% had past-year alcohol abuse and 4.5% had alcohol dependence. Among respondents with past-year MDD, the prevalence of cannabis abuse was 2.5% and that of dependence was 2.9%. For drugs other than cannabis, the prevalence of abuse was 2.3% and dependence was 2.9%. Generalized anxiety disorder was present in 24.9%. Suicide attempts were reported by 6.6% of respondents with past-year MDD. Among respondents accessing treatment, 37.5% perceived that others held negative opinions about them or treated them unfairly because of their disorder. CONCLUSIONS: MDD is a common, burdensome, and stigmatized condition in Canada. Seeking help from professionals was reported at a higher frequency than in prior Canadian studies, but there has been no increase in AD use among Canadians with MDD.

Prevalence of Bipolar I and II Disorder in Canada.

OBJECTIVE: Current epidemiologic knowledge about bipolar disorder (BD) in Canada is inadequate. To date, only 3 prevalence studies have been conducted: only 1 was based on a national sample, and none distinguished between BD I and II. The objective of this study was to estimate the prevalence of BD I and II in Canada in 2012. METHOD: Data were obtained from the 2012 Canadian Community Health Survey: Mental Health and Well-being, a cross-sectional survey of a nationally representative sample of household residents ages 15 years and older (n = 25 113). The survey response rate was 68.9%. Interviews were based on the World Health Organization Composite International Diagnostic Interview (CIDI). Prevalence was estimated using generalized linear modelling. Prevalence of self-reported diagnosis of BD and use of lithium were also estimated. RESULTS: The estimated lifetime prevalence of BD I and II (based on the CIDI) in Canada in 2012 was 0.87% (95% CI 0.67% to 1.07%) and 0.57% (95% CI 0.44% to 0.71%), respectively. Prevalence did not differ by sex. The estimated prevalence of self-reported BD was 0.87% (95% CI 0.65% to 1.07%). There was a lack of congruence between CIDI-defined and self-reported BD, and few people taking lithium were positive for BD on the CIDI, which raises some concerns about the validity of the CIDI's assessment of BD. CONCLUSIONS: These prevalence estimates align with those reported in prior literature. However, caution should be exercised when interpreting general population studies that use CIDI-defined BD owing to the possibility of misclassification.