Role of intense affects in predicting short-term risk for suicidal behavior: a prospective study.

We examined the utility of the Affective States Questionnaire (ASQ) in predicting acute risk for suicidal behavior. Subjects at a VHA Medical Center were interviewed using the ASQ and again 3 months later when their suicidal behaviors over that period were examined. The ASQ had a sensitivity of 60% for predicting suicidal behavior over the follow-up period, and specificity of 74%. The false positive rate was relatively low for a sample not highly selected for suicide risk and utilizing a short period of 3 months for suicidal behavior. Subgroups combining the ASQ with disability level or a diagnosis of substance abuse greatly reduced the percentage of false positives. The ASQ is able to improve significantly our ability to predict acute risk of suicidal behavior in clinical psychiatric populations.

A suicide prevention program in a region with a very high suicide rate.

CONTEXT: Suicide is a major cause of mortality worldwide. Rates vary widely within and between countries. A suicide prevention program has never been tested in a region with a very high suicide rate in comparison with control regions without such intervention over the same period. OBJECTIVE: To determine the effectiveness of a depression-management educational program for general practitioners (GPs) on the suicide rate in a region with a high suicide rate in Hungary. DESIGN: Effects were compared with a control region, the larger surrounding county, and Hungary. SETTING: Southwest Hungary. PARTICIPANTS: Twenty-eight GPs servicing 73,000 inhabitants participated in the educational program. INTERVENTION: A 5-year depression-management educational program for GPs and their nurses was implemented together with establishment of a Depression Treatment Clinic and psychiatrist telephone consultation service in the intervention region. MAIN OUTCOME MEASURES: The primary study outcome measure was annual suicide rate. The secondary outcome measure was antidepressant prescription use. RESULTS: The annual suicide rate in the intervention region decreased from the 5-year preintervention average of 59.7 in 100,000 to 49.9 in 100,000. The decrease was comparable with the control region but greater than both the county and Hungary (P < .001 and P < .001, respectively). In rural areas, the female suicide rate in the intervention region decreased by 34% and increased by 90% in the control region (P < .07). The increase in antidepressant treatment was greater in the intervention region compared with the control region, the county, and Hungary and in women compared with men (P < .002). CONCLUSIONS: A GP-based intervention produced a greater decline in suicide rates compared with the surrounding county and national rates. Increases in patients with depression treated and of dosing were modest and may require additional measures such as depression-care managers. The importance of alcoholism in local suicides was unanticipated and not addressed. Optimal suicide prevention plans must consider major local risk factors.

Depression, desperation, and suicidal ideation in college students: results from the American Foundation for Suicide Prevention College Screening Project at Emory University.

The objective of this investigation was to examine suicidal ideation and depression in undergraduate college students who participated in the American Foundation for Suicide Prevention-sponsored College Screening Project at Emory University. The principal measure of depressive symptoms was the nine-item depression module from the Patient Health Questionnaire (PHQ-9). Additional questions were focused on current suicidal ideation, past suicide attempts, and episodes of deliberate self-harm and on symptoms of anxiety and distress. Seven hundred and twenty-nine students participated over a 3-school-year interval (2002-2005). Most notably, 11.1% of the students endorsed current (past 4 weeks) suicidal ideation and 16.5% had a lifetime suicide attempt or self-injurious episode. Students with current suicidal ideation had significantly higher depression symptom severity than those without suicidal ideation (t = -9.34, df = 706, P<.0001, d = 1.9), and 28.5% of the students with PHQ-9 scores of 15 or higher reported suicidal ideation compared to 5.7% of those with lower scores (chi(2) = 56.29, df = 1, P<.0001, two-tailed). Suicidal ideation was prominently associated with symptoms of desperation (odds ratio 2.6, 95% CI 1.5-4.6, P<.001). The vast majority of students with moderately severe to severe depression (85%) or current suicidal ideation (84%) were not receiving any psychiatric treatment at the time of assessment. These results suggest that there is a strong relationship between severity of depressive symptoms and suicidal ideation in college students, and that suicidal feelings and actions are relatively common in this group. This underscores the need to provide effective mental health outreach and treatment services to this vulnerable population. As this analysis was based on data collected at a single institution, the results may not be representative of all college students or young adults.

An interactive web-based method of outreach to college students at risk for suicide.

OBJECTIVE AND PARTICIPANTS: From 2002 to 2005, the authors tested an interactive, Web-based method to encourage college students at risk for suicide to seek treatment. METHODS: The authors invited students at 2 universities to complete an online questionnaire that screened for depression and other suicide risk factors. Respondents received a personalized assessment and were able to communicate anonymously with a clinical counselor online. At-risk students were urged to attend in-person evaluation and treatment. RESULTS: A total of 1,162 students (8% of those invited) completed the screening questionnaire; 981 (84.4%) were designated as at high or moderate risk. Among this group, 190 (19.4%) attended an in-person evaluation session with the counselor, and 132 (13.5%) entered treatment. Students who engaged in online dialogues with the counselor were 3 times more likely than were those who did not to come for evaluation and enter treatment. CONCLUSIONS: The method has considerable promise for encouraging previously untreated, at-risk college students to get help.

Physician-assisted suicide in Oregon: a medical perspective.

This article examines the Oregon Death with Dignity Act from a medical perspective. Drawing on case studies and information provided by doctors, families, and other care givers, it finds that seemingly reasonable safeguards for the care and protection of terminally ill patients written into the Oregon law are being circumvented. The problem lies primarily with the Oregon Public Health Division ("OPHD"), which is charged with monitoring the law. OPHD does not collect the information it would need to effectively monitor the law and in its actions and publications acts as the defender of the law rather than as the protector of the welfare of terminally ill patients. We make explicit suggestions for what OPHD would need to do to change that.

Physician-assisted suicide in Oregon: a medical perspective.

This Article examines the Oregon Death with Dignity Act from a medical perspective. Drawing on case studies and information provided by doctors, families, and other care givers, it finds that seemingly reasonable safeguards for the care and protection of terminally ill patients written into the Oregon law are being circumvented. The problem lies primarily with the Oregon Public Health Division ("OPHD"), which is charged with monitoring the law. OPHD does not collect the information it would need to effectively monitor the law and in its actions and publications acts as the defender of the law rather than as the protector of the welfare of terminally ill patients. We make explicit suggestions for what OPHD would need to do to change that.

Psychodynamic Treatment of Combat Veterans with PTSD at Risk for Suicide.

Posttraumatic stress disorder is a condition associated with suicide in both military personnel and combat veterans. Most veterans with PTSD, however, are not at risk of suicide. The major factor distinguishing those who attempted or were preoccupied with suicide is persistent severe guilt over behavior in combat while emotionally out of control. A 12-session short-term, psychodynamic psychotherapy, presented here, showed promise of success in dissipating the guilt from combat-related actions in veterans of the war in Vietnam. Preliminary work with combat veterans of the wars in Iraq and Afghanistan indicates it may be equally successful in treating them. Basic aspects of the psychodynamic approach could also be incorporated into current therapies and should improve their ability to treat veterans with PTSD at risk for suicide. Case examples are provided.

Problems in psychotherapy with suicidal patients.

OBJECTIVE: The authors studied recurrent problems in psychotherapy with suicidal patients by examining the cases of patients who died by suicide while receiving open-ended psychotherapy and medication. METHOD: Therapists for 36 patients who died by suicide while in treatment filled out clinical, medication, and psychological questionnaires and wrote detailed case narratives. They then presented their cases at an all-day workshop, and critical problems were identified in the cases. RESULTS: Six recurrent problem areas were identified: poor communication with another therapist involved in the case, permitting patients or relatives to control the therapy, avoidance of issues related to sexuality, ineffective or coercive actions resulting from the therapist's anxieties about a patient's potential suicide, not recognizing the meaning of the patient's communications, and untreated or undertreated symptoms. CONCLUSIONS: These cases illuminate common problems therapists face in working with suicidal patients and highlight an unmet need for education of psychiatrists and other mental health professionals who work with this population.

Suicide prevention strategies: a systematic review.

CONTEXT: In 2002, an estimated 877,000 lives were lost worldwide through suicide. Some developed nations have implemented national suicide prevention plans. Although these plans generally propose multiple interventions, their effectiveness is rarely evaluated. OBJECTIVES: To examine evidence for the effectiveness of specific suicide-preventive interventions and to make recommendations for future prevention programs and research. DATA SOURCES AND STUDY SELECTION: Relevant publications were identified via electronic searches of MEDLINE, the Cochrane Library, and PsychINFO databases using multiple search terms related to suicide prevention. Studies, published between 1966 and June 2005, included those that evaluated preventative interventions in major domains; education and awareness for the general public and for professionals; screening tools for at-risk individuals; treatment of psychiatric disorders; restricting access to lethal means; and responsible media reporting of suicide. DATA EXTRACTION: Data were extracted on primary outcomes of interest: suicidal behavior (completion, attempt, ideation), intermediary or secondary outcomes (treatment seeking, identification of at-risk individuals, antidepressant prescription/use rates, referrals), or both. Experts from 15 countries reviewed all studies. Included articles were those that reported on completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates. We included 3 major types of studies for which the research question was clearly defined: systematic reviews and meta-analyses (n = 10); quantitative studies, either randomized controlled trials (n = 18) or cohort studies (n = 24); and ecological, or population- based studies (n = 41). Heterogeneity of study populations and methodology did not permit formal meta-analysis; thus, a narrative synthesis is presented. DATA SYNTHESIS: Education of physicians and restricting access to lethal means were found to prevent suicide. Other methods including public education, screening programs, and media education need more testing. CONCLUSIONS: Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates. Other interventions need more evidence of efficacy. Ascertaining which components of suicide prevention programs are effective in reducing rates of suicide and suicide attempt is essential in order to optimize use of limited resources.

Factors contributing to therapists' distress after the suicide of a patient.

OBJECTIVE: Factors contributing to therapists' severe distress after the suicide of a patient were investigated. METHOD: Therapists for 34 patients who died by suicide completed a semistructured questionnaire about their reactions, wrote case narratives, and participated in a workshop. RESULTS: Thirteen of the 34 therapists were severely distressed. Four factors were identified as sources of severe distress: failure to hospitalize an imminently suicidal patient who then died, a treatment decision the therapist felt contributed to the suicide, negative reactions from the therapist's institution, and fear of a lawsuit by the patient's relatives. Although one emotion was sometimes dominant in the therapist's response to the suicide, severely distressed therapists, compared to others, reported a significantly larger number of intense emotional states. CONCLUSIONS: Over one-third of therapists who experienced a patient's suicide were found to suffer severe distress, pointing to the need for further study of the long-term effects of patient suicide on professional practice.

Determination of precipitating events in the suicide of psychiatric patients.

Data from therapists who were treating patients when they killed themselves were used to provide information about precipitating events that was missing from accounts obtained from suicide victims' relatives and friends. Among 26 patient suicides studied, the therapists identified a precipitating event in 25 cases; in 19 of these, supporting evidence linked the identified event to the suicide. A schema was developed that identifies nine types of evidence provided by therapists in determining that an event precipitated the suicide. Use of the schema is likely to improve accurate identification of events that precipitate patient suicides, and distinguish them from unrelated coterminous events or suicide risk factors.

Desperation and other affective states in suicidal patients.

Data collected from 26 therapists who were treating patients when they died by suicide were used to identify intense affective states in such patients preceding the suicide. Eleven therapists provided comparable data on 26 patients they had treated who were seriously depressed but not suicidal. Although the two groups had similar numbers diagnosed with MDD, the suicide patients showed a significantly higher total number of intense affects in addition to depression. The acute affective state most associated with a suicide crisis was desperation. Hopelessness, rage, abandonment, self-hatred, and anxiety were also significantly more frequently evidenced in the suicide patients.

Confronting depression and suicide in physicians: a consensus statement.

OBJECTIVE: To encourage treatment of depression and prevention of suicide in physicians by calling for a shift in professional attitudes and institutional policies to support physicians seeking help. PARTICIPANTS: An American Foundation for Suicide Prevention planning group invited 15 experts on the subject to evaluate the state of knowledge about physician depression and suicide and barriers to treatment. The group assembled for a workshop held October 6-7, 2002, in Philadelphia, Pa. EVIDENCE: The planning group worked with each participant on a preworkshop literature review in an assigned area. Abstracts of presentations and key publications were distributed to participants before the workshop. After workshop presentations, participants were assigned to 1 of 2 breakout groups: (1) physicians in their role as patients and (2) medical institutions and professional organizations. The groups identified areas that required further research, barriers to treatment, and recommendations for reform. CONSENSUS PROCESS: This consensus statement emerged from a plenary session during which each work group presented its recommendations. The consensus statement was circulated to and approved by all participants. CONCLUSIONS: The culture of medicine accords low priority to physician mental health despite evidence of untreated mood disorders and an increased burden of suicide. Barriers to physicians' seeking help are often punitive, including discrimination in medical licensing, hospital privileges, and professional advancement. This consensus statement recommends transforming professional attitudes and changing institutional policies to encourage physicians to seek help. As barriers are removed and physicians confront depression and suicidality in their peers, they are more likely to recognize and treat these conditions in patients, including colleagues and medical students.

The Dutch experience.

Euthanasia has been legally sanctioned in the Netherlands by a series of court decisions going back to the 1970s. The author discusses the cultural and historical factors that may have contributed to this development. In the past decade, studies sanctioned by the Dutch government reveal that guidelines established for the regulation of euthanasia--a voluntary, well-considered, persistent request, intolerable suffering that cannot be relieved, consultation with a colleague, and reporting of cases--are consistently violated. Of greatest concern is the number of patients who are put to death without their consent--there are more involuntary than voluntary cases. Euthanasia intended originally for the exceptional case has become an accepted way of dealing with the physical and mental distress of serious or terminal illness. In the process palliative care has become one of the casualties while hospice care lags behind that of other countries. Case examples are given.

An innovative approach to treating combat veterans with PTSD at risk for suicide.

Suicide rates among military personnel had a significant drop in 2013, but there is no evidence of a drop among veterans. The problem of suicide among combat veterans with posttraumatic stress disorder (PTSD) remains a source of concern. The Department of Defense and the Department of Veterans Affairs are now calling for innovative treatment approaches to the problem. A short-term psychodynamic therapy presented here may be able to fill that need by dissipating the guilt from veterans' combat-related actions that leads to suicidal behavior. The treatment showed promise of success with veterans of the war in Vietnam. Preliminary work with combat veterans of the wars in Iraq and Afghanistan indicates that it may be equally successful in treating them. Basic aspects of the psychodynamic approach could be incorporated into current therapies and should improve their ability to treat veterans with PTSD at risk for suicide.