Access to Firearms Among People Assessed by Psychiatric Services in the Emergency Department.

OBJECTIVE: In Canada, 80% of firearm-related deaths are suicides. Access to firearms is associated with increased suicide rates. This study examines the frequency and factors that influence assessment of firearm access in an emergency setting. METHODS: A total of 15,847 consecutive adults seen for psychiatric consultation in two tertiary emergency departments (EDs) in Winnipeg, Manitoba were interviewed. Data captured whether access to firearms was assessed, and whether respondents endorsed access or not. Comparisons were done to determine group differences among those with and without and with known and unknown firearm access. RESULTS: Access to firearms was unknown in 47% (n = 7,363) of psychiatric ED consultations, including 43% (n = 998) of individuals who presented with a suicide attempt. Female sex was associated with decreased odds of firearm access (odds ratio [OR] 0.28; 95% CI, 0.22 to 0.35). Being single was associated with lower odds of known firearm access (OR 0.83; 95% CI, 0.77 to 0.89) yet higher likelihood of firearm access (OR 1.36; 95% CI, 1.11 to 1.68). Presenting with a suicide attempt (OR 2.45; 95% CI, 1.80 to 3.34), preparatory acts (OR 6.40; 95% CI, 4.38 to 9.36) and suicidal ideation (OR 2.45; 95% CI, 1.87 to 3.21) were associated with increased odds of reporting access. When clinicians felt there was a high likelihood of future suicide, firearm access remained unknown in half of cases. CONCLUSION: Firearm ownership and access is an essential component of a suicide risk assessment and remains unknown in half of individuals seen by psychiatry in this tertiary care ED sample. People presenting with suicidal ideation and attempts were more likely to report access to firearms.

Correlates of Nonsuicidal Self-Injury and Suicide Attempts Among Tertiary Care, Emergency Department Patients.

OBJECTIVE: In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the distinction between nonsuicidal self-injury (NSSI) and suicidal behaviour disorder is highlighted in the section Conditions for Further Study. Diagnostic criteria classify NSSI and suicidal behaviour disorder as distinct disorders, with the latter including suicide attempt (SA). This study examined the prevalence and correlates of NSSI in emergency department (ED) settings and compared them to SA. METHODS: Data came from adult referrals to psychiatric services in 2 EDs between January 2009 and June 2011 (n = 5336). NSSI was compared with SA, as well as no suicidal behaviour, across a broad range of demographic and diagnostic correlates. RESULTS: NSSI was more highly associated with female sex, childhood abuse, anxiety disorders, major depressive disorder (MDD), aggression and impulsivity, age under 45, and substance use disorders (SUDs), compared with presentations without suicidal behaviour. Comparing NSSI and SA, no differences were observed on sex, age, history of child abuse, or presence of anxiety or SUDs. Recent life stressors (OR 1.44; 95% CI 1.05 to 1.99), active suicidal ideation (OR 8.84; 95% CI 5.26 to 14.85), MDD (OR 3.05; 95% CI 2.23 to 4.17), previous psychiatric care or SA (OR 1.89; 95% CI 1.36 to 2.64), and single marital status (OR 1.63; 95% CI 1.20 to 2.22) contributed to a higher SA rate. Among people with NSSI, 83.7% presented only once to an ED. Among people who presented multiple times, only 18.2% re-presented with NSSI. CONCLUSIONS: NSSI is associated with early life adversity and psychiatric comorbidity. Most people present only once to ED services, and self-harm presentations seemed to change over time. Future studies should continue to clarify whether NSSI and SA have distinct risk profiles.

Predictors of Future Suicide Attempts Among Individuals Referred to Psychiatric Services in the Emergency Department: A Longitudinal Study.

This study examined which factors predict future suicide attempts (SAs) among people referred to psychiatric services in the emergency department (ED). It included consecutive adult (age >18 years) presentations (N = 6919) over a 3-year period to the two tertiary care hospitals in Manitoba, Canada. Medical professionals assessed each individual on 19 candidate risk factors. Stepwise logistic regression and receiver operating characteristic curves examined the association between the baseline variables and future SAs within the next 6 months. A total of 104 individuals re-presented to the ED with future SAs. Of the 19 baseline variables, only two independently accounted for the variance in future attempts. High-risk scores using this two-item model were associated with elevated odds of future SA (odds ratio, 3.22; 95% confidence interval, 1.62-6.42; p < 0.01), but this was tempered by a low positive predictive value. Further evaluation is required to determine if this two-item tool could help identify people requiring more comprehensive risk assessment referred to psychiatry in the ED.

Drug use, abuse, and dependence and the persistence of nicotine dependence.

INTRODUCTION: Illicit drug use and nicotine dependence (ND) frequently co-occur. Yet, to date very few studies have examined the role of alcohol and illicit drug use in ND persistence. The objectives of this study were to investigate the relationships between specific classes of drug use, abuse, and dependence and the persistence of ND over time among adults in the United States. METHODS: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, a national survey of 34,653U.S. adults interviewed between 2001-2002 and reinterviewed 3 years later. Logistic regression analyses were used to investigate the relationships between various classes of drug use, abuse, and dependence among adults with ND at Wave 1 and the odds for persistent ND at Wave 2. Analyses were adjusted for differences in demographic characteristics, mood/anxiety disorders, alcohol use disorders, and other substance use disorders. RESULTS: Lifetime drug use was not associated with significantly increased likelihood for persistent ND. Sedative abuse was associated with increased odds for nicotine persistence, but no other types of drug abuse were predictive of ND persistence, after adjusting for demographics, mood/anxiety, and alcohol use disorders. All types of drug dependence were associated with persistence of ND; the strongest associations emerged between opioid and tranquilizer dependence and persistent ND, while the associations between cannabis and cocaine dependence were no longer significant after adjusting for mood/anxiety disorders. CONCLUSIONS: Clinicians should take care to evaluate the presence and/or history of drug dependence among patients seeking treatment for smoking cessation. These data suggest that a history of substance dependence predicts increased vulnerability to persistent ND.

A cross-sectional examination of sudden-death bereavement in university students.

ObjectivesThe objective of this research was to determine the unique contributions of sudden death bereavement to the mental health of university students compared to non-sudden death bereaved university students. Methods: We surveyed 1047 bereaved university students (retention rate 92%) and compared the non-sudden death bereaved university student population to the sudden death bereaved university population on outcomes including mental health symptomatology, and complicated grief using logistic regressions. Results: Sixty two percent of the sample reported sudden death bereavement. There were no differences on measures of PTSD, generalized anxiety disorder, depression, suicidal ideation, and at-risk drinking behavior across types of bereavement. However, sudden death bereavement compared to general bereavement was associated with increased likelihood of complicated grief. Conclusions: Sudden death bereavement in university students is associated with elevated risk of complicated grief. These findings confirm previous research and provide more insight into the unique needs of university student coping with sudden loss.

Ambivalence About Living and the Risk for Future Suicide Attempts: A Longitudinal Analysis.

OBJECTIVE: While suicidal ideation is a recognized risk factor for future suicidal behavior, clinicians often subtype ideation in an effort to further clarify risk. This study referred to the SAFE (Suicide Assessment Form in Emergency Psychiatry) database to examine individuals who were assessed for suicidal ideation in the emergency department (ED) to determine whether ideation subtypes (active desire for death versus ambivalence about living) differentially predicted future suicide attempt. METHODS: Participants were individuals presenting to psychiatric services in the ED between January 1, 2009, and December 31, 2013, at 2 hospitals in Manitoba, Canada. People presenting with suicidal ideation were subtyped as having either ambivalence about living or active suicidal ideation. These presentations were examined as predictors of suicide attempt (defined by the Columbia Classification Algorithm for Suicide Assessment scale) within 6 months in regression models that adjusted for confounders. RESULTS: Of the 5,655 individuals presenting to the ED during the study, 158 (3.1%) presented again within 6 months with a suicide attempt. Individuals presenting with ambivalence about living showed more than a doubling in risk for future suicide attempts (odds ratio [OR] = 2.57, 95% CI = 1.64-4.02, P < .001). Active suicidal ideation also predicted attempts (defined by the within 6 months, with more than a tripling of risk compared to people who were not suicidal at baseline (OR = 3.75, 95% CI = 2.61-5.34, P < .001). CONCLUSIONS: Psychiatric presentations to the ED often include suicidal ideation. Both active suicidal ideation and ambivalence about living are concerning presentations associated with risk of attempt within 6 months. Clinicians should be mindful that differentiating between active suicidal ideation and ambivalence about living may downplay the severity of the latter presentation.

Population trends in substances used in deliberate self-poisoning leading to intensive care unit admissions from 2000 to 2010.

OBJECTIVE: To examine population trends in serious intentional overdoses leading to admission to intensive care units (ICUs) in Winnipeg, Manitoba, Canada. METHOD: Participants consisted of 1,011 individuals presenting to any of the 11 ICUs in Winnipeg, Canada, with deliberate self-poisonings from January 2000 to December 2010. Eight categories of substances were created: poisons, over-the-counter medications, prescription medications, tricyclic antidepressants (TCAs), sedatives and antidepressants, anticonvulsants, lithium, and cocaine. Using the population of Winnipeg as the denominator, we conducted generalized linear model regression analyses using the Poisson distribution with log link to determine significance of linear trends in overdoses by substance over time. RESULTS: Women accounted for more presentations than men (57.8%), and the largest percentage of overdoses occurred among individuals in the 35- to 54-year age range. A large proportion of admissions were due to multiple overdoses, which accounted for 65.7% of ICU admissions. At the population level, multiple overdoses increased slightly over time (incidence rate ratio [IRR] = 1.02, P < .05), whereas use of poisons (IRR = 0.897, P < .01), over-the-counter medications (IRR = 0.910, P < .01), nonpsychotropic prescription medications (IRR = 0.913, P < .01), anticonvulsants (IRR = 0.880, P < .01), and TCAs (IRR = 0.920, P < .01) decreased over time. Overdoses did not change over time as a function of age or sex. However, severity of overdoses classified by length of stay increased over time (IRR = 1.08, P < .01). CONCLUSIONS: It is important for physicians to exercise vigilance while prescribing medication, including being aware of other medications their patients have access to.

Method of suicide attempt and reaction to survival as predictors of repeat suicide attempts: a longitudinal analysis.

OBJECTIVE: To evaluate whether reaction to survival of a suicide attempt and method of the index attempt predicted repeat suicide attempts within 6 months. METHOD: Data came from the Suicide Assessment Form in Emergency Psychiatry (SAFE) Database Project, which contains information on all presentations to emergency psychiatric services at the 2 tertiary hospitals in Manitoba, Winnipeg, Canada (N = 7,007). During a 4-year period (2009-2012), 922 individuals presented with suicide attempts. Logistic regressions were used to examine whether a person's reaction to attempt survival and the method of attempt predicted repeat suicide attempt within 6 months. RESULTS: Of the 922 participants, 82 (8.8%) presented with another suicide attempt within 6 months. Ambivalence about attempt survival (adjusted odds ratio [OR] = 2.84; 95% CI, 1.45-5.54; P < .01) and wishing to be dead (adjusted OR = 2.68; 95% CI, 1.17-6.17; P < .05) predicted future attempts even when adjusted for age, sex, depression, substance abuse, and method of the initial attempt. Method of the index attempt did not predict future suicide attempts in adjusted models (adjusted OR = 0.66; 95% CI, 0.35-1.25; P > .05). CONCLUSIONS: Assessment of the patient's reaction to survival, regardless of method of attempt, is important to identify risk of repeat attempts.