[Why do we require clinical guidelines for suicide prevention?] / Warum brauchen wir Leitlinien für Suizidprävention?

At present, there are no German guidelines regarding suicidal behaviors in adulthood despite their relevance to public health and the well-established evidence about their prevention. This paper first describes the history and background of working with guidelines. The current status of guidelines for mental illness in Germany is presented and examined for suicide-preventive content. The need for evidence-based suicide prevention and a specific guideline for suicide prevention in adults is discussed.Only via targeted suicide prevention strategies and interventions for the respective risk groups, and by paying particular attention to age and gender specificity in the outpatient as well as inpatient sector, can a high level of care for all patients be ensured. Such strategies have to pay specific attention to the interface between the individual care sectors and need to take comprehensive, easily accessible, needs-based, and affordable sustainable medical care into account. This applies to the outpatient and inpatient sectors as well as to their interfaces. Suicidality is a cross-diagnosis syndrome that occurs in different care contexts and requires complex treatment; therefore, intersectoral and multiprofessional aspects must particularly be addressed in the guideline. Scientific evidence and interdisciplinary expert consensus on the management of suicidal behavior in medical care can help reduce morbidity and mortality associated with suicidality. In August 2021, the funding of an S3 guideline "Management of Suicidality" was approved by the Federal Joint Committee.

[Suicide and Suicide Prevention in Psychiatric Hospitals]. / Suizid und Suizidprävention im psychiatrischen Krankenhaus.

Suicide prevention is a central topic of psychiatry and psychotherapy. Times of changes in psychiatric inpatient treatment conceptions usually come along with an increase of psychopathology and with increasing suicide rates in psychiatric hospitals to, like seen in the seventies and eighties of last century in Germany. After a real increase of inpatient suicides during those years the number and rate of inpatient suicides decreased from about 280 of 100 000 admissions of patients in 1980 to about 50 in 2014. Young male schizophrenic patients were identified as the new high risk group despite the severely depressed patients with delusions as a traditional high risk group. Nowadays suicide prevention is part of all educational programs in psychiatry and psychotherapy.

[40 years in-patient suicide research of the working group "Suicidality and the psychiatric hospital"]. / 40 Jahre Kliniksuizidverbundstudie der AG "Suizidalität und Psychiatrisches Krankenhaus".

OBJECTIVE: To give an retrospective overview according to the so-called in-patient suicide especially in German psychiatric hospitals. METHOD: Summary of results of the working group "Suicidality and the psychiatric hospital" during the last four decades in Germany. RESULTS: First, it could be shown that there was a real increase of in-patient suicides during the 70(th) and 80(th) years. Two other results are important 1) an impressive decrease of suicide rates in the two last decades and 2) the observation of a change from the new high-risk group "young schizophrenic patients" back to the traditional suicide risk group of depressed patients.

How therapists react to patient's suicide: findings and consequences for health care professionals' wellbeing.

OBJECTIVES: To test the robustness of the findings of previous studies in a large aggregated sample regarding (a) the impact of a patient's suicide on therapist's distress; (b) identify a potential subgroup of therapists needing special postvention; (c) and assess potential differences in overall distress between professional groups and at different levels of care. METHODS: A questionnaire, characterizing the therapists, their reactions and the patients, had been sent out to 201 psychiatric hospitals in Germany providing different levels of care. Aggregated data from previous studies have been used. RESULTS: In 39.6% of all cases, therapists suffer from severe distress after a patients' suicide. The global item "overall distress" can be used as an indicator to identify a subgroup of therapists that might need individualized postvention. No significant difference in overall distress experienced was observed between professional groups and at different levels of care. CONCLUSION: Our data suggest that identifying the severely distressed subgroup could be done using a visual analogue scale for overall distress. As a consequence, more specific, individualized and intensified help could be provided to these professionals, helping them to overcome distress and thereby ensuring delivery of high quality care to the patient.

Association between leptin levels and doses of clomethiazole during alcohol withdrawal: a pilot study.

AIMS: The issue of leptin as a putative state marker of alcohol use and its role in craving has been raised in the last few years. Recently, a strong GABA-ergic modulation of leptin was postulated. The aim of the pilot study was to examine leptin levels in correlation with the strongly GABA-mimetic active substance clomethiazole. The main hypothesis was that higher doses of the strong GABA-mimetic clomethiazole are positively correlated with higher leptin levels. METHODS: Twenty-eight alcohol-dependent patients (3 females, median age 36 years) undergoing alcohol withdrawal were included. In 18 patients with and 10 without clomethiazole, serum leptin was analyzed at day 1 and day 7 of alcohol withdrawal. Both groups did not differ by age, BMI, or alcohol use characteristics. RESULTS: In the clomethiazole group, significant correlations were found between leptin levels at day 1 and clomethiazole dose (p = 0.004), clomethiazole and leptin at day 1/BMI (p = 0.009) and leptin at day 1 and clomethiazole/body surface (p = 0.006). Furthermore, patients with higher clomethiazole doses demonstrated significant higher leptin levels at day 1 (p = 0.044) and day 7 (p = 0.046). CONCLUSIONS: Our pilot data show a strong association between leptin levels and clomethiazole doses, thus supporting further research.

The therapist's reaction to a patient's suicide: results of a survey and implicationsfor health care professionals'well-being.

BACKGROUND: A substantial proportion of therapists experience the loss of a patient to suicide at some point during their professional life. AIMS: To assess (1) the impact of a patient's suicide on therapists distress and well-being over time, (2) which factors contribute to the reaction, and (3) which subgroup might need special interventions in the aftermath of suicide. METHODS: A 63-item questionnaire was sent to all 185 Psychiatric Clinics at General Hospitals in Germany. The emotional reaction of therapists to patient's suicide was measured immediately, after 2 weeks, and after 6 months. RESULTS: Three out of ten therapists suffer from severe distress after a patients' suicide. The item "overall distress" immediately after the suicide predicts emotional reactions and changes in behavior. The emotional responses immediately after the suicide explained 43.5% of the variance of total distress in a regression analysis. LIMITATIONS: The retrospective nature of the study is its primary limitation. CONCLUSIONS: Our data suggest that identifying the severely distressed subgroup could be done using a visual analog scale for overall distress. As a consequence, more specific and intensified help could be provided to these professionals.

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.

Patient suicide: a survey of therapists' reactions.

A substantial proportion of therapists will at some point in their professional life experience the loss of a patient to suicide. Our aims were to assess how therapists react to patient's suicide over time and which factors contribute to the reaction. One third of the therapists, mostly women, suffer from severe distress. The impact is not different for therapists in institutional settings and therapists in private practice. The item "overall distress" immediately after the suicide predicts emotional reactions and changes in behavior. Our data suggest that identifying the severely distressed subgroup could be done using a visual analogue scale for overall distress. As a consequence, more specific and intensified help could be provided to these individuals.

Time patterns of inpatient suicides.

Abstract Objective. Time patterns of suicides have been investigated in many population-based studies, but there are no studies exploring time patterns of suicides during psychiatric inpatient stay up to now. Methods. All inpatient suicides (1998-2007) of a psychiatric university hospital were identified by the German psychiatric basic documentation system (DGPPNBADO). Descriptive and univariate analyses were performed to analyse time patterns of inpatient suicides. Results. No significant differences could be found for the occurrence of the 37 inpatient suicides due to season (χ(2)=1.595, P=0.696), month (χ(2)=4.838, P=0.958) or weekday (χ(2)=5.189, P=0.550) of suicide. Furthermore, we could not find an unequal distribution of suicides due to month of birth (χ(2)=12.622, P=0.337). 78.4% of inpatient suicides occurred within 50 days after admission. Fourteen inpatients committed suicide around public holidays, two around their birthday. Conclusions. Apart from a notably enhanced risk of suicide in the period after admission, we could not find any time patterns to be of high relevance to inpatient suicides. There may be more relevant risk factors than cyclic or temporal variations.

Phosphatidylethanol: normalization during detoxification, gender aspects and correlation with other biomarkers and self-reports.

Phosphatidylethanol (PEth) is a direct ethanol metabolite, and has recently attracted attention as biomarker of ethanol intake. The aims of the current study are: (1) to characterize the normalization time of PEth in larger samples than previously conducted; (2) to elucidate potential gender differences; and (3) to report the correlation of PEth with other biomarkers and self-reported alcohol consumption. Fifty-seven alcohol-dependent patients (ICD 10 F 10.25; 9 females, 48 males) entering medical detoxification at three study sites were enrolled. The study sample was comprised of 48 males and 9 females, with mean age 43.5. Mean gamma glutamyl transpeptidase (GGT) was 209.61 U/l, average mean corpuscular volume (MCV) was 97.35 fl, mean carbohydrate deficient transferrin (%CDT) was 8.68, and mean total ethanol intake in the last 7 days was 1653 g. PEth was measured in heparinized whole blood with a high-pressure liquid chromatography method, while GGT, MCV and %CDT were measured using routine methods. PEth levels at day 1 of detoxification ranged between 0.63 and 26.95 micromol/l (6.22 mean, 4.70 median, SD 4.97). There were no false negatives at day 1. Sensitivities for the other biomarkers were 40.4% for MCV, 73.1% for GGT and 69.2% for %CDT, respectively. No gender differences were found for PEth levels at any time point. Our data suggest that PEth is (1) a suitable intermediate term marker of ethanol intake in both sexes; and (2) sensitivity is extraordinary high in alcohol dependent patients. The results add further evidence to the data that suggest that PEth has potential as a candidate for a sensitive and specific biomarker, which reflects longer-lasting intake of higher amounts of alcohol and seemingly has the above mentioned certain advantages over traditional biomarkers.

[Suicidal behaviour of elderly psychiatric inpatients--prevalence and risk factors]. / Suizidales Verhalten stationär-psychiatrischer Patienten im höheren Lebensalter - Prävalenz und Risikofaktoren.

OBJECTIVE: The study aimed at evaluating prevalence and risk factors of suicidal behaviour of elderly psychiatric inpatients based on the German psychiatric basic documentation system (DGPPN-BADO). METHODS: A total of 5,356 elderly psychiatric inpatients (> 65 years) with 7,658 episodes of inpatient care in a psychiatric university hospital between 1996 and 2006 was included in the study. Besides descriptive analyses, univariate analyses and binary logistic regression analyses were performed. RESULTS: Four inpatient suicides and 14 attempted suicides of twelve inpatients were recorded during the 11-year period. Three of the 4 inpatient suicides and 6 of the 12 inpatients attempting suicide during hospital stay had a diagnosis of depression. Furthermore, 280 suicides before admission were attempted by 262 patients. Regression analysis revealed life time suicide attempt, ICD-10 diagnosis F43, period of onset of present episode less than one week and ICD-10 diagnosis F32 / F33 as significant predictors of attempted suicide before admission. Suicidal thoughts without concomitant suicide attempt before admission were recorded for 389 admissions of 346 patients. According to regression analysis, risk of suicidal thoughts before admission is increased for patients with life time suicide attempt, ICD-10 diagnosis F43, ICD-10 diagnosis F32 / F33, ICD-10 diagnosis F30 / F31, greater number of hospital admissions, short cumulative length of stay and non-chronic course of disease. CONCLUSIONS: Examination of risk faktors of suicidal behaviour within the framework of hospital admissions should not be restricted exclusively to period of hospital stay. Relevant risk factors can be found even before hospital stay and could be a cue for suicide prevention already in the forefront of admission.

Predicting inpatient suicides and suicide attempts by using clinical routine data?

OBJECTIVE: The study aimed at exploring prevalence and risk factors of inpatient suicides and attempted suicides in a psychiatric hospital. METHOD: Based on the German psychiatric basic documentation system, 20,543 patients with 40,451 episodes of inpatient care (1995-2004) in a psychiatric state hospital were included. Besides univariate analyses, multivariate logistic regression analyses and classification and regression tree analyses were performed. RESULTS: Forty-one inpatient suicides were recorded. Risk of inpatient suicide is increased for patients with resistance to psychopharmacological treatment, previous suicide attempt, severe side effects and supportive psychotherapy before admission. Two hundred fourteen inpatient suicide attempts occurred during the 10-year period. Risk factors of inpatient suicide attempt are assault, personality disorder, previous suicide attempt, psychopharmacological treatment resistance, suicidal thoughts at admission, schizophrenia, depression, female sex and length of stay. CONCLUSION: The identified risk factors underline the need for a cautious investigation of previous suicide attempts as well as for giving special attention to patients who have problems with psychopharmacotherapy during hospitalization.

["So many questions and no answers"--the situation of the bereaved of suicide]. / "Viele fragen und keine antworten"--hinterbliebene nach kliniksuizid.

OBJECTIVE: Research of inpatient suicide is dominated by studies of epidemiology, predictors and prevention of suicide. In contrast, burden and needs of the bereaved are still not systematically evaluated. METHODS: All relatives of inpatient suicides of depressive or schizophrenic patients in the years 1995 to 2004 (n = 20) got an invitation for an interview about the suicide, their burden and needs due to the suicide of their family member. 13 relatives could be contacted, 9 (69.2 %) bereaved family members could be interviewed. The recorded data were analysed using a summarizing content analysis. RESULTS: Five relatives lost their child, two their spouses and two a parent. Four out of nine relatives suffer from ongoing feelings of guilt and/or restlessness due to the question, "why" the suicide happened. Eight caregivers had wished more initiative of supporting them from the professionals of the psychiatric institution, in which their ill family member was treated. Four relatives retrospectively assumed, that meeting other bereaved would have probably helped them. CONCLUSIONS: Professionals of the inpatient suicide treatment team should be more proactive in offering the bereaved relatives possibilities to talk to them. Furthermore, support should be offered repeatedly, not only once when the relatives pick up the belongings of their lost family member from the clinic.

[Situation of treatment for depressed in-patients in Germany]. / Zur Situation der stationären Depressionsbehandlung in Deutschland.

OBJECTIVE: To show the treatment situation for severely depressed in-patients in German clinics for psychiatry and psychotherapy. METHODS: A questionnaire was sent to all German "depression units" including questions about number of beds and admission, treatment strategies and diagnostic profile in the year 2005. RESULTS: 65 of 71 clinics which are members of the "Working Group Depression Units" responded 52 reports could be used for the study. Treatment included antidepressants, psychotherapy, group therapies, psychoeducation, occupational and sport therapies, social work, cooperation with self help group for depressives and including relatives. CONCLUSION: German specialized depression units represent a high level of depression treatment.

Phosphatidylethanol as a sensitive and specific biomarker: comparison with gamma-glutamyl transpeptidase, mean corpuscular volume and carbohydrate-deficient transferrin.

Phosphatidylethanol (PEth), a direct ethanol metabolite, is detectable in blood for more than 2 weeks after sustained ethanol intake. Our aim was to assess the usefulness of PEth [comparing sensitivity, specificity and the area under the curve (AUC)] as compared with carbohydrate-deficient transferrin (CDT), gamma-glutamyl transpeptidase (GGT) and mean corpuscular volume (MCV), calculating the results from sober patients against those from alcohol-dependent patients during withdrawal. Fifty-six alcohol-dependent patients (ICD-10 F 10.25) in detoxification, age 43 years, GGT 81 U/l, MCV 96.4 fl, %CDT 4.2, 1400 g ethanol intake in the last 7 days (median), were included in the study. Over the time of 1 year, 52 samples from 35 sober forensic psychiatric addicted in-patients [age 34 years, GGT 16 U/l, MCV 91 fl, CDT 0.5 (median)] in a closed ward were drawn and used for comparison . PEth was measured in heparinized whole blood with a high-performance liquid chromatography method. GGT, MCV and %CDT were measured using routine methods. A receiver operating characteristic curve analysis was carried out, with 'current drinking status' (sober/drinking) as the state variable and PEth, MCV, GGT and CDT as test variables. The resulting AUC was 0.974 (P < 0.0001, confidence interval 0.932-1.016) for PEth. At a cut-off of 0.36 micromol/l, the sensitivity was 94.5% and specificity 100%. The AUC for CDT, GGT and MCV were 0.931, 0.894 and 0.883, respectively. A significant Spearman's rank correlation was found between PEth and GGT (r = 0.739), CDT (r = 0.643), MVC (r = 0.639) and grams of ethanol consumed in the last 7 days (r = 0.802). Our data suggest that PEth has potential to be a sensitive and specific biomarker, having been found in previous studies to indicate longer lasting intake of higher amounts of alcohol.