Health care contacts before and after attempted suicide among adolescent and young adult versus older suicide attempters.

BACKGROUND: The pattern of all health care contacts among young people before and after attempted suicide is not well documented. Neither is it known if the health care contacts of young suicide attempters differ from those of older suicide attempters. This study investigated the age-related clinical characteristics of suicide attempters and the pattern of their contacts with health care before and after attempted suicide in different age groups, particularly adolescence and young adulthood. METHOD: All consecutive 1198 suicide attempters treated in hospital emergency rooms in Helsinki between January 1997 and January 1998 were identified and divided into three age groups (15-24 years, 25-39 years, 40 years and over). Data were gathered on all health care contacts 1 year before and after the index attempt. RESULTS: Although adolescent and young adult suicide attempters suffered from severe mental disorders, a remarkable proportion of them were left without psychiatric consultation and aftercare recommendation following the attempt. Two-thirds of 15-19-year-old male suicide attempters had no treatment contact during the month before the attempt, while a quarter of them were referred to psychiatric consultation and a half had no healthcare contact in the month following the attempt. CONCLUSIONS: These findings indicate considerable scope for improvement in the assessment of young suicide attempters and their referral to aftercare.

Repetition of attempted suicide among teenagers in Europe: frequency, timing and risk factors.

BACKGROUND: Adolescents in many countries show high rates of suicide attempts and repetitions of attempts as a common feature. Attempted suicide is the best predictor of future suicide. Repetition of attempts further increases the risk of suicide. The present study sought to identify patterns and risk factors for repetition of attempts in older teenagers. METHODS: Data were collected by uniform procedures in a longitudinal follow-up study in seven European centres participating in the WHO/EURO Multicentre Study on Suicidal Behaviour. Information on attempted suicide in the 15-19-year age group during the period 1989-1995 was analysed. RESULTS: A total of 1,720 attempts by 1,264 individuals over a mean follow-up period of 204 weeks (SD 108.9) were recorded. When life-table analysis was performed, 24% of the individuals who had previously attempted suicide made another attempt within one year after the index attempt, compared with 6.8% of the "first-evers", with no major gender difference. Cox regression analysis revealed that previous attempted suicide (OR 3.3, 95% CI 2.4-4.4) and use of "hard" methods (OR 1.5, 95% CI 1.1-2.1) were both significantly associated with repetition of attempted suicide. Stepwise Cox regression analysis showed that a history of previous attempted suicide was the most important independent predictor of repetition (OR 3.2, 95% CI 2.4-4.4). CONCLUSION: For young suicide attempters, follow-up and adequate aftercare are very important if repetition and risk of suicide are to be reduced. This applies particularly to those who have already made more than one attempt.

Attempted suicide rates and trends during a period of severe economic recession in Helsinki, 1989-1997.

BACKGROUND: This study investigated attempted suicide trends during a deep economic recession in the 1990s in a well-defined urban catchment area. METHODS: The data covered every suicide attempt treated in health care during sample periods in 1989-1997 in Helsinki, Finland. Annual rates were estimated, 3-year moving averages for trends calculated, and significances tested. RESULTS: The overall attempted suicide rate remained stable over the 9-year study period. Against expectations, male rates decreased significantly (P < 0.01), especially among those aged 15-34. There was a convergence of female and male rates, although male rates remained higher. The proportion of poisonings as method increased (P < 0.01). CONCLUSIONS: Despite the deep economic recession, with rapidly rising unemployment attempted suicide rates remained unexpectedly stable. The total attempted suicide rate did not increase as might have been anticipated, and the male rate even decreased.

Long-term risk factors for suicide mortality after attempted suicide--findings of a 14-year follow-up study.

OBJECTIVE: To determine the risk of suicide over a 14-year follow-up period, and to investigate the long-term risk factors for suicide using survival analysis. METHOD: Data were collected on all unselected deliberate self-poisoning patients (n=1018) treated during 1983 in the emergency unit of Helsinki University Central Hospital. RESULTS: By the end of the 14 -year follow-up period 222 (21.7%) of these patients had died. Sixty-eight (6.7%) had committed suicide; 44 (9.2%) men and 24 (4.5%) women. The long-term risk factors for suicide were male sex, previous psychiatric treatment, previous suicide attempts, somatic disease and a self-reported 'wish to die' motive for the index suicide attempt. CONCLUSION: The essential risk factors for suicide were being male and having previous suicide attempts. In addition, history of earlier psychiatric treatment, presence of somatic disease and genuine intent to die in the index suicide attempt suggest that the long-term risk has remained high for over a decade. The findings emphasize the need for long-term planning and treatment of suicide attempters met in the emergency room of general hospitals.

Transitions of employment status among suicide attempters during a severe economic recession.

Previous studies have shown a positive association between unemployment and attempted suicide. This study investigated transitions of employment status among suicide attempters during the severe economic recession. The main research question was whether inequality in the labour market also prevails among as selected a population as suicide attempters. The material consisted of 2495 persons who attempted suicide during 1989-1994 in Helsinki, Finland. Logistic regression analysis and survival analysis were used. Unemployment rates among suicide attempters were higher than in the general population, male rates being higher than female rates throughout the recession. There were significant changes in the employment status of the entire attempted suicide population from 1989 to 1994, especially in terms of the transition from employment to unemployment. Gender, age and education level predicted exit from the labour market. Among suicide attempters young middle-aged men with low education had the highest risk of unemployment.

Excess mortality of suicide attempters.

BACKGROUND: Excessive mortality of suicide attempters has emerged from many follow-up studies. Completed suicide is the main cause of excess deaths, but the increased risk of deaths from other unnatural and natural causes is also of major public health concern. We lack follow-up studies of the different causes of death in cohorts of suicide attempters. The present study aimed to determine the mortality by suicide and other causes of death and to investigate risk factors. METHODS: This mean 5.3-year follow-up study was based on an unselected cohort of suicide attempts by both violent and non-violent methods, treated in hospitals in a well-defined urban catchment area in Helsinki. In total, 2782 patients aged 15 years and over admitted to the emergency rooms after suicide attempt between 1989 and 1996 were included in the follow-up analysis. Standardised mortality ratios (SMR) for suicide, disease, accident, homicide, and undetermined death were calculated. RESULTS: Mortality from all causes was 15 times higher than that expected among men and nine times higher in women. SMRs in men were 5402 (95% CI 4339-6412) for suicide, 2480 (95% CI 925-4835) for homicide, and 11,139 (95% CI 6884-16,680) for undetermined cause, and for women 7682 (95% CI 5423-9585), 3763 (95% CI 52-5880) and 15,681 (95% CI 6894-22,294), respectively. Fifteen percent of all suicide attempters died during the average 5.3-year follow-up of the index attempt. Deaths from suicide accounted for 37% of all excess deaths in men and 44% in women. The mortality ratio was highest during the 1st follow-up year. The total number of lost years of life among the 413 suicide attempters who died during follow-up was 13,883. The risk factors for all causes of death were male sex, single, retirement, drug overdose as a method, an index attempt not involving alcohol, and a repeated attempt. CONCLUSION: A suicide attempt indicates a severe risk of premature death, and suicide is the main cause of excess deaths. However, it appears that concentrating efficient treatment only on the most suicidal patients could prevent no more than two of five premature deaths. More effort is therefore needed to prevent the excess mortality of suicide attempters by also addressing causes of death other than suicide.

Suicide attempts and personality disorder.

OBJECTIVE: The purpose of the present study was to compare clinical characteristics of suicide attempters with or without personality disorders. METHOD: A systematic sample (n = 114) of patients from consecutive cases of attempted suicide referred to general hospitals in Helsinki was interviewed and diagnosed according to DSM-III-R. Forty-six subjects with DSM-III-R personality disorders were identified and divided into clusters A (n = 4), B (n = 34) and C (n = 8). These subjects were compared with 65 suicide attempters without personality disorders in terms of clinical characteristics and treatment received. RESULTS: Suicide attempters with personality disorders more often had a history of previous suicide attempts and lifetime psychiatric treatment than comparison subjects. However, suicide attempts did not differ in terms of suicide intent, hopelessness, lethality or impulsiveness between subjects with or without personality disorders. CONCLUSION: Although suicidal behaviour is a more persistent feature among those with personality disorders, their clinical characteristics at the time of a suicide attempt may not differ from those without personality disorders.

Attempted suicide and major public holidays in Europe: findings from the WHO/EURO Multicentre Study on Parasuicide.

OBJECTIVE: The aim of the study was to examine the relationship between suicide attempts and major public holidays in Europe. METHOD: The analysis was based on data on 24 388 suicide attempts by persons aged 15 years or older in the period 1989-1996. Data from 13 centres (representing 11 countries) participating in the WHO/EURO Multicentre Study on Parasuicide were analysed. The analysis of the fluctuation of suicide attempts around public holidays was based on the daily number of suicide attempts for each centre. For each day in the period under examination a mean number of suicide attempts (mu) was calculated. The analysis was based on the assumption that the data followed a Poisson distribution. The observed number of daily suicide attempts was compared with the expected number of attempts. A multiplicative model for the expected number in each centre was developed. RESULTS: Before Christmas there were fewer suicide attempts than expected, and after Christmas there were approximately 40% more attempts than expected. In addition, more attempts than expected were registered on New Year's Day. In countries where people have the day off work on Whit Monday there were significantly fewer attempts during the 3 days before, but where Whit Monday is a normal working day significantly fewer attempts occurred on the Monday to Wednesday after Whit Sunday. CONCLUSION: There appears to be a transposition of a significant number of suicide attempts from before (and during) a major public holiday until after it. The division of holidays into non-working and working days showed that a 'holiday effect' could only be found around major public holidays, particularly Christmas, Easter and Whitsun. These findings support the theory of the 'broken-promise effect' for major public holidays.

Treatment received by alcohol-dependent suicide attempters.

The purpose of this study was to examine the clinical features of alcohol-dependent suicide attempters and the treatment they received before and after the index attempt. A total of 47 subjects with current DSM-III-R alcohol dependence were identified from a systematic sample of 114 suicide attempters in Helsinki. All of them were comprehensively interviewed after the attempt, and the treatment they had received was established from psychiatric and other health-care records and follow-up interviews. Most had a history of psychiatric (83%) or substance abuse (83%) treatment. During the final month before the attempt, half of the subjects (51%) had been treated by health care services; 11% had received disulfiram-treatment and 6% had received psychotherapy. Subjects complied with recommended aftercare more often when they had been actively referred. After 1 month, 64% were being treated by health care services. However, only 14% were receiving disulfiram-treatment and 9% were receiving psychotherapy. These findings suggest that the quality and activity of treatment offered to suicide attempters with alcohol dependence should be improved.

Inadequate treatment for major depression both before and after attempted suicide.

OBJECTIVE: The authors' goal was to investigate the treatment received by suicide attempters with major depression before and after the index attempt. METHOD: Forty-three patients with current unipolar DSM-III-R major depression were identified in a diagnostic study from a systematic sample of suicide attempters in Helsinki. All were comprehensively interviewed and investigated after the attempt, and their treatment was ascertained from psychiatric and other health care records and follow-up interviews. RESULTS: During the month just before the suicide attempt, seven (16%) of the patients had received antidepressants in adequate doses, seven had received weekly psychotherapy, and none had received ECT. Although almost all of the patients complied with the recommended aftercare following the suicide attempt, after 1 month only seven (17%) were receiving antidepressants in adequate doses, nine (22%) were receiving weekly psychotherapy, and none had been given ECT. CONCLUSIONS: It seems that few suicide attempters with major depression receive adequate treatment for depression before the suicide attempt and that, despite their well-known high risk for suicide, the treatment situation is not necessarily any better after the attempt. These findings suggest that the recognition of depression and the quality of treatment received for major depression among suicide attempters should be investigated and improved to prevent suicide.

Relation between attempted suicide and suicide rates among young people in Europe.

STUDY OBJECTIVE: To determine if there are associations between rates of suicide and attempted suicide in 15-24 year olds in different countries in Europe. DESIGN: Attempted suicide rates were based on data collected in centres in Europe between 1989 and 1992 as part of the WHO/EURO Multicentre Study of Parasuicide. Comparison was made with both national suicide rates and local suicide rates for the areas in which the attempted suicide monitoring centres are based. SETTING: 15 centres in 13 European countries. PATIENTS: Young people aged 15-24 years who had taken overdoses or deliberately injured themselves and been identified in health care facilities. MAIN RESULTS: There were positive correlations (Spearman rank order) between rates of attempted suicide and suicide rates in both sexes. The correlations only reached statistical significance for male subjects: regional suicide rates, r = 0.65, p < 0.02; national suicide rates, r = 0.55, p < 0.02. CONCLUSIONS: Rates of attempted suicide and suicide in the young covary. The recent increase in attempted suicide rates in young male subjects in several European countries could herald a further increase in suicide rates.

Hopelessness, impulsiveness and intent among suicide attempters with major depression, alcohol dependence, or both.

The present study examined differences in hopelessness, impulsiveness and suicide intent between suicide attempters with either major depression or alcohol dependence, comorbid major depression and alcohol dependence, and those without these disorders. A sample of 114 patients from consecutive cases of attempted suicide referred to a general hospital in Helsinki was interviewed and diagnosed according to DSM-III-R. Suicide intent was measured by the Beck Suicide Intent Scale (SIS) and hopelessness was assessed by the Beck Hopelessness Scale (HS). Impulsiveness of the suicide attempt was measured by two items of the SIS. Suicide attempters with major depression without comorbid alcohol dependence had higher suicide intent and lower impulsiveness than attempters with non-depressive alcohol dependence. Suicide attempts may differ between subjects with major depression, alcoholism or both disorders in terms of impulsiveness and suicide intent.

Mental disorders and comorbidity in attempted suicide.

The present study examined the prevalence and comorbidity of mental disorders according to DSM-III-R among male and female suicide attempters. A systematic sample of 114 patients from consecutive cases of attempted suicide referred to a general hospital in Helsinki between 1 January and 31 July 1990 was interviewed. In 98% of the cases at least one Axis I diagnosis was made. Depressive syndromes were more common among females (85%) than males (64%), and alcohol dependence was more common among males (64%) than females (21%). A high proportion of suicide attempters (82%) suffered from comorbid mental disorders. Comorbidity appears to play an important role in parasuicide.

Alcohol problems among suicide attempters in the Nordic countries.

The purpose of this study was to see whether and how the number of suicide attempters with alcohol problems and their drinking habits differ between the Nordic areas under study. Problem-drinkers were defined as persons who themselves felt that they had an alcohol problem. The analyses were based on data collected at five Nordic research centers participating in the WHO/Euro Multicentre Study on Parasuicide, namely: Helsinki (Finland); Umeå and Stockholm (Sweden); Slr-Trlndelag (Norway); and Odense (Denmark). The results showed that the frequency of problem-drinking among suicide attempters differed markedly between the areas under study; the Finnish male and the Danish female suicide attempters included the highest proportions of self-identified problem-drinkers. The pattern of drinking among the suicide attempters also differed between the areas. The analyses indicate that the point when alcohol becomes a problem to somebody, especially to a degree that it increases the risk of suicidal behavior, not only depends on how much and how often the person drinks alcohol; the prevailing drinking pattern, the attitudes towards drinking alcohol, and the level of social control are also important factors to take into consideration when relations between alcohol and suicidal behavior are under study.

Project plan for studies on suicide, attempted suicide, and suicide prevention.

Completed and attempted suicide are major public health problems in most western countries. The importance of suicidal behavior as a health problem, particularly among adolescents and young adults, has been emphasized by the European Union, the WHO (Europe), as well as the Finnish authorities. Due to the exceptionally high suicide mortality, suicide prevention has been one of the main targets of Finnish health policy since the late 1980s. However, to develop feasible strategies for suicide prevention, better knowledge of the phenomenon of self-destruction is necessary. The Department of Mental Health of the National Public Health Institute has been actively involved in suicide research and the development of suicide strategies both in Finland and western Europe since 1986. The success is based on a long tradition of suicide research in Finland, the representative and reliable suicide data, a highly motivated research group, and also the necessary economic support by both the National Public Health Institute and the Finnish Academy. This article outlines our groups research plan for the next few years.

Parasuicide in the Nordic countries.

This article gives an account of some findings of the WHO/EURO multicentre study on parasuicide from the five Nordic centres: Helsinki (Finland), Stockholm (Sweden), and the countries of Funen (Denmark), Sø-Trøndelag (Norway) and Västerbotten (Sweden). For parasuicide patients treated in hospital in these five Nordic centres, the parasuicide rates per 100,000 inhabitants per annum were 222 for women, 213 for men and 224 for both sexes combined. In all the Nordic centres except Helsinki, women had higher parasuicide rates than men. The female/male parasuicide ratio was 1.16 for all Nordic centres. The highest parasuicide rates in the whole material were found in Helsinki, Stockholm and Funen, and the lowest in Sør-Trøndelag and Västerbotten. The highest parasuicide rates lay in the 30-39 age interval, i.e. the peak of parasuicide rates was in older age groups than previously reported. Single people, especially divorcees and those who have never been married, constitute a high-risk group in both sexes. The risk of parasuicide for single men is three times that for married men in all the Nordic centres except Sør-Trøndelag, where the risk is five times higher. The parasuicide risk for single women is twice as high as for married women except for women in Funen, where the risk for single and married women is almost equal. Exceptionally high parasuicide rates are also reported for Finnish citizens in Sweden, compared with Finns from the Helsinki centre. Parasuicide rates appear to be correlated with population density, since the densely populated areas of Helsinki, Stockholm and Funen evince higher parasuicide rates than the sparsely populated areas of Sør-Trøndelag and Västerbotten.