Clinical characteristics and 6-month follow-up of adults with and without alcohol use disorder who self-harm.

Background: Alcohol use disorder (AUD) is associated with suicidal behavior, but prospective clinical studies are lacking. Aim: To compare clinical characteristics and 6-month outcomes in persons with and without AUD who self-harm. Methods: 804 adults (mean age 33, age range 18-95, 541 women and 263 men, 666 with suicide attempts and 138 with non-suicidal self-injuries at index) at three Swedish university hospitals took part in a research interview that included the Mini International Neuropsychiatric Interview (MINI). Subsequent non-fatal suicidal behavior within six months was identified by record review; suicides were identified by national register. Results: At index, 39% of the men and 29% of the women had AUD. Over two thirds of these cases (69%) were identified by the MINI, but not by clinical AUD diagnosis. While trait impulsivity was more common among persons with AUD than those without (56% vs 36%, P adj = <.001), impulsivity in connection with the index attempt was noted in half of the participants in each group (48% vs 52%, P adj = 1). Subsequent suicidal behavior (fatal/non-fatal) occurred in 67 persons with AUD (26%) and in 98 without AUD (18%), a 60% higher risk among persons with AUD (OR = 1.60, 95% [CI 1.13-2.28], P = .009). Four persons with AUD (2%) and six without (1%) died by suicide within 6 months. Conclusion: Almost a third of patients presenting at psychiatric emergency settings after self-harm fulfilled criteria for AUD, but clinicians often missed this diagnosis. Risk for subsequent suicidal behavior was elevated in patients with AUD. Educational interventions to improve recognition of alcohol use disorder may aid clinicians in the assessment and management of patients who present with self-harm.

Attention deficit hyperactivity disorder in adults who present with self-harm: a comparative 6-month follow-up study.

BACKGROUND: ADHD is common in psychiatric populations. This study aimed to compare clinical characteristics in adults with and without ADHD who presented with self-harm, and to compare later risk of suicidal behaviour within 6 months. METHODS: Eight hundred four adults presented with self-harm (with and without suicidal intent) at psychiatric emergency services at three Swedish hospitals. Persons with a discharge ICD-10 diagnosis F90.0-F90.9 or a prescription for ADHD medication were considered to have ADHD (n = 93). Medical records were reviewed for evidence of subsequent suicide attempts (SA) within 6 months; suicides were identified by national register. RESULTS: Recent relationship problems were more prevalent in the ADHD group. While the index episodes of those with ADHD were more often non-suicidal, and actual SAs more often rated as impulsive, medical lethality at presentation did not differ in attempters with and without ADHD. Subsequent SAs (fatal or non-fatal) were observed in 29% of the ADHD group and 20% in all others (P = .005). A logistic regression model showed elevated risk of suicidal behaviour during follow-up in the ADHD group (OR = 1.70, CI 1.05-2.76), although a final regression model suggested that this association was partly explained by age and comorbid emotionally unstable personality disorder. CONCLUSIONS: Findings highlight the need for clinicians to take self-harm seriously in adults with ADHD.

Suicidal and non-suicidal self-injurious behaviour in patients with bipolar disorder and comorbid attention deficit hyperactivity disorder after initiation of central stimulant treatment: a mirror-image study based on the LiSIE retrospective cohort.

BACKGROUND: Currently, our understanding regarding treatment of adult attention deficit hyperactivity disorder (ADHD) co-occurring with bipolar disorder (BD) remains limited. The aim of this study was to evaluate the impact of central stimulant (CS) treatment on suicidal and non-suicidal self-injurious behaviour in patients with a pre-existing diagnosis of BD or schizoaffective disorder (SZD). Specifically, we tested the hypothesis that CS treatment significantly decreased the number of suicide attempts and non-suicidal self-injury events. METHODS: A mirror-image study in patients with a dual diagnosis of BD or SZD and ADHD, comparing suicide attempts and non-suicidal self-injury events within 6 months and 2 years before and after CS initiation. This study was part of a retrospective cohort study (LiSIE) into effects and side-effects of lithium for maintenance treatment of BD as compared with other mood stabilisers. RESULTS: Of 1564 eligible patients, 206 patients met the inclusion criteria. Within the 6 months after CS initiation, suicide attempts and non-suicidal self-injury events decreased significantly, both in terms of numbers of patients having such events (p = 0.013) and numbers of events experienced (p = 0.004). These effects were preserved 2 years after CS initiation. CONCLUSIONS: CS treatment may reduce the risk of suicide attempts and non-suicidal self-injury events in patients with a dual diagnosis of BD or SZD and ADHD. Based on our findings, clinicians should not withhold CS treatment from patients with concomitant ADHD for fear of deterioration of the underlying BD. However, to minimise the risk of manic episodes concomitant mood stabiliser treatment and close monitoring remains warranted.

Predicting suicide: A comparison between clinical suicide risk assessment and the Suicide Intent Scale.

BACKGROUND: How suicide risk should be assessed is under discussion with arguments for both actuarial and clinical approaches. The aim of the present study was to compare the predictive accuracy of a clinical suicide risk assessment to that of the Suicide Intent Scale (SIS) in predicting suicide within one year of an episode of self-harm with or without suicidal intent. METHODS: Prospective clinical study of 479 persons assessed in a psychiatric emergency department after an episode of self-harm. The clinical risk assessment and the SIS rating were made independently of each other. Suicides within one year were identified in the National Cause of Death Register. Receiver operating characteristic (ROC) curves were constructed, optimal cut-offs were identified and accuracy statistics were calculated. RESULTS: Of 479 participants, 329 (68.7%) were women. The age range was 18-95 years. During one-year follow up, 14 participants died by suicide. The area under the curve (AUC) for the clinical risk assessment and the SIS score were very similar, as were the accuracy statistic measures at the optimal cut-offs of the respective methods. The positive predictive value (PPV) of each assessment method was 6%. LIMITATIONS: The clinical suicide risk assessment is not standardized. The number of suicides is small, not allowing for stratification by e.g. gender or diagnosis. CONCLUSION: Predictive accuracy was similar for a clinical risk assessment and the SIS, and insufficient to guide treatment allocation.

Are non-psychiatric hospitalisations before self-harm associated with an increased risk for suicide among young people?

OBJECTIVE: This study aimed to investigate any increased risk for suicide in young people with admission for self-harm and if the risk is further increased due to somatic inpatient admissions before a first act of self-harm. METHODS: This register study included 16,235 cases in the ages 16-24, with a first admission for self-harm, and 32,465 matched controls. All admissions and diagnoses were recorded from the year preceding cases first admission for self-harm. Subjects were followed until death or end of study, registering the cause of death for all deceased. Group differences were analysed using survival analysis with death by suicide as primary outcome. RESULTS: In cases with a previous somatic admission, the risk for death by suicide during the study period was higher than in cases without a somatic admission (457 and 316 suicides per 100,000 people and year, respectively, p = 0.01). For cases with a somatic admission, the hazard ratio was 1.43 (95% confidence interval 1.04-1.98) compared with those without somatic admissions (controlled for age, sex and psychiatric admission). Survival of cases with a previous somatic admission compared with those without was 98.4% versus 99.2% after the first year, 97.8% versus 98.9% after the second year, and 95.5% versus 96.9% after the tenth year. CONCLUSIONS: This study suggests that admission for physical illness before self-harm is associated with a higher risk for suicide among young people, and that their contact with healthcare due to physical problems could provide an opportunity to detect suicide risk.

Reasons for lithium discontinuation in men and women with bipolar disorder: a retrospective cohort study.

BACKGROUND: Lithium remains first choice as maintenance treatment for bipolar affective disorder. Yet, about half of all individuals may stop their treatment at some point, despite lithium's proven benefits concerning the prevention of severe affective episodes and suicide. METHODS: Retrospective cohort study in the Swedish region of Norrbotten into the causes of lithium discontinuation. The study was set up to (1) test whether patients with bipolar affective disorder or schizoaffective disorder, treated with lithium maintenance therapy, were more likely to discontinue lithium because of adverse effects than lack of therapeutic effectiveness, (2) explore gender differences, (3) understand the role of diagnosis and (4) identify who, patient or doctor, took the initiative to stop lithium. Review of medical records for all episodes of lithium discontinuation that had occurred between 1997 and 2013 with the intent to stop lithium for good. RESULTS: Of 873 patients treated with lithium, 54% discontinued lithium, corresponding to 561 episodes of lithium discontinuation. In 62% of episodes, lithium was discontinued due to adverse effects, in 44% due to psychiatric reasons, and in 12% due to physical reasons interfering with lithium treatment. The five single most common adverse effects leading to lithium discontinuation were diarrhoea (13%), tremor (11%), polyuria/polydipsia/diabetes insipidus (9%), creatinine increase (9%) and weight gain (7%). Women were as likely as men to take the initiative to stop lithium, but twice as likely to consult a doctor before taking action (p < 0.01). Patients with type 1 BPAD or SZD were more likely to discontinue lithium than patients with type 2 or unspecified BPAD (p < 0.01). Patients with type 1 BPAD or SZD were more likely to refuse medication (p < 0.01). Conversely, patients with type 2 or unspecified BPAD were three times as likely to discontinue lithium for lack or perceived lack of effectiveness (p < 0.001). CONCLUSIONS: Stopping lithium treatment is common and occurs mostly due to adverse effects. It is important to discuss potential adverse effects with patients before initiation and continuously during lithium treatment, to reduce the frequency of potentially unnecessary discontinuations.

Does a new spatial design in psychiatric inpatient care influence patients' and staff's perception of their care/working environment? A study protocol of a pilot study using a single-system experimental design.

BACKGROUND: Research shows that worn-out physical environments are obstacles to psychiatric inpatient care. Patients want better relationships with staff and things to do; staff want an environment that offers hope, a calm atmosphere, and joint activities. A county council in northern Sweden and Philips Healthcare partnered to create solutions to the environmental challenges of psychiatric inpatient care. One ward at a county psychiatric clinic was selected for a pilot project to test solutions that could improve the care environment for patients, staff, and relatives. The aim of the overall project is to evaluate the effects of a newly designed psychiatric inpatient ward on patients and staff in terms of quality of care and stress. In this study, we focus on the feasibility through testing questionnaires and exploring barriers to recruiting staff and patients. METHODS: This study had a single-system experimental design, comparing a psychiatric unit pre- and post-implementation of the novel spatial design, using repeated measures with the same questionnaires twice a week during baseline and intervention phases. Primary outcomes were quality interactions (patients) and perceived stress (staff). Secondary outcomes were levels of anxiety and depression (patients), and stress of conscience (staff). A process evaluation was aimed to describe contextual factors and participant experiences of the new design. Data was collected using questionnaires and semi-structured individual interviews with patients and focus group discussions with staff. Both visual and statistical methods were used to analyse the quantitative data and content analysis for the qualitative data. DISCUSSION: The findings will contribute insights into whether and how a new spatial design might contribute to quality interactions and reduced stress. This is relevant both nationally and internationally, as similar interventions are needed but sparse. The findings will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03140618, registered 4 May 2017.

Family history of suicide and interpersonal functioning in suicide attempters.

Difficulties in interpersonal relationships are associated with a wide range of psychiatric diagnoses and have been reported as a trigger for suicidal behavior, too. The aim of this study was to examine the relationship between interpersonal problems and family history of suicide in suicide attempters and to describe relevant patterns of interpersonal problems in this patient group. The study involves 181 patients having their clinical follow-up after a suicide attempt. Family history of suicide was assessed by using the Karolinska Self Harm History Interview or retrieved in patient records. The Inventory of Interpersonal Problems was used to assess personal style in an interpersonal context. Suicide attempters with a family history of suicide had significantly more often an intrusive personal style. The results remained significant after adjustment for personality disorder. The specific interpersonal patterns associated with family history of suicide may interfere with the ability to create stable, long-lasting relationships. In regards to treatment, these personal qualities could cause difficulties in the alliance with health care personnel and make it harder for suicide attempters to accept or benefit from treatment. Attention to suicide attempters' interpersonal problems is of importance to lower their distress.

Lithium intoxication: Incidence, clinical course and renal function - a population-based retrospective cohort study.

When prescribing lithium, the risk of toxicity remains a concern. In this study, we examined a cohort of patients exposed to lithium between 1997 and 2013. The aims of this study were to determine the frequency of lithium intoxication and to evaluate the clinical course and changes in renal function. Of 1340 patients, 96 had experienced at least one episode of lithium levels ⩾1.5 mmol/L, yielding an incidence of 0.01 per patient-year. Seventy-seven patients available for review had experienced 91 episodes, of whom 34% required intensive care and 13% were treated with haemodialysis. There were no fatalities. Acute kidney injury occurred, but renal function at baseline was not different to renal function after the episode. Renal impairment was often associated with co-morbidities and other factors. Both intermittent and continuous-venovenous haemodialysis were used, but the clearance of continuous-venovenous haemodialysis can be too low in cases where large amounts of lithium have been ingested. Saline and forced diuresis have been used and are safe. Lithium intoxication seems rare and can be safely managed in most cases. Physicians should not withhold lithium for fear of intoxication in patients who benefit from it. Yet, physicians should have a low threshold to screen for toxicity.

Gender-sensitive and youth-friendly physiotherapy: Steps toward a stress management intervention for girls and young women.

This article describes and evaluates initial steps of a gender-sensitive, youth-friendly group intervention model designed for teenage girls and young women who experience stress-related or psychosomatic problems. Fifty-four young women (16-25 years of age) participated in a gender-sensitive physiotherapy stress management course at a youth health center. Inclusion criteria were self-defined stress-related problems and a wish to participate in the group intervention. Measurements of aspects of body perception, self-image, multiple somatic problems, and mental health symptom areas were assessed both before and after intervention with the Body Perception Questionnaire ad modum Schiöler, social analysis of social behavior, and Adult Self-Report scale. Significant positive changes were found in aspects of body perception, self-image, and mental health and somatic symptoms. The changes were most significant in lower internalization of anxiety and depression symptoms. Symptoms such as headaches and sleeping problems decreased. Participants were more satisfied with their bodies and more able to listen to body signals. Among cognitive issues, significant change occurred in thought problems, but not in attention problems. The intervention model needs further evaluation in controlled trials, but is promising and should be developed further in other physiotherapy settings and subgroups of young people.

Professional Care as an Option Prior to Self-Harm.

BACKGROUND: Deliberate self-harm (DSH) is a growing problem among young people and is a major risk factor for suicide. Young adults experiencing mental distress and suicidal ideation are reluctant to seek help, requiring new strategies to reach this group. AIMS: The present study explored young people's views of professional care before first contact for DSH, and factors that influenced the establishing of contact. METHOD: Interviews with 10 young individuals, shortly after they had harmed themselves, were analyzed using qualitative content analysis. RESULTS: The participants emphasized the importance of receiving more knowledge on where to turn, having different help-seeking options, and receiving immediate help. Family and friends were vital for support and making health care contact. The quality of the professional contact was stressed. Several reasons for not communicating distress were mentioned. Two themes were identified: "A need for a more flexible, available and varied health care" and "A struggle to be independent and yet being in need of reliable support." CONCLUSION: These findings suggest that easy and direct access to professional help is a decisive factor for young people experiencing psychological problems and that health services must find new ways of communicating information on seeking mental health help.

Professional care after deliberate self-harm: a qualitative study of young people's experiences.

BACKGROUND: Deliberate self-harm (DSH) is increasingly common among young people. At the same time, treatment and support after DSH are often hampered by low compliance. AIM: To explore young people's perceptions of care and support during a 6-month period following their first contact for DSH. METHODS: We conducted nine semistructured interviews with young people aged 16-24 years 6 months after their first contact for DSH. The interviews were analyzed using qualitative content analysis. RESULTS: Three main themes were extracted from the interviews. "Am I really in good hands?" describes whether the participants felt they were being listened to and taken seriously and whether they could rely on the competence of the professionals and the appropriateness of treatment, including keeping agreements and communication with other relevant agencies. "Help should match life circumstances" comprises how basic practicalities such as travel possibilities affect treatment and concomitant assistance in everyday living. Financial matters and jobseeking were perceived as necessary for optimal treatment and well-being. "Making yourself better" includes participants' efforts to manage on their own, through realizing their own responsibility to be engaged and actively take part in treatment planning. CONCLUSION: Flexibility and responsiveness to young people's own views and specific needs in treatment arrangements are of crucial importance. The significance of basic practical help cannot be underestimated and should not be overlooked.

Suicide in Bosnia and Herzegovina and the city of Sarajevo.

BACKGROUND: Besides the war experience (1992-1995), Bosnia and Herzegovina (BiH) constitutes an interesting area for studies on suicidal behavior from an ethnic and religious perspective with its mixed ethnic population of Bosniaks, Serbs, and Croats. AIMS: The study investigates suicide in BiH and the capital city of Sarajevo before (1985-1991) and after the war (1998-2006), with special reference to gender and ethnicity. METHOD: Official suicide data were gathered for the two periods with regard to gender, ethnicity, and suicide methods used. RESULTS: No differences in suicide rates were found in BiH and Sarajevo before and after the war. The male-to-female suicide rate ratio in BiH was significantly higher after the war than before the war, with an opposite tendency seen in Sarajevo. Before and after the war, the highest and stable suicide rates were among Serbs in BiH. In Sarajevo the highest suicide rates were found among Croats after the war. Hanging was the most common suicide method used, both before and after the war, while firearms were more commonly used after the war. Poisoning was a rarely used method in both periods. CONCLUSION: The stable suicide rates in BiH over the pre- and postwar periods indicate no evident influence of the Bosnian war on the postwar level of suicide rates, except for women in Sarajevo. Beside this exception, the findings indicate a long-established underlying pattern in suicide rates that was not immediately changed, even by war. The study supports earlier findings that the accessibility of means influences the choice of suicide method used.

Gender distribution of suicide attempts among immigrant groups in European countries--an international perspective.

BACKGROUND: Studies report high rates of suicide attempts for female immigrants. This study assesses variations in the distribution of suicide attempts across gender in immigrant and non-immigrant groups in Europe. METHOD: Data on 64 native and immigrant groups, including 17,662 local and 3755 immigrant person-cases collected, between 1989 and 2003, in 24 million person-years were derived from the WHO/EURO Multicentre Study on Suicidal Behaviour. Female-to-male ratios of suicide attempt rates (SARs) were calculated for all groups. RESULTS: The cases were combined into four major categories: hosts; European and other Western immigrants; non-European immigrants; and Russian immigrants. The non-European immigrants included higher female SARs than the Europeans, both hosts and immigrants. Unlike the other groups, the majority of suicide attempters among the Russian immigrants in Estonia and Estonian hosts were male. This was also true for immigrants from Curaçao, Iran, Libya and Sri Lanka. When the single groups with a male majority were excluded, the correlation between female and male SARs was relatively high among the European immigrants (r = 0.74, P < 0.0005) and lower among the non-European immigrants (r = 0.55, P < 0.03). Generalized estimating equation analysis yielded a highly significant difference (P < 0.0005) in gender ratios of suicide attempts between hosts (ratio 1.52) and both non-European immigrants (ratio 2.32) and Russian immigrants (0.68), but not the European immigrants. CONCLUSIONS: The higher suicide attempt rates in non-European immigrant females compared with males may be indicative of difficulties in the acculturation processes in Europe. Further understanding of factors underlying suicidal behaviour in immigrant and minority groups is necessary for planning effective prevention strategies.

Attempted suicide among immigrants in European countries: an international perspective.

PURPOSE: This study compares the frequencies of attempted suicide among immigrants and their hosts, between different immigrant groups, and between immigrants and their countries of origin. METHODS: The material, 27,048 persons, including 4,160 immigrants, was obtained from the WHO/EURO Multicentre Study on Suicidal Behaviour, the largest available European database, and was collected in a standardised manner from 11 European centres in 1989-2003. Person-based suicide-attempt rates (SARs) were calculated for each group. The larger immigrant groups were studied at each centre and compared across centres. Completed-suicide rates of their countries of origin were compared to the SARs of the immigrant groups using rank correlations. RESULTS: 27 of 56 immigrant groups studied showed significantly higher, and only four groups significantly lower SARs than their hosts. Immigrant groups tended to have similar rates across different centres. Moreover, positive correlation between the immigrant SAR and the country-of-origin suicide rate was found. However, Chileans, Iranians, Moroccans, and Turks displayed high SARs as immigrants despite low suicide rates in the home countries. CONCLUSIONS: The similarity of most immigrant groups' SARs across centres, and the correlation with suicidality in the countries of origin suggest a strong continuity that can be interpreted in either cultural or genetic terms. However, the generally higher rates among immigrants compared to host populations and the similarity of the rates of foreign-born and those immigrants who retained the citizenship of their country of origin point to difficulties in the acculturation and integration process. The positive correlation found between attempted and completed suicide rates suggests that the two are related, a fact with strong implications for suicide prevention.

The association between life events and suicide intent in self-poisoners with and without a history of deliberate self-harm: a preliminary study.

The associations between life events in the 12 months preceding an episode of self-poisoning resulting in hospital attendance (the index episode), and the suicide intent of this episode were compared in individuals for whom the index episode was their first, episode and in individuals in whom it was a recurrence of DSH. Results indicated a significant interaction between independent life events, repetition status, and gender in the prediction of suicide intent, the association between life events and intent being moderated by repetition status in women only. The results provide preliminary evidence to suggest the presence of a suicidal process in women, in which the impact of negative life events on suicide intent diminishes across episodes.

Problem-solving ability and repetition of deliberate self-harm: a multicentre study.

BACKGROUND: While recent studies have found problem-solving impairments in individuals who engage in deliberate self-harm (DSH), few studies have examined repeaters and non-repeaters separately. The aim of the present study was to investigate whether specific types of problem-solving are associated with repeated DSH. METHOD: As part of the WHO/EURO Multicentre Study on Suicidal Behaviour, 836 medically treated DSH patients (59% repeaters) from 12 European regions were interviewed using the European Parasuicide Study Interview Schedule (EPSIS II) approximately 1 year after their index episode. The Utrecht Coping List (UCL) assessed habitual responses to problems. RESULTS: Factor analysis identified five dimensions--Active Handling, Passive-Avoidance, Problem Sharing, Palliative Reactions and Negative Expression. Passive-Avoidance--characterized by a pre-occupation with problems, feeling unable to do anything, worrying about the past and taking a gloomy view of the situation, a greater likelihood of giving in so as to avoid difficult situations, the tendency to resign oneself to the situation, and to try to avoid problems--was the problem-solving dimension most strongly associated with repetition, although this association was attenuated by self-esteem. CONCLUSIONS: The outcomes of the study indicate that treatments for DSH patients with repeated episodes should include problem-solving interventions. The observed passivity and avoidance of problems (coupled with low self-esteem) associated with repetition suggests that intensive therapeutic input and follow-up are required for those with repeated DSH.

Childhood sexual abuse predicts poor outcome seven years after parasuicide.

BACKGROUND: There is substantial empirical research linking borderline personality disorder with prolonged mental instability and recurrent suicidality. At the same time, a growing body of observations links borderline personality disorder to sexual abuse and other forms of abuse and trauma in childhood. The aim of this study was to investigate among patients admitted for parasuicide the predictive value for outcome 7 years after the parasuicide of a diagnosis of borderline personality disorder compared to the predictive value of a history of childhood sexual abuse. METHODS: Semi-structured interviews were conducted at the time of the index parasuicide, with follow-up interviews 7 years later. In addition, information was collected from medical records at the psychiatric clinic. A logistic regression analysis was used to assess the specific influence of the covariates borderline personality disorder, gender and reported childhood sexual abuse on the outcome variables. RESULTS: Univariate regression analysis showed higher odds ratios for borderline personality disorder, female gender and childhood sexual abuse regarding prolonged psychiatric contact and repeated parasuicides. A combined logistic regression model found significantly higher odds ratios only for childhood sexual abuse with regard to suicidal ideation, repeated parasuicidal acts and more extensive psychiatric support. CONCLUSION: The findings support the growing body of evidence linking the characteristic symptoms of borderline personality disorder to childhood sexual abuse, and identify sexual abuse rather than a diagnosis of borderline personality disorder as a predictor for poor outcome after a parasuicide. The findings are relevant to our understanding and treatment of parasuicide patients, especially those who fulfil the present criteria for borderline personality disorder.

Self-reported suicidal and help seeking behaviours in the general population in Latvia.

BACKGROUND: The aims of this study were to assess the prevalence of suicidal behaviours in the general population in Latvia, to identify risk groups for suicidal behaviour, to examine a possible continuous sequence of suicidal behaviours with underlying gradient of severity, to assess patterns of help seeking behaviours and preferences of different types of services for suicidal persons. METHOD: A postal survey of a stratified proportional sample of the general population aged 18 and older was carried out. RESULTS: The last year and lifetime prevalence of any type of suicidal behaviours was 52.6 and 60.2 %. The incidence of self-reported suicide attempts was 1.8 and 5.1 %, respectively. Females reported significantly less serious types (includes ideation, plans and/or attempts) of suicidal behaviours (OR 0.04, p = 0.001) during last year than males. Younger age, lower level of education, urban residency and Latvian ethnicity were identified as risk factors for serious types of suicidal behaviours in both genders. Non-cohabitation status (OR 5.3, p = 0.01) and lower level of education for males, but higher levels of education for females were identified as significant risk factors for mild types (solely life-weariness and/or death wishes) of suicidal behaviours. The results indicated no simple cumulative relationship between the suicidal behaviours. Age, gender, previous help seeking experience and severity of self-reported suicidal behaviours influenced help seeking behaviours. The overall acceptance of professional services was high, but people who reported suicidal behaviours ranked them lower. CONCLUSIONS: A postal survey can provide a reasonable coverage of suicidal behaviours and description of risk groups in the general population. Higher prevalence of suicidal behaviours among males might indicate that nowadays males are under certain stress in Latvia.

Season of birth variations in suicide methods in relation to any history of psychiatric contacts support an independent suicidality trait.

BACKGROUND: Due to reports on season of birth variations in suicidal behaviour as well as in cerebrospinal fluid levels of monoamine metabolites, we investigated season of birth variations in suicide methods for completed suicides in relation to any history of psychiatric contacts. Relationships with the psychiatric diagnoses for those with psychiatric contacts were also studied. METHODS: Sociodemographic variables and suicide methods were examined for all the 693 suicide victims during 1961-1980 in Västerbotten, Sweden. Information on any history of psychiatric contacts was obtained from psychiatric in-patient and out-patient records. RESULTS: Gender differences in the choice of suicide method were found in the group without any history of psychiatric contacts, but not in those with such a history. Only those without a history of psychiatric contacts showed season of birth variations for suicide methods -- those born during February to April were significantly more likely, and those born during October to January significantly less likely, to have preferred hanging rather than poisoning or petrol gases. These associations were stronger for the determined suicides, for males, and for urban residence. Suicide victims with a history of psychiatric contacts were significantly younger than those without. LIMITATIONS: No psychological autopsies for those without psychiatric contacts. No information on eventual contacts with general practitioners. No measures of monoamine neurotransmitters were available. CONCLUSIONS: Season of birth association for suicide methods is likely to be mediated by a suicidality trait independently of specific major psychiatric disorders. Monoamine neurotransmitters, particularly serotonin, are likely to underlie such a trait.