Is suicide contagious? A study of the relation between exposure to the suicidal behavior of others and nearly lethal suicide attempts.

This study sought to determine the association between nearly lethal suicide attempts and exposure to the suicidal behavior of parents, relatives, friends, or acquaintances and to accounts of suicide in the media. The authors conducted a population-based case-control study in Houston, Texas, from November 1992 through July 1995. They interviewed 153 victims of attempted suicide aged 13--34 years who had been treated at emergency departments in Houston and a random sample of 513 control subjects. After controlling for potentially confounding variables, the authors found that exposure to the suicidal behavior of a parent (adjusted OR = 1.5; 95% CI: 0.6, 3.6; p = 0.42) or a nonparent relative (adjusted OR = 1.2; 95% CI: 0.7, 2.0; p = 0.55) was not significantly associated with nearly lethal suicide attempts. Both exposure to the suicidal behavior of a friend or acquaintance (adjusted OR = 0.6; 95% CI: 0.4, 1.0; p = 0.05) and exposure to accounts of suicidal behavior in the media (adjusted OR = 0.2; 95% CI: 0.1, 0.3; p = 0.00) were associated with a lower risk of nearly lethal suicide attempts. Exposure to accounts of suicidal behavior in the media and, to a lesser extent, exposure to the suicidal behavior of friends or acquaintances may be protective for nearly lethal suicide attempts, but further research is needed to better understand the mechanisms underlying these findings.

Alcohol consumption and nearly lethal suicide attempts.

We conducted a case-control study of the association between nearly lethal suicide attempts and facets of alcohol consumption; namely, drinking frequency, drinking quantity, binge drinking, alcoholism, drinking within 3 hours of suicide attempt, and age began drinking. Subjects were 13-34 years of age. In bivariable analyses, all measures were associated with nearly lethal suicide attempts. Odds ratios ranged from 2.4 for alcoholism to 7.0 for drinking within 3 hours of attempt. All exposure variables except age began drinking exhibited a J-shaped relationship between alcohol exposure and nearly lethal suicide attempt. After controlling for potential confounders and other measures of alcohol exposure, drinking within 3 hours of attempt remained most strongly (odds ratios > 6) associated. Alcoholism remained significantly associated in most models, but at lower strength.

Identification of nearly fatal suicide attempts: Self-Inflicted Injury Severity Form.

The Self-Inflicted Injury Severity Form (SIISF) was developed as an epidemiological research tool for identifying individuals in hospital emergency departments who have life-threatening self-inflicted injuries. Data were collected from 715 patients with self-inflicted injuries in two large hospitals. In 295 of these cases, a second set of data was independently collected for assessment of interrater reliability. Validity was assessed by comparing the SIISF results with simultaneously collected Risk-Rescue Ratings. Assessment of interrater reliability found that only 2.4% of physicians disagreed on the suicide method used. The kappa statistic for method used was .94, indicating excellent agreement. The SIISF was found to distinguish between severe and less severe injuries. Thus, it appears to provide a simple method to distinguish patients who have life-threatening self-inflicted injuries.

The role of prior pain experience and expectancy in psychologically and physically induced pain.

Cognitive theories regarding symptom formation suggest that environmental factors such as warnings of impending pain and earlier experiences with pain can lead to a cognitive schema in which pain is selectively monitored. This study evaluated the role of prior experience with pain in the development of expectancy induced somatoform pain. Subjects from two experimental groups were connected to a sham stimulator and told to expect a headache. One of these groups, the physical stimulation first group, was exposed to pain induction by ice water and by pressure prior to the sham stimulation. A second group, the sham stimulation first group, received the sham stimulation followed by the cold water and pressure pain induction techniques. Subjects in the physical stimulation first group showed significant increases in their pain reports as settings on the sham stimulator were increased. Significant increases were not noted in the sham stimulation first group. The two groups did not differ in the number of subjects reporting pain or the mean maximal pain reported during the sham stimulation. Duration of cold water tolerance and the time until the analgesic threshold level for cold water were significantly shorter in subjects who had the sham stimulation first. This study suggests that prior pain can influence the reactivity to external suggestion for pain but does not increase the frequency of pain reports. It does suggest that the selective monitoring induced during the sham stimulation may influence later pain behaviours as was seen during the cold water tolerance testing.

Sexually transmitted disease prevention services for female chronically mentally ill patients.

Chronically and variably impaired autonomy makes women with chronic mental illness particularly vulnerable to contracting sexually transmitted diseases (STDs) including AIDS. A lack of female controlled protective devices also adds to the vulnerability of these patients. In this context, the authors make recommendations for the design of clinically comprehensive and ethically justified programs to minimize the risk of mentally ill women for STDs. When female chronically mentally ill patients are at risk of STDs, barriers to the exercise of their autonomy must be identified and clinically treated. Preventive clinical interventions can also be usefully augmented by educational strategies and facilitate patients' communication and behavioral skills, particularly in order to enable them to abstain from unwanted sex or to make prospective male partners wear a condom. Outreach efforts to the male partners of female patients and to the homeless mentally ill may also be required. Preventive services could be integrated and coordinated with STD clinics, substance abuse treatment programs and family planning programs.

Anxiety in experimentally induced somatoform symptoms.

This study examined the anxiety and pain reports in a group of subjects during a stimulation experiment in which the subjects were misinformed that an electrical current was being conducted through electrodes attached to their heads. The experiment's purpose was to determine how the subjects' reporting of pain was related to their reporting of anxiety over time. One subset of the subjects rated pain only, a second rated pain and anxiety, and a third rated pain and hunger. The three groups did not differ significantly in the frequency or intensity of their pain reports. The separate ratings for both anxiety and pain increased in a parallel manner. These results, however, do not support the theories involving the suppression of awareness of affect in somatofom disorders.

Respecting the autonomy of chronic mentally ill women in decisions about contraception.

Treatment of women patients with chronic mental illness who are at risk of unwanted pregnancies presents ethical challenges to the clinician who wishes to respect the patient's autonomy while also helping her avert the potential adverse consequences of unwanted pregnancy. The clinician who simply allows the patient to continue at risk or coerces her into using contraception may not have adequately considered the variable nature of the patient's autonomy. The authors suggest that the clinician should assess and treat conditions underlying the patient's variable impairment of autonomy to maximize her ability to participate in family planning decisions. Case examples are used to illustrate assessment of patients' decision-making capacity, development of family planning approaches that respect patients' autonomy, and use of a newly available contraceptive implant.

PIP: Chronically mentally ill women of reproductive age pose major ethical dilemmas for mental health professionals if the patient does not accept contraception. Ethically questionable responses have ranged from letting the patient continue at risk of pregnancy out of a respect for her autonomy to manipulating or coercing the patient into using contraception. A third course of action assumes that mentally ill women exhibit both chronically and variably impaired autonomy with limitations in decision-making ability manifested in varying degrees over time. 3 case histories illustrate these issues. A 38-year-old schizophrenic woman wanted to become pregnant and was having unprotected intercourse. It was questionable whether the patient could give informed consent or understand contraceptive options. This impaired autonomy might lead a psychiatrist to act paternalistically to forestall a pregnancy. An alternative to this response would be to improve the patient's capacity to participate in the informed-consent process by treating underlying factors which pose barriers to the exercise of autonomy. If impairment is too severe for this treatment, beneficence-based obligations to potential children may override concerns for the patient's autonomy. In the second case, a 30-year-old schizophrenic woman was admitted in active labor in a psychotic state. Her baby was put in foster care. When her psychosis cleared, she refused to discuss birth control. The reproductive risks encountered by chronically mentally ill pregnant women can not be predicted with certainty and are not serious enough to constitute reasons to control the mother's decision-making process. In this case, an alternative approach may be to offer only reversible methods of birth control and provide information about HIV and other sexually transmitted diseases. In a hypothetical case, a 24-year-old schizophrenic woman consented to receive a contraceptive implant at the end of a hospitalization. When she regressed into a psychotic state, she requested that the implant be removed. Her doctors chose to honor the decision she made while she was not acutely psychotic and did not remove the implant. Because the risks the patient runs without the contraceptive are preventable, reversible, or uncertain, the clinician may not be justified in every case in refusing to honor a request by a patient even when she is severely psychotic. Removal of the device may relieve the patient of anxiety, even if the anxiety is delusional. The frustration involved with these problems may lead clinicians to accept any decision made by a patient, even if the principle of autonomy is thus inappropriately applied. An awareness of the variable nature of chronic mental illness, on the other hand, may help clinicians avoid a paternalistic approach. This requires the support of hospitals and clinics which, unfortunately, sometimes override ethical considerations because they must operate with a shortage of staff and resources. With contraceptive implants now available, mental health facilities should develop guidelines which address the unique ethical issues involved in their use.

Evaluating the evaluations of psychiatry residents.

This survey assessed the perceptions of psychiatry residents and faculty about resident evaluations. Current residents, former residents, and faculty of a psychiatry residency program were asked about the value and effect of feedback in 15 specific areas and rated their preferences for evaluation methods. Residents and faculty most valued feedback that addressed practical clinical skills. Evaluations reportedly improved skills in half of the areas surveyed. Most respondents preferred face-to-face evaluations from individual faculty. This study confirms the value of resident evaluations addressing clinical skills, but it highlights discrepancies in expectations and merits of several methods of evaluation.

Stereological analyses of hepatocyte changes parallel arsenic accumulation in the livers of green sunfish.

Cellular changes in hepatocytes of green sunfish (Lepomis cyanellus) exposed to arsenic-contaminated or control lake water were compared with the level of arsenic in the liver. Standard stereological procedures involved conversion of two-dimensional data (i.e. fractional measurements of morphological changes) to three-dimensional data for interpretation. Both the volume and numbers of nuclei increased slightly with increasing concentration of arsenic in the liver. Significant increases (p less than 0.01) were observed in the volumes occupied by necrotic and fibrous bodies as arsenic levels in the liver increased; linear regression analysis of these data resulted in 0.9066 and 0.9359 correlation coefficients for necrotic and fibrous bodies, respectively, when volume changes were considered on a unit body weight basis. The volume occupied by necrotic areas, abnormal lysosomes, and autophagic vacuoles increased with increased arsenic concentration. The surface density of rough endoplasmic reticulum increased with increasing arsenic concentration; linear regression resulted in a correlation coefficient of 0.8367 when data were based on unit body weight.

Weaving a tangled web: the psychology of deception and self deception in psychogenic pain.

Accounting for the unusual economy of secondary gain or reinforcement, understanding abnormal illness behavior and evaluating for the role of the unconscious and primary gain are three important problems which complicate the understanding of psychogenic pain. These problems might be addressed in part by an examination of the experimental studies of the social psychology of deception of self and others. The forced compliance situation, in which subjects who lie for a certain level of compensation persist in telling the lie in other settings, is one of the best studied of these experimental situations. Ways in which this experimental work might apply to problems in understanding pain patients are explored. Possible applications of this research to treatment are discussed along with areas for further research.