Real-Time Monitoring of Non-linear Suicidal Dynamics: Methodology and a Demonstrative Case Report.

In recent years, a number of different authors have stressed the usefulness of non-linear dynamic systems approach in suicide research and suicide prevention. This approach applies specific methods of time series analysis and, consequently, it requires a continuous and fine-meshed assessment of the processes under consideration. The technical means for this kind of process assessment and process analysis are now available. This paper outlines how suicidal dynamics can be monitored in high-risk patients by an Internet-based application for continuous self-assessment with integrated tools of non-linear time series analysis: the Synergetic Navigation System. This procedure is illustrated by data from a patient who attempted suicide at the end of a 90-day monitoring period. Additionally, future research topics and clinical applications of a non-linear dynamic systems approach in suicidology are discussed.

Nothing like Christmas--suicides during Christmas and other holidays in Austria.

BACKGROUND: Contrary to the myth that suicides increase around Christmas, multiple studies reveal that suicide rates decrease towards Christmas and return back to normal or even peak in the beginning of the new year. We aimed to replicate this effect for Austria. METHODS: The analyses were based on the official suicide statistics 2000-13 using Poission regression and Bayesian changepoint analysis. We also investigated changes of suicide rates during other major holidays and weekends. Seasonal effects were controlled for by using restricted control periods. RESULTS: Suicide rates declined before Christmas and were minimal on December 24th, remained low until the end of the year, peaked on New Year's day, but remained at average level in New Year's week. In contrast, suicide rates increased in the week after Easter and on Mondays/Tuesdays after weekends. No significant effects were found in the week after Whitsun and summer holidays. CONCLUSION: Compared with other holidays, Christmas time is clearly associated with fewer suicides in Austria, too, and may even counteract the 'broken promise' effect. This finding may help clarifying common myths in suicide prevention and may enhance the proper timing of preventive efforts.

Explaining the suicide risk of sexual minority individuals by contrasting the minority stress model with suicide models.

Many studies have found elevated levels of suicide ideation and attempts among sexual minority (homosexual and bisexual) individuals as compared to heterosexual individuals. The suicide risk difference has mainly been explained by minority stress models (MSTM), but the application of established suicidological models and testing their interrelations with the MSTM has been lacking so far. Therefore, we have contrasted two established models explaining suicide risk, the Interpersonal Psychological Theory (IPT) (Joiner, 2005) and the Clinical Model (CM) (Mann et al., 1999), with the MSTM (Meyer, 2003) in a Bavarian online-sample of 255 adult sexual minority participants and 183 heterosexual participants. The results suggested that the CM and the IPT model can well explain suicide ideation among sexual minorities according to the factors depression, hopelessness, perceived burdensomeness, and failed belongingness. The CM and the IPT were intertwined with the MSTM via internalized homophobia, social support, and early age of coming out. Early coming out was associated with an increased suicide attempt risk, perhaps through violent experiences that enhanced the capability for suicide; however, coming out likely changed to a protective factor for suicide ideation by enhanced social support and reduced internalized homophobia. These results give more insight into the development of suicide risk among sexual minority individuals and may be helpful to tailor minority-specific suicide prevention strategies.

Religion and suicide risk in lesbian, gay and bisexual Austrians.

Religion is known to be a protective factor against suicide. However, religiously affiliated sexual minority individuals often report a conflict between religion and sexual identity. Therefore, the protective role of religion against suicide in sexual minority people is unclear. We investigated the effect of religion on suicide risk in a sample of 358 lesbian, gay and bisexual Austrians. Religion was associated with higher scores of internalized homophobia, but with fewer suicide attempts. Our data indicate that religion might be both a risk and a protective factor against suicidality in religiously affiliated sexual minority individuals.

Hiking in suicidal patients: neutral effects on markers of suicidality.

BACKGROUND: Regular physical activity promotes physical and mental health. Psychiatric patients are prone to a sedentary lifestyle, and accumulating evidence has identified physical activity as a supplemental treatment option. METHODS: This prospective, randomized, crossover study evaluated the effects of hiking in high-risk suicidal patients (n = 20) who performed 9 weeks of hiking (2-3 hikes/week, 2-2.5 hours each) and a 9-week control period. RESULTS: All patients participated in the required 2 hikes per week and thus showed a compliance of 100%. Regular hiking led to significant improvement in maximal exercise capacity (hiking period Δ: +18.82 ± 0.99 watt, P < .001; control period: P = .134) and in aerobic capability at 70% of the individual heart rate reserve (hiking period Δ: +8.47 ± 2.22 watt; P = .010; control period: P = .183). Cytokines, associated previously with suicidality (tumor necrosis factor-α, interleukin-6, S100), remained essentially unchanged. CONCLUSIONS: Hiking is an effective and safe form of exercise training even in high-risk suicidal patients. It leads to a significant improvement in maximal exercise capacity and aerobic capability without concomitant deterioration of markers of suicidality. Offering this popular mode of exercise to these patients might help them to adopt a physically more active lifestyle.

Suicide risk and sexual orientation: a critical review.

Many studies have reported higher rates of suicide attempts among sexual minority individuals compared with their heterosexual counterparts. For suicides, however, it has been argued that there is no sexual orientation risk difference, based on the results of psychological autopsy studies. The purpose of this article was to clarify the reasons for the seemingly discrepant findings for suicide attempts and suicides. First, we reviewed studies that investigated if the increased suicide attempt risk of sexual minorities resulted from biased self-reports or less rigorous assessments of suicide attempts. Second, we reanalyzed the only two available case-control autopsy studies and challenge their original "no difference" conclusion by pointing out problems with the interpretation of significance tests and by applying Bayesian statistics and meta-analytical procedures. Third, we reviewed register based and clinical studies on the association of suicides and sexual orientation. We conclude that studies of both suicide attempts and suicides do, in fact, point to an increased suicide risk among sexual minorities, thus solving the discrepancy. We also discuss methodological challenges inherent in research on sexual minorities and potential ethical issues. The arguments in this article are necessary to judge the weight of the evidence and how the evidence might be translated into practice.

Nonlinear dynamics: theoretical perspectives and application to suicidology.

Despite decades of research, the prediction of suicidal behavior remains limited. As a result, searching for more specific risk factors and testing their predictive power are central in suicidology. This strategy may be of limited value because it assumes linearity to the suicidal process that is most likely nonlinear by nature and which can be more adequately described and analyzed with nonlinear dynamics. The goal of moving nonlinear dynamics from theory to practice and to real-world phenomena can now be realized with Internet-based monitoring systems such as the Synergetic Navigation System.

A closer look at self-reported suicide attempts: false positives and false negatives.

The validity of self-reported suicide attempt information is undermined by false positives (e.g., incidences without intent to die), or by unreported suicide attempts, referred to as false negatives. In a sample of 1,385 Austrian adults, we explored the occurrence of false positives and false negatives with detailed, probing questions. Removing false positives decreased the rate of suicide attempters from 4.3% to 2.7%. Probing questions also revealed 0.8% false negatives. We recommend using probing questions with both those who report a suicide attempt and those who do not report a suicide attempt to increase the validity of self-reported suicide-related information.

The contribution of school to the feeling of acceptance and the risk of suicide attempts among Austrian gay and bisexual males.

School-related factors contributing to the suicidality of lesbian, gay, and bisexual individuals are understudied, especially in German-speaking Europe. Among our Web-based sample of 468 Austrian gay or bisexual adults, 18% attempted suicide and about one half of them reported that hard times at school related to one's homosexuality partly or mainly caused the attempt. Such suicide attempts were associated with a lack of acceptance at school and harassment experiences. In contrast to suicide attempts, acceptance at school was significantly associated with protective factors such as teachers intervening against homophobia or presence of openly homosexual teachers or peers. These findings may be important for consideration in school-based suicide prevention programs.

The relation between sexual orientation and suicide attempts in Austria.

Previous studies indicate that homosexual or bisexual individuals are at a higher risk of attempting suicide compared to heterosexuals. To overcome biases in these studies, more rigorous definitions of "suicide attempts" and the assessment of multiple dimensions of sexual orientation are needed. In addition, studies from the German speaking region are sparse, especially those not recruiting participants from the gay or lesbian communities. We solicited self-reported suicide attempts among 1,382 Austrian adults recruited through structured snowball sampling from students' social networks. Suicide attempts were more frequently reported by those participants with homosexual or bisexual fantasies, partner preference, behavior, and self-identification, compared to their heterosexually classified counterparts. This was true for any dimension of sexual orientation and for suicide attempts with intent to die or suicide attempts that required medical treatment. Our Austrian study confirmed existing evidence that homosexual and bisexual individuals are at an increased risk for attempting suicide. This should be considered in suicide preventive efforts.

[Are near-death experiences following attempted suicide important for suicide risk assessment? A case report]. / Sind Nahtoderlebnisse nach Suizidversuchen bedeutsam für die weitere Suizidrisikoeinschätzung? Ein Fallbericht.

We describe a 59-year old patient who reported a near-death experience following attempted suicide. The near-death experience induced reduction of suicidality. Previous studies suggested a high prevalence of near-death experiences following attempted suicide and that near-death experiences may decrease rather than increase subsequent suicide risk. Implications for suicide risk assessment are discussed.

Childhood gender nonconformity and harassment as predictors of suicidality among gay, lesbian, bisexual, and heterosexual Austrians.

The role of childhood gender role nonconformity (CGNC) and childhood harassment (CH) in explaining suicidality (suicide ideation, aborted suicide attempts, and suicide attempts) was examined in a sample of 142 lesbian, gay, and bisexual (LGB) adults and 148 heterosexual adults in Austria. Current and previous suicidality, CGNC, and CH were significantly greater in LGB participants compared to heterosexual participants. After controlling for CGNC, the effect of sexual orientation on CH diminished. CGNC correlated significantly with current suicidality in the LGB but not in the heterosexual group, and only non-significant correlations were found for CGNC with previous suicidality. Controlling for CH and CGNC diminished the effect of sexual orientation on current suicidality. Bayesian multivariate analysis indicated that current suicidality, but not previous suicidality, depended directly on CGNC. CH and CGNC are likely implicated in the elevated levels of current suicidality among adult LGB participants. As for previous suicidality, the negative impact of CGNC on suicidality might be overshadowed by stress issues affecting sexual minorities around coming out. The association of CGNC with current suicidality suggests an enduring effect of CGNC on the mental health and suicide risk of LGB individuals.

County council politicians' attitudes toward suicide and suicide prevention: a qualitative cross-cultural study.

The purpose of the present study was to compare county council politicians' attitudes toward suicide and suicide prevention in five European countries. A questionnaire was distributed and here the responses to the open-ended questions are analyzed qualitatively. Considerable differences were found in what the politicians in the five countries believed to be the most important causes of suicide and how suicide can be prevented. There were also differences in to what degree the politicians revealed a judgmental attitude toward suicide, which seemed to be related to the magnitude of the problem in the respective countries. A certain implicit inconsistency in the logic directing the politicians' responses was found when their views on causes to suicide and suicide prevention strategies were compared. The responses indicate a need for increased consciousness and knowledge about suicide and suicide prevention among politicians in all the five countries. This is important since they are responsible for initiating and funding suicide preventive efforts.

[Does antidepressant therapy increase suicide risk in children ad adolescents? - A comment]. / Erhöht die Therapie mit Antidepressiva das Suizidrisiko bei Kindern und Jugendlichen? - Eine Stellungnahme.

Recent data indicate increasing suicide rates for children and adolescents in the United States, Great Britain and the Netherlands. These facts call for a critical discussion of prescription rates of antidepressants for pediatric use. Obviously the U.S. and European regulators issued public warnings about a possible association between antidepressants and suicidal thinking and behaviour have discouraged physicians to use antidepressants in this age group. Untreated depression means impairment of psychosocial development of children and their families. Alarmingly there is no evidence of a significant increase in the use of treatment alternatives as for example psychotherapy. High relapse rate with early onset of depressions are common and therefore children with depression need all our attention and best treatment available. Current Austrian suicidal statistics do not yet demonstrate increasing suicidal rates in adolescents as seen in the U.S., the U.K. and the Netherlands. Thus all our alertness is needed to avoid any analogical progress in suicide rates and despite regulatory warnings and certainly after a careful risk-benefit analyses physicians have to consider pharmacological treatment options in depressive children and adolescents.

Bioenergetic exercises in inpatient treatment of Turkish immigrants with chronic somatoform disorders: a randomized, controlled study.

OBJECTIVE: The aim of this study was to examine whether bioenergetic exercises (BE) significantly influence the inpatient psychotherapeutic treatment results for Turkish immigrants with chronic somatoform disorders. METHOD: In a 6-week randomized, prospective, controlled trial, we treated a sample of 128 Turkish patients: 64 were randomly assigned to BE and 64 participated in gymnastic exercises in lieu of BE. The Symptom Checklist (SCL-90-R) and State-Trait Anger Expression Inventory (STAXI) were employed. RESULTS: According to the intent-to-treat principle, the bioenergetic analysis group achieved significantly better treatment results on most of the SCL-90-R and STAXI scales. CONCLUSIONS: BE appears to improve symptoms of somatization, social insecurity, depressiveness, anxiety, and hostility in the inpatient therapy of subjects with chronic somatoform disorders. Reduction of the anger level and reduction in directing anger inwards, with a simultaneous increase of spontaneous outward emotional expression, could be expected.

Suicide attempts versus suicidal ideation in bulimic female adolescents.

BACKGROUND: Suicide attempts by adolescents continue to be a major public health problem. The purpose of this study was to examine the difference in the family functioning and sociopsychopathological risk factor relationship between female bulimic adolescents with suicidal ideation only, and those who attempted suicide. METHODS: A group of 211 patients were observed for 12 months. Data from 63 subjects (SUG [suicide group], age 17.2 +/- 1.3 years) who had attempted suicide were then compared with 148 (control group, age 18.1 +/- 1.5 years) who had expressed suicidal ideation but did not follow through. RESULTS: Those in the suicide attempt group had been exposed more frequently to physical/sexual violence in childhood. As adults they either lived alone or were dissatisfied with their partnership. The frequency of borderline personality disorders and depressive disorders in this group was significant. Psychosomatic symptoms, disturbed coenesthesia, substance abuse, social impairment and interference with their perception of their own life circumstances, as well as their job performance, often preceded the suicide attempt. Nine genuine risk factors that occurred significantly more often in the SUG were calculated out of all the stress factors using stepwise logistic regression: 'as a child I was even hit with a stick or whip', 'I had no set orientation in life', 'I had a feeling of loneliness despite family and friends', 'I could not relax', 'incapable of dealing with the public', 'I do not like to be touched', 'parents have psychiatric disorders', 'misuse of stimulants', and 'as a child I felt lonely' (odds ratio, 10.56-1.90). CONCLUSION: Adverse family experiences and multiple sociopsychopathological factors may increase the risk of suicide in female bulimic adolescents.

Aripiprazole in the treatment of patients with borderline personality disorder: a double-blind, placebo-controlled study.

OBJECTIVE: Aripiprazole is a relatively new atypical antipsychotic agent that has been successfully employed in therapy for schizophrenia and schizoaffective disorders. A few neuroleptics have been used in therapy for patients with borderline personality disorder, which is associated with severe psychopathological symptoms. Aripiprazole, however, has not yet been tested for this disorder, and the goal of this study was to determine whether aripiprazole is effective in the treatment of several domains of symptoms of borderline personality disorder. METHOD: Subjects meeting criteria for the Structured Clinical Interview for DSM-III-R Personality Disorders for borderline personality disorder (43 women and 9 men) were randomly assigned in a 1:1 ratio to 15 mg/day of aripiprazole (N=26) or placebo (N=26) for 8 weeks. Primary outcome measures were changes in scores on the symptom checklist (SCL-90-R), the Hamilton Depression Rating Scale (HAM-D), the Hamilton Anxiety Rating Scale (HAM-A), and the State-Trait Anger Expression Inventory and were assessed weekly. Side effects and self-injury were assessed with a nonvalidated questionnaire. RESULTS: According to the intent-to-treat principle, significant changes in scores on most scales of the SCL-90-R, the HAM-D, the HAM-A, and all scales of the State-Trait Anger Expression Inventory were observed in the subjects treated with aripiprazole after 8 weeks. Self-injury occurred in the groups. The reported side effects were headache, insomnia, nausea, numbness, constipation, and anxiety. CONCLUSIONS: Aripiprazole appears to be a safe and effective agent in the treatment of patients with borderline personality disorder.

Familial and sociopsychopathological risk factors for suicide attempt in bulimic and in depressed women: prospective study.

OBJECTIVE: This study was carried out to examine sociopsychopathological predictors of prospective observed suicide attempts in bulimic women purging type without comorbid major depression (BNG) at the time of study entry and in woman with major depression without comorbid eating disorder at the time of study entry (MDG). METHODS: Data from 28 BNG (age 23.5 +/- 3.6) and 126 MDG women (age 33.4 +/- 5.1) who had attempted suicide during 12 months' monitoring were compared. RESULTS: A univariate comparison of the two groups revealed various differences. Analysis of risk factors for suicide attempts using stepwise logistic regression was conducted separately for each group. The derived logistic models showed that patients from the BNG group had a history of higher incidence of sexual abuse in childhood, as well as abuse of laxatives and illicit drugs; they also lacked orientation in life, felt lonely despite family and friends, tended to direct their anger outward, and were unable to relax. CONCLUSIONS: Sociopsychopathological risk factors for suicide attempts in the BNG and MDG appear to vary.

Change in instrumental activities of daily living disability in female senior patients with musculosceletal pain: a prospective, randomized, controlled trial.

Previous studies found that depressive symptoms and low functional self-efficacy are associated with the occurrence of disabling musculoskeletal pain, and diminished quality of life in elderly people. The target of this study was to consider the change in instrumental activities of daily living (IADL) disability and health related quality of life after integrative psychotherapeutic treatment program of depressive symptoms in senior female patients with musculoskeletal pain. In an 8-week outpatient-based, random, prospective, controlled trial, 36 female patients between 70 and 79 with a history of clinically evident musculoskeletal pain and afflicted with depressive symptoms, but who were able to bathe, walk, dress, and transferring inside the house were evaluated. The study was performed using the Center for Epidemiological Studies Depression Scale (CES-D), IADL, and the Health Survey (SF-36). In comparison with the untreated group, according to the intent-to-treat principle, significant changes on the CES-D (P < 0.01), IADL (P < 0.01), and all scales of SF-36 were observed after eight weeks in the treated subjects. The treatment of moderate depression with integrative psychotherapy may be efficacious in improving of IADL disability and health related quality of life in affected senior female patients with musculoskeletal pain.