Suicide risk after nonfatal self-harm: a national cohort study, 2000-2008.

OBJECTIVE: To study the short-term risk of suicide after nonfatal deliberate self-harm and its association with coexisting mental disorders and with the method of self-harm used. METHOD: We used linked Swedish national registers to design a cohort study with 34,219 individuals (59% females) who were admitted to hospital in 2000-2005 after deliberate self-harm (ICD-10-defined). They were followed for 3-9 years. The studied outcome was completed suicide; Cox regression models yielded hazard ratios (HRs) for suicide risk. Temporal patterns were plotted with Kaplan-Meier survival curves, calculated separately for each mental disorder and for the method used at the previous self-harm event. RESULTS: 1,182 subjects committed suicide during follow-up (670 males and 512 females). Coexisting bipolar disorder (in males, adjusted HR = 6.3; 95% confidence interval [CI], 3.8-10.3; in females, adjusted HR = 5.8; 95% CI, 3.4-9.7) and nonorganic psychotic disorder (in males, adjusted HR = 5.1; 95% CI, 3.5-7.4; in females, adjusted HR = 4.6; 95% CI, 2.8-7.7) implied the highest risk of suicide after previous self-harm. Hanging as index self-harm method was a strong predictor of later suicide in both males (adjusted HR = 5.3; 95% CI, 4.0-7.0) and females (adjusted HR = 4.5; 95% CI, 2.5-8.1). Of those with bipolar disorder who used a method other than poisoning at the index event, 20.4% had already committed suicide after 3-9 years. CONCLUSION: Individuals with severe mental disorders (affective and psychotic disorders) have a poor prognosis in the first years after hospital admission due to self-harm. The risk of subsequent suicide is higher after attempts by hanging and other self-injury methods (vs self-poisoning). Aftercare for those with a self-harm episode should focus on treatment of the mental disorder present at the time of the episode.

Assessment and treatment of asylum seekers after a suicide attempt: a comparative study of people registered at mental health services in a Swedish location.

BACKGROUND: Even though asylum seekers are considered vulnerable to mental ill-health, knowledge of their suicidal behaviour is limited. The aim of this study was to improve our understanding of factors that influence the clinical assessment of asylum seekers who have attempted suicide compared to the assessment of non-asylum seekers. METHODS: The study focused on 88 asylum seekers registered for suicide attempts in mental health services 2005-2009, who were matched for age and gender and compared with 88 suicide attempters with Swedish personal identity numbers. The medical records were analysed with a quantitative protocol, focusing on social risk and protective factors, health history, current clinical picture as well as the assessment procedure, diagnostics, patterns of treatment and follow-up in this clinical group. Data was analysed using the chi-square test, Fisher's exact probability test, and the Mann-Whitney U test. RESULTS: As in earlier studies, asylum seekers were more traumatized, had different social risk factors and received different diagnoses than the controls. Asylum seekers were referred to less specialized follow-up after treatment, in spite of their health history and of previous and current clinical pictures indicating a similar or--in the case of the female asylum seekers--more serious mental health condition. Female asylum seekers also received more intense and prolonged in-patient treatment than female controls. Asylum seekers appeared to have social networks more often than the control group. However, there was less documentation of the social context, previous suicidal behaviour, and on suicide in the family and close environment of the asylum-seeking men. Information on suicidal intent was lacking in a majority of both groups. The time relation of the suicide attempt and the asylum process suggested the importance of the asylum decision, as well as the possible role of earlier mental health problems and premigration stress, for the suicidal behaviour. CONCLUSIONS: The groups had different sets of risk factors and clinical pictures. There was a lack of early and thorough exploration of suicide intent for both groups, and of contextual and subjective factors for the asylum seekers. Differences in follow-up indicate unequal access to care.

Gender differences in the treatment of patients with bipolar disorder: a study of 7354 patients.

BACKGROUND: Gender differences in treatment that are not supported by empirical evidence have been reported in several areas of medicine. Here, the aim was to evaluate potential gender differences in the treatment for bipolar disorder. METHODS: Data was collected from the Swedish National Quality Assurance Register for bipolar disorder (BipoläR). Baseline registrations from the period 2004-2011 of 7354 patients were analyzed. Multiple logistic regression analysis was used to study the impact of gender on interventions. RESULTS: Women were more often treated with antidepressants, lamotrigine, electroconvulsive therapy, benzodiazepines, and psychotherapy. Men were more often treated with lithium. There were no gender differences in treatment with mood stabilizers as a group, neuroleptics, or valproate. Subgroup analyses revealed that ECT was more common in women only in the bipolar I subgroup. Contrariwise, lamotrigine was more common in women only in the bipolar II subgroup. LIMITATIONS: As BipoläR contains data on outpatient treatment of persons with bipolar disorder in Sweden, it is unclear if these findings translate to inpatient care and to outpatient treatment in other countries. CONCLUSIONS: Men and women with bipolar disorder receive different treatments in routine clinical settings in Sweden. Gender differences in level of functioning, bipolar subtype, or severity of bipolar disorder could not explain the higher prevalence of pharmacological treatment, electroconvulsive therapy, and psychotherapy in women. Our results suggest that clinicians׳ treatment decisions are to some extent unduly influenced by patients׳ gender.

Suicide after release from prison: a population-based cohort study from Sweden.

OBJECTIVE: Released prisoners have high suicide rates compared with the general population, but little is known about risk factors and possible causal pathways. We conducted a population-based cohort study to investigate rates and risk factors for suicide in people previously imprisoned. METHOD: We identified individuals released from prison in Sweden between January 1, 2005, and December 31, 2009, through linkage of national population-based registers. Released prisoners were followed from the day of release until death, emigration, new incarceration, or December 31, 2009. Survival analyses were conducted to compare incidence rates and psychiatric morbidity with nonconvicted population controls matched on gender and year of birth. RESULTS: We identified 38,995 releases among 26,985 prisoners (7.6% female) during 2005-2009. Overall, 127 suicides occurred, accounting for 14% of all deaths after release (n = 920). The mean suicide rate was 204 per 100,000 person-years, yielding an incidence rate ratio of 18.2 (95% CI, 13.9-23.8) compared with general population controls. Previous substance use disorder (hazard ratio [HR] = 2.1; 95% CI, 1.4-3.2), suicide attempt (HR = 2.5; 95% CI, 1.7-3.7), and being born in Sweden versus abroad (HR = 2.1; 95% CI, 1.2-3.6) were independent risk factors for suicide after release. CONCLUSIONS: Released prisoners are at high suicide risk and have a slightly different pattern of psychiatric risk factors for suicide compared with the general population. Results suggest appropriate allocation of resources to facilitate transition to life outside prison and increased attention to prisoners with both a previous suicide attempt and substance use disorder.

Attempted suicide in bipolar disorder: risk factors in a cohort of 6086 patients.

OBJECTIVE: Bipolar disorder is associated with high risk of self-harm and suicide. We wanted to investigate risk factors for attempted suicide in bipolar patients. METHOD: This was a cohort study of 6086 bipolar patients (60% women) registered in the Swedish National Quality Register for Bipolar Disorder 2004-2011 and followed-up annually 2005-2012. Logistic regression was used to calculate adjusted odds ratios for fatal or non-fatal attempted suicide during follow-up. RESULTS: Recent affective episodes predicted attempted suicide during follow-up (men: odds ratio = 3.63, 95% CI = 1.76-7.51; women: odds ratio = 2.81, 95% CI = 1.78-4.44), as did previous suicide attempts (men: odds ratio = 3.93, 95% CI = 2.48-6.24; women: odds ratio = 4.24, 95% CI = 3.06-5.88) and recent psychiatric inpatient care (men: odds ratio = 3.57, 95% CI = 1.59-8,01; women: odds ratio = 2.68, 95% CI = 1.60-4.50). Further, those with many lifetime depressive episodes were more likely to attempt suicide. Comorbid substance use disorder was a predictor in men; many lifetime mixed episodes, early onset of mental disorder, personality disorder, and social problems related to the primary group were predictors in women. CONCLUSION: The principal clinical implication of the present study is to pay attention to the risk of suicidal behaviour in bipolar patients with depressive features and more severe or unstable forms of the disorder.

Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study.

OBJECTIVE: To study the association between method of attempted suicide and risk of subsequent successful suicide. DESIGN: Cohort study with follow-up for 21-31 years. SETTING: Swedish national register linkage study. PARTICIPANTS: 48,649 individuals admitted to hospital in 1973-82 after attempted suicide. MAIN OUTCOME MEASURE: Completed suicide, 1973-2003. Multiple Cox regression modelling was conducted for each method at the index (first) attempt, with poisoning as the reference category. Relative risks were expressed as hazard ratios with 95% confidence intervals. RESULTS: 5740 individuals (12%) committed suicide during follow-up. The risk of successful suicide varied substantially according to the method used at the index attempt. Individuals who had attempted suicide by hanging, strangulation, or suffocation had the worst prognosis. In this group, 258 (54%) men and 125 (57%) women later successfully committed suicide (hazard ratio 6.2, 95% confidence interval 5.5 to 6.9, after adjustment for age, sex, education, immigrant status, and co-occurring psychiatric morbidity), and 333 (87%) did so with a year after the index attempt. For other methods (gassing, jumping from a height, using a firearm or explosive, or drowning), risks were significantly lower than for hanging but still raised at 1.8 to 4.0. Cutting, other methods, and late effect of suicide attempt or other self inflicted harm conferred risks at levels similar to that for the reference category of poisoning (used by 84%). Most of those who successfully committed suicide used the same method as they did at the index attempt-for example, >90% for hanging in men and women. CONCLUSION: The method used at an unsuccessful suicide attempt predicts later completed suicide, after adjustment for sociodemographic confounding and psychiatric disorder. Intensified aftercare is warranted after suicide attempts involving hanging, drowning, firearms or explosives, jumping from a height, or gassing.

Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long term follow-up.

OBJECTIVE: To investigate the impact of coexistent psychiatric morbidity on risk of suicide after a suicide attempt. DESIGN: Cohort study with follow-up for 21-31 years. SETTING: Swedish national register based study. PARTICIPANTS: 39 685 people (53% women) admitted to hospital for attempted suicide during 1973-82. MAIN OUTCOME MEASURE: Completed suicide during 1973-2003. RESULTS: A high proportion of suicides in all diagnostic categories took place within the first year of follow-up (14-64% in men, 14-54% in women); the highest short term risk was associated with bipolar and unipolar disorder (64% in men, 42% in women) and schizophrenia (56% in men, 54% in women). The strongest psychiatric predictors of completed suicide throughout the entire follow-up were schizophrenia (adjusted hazard ratio 4.1, 95% confidence interval 3.5 to 4.8 in men, 3.5, 2.8 to 4.4 in women) and bipolar and unipolar disorder (3.5, 3.0 to 4.2 in men, 2.5, 2.1 to 3.0 in women). Increased risks were also found for other depressive disorder, anxiety disorder, alcohol misuse (women), drug misuse, and personality disorder. The highest population attributable fractions for suicide among people who had previously attempted suicide were found for other depression in women (population attributable fraction 9.3), followed by schizophrenia in men (4.6), and bipolar and unipolar disorder in women and men (4.1 and 4.0, respectively). CONCLUSION: Type of psychiatric disorder coexistent with a suicide attempt substantially influences overall risk and temporality for completed suicide. To reduce this risk, high risk patients need aftercare, especially during the first two years after attempted suicide among patients with schizophrenia or bipolar and unipolar disorder.

Excess mortality in persons with severe mental disorder in Sweden: a cohort study of 12 103 individuals with and without contact with psychiatric services.

BACKGROUND: Investigating mortality in those with mental disorder is one way of measuring effects of mental health care reorganisation. This study's aim was to investigate whether the excess mortality in those with severe mental disorder remains high in Sweden after the initiation of the Community Mental Health Care Reform. We analysed excess mortality by gender, type of mental health service and psychiatric diagnosis in a large community-based cohort with long-term mental disorder. METHODS: A survey was conducted in Stockholm County, Sweden in 1997 to identify adults with long-term disabling mental disorder (mental retardation and dementia excluded). The 12 103 cases were linked to the Hospital Discharge Register and the Cause of Death Register. Standardised mortality ratios (SMRs) for 1998-2000 were calculated for all causes of death, in the entire cohort and in subgroups based on treatment setting and diagnosis. RESULTS: Mortality was increased in both genders, for natural and external causes and in all diagnostic subgroups. Excess mortality was greater among those with a history of psychiatric inpatient care, especially in those with substance use disorder. For the entire cohort, the number of excess deaths due to natural causes was threefold that due to external causes. SMRs in those in contact with psychiatric services where strikingly similar to those in contact with social services. CONCLUSION: Mortality remains high in those with long-term mental disorder in Sweden, regardless of treatment setting. Treatment programs for persons with long-term mental disorder should target physical as well as mental health.

Predictors of suicide in a community-based cohort of individuals with severe mental disorder.

BACKGROUND: Rate of suicide is probably an indicator of the quality of mental health services within an area. The aim of this study was to identify predictors of suicide in a large community-based cohort of persons with long-term mental disorder. METHODS: A survey was conducted in Stockholm County, Sweden, in 1997 to identify adults with long-term disabling mental disorder (mental retardation and dementia excluded). The survey included an inventory of unmet needs as perceived by the service providers. The 12,247 cases were linked to the national in-patient register and the cause-of-death register. Predictors of suicide in 1997-2000 were determined by bivariate analysis and multiple logistic regression. RESULTS: Predictors of suicide included a history of in-patient psychiatric care, previous suicide attempt, substance abuse and unmet need of a contact person. Personality disorder, especially borderline personality disorder, was the strongest diagnostic predictor of suicide among those with a history of in-patient psychiatric care. CONCLUSION: Unmet needs may signal increased suicide risk in persons with severe mental disorder. Methods to improve suicide prevention in persons with personality disorder should be further developed. Interventions to reduce suicide in persons with a long-term mental disorder will require collaboration between psychiatric and social services.