Definitions of suicidal behavior: lessons learned from the WHo/EURO multicentre Study.

Based on the experience matured during the 15 years of the WHO/EURO Multicentre Study on Suicidal Behavior, this paper provides an excursus on main elements that characterize components for definitional needs. It describes the rationale for choosing the initial set of definitions within the study and the subsequent problems and developments. As a result, unifying terminologies are proposed.

Repetition of suicidal behaviour in elderly Europeans: a prospective longitudinal study.

The aim of this study was to assess any predictive factors for repeated attempted suicide and completed suicide in a 1-year follow-up on a sample of elderly European suicide attempters (60 years and over). From 1990 to 1993, 63 subjects completed the first interview and were recontacted after 1 year. At follow-up, eight subjects (12.7%) had taken their lives and seven (11.1%) had repeated at least one suicide attempt. On comparison of repeaters and non-repeaters, differences emerged in terms of death of the father in childhood and for mean Suicidal Intent Score. At the end of follow-up period, repeaters reported a more frequent desire to repeat suicidal behaviour and judged their mental health and social assistance received to be worse. Suicides and non-repeaters differed especially in relation to death of father during childhood and number of contacts with General Practitioner. Interpretation of the results must take into account the smallness of the test sample, the difficulties in obtaining complete data for the follow-up interview, the lack of a control group and a diagnosis formulated in a hospital consultation setting. The study confirms, however, the high risk of repetition of suicidal behaviour in the elderly. In old age suicidal ideation is often sustained over long periods of time and requests for help are addressed to relatives and GPs. An interesting finding is the more frequent death of the father during childhood among repeaters.

Attempted and completed suicide in older subjects: results from the WHO/EURO Multicentre Study of Suicidal Behaviour.

OBJECTIVE: The authors present an analysis of findings for the 65 years and over age group from the WHO/EURO Multicentre Study of Suicidal Behaviour (1989-93). METHODS: Multinational data on non-fatal suicidal behaviour is derived from 1518 subjects in 16 European centres. Local district data on suicide were available from 10 of the collaborating centres. RESULTS: Stockholm (Sweden), Pontoise (France) and Oxford (UK) had the highest suicide attempts rates. In most centres, the majority of elderly who attempted suicide were widow(er)s, often living alone, who used predominantly voluntary drug ingestion. Non-fatal suicidal behaviour decreased with increasing age, whereas suicide rates rose. The ratio between fatal and non-fatal behaviours was 1:2, that for males/females almost 1:1. In the years considered, substantial stability in suicide and attempted suicide rates was observed. As their age increased, suicidal subjects displayed only a limited tendency to repeat self-destructive acts. Moreover, there was little correlation between attempted suicide and suicide rates, which carries different clinical implications for non-fatal suicidal behaviour in the elderly compared with younger subjects in the same WHO/EURO study.

Recommended care for young people (15-19 years) after suicide attempts in certain European countries.

Data on recommended care for young people aged 15-19 years after attempted suicide from nine European research centres during the period 1989-1992 were analysed in terms of gender, history of previous suicide attempt and methods used. Altogether 438 suicide attempts made by 353 boys and 1,102 suicide attempts made by 941 girls were included. Analyses of the total data from all centres showed that young people with a history of previous suicide attempt and those using violent methods had significantly higher chance of being recommended aftercare than first-time attempters or those choosing self-poisoning. There were no significant differences of being recommended care between genders. Logistic regression analyses of the material were performed and the results were similar. Both having previous attempted suicide (odds ratio 2.0, 95% CI 1.53-2.61) and using "hard" methods (odds ratio 1.71, 95% CI 1.49-1.96) were significantly associated with increased possibility of being recommended aftercare. When individual centres were analysed, large disparities of recommended care after suicide attempts were found and there were no uniform criteria of recommending care for young suicide attempters in Europe.

Some perspectives on suicidal behaviour.

OBJECTIVE: To try and specify questions of special relevance for suicidological research. METHODS: Discussing the merits of questions pertaining to epidemiology and various theories on suicidal behaviour. RESULTS: Four types of questions are defined: How many persons show suicidal behaviour? Who are they? Why do they do it? and What can we do about it? Answers to the first three questions are required when approaching question four: What can we do about it? CONCLUSION: The complex patterns and backgrounds of suicidal behaviour call for interdisciplinarity and for an increase in both multifactorial and process-related approaches as well as practicable, evidence-based and feasible intervention efforts.

Methods used for parasuicide: results of the WHO/EURO Multicentre Study on Parasuicide.

BACKGROUND: National suicide statistics show remarkable differences in the frequencies of various methods used for completed suicide. The WHO/EURO Multicentre Study on Parasuicide makes possible for the first time an international comparison of the frequencies of methods used in attempted suicide, because the data are based on geographical catchment areas of medical institutions. METHOD: Ongoing standardized monitoring of attempted suicide in all medical institutions serving the catchment areas was performed in 14 centres in 12 European countries. The data analysis is based on 20,649 events involving 15,530 persons, recorded between 1989 and 1993. RESULTS: The comparison of rates per 100,000 shows striking differences between the centres. The highest rates for drug overdoses were found for female attempters in Oxford (347/100,000), Helsinki (238/100,000) and Stockholm (221/100,000). Guipuzcoa had the lowest rates (61/100,000). The differences were most prominent in the age group 15-24, with outstanding rates for women in Oxford (653/100,000), which was mainly due to the frequent use of analgesics. Szeged had outstandingly high rates for pesticides and solvents. In some centres the use of multiple methods was frequent. CONCLUSIONS: There is a need, especially for areas with high frequencies for certain methods, to understand the factors involved and to develop new and specific prevention projects and to monitor their effects. The WHO/EURO Multicentre Study on Parasuicide has proved to be a useful and reliable instrument for continuous monitoring of trends in parasuicide.

A cross-cultural study of suicide intent in parasuicide patients.

As part of the WHO/EURO Multicentre Study on Parasuicide, the level of suicide intent among female and male parasuicide patients from various European regions was compared. From nine regions, a total of 1,212 parasuicide patients, 752 females and 460 males, were included in the study. Although some statistical significant differences in level of suicide intent between the regions and genders were found, the effect sizes of these relationships were so small that the differences have neither theoretical nor practical significance. As far as level of suicide intent is concerned, the WHO study has succeeded in recruiting a relatively homogeneous group of self-harming patients across borders of region, culture, and country.

Physical illness and parasuicide: evidence from the European Parasuicide Study Interview Schedule (EPSIS/WHO-EURO).

OBJECTIVE: The aim of this research was to identify psychosocial characteristics which might predict future suicidal behavior in parasuicidal subjects in Europe. METHOD: The interview utilized for the survey (European Parasuicide Study Interview Schedule--EPSIS) was administered to 1269 parasuicides aged fifteen years and over, within one week of hospital admission after a suicide attempt, and is part of a longitudinal multicenter study. EPSIS included a brief medical questionnaire, scales rating depression, hopelessness, self-esteem, suicide intention, questions on sociodemographic characteristics, an interview on life events and social support, a description of the parasuicidal act, and an evaluation of factors precipitating the index parasuicide. RESULTS: Physical illness proved to be very frequent among suicide attempters. One in two subjects suffered from an acute, chronic, or chronic disorder in relapse at the time of the parasuicide. Subjects with a physical illness were significantly more depressed, particularly subjects from the intermediate age band and ones affected by a chronic physical disease in relapse. Forty-two percent of patients with physical illness rated their somatic problem as a factor precipitating the attempt and 22 percent judged it to be major one. Furthermore, subjects with physical illnesses considered psychiatric symptoms and disorders to be relevant factors in triggering suicidal behavior, to a greater extent than non-sufferers. The importance of physical illness in contributing to suicidal behavior increased with advancing age. CONCLUSIONS: More careful attention to somatic conditions and their subjective implications would probably augment chances of effectively preventing suicide.

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.

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.

A repetition-prediction study of European parasuicide populations: a summary of the first report from part II of the WHO/EURO Multicentre Study on Parasuicide in co-operation with the EC concerted action on attempted suicide.

One of the aims of the European Study on Parasuicide, which was initiated by the Regional Office for the European Region of the World Health Organization in the mid-1980s, was to try to identify social and personal characteristics that are predictive of future suicidal behaviour. A follow-up interview study (the Repetition-Prediction Study) was designed, and to date 1145 first-wave interviews have been conducted at nine research centres, representing seven European countries. The present paper provides an abridged version of the first report from the study. The design and the instrument used (The European Parasuicide Study Interview Schedules, EPSIS I and II) are described. Some basic characteristics of the samples from the various centres, such as sex, age, method of suicide attempt, and history of previous attempts, are presented and compared. The male/female sex ratio ranged from 0.41 to 0.85; the mean age range for men was 33-45 years and that for women was 29-45 years. At all of the centres, self-poisoning was the most frequently employed method. On average, more than 50% of all respondents had attempted suicide at least once previously. The representativeness of the samples is discussed. There were differences between the centres in several respects, and also in some cases the representativeness of the different samples varied. Results obtained from analyses based on pooled data should therefore be treated with caution.

[Suicidal thoughts and suicidal attempts among 15-24 years old individuals in the Danish educational system]. / Selvmordstanker og selvmordsforsøg blandt 15-24-årige i det danske uddannelsessystem.

The purpose of the study is by the instrumentality of an anonymous and voluntary interview study to expose the extent of suicidal ideation and suicide attempts among 15-24-year-olds in the Danish educational system. 3042 persons participated in the study. About 40% of those interviewed had at least once had suicidal ideation and almost one in every twenty confirmed that they had attempted to commit suicide. Furthermore, the study showed that almost one in every ten had experienced suicide in the family. The study showed that frequent or chronical suicidal ideation and self-destructive behaviour can be considered risk factors of suicide attempts and possible predictors of future suicidal behaviour. It also appeared that the students who had experienced suicide in the family had a risk of committing suicide that was three times as high as that of the students who had not experienced suicide in the family. The results of the study also suggest that it is probably only the tip of the iceberg which is detected or registered by the treatment system. To all appearance, close on 75-90% of young suicide attempts are not registered officially. This bears witness of the fact that many of these 15-24-year-olds apparently received no help after their suicide attempt.

Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989-1992. Results of the WHO/EURO Multicentre Study on Parasuicide.

The World Health Organization/EURO Multicentre Project on Parasuicide is part of the action to implement target 12 of the WHO programme, "Health for All by the Year 2000', for the European region. Sixteen centres in 13 European countries are participating in the monitoring aspect of the project, in which trends in the epidemiology of suicide attempts are assessed. The highest average male age-standardized rate of suicide attempts was found for Helsinki, Finland (314/100,000), and the lowest rate (45/100,000) was for Guipuzcoa, Spain, representing a sevenfold difference. The highest average female age-standardized rate was found for Cergy-Pontoise, France (462/100,000), and the lowest (69/100,000) again for Guipuzcoa, Spain. With only one exception (Helsinki), the person-based suicide attempt rates were higher among women than among men. In the majority of centres, the highest person-based rates were found in the younger age groups. The rates among people aged 55 years or over were generally the lowest. For the majority of the centres, the rates for individuals aged 15 years or over decreased between 1989 and 1992. The methods used were primarily "soft' (poisoning) or cutting. More than 50% of the suicide attempters made more than one attempt, and nearly 20% of the second attempts were made within 12 months after the first attempt. Compared with the general population, suicide attempters more often belong to the social categories associated with social destabilization and poverty.

A repetition-prediction study on European parasuicide populations. Part II of the WHO/Euro Multicentre Study on Parasuicide in cooperation with the EC Concerted Action on Attempted Suicide.

One of the aims of the inter-European study on parasuicide, which was initiated by WHO/Euro in the mid-1980s, was to try and identify social and personal characteristics predictive of future suicidal behavior. A follow-up interview study (the Repetition-Prediction Study) was designed, and so far 1145 interviews have been carried out at nine research centers, representing seven European countries. The study and the instrument used (the European Parasuicide Study Interview Schedules, EPSIS I and II) are described here. Some basic characteristics of the material from the various centers are presented and compared, and the representativeness of the samples are discussed. There were differences between the centers in several respects. Results from analyses based on pooled data have to be treated with some caution because of the possible lack of representativeness.

The WHO-EURO Multicentre Study: risk of parasuicide and the comparability of the areas under study.

The 15 areas under study in the WHO/Euro Multicentre Study on Parasuicide vary considerably with regard to socio-economic factors, culture, life-styles, etc. In this paper, the authors discuss whether the traditional high risk factors for suicidal behavior (such as unemployment, abuse, divorce, etc.) take on different weights depending on local societal and cultural settings. Results from analyzing covariations between various background factors characteristic of the different areas under study and the frequency of attempted suicide showed weak or insignificant correlations, indicating that high-risk factors can only be identified from international pooled data with great care.

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.

Background and introduction to the WHO/EURO Multicentre Study on Parasuicide.

In most European countries, suicidal behavior is a major public health problem and a considerable drain on resources at both the primary and secondary health care levels. Unfortunately, due to cross-cultural differences both in medical treatment of nonfatal suicidal behavior and in research methodologies, it has proved almost impossible to make valid comparisons between countries. It is therefore imperative that international studies based on the same definitions and methodologies be facilitated if we want to extend our knowledge of suicidal behavior and be able to make suggestions for intervention and prevention. The WHO Regional Office for Europe decided to support a collaborative multicenter study, designed to provide a reliable epidemiological picture of parasuicide in Europe. This article provides an introduction to the study.

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.

Suicide in Denmark, 1922-1991: the choice of method.

The authors describe methods of suicide registered in Denmark during the last 70 years. The preferred method was initially hanging then later poisoning, first mainly with household gas, later with other agents, especially overdoses of medicine. In recent years there has, however, also been an increasing number of hangings, drownings and other methods of suicide, and there seems to be an increasing inclination towards selecting more violent methods. The Danes' choice of method for committing suicide differ somewhat from that in the other Scandinavian countries; in particular, there have been far more cases of self-poisoning in Denmark.

[Suicide in Denmark over 70 years, 1922-1991. General tendencies]. / Selvmord i Danmark gennem 70 år, 1922-1991. Generelle tendenser.

The frequency of suicide in Denmark has been studied for a period of 70 years. Rates of suicide per 100,000 inhabitants, 15 years and over, by age and sex have been calculated, the calculation being based on data from the Danish Cause-of-Death statistics and from the Population statistics provided by Danmarks Statistik. Although the frequency of suicide has varied during the period under study, the overall trend has been one of significant increase. The increase is in great part due to the fact that an increasing number of women, especially women in their 50s, commit suicide. The increase in male rates is more evenly distributed over all age groups and, contrary to what is the case for women, the age-effect is still strong for men.