Elderly suicide in Finland.

Suicide mortality among the elderly is high in most Western countries. We investigated the characteristics of suicide victims 65 years or older in a nationwide psychological autopsy study, the research phase of the National Suicide Prevention Project in Finland. This study population included all completed suicides (N = 1,397, of whom 211 were 65 years or older) that occurred in Finland during a 12-month research period in 1987-1988. The elderly suicide victims were found to have used violent suicide methods more often than the young. Although almost 70% of the elderly persons who had committed suicide had been in contact with health care services during the month before their death, their suicidal intentions were rarely communicated in these contacts. They had been referred to psychiatric services less often than the young, and only 8% had received adequate antidepressive medication. The fact that most elderly suicides have contact with health care services during their final month suggests a potential for suicide prevention. However, the major obstacle to this is the poor recognition of mental disorders and suicidal ideation among the elderly.

Suicide attempts and personality disorder.

OBJECTIVE: The purpose of the present study was to compare clinical characteristics of suicide attempters with or without personality disorders. METHOD: A systematic sample (n = 114) of patients from consecutive cases of attempted suicide referred to general hospitals in Helsinki was interviewed and diagnosed according to DSM-III-R. Forty-six subjects with DSM-III-R personality disorders were identified and divided into clusters A (n = 4), B (n = 34) and C (n = 8). These subjects were compared with 65 suicide attempters without personality disorders in terms of clinical characteristics and treatment received. RESULTS: Suicide attempters with personality disorders more often had a history of previous suicide attempts and lifetime psychiatric treatment than comparison subjects. However, suicide attempts did not differ in terms of suicide intent, hopelessness, lethality or impulsiveness between subjects with or without personality disorders. CONCLUSION: Although suicidal behaviour is a more persistent feature among those with personality disorders, their clinical characteristics at the time of a suicide attempt may not differ from those without personality disorders.

Life events and completed suicide in schizophrenia: a comparison of suicide victims with and without schizophrenia.

Adverse life events are an established risk factor in completed suicide. However, few studies have examined life events and suicide in schizophrenia. We investigated and compared schizophrenia suicide victims and age- and sex-matched victims without schizophrenia as part of a psychological autopsy study of all suicides in Finland over a 12-month period. Recent life events were examined retrospectively by interviewing next of kin using a structured life event questionnaire. Overall, nearly half (46%) the schizophrenia subjects had had adverse life events before suicide, significantly less than the nonschizophrenia subjects (83%). In both groups, however, suicide was preceded by life events independent of the victims' own behavior, such as death of a close person or illness in the family. Life events overall were more common among schizophrenia outpatients (52%) than inpatients (22%), and the association of life events with suicide was clearest among a subgroup of outpatients in residual phase who had used neuroleptic medication regularly. Overall, the prevalence of recent adverse life events varied between clinical subgroups of victims with schizophrenia, which may have implications for suicide prevention.

Alcohol-related problems among adolescent suicides in Finland.

We studied 106 adolescent suicides out of a total nationwide population of 1397 suicides. Forty-four (42%) of these 13-22-year-old victims were classified as having suffered either a DSM-III-R alcohol use disorder or diagnostically subthreshold alcohol misuse according to retrospective evaluation using the Michigan Alcoholism Screening Test (MAST). These victims were found to differ from the other adolescent suicides in several characteristics: they were more likely to have comorbid categorical DSM-III-R disorders, antisocial behaviour, disturbed family backgrounds, precipitating life-events as stressors and severe psychosocial impairment. In addition, they also had a greater tendency to be alcohol-intoxicated at the time of the suicidal act, which tended to occur during weekends, suggesting that drinking in itself, and its weekly pattern, each contributed to the completion of their suicides.

The treatment received by substance-dependent male and female suicide victims.

Within a nation-wide psychological autopsy study we investigated use of treatment services and recognition of substance abuse problems among male and female substance-dependent suicide victims. Although during their final month half of the male subjects and two-thirds of the female subjects contacted health care services, in only one-sixth and one-third of cases, respectively, were substance abuse problems currently recognized. During their final year, 37% of the males and 67% of the females received psychiatric care. This was associated with Axis-I comorbid disorders among males, with lower socio-economic status and abuse of prescribed drugs among females, and with previous suicide attempts among both sexes. Due to their high psychiatric morbidity and tendency to have contacts with psychiatric services, the recognition, treatment and follow-up of subjects with substance use disorders in psychiatric care would appear to be of major importance for suicide prevention.

Treatment received by alcohol-dependent suicide attempters.

The purpose of this study was to examine the clinical features of alcohol-dependent suicide attempters and the treatment they received before and after the index attempt. A total of 47 subjects with current DSM-III-R alcohol dependence were identified from a systematic sample of 114 suicide attempters in Helsinki. All of them were comprehensively interviewed after the attempt, and the treatment they had received was established from psychiatric and other health-care records and follow-up interviews. Most had a history of psychiatric (83%) or substance abuse (83%) treatment. During the final month before the attempt, half of the subjects (51%) had been treated by health care services; 11% had received disulfiram-treatment and 6% had received psychotherapy. Subjects complied with recommended aftercare more often when they had been actively referred. After 1 month, 64% were being treated by health care services. However, only 14% were receiving disulfiram-treatment and 9% were receiving psychotherapy. These findings suggest that the quality and activity of treatment offered to suicide attempters with alcohol dependence should be improved.

Suicide victims with schizophrenia in different treatment phases and adequacy of antipsychotic medication.

BACKGROUND: To investigate clinical characteristics and adequacy of antipsychotic treatment in different phases of illness and treatment among suicide victims with schizophrenia. METHOD: As part of the National Suicide Prevention Project, a nationwide psychological autopsy study in Finland, all DSM-III-R schizophrenic suicide victims with a known treatment contact (N = 88) were classified according to the phase of illness (active/residual) and treatment (inpatient/recent discharge/other). Characteristics of victims in terms of known risk factors for suicide in schizophrenia, as well as adequacy of the neuroleptic treatment, were examined. RESULTS: Fifty-seven percent of suicide victims with active phase schizophrenia were prescribed inadequate neuroleptic treatment or were non-compliant, and 23% were estimated to be compliant nonresponders. Inpatient suicide victims had the highest proportion of negative or indifferent treatment attitudes (81%), whereas recently discharged suicide victims had the highest prevalence of comorbid alcoholism (36%), paranoid subtype (57%), and recent suicidal behavior or communication (74%), as well as the highest number of hospitalizations during their illness course and shortest last hospitalization. CONCLUSION: Suicide risk factors in different treatment phases of schizophrenia may differ. Substantial numbers of suicide victims with schizophrenia are receiving inadequate neuroleptic medication, are noncompliant, or do not respond to adequate typical antipsychotic medication. Adequacy of psychopharmacologic treatment, particularly in the active illness phase, may be an important factor in suicide prevention among patients with schizophrenia.

Female psychoactive substance-dependent suicide victims differ from male--results from a nationwide psychological autopsy study.

Suicides involving alcohol or other substance dependence have been studied in male-dominated populations. We studied male and female suicide victims with DSM-III-R psychoactive substance dependence (PSD) separately in a nationwide psychological autopsy study in Finland. The subjects were substance-dependent males from a systematic random sample and all substance-dependent female suicide victims from the total population of suicides committed over a 1-year period in Finland. Comparisons by sex and age were made, and two logistic models were created predicting sex. Females were more likely to have abused or been dependent on prescribed medication. Female victims aged 40 years or less had a relatively high frequency of borderline personality disorder (BPD), frequent previous suicide attempts, and suicidal communication, whereas older females were more like older males. The onset of a comorbid axis I disorder preceded substance dependence more often among females. Male and female substance-dependent suicide victims differ in a number of characteristics, including previous suicidality, age-related variation in personality disorders, and type of substance used. Findings from studies of predominantly male substance-dependent suicide victims cannot necessarily be generalized to females.

Completed suicide among adolescents with no diagnosable psychiatric disorder.

The characteristics of male adolescent suicide victims with (n = 84) and without (n = 8) a diagnosable psychiatric disorder were compared. Using psychological autopsy methods--interviews with victims' family members and health care professionals, and review of records (e.g., medical, school, police)-data were collected on all adolescent suicides in Finland during a 12-month period. Compared with adolescents with a psychiatric disorder, those with no disorder tended to come from less disturbed families, had shown less antisocial behavior, and had less frequently utilized health care and social services. Adolescents with no disorder more often communicated suicidal thoughts for the first time just before the suicide, and difficulties with the law (discipline problems) were more common precipitants than among those with a disorder. It was concluded that the process leading to suicide seems to be relatively short among male adolescents with no diagnosable psychiatric disorder. Communication of suicidal intent and problems with discipline are among the few clinical warning signs.

Inadequate treatment for major depression both before and after attempted suicide.

OBJECTIVE: The authors' goal was to investigate the treatment received by suicide attempters with major depression before and after the index attempt. METHOD: Forty-three patients with current unipolar DSM-III-R major depression were identified in a diagnostic study from a systematic sample of suicide attempters in Helsinki. All were comprehensively interviewed and investigated after the attempt, and their treatment was ascertained from psychiatric and other health care records and follow-up interviews. RESULTS: During the month just before the suicide attempt, seven (16%) of the patients had received antidepressants in adequate doses, seven had received weekly psychotherapy, and none had received ECT. Although almost all of the patients complied with the recommended aftercare following the suicide attempt, after 1 month only seven (17%) were receiving antidepressants in adequate doses, nine (22%) were receiving weekly psychotherapy, and none had been given ECT. CONCLUSIONS: It seems that few suicide attempters with major depression receive adequate treatment for depression before the suicide attempt and that, despite their well-known high risk for suicide, the treatment situation is not necessarily any better after the attempt. These findings suggest that the recognition of depression and the quality of treatment received for major depression among suicide attempters should be investigated and improved to prevent suicide.

Antecedents of suicide in people with schizophrenia.

BACKGROUND: Suicides among people with schizophrenia are commonly believed to be impulsive and to occur unexpectedly. METHOD: As part of the National Suicide Prevention Project in Finland, a nationwide psychological autopsy study, suicide victims with DSM-III-R schizophrenia (n = 86; n = 64 in the active illness phase) and others (n = 1109; n = 666 without any evidence for psychosis) were compared for communication of suicidal intent (CSI), as well as previous suicide attempts known by the next of kin and/or an attending health care professional during the latest treatment relationship. RESULTS: More victims with schizophrenia (84%) had a history of previous CSI, and/or had made previous suicide attempt(s) than others (70%). Also, victims with active illness schizophrenia (56%) had more CSI and/or had made suicide attempts during their last three months than victims with no psychosis (41%). CONCLUSIONS: CSI and/or suicide attempts occur at least as often in people with schizophrenia as in those without schizophrenia, even in the active phase of the illness.

Suicide and schizophrenia: a nationwide psychological autopsy study on age- and sex-specific clinical characteristics of 92 suicide victims with schizophrenia.

OBJECTIVE: The authors examined the clinical characteristics of suicide victims with schizophrenia in the general population of Finland. METHOD: As part of the nationwide National Suicide Prevention Project in Finland, all suicides over a 12-month period of persons with DSM-III-R schizophrenia were investigated by using the psychological autopsy method. Clinical characteristics and their variation with age, sex, and illness duration were examined. RESULTS: Among all suicide victims, 7% (N = 92) were identified as having suffered schizophrenia. Suicides occurred throughout the course of schizophrenia. Both active illness (78%) and depressive symptoms (64%) were highly prevalent immediately before suicide, and a history of suicide attempts (71%) was also common. Women were more likely than men to have committed suicide during an acute exacerbation of the illness. Marked variation in depressive symptoms, alcoholism, and suicide methods was found among sexes and age groups. Alcoholism was most common among middle-aged men (45%), whereas middle-aged women had a high rate of depressive symptoms (88%). Younger male subjects most often used violent suicide methods. CONCLUSIONS: Suicide may occur at any point during the course of schizophrenia. The results indicate clinically important variation in depression, alcoholism, and suicide methods among suicide victims with schizophrenia. This suggestion of age- and sex-specific risk factors for suicide in schizophrenia needs further investigation.

Recent life events and suicide in personality disorders.

This study investigates the relationships between personality disorders, recent life events, and comorbid axis I disorders in suicide. Life events during the last week and last 3 months before suicide of 56 suicide victims with a DSM-III-R axis II personality disorder (PD) were compared with those of 56 age- and sex-matched comparison suicides with evidence of no PD. These victims were from a random sample of suicides representing a total 1-year nationwide suicide population in Finland. Life events had been more common among PD victims, particularly job problems, family discord, financial trouble, unemployment, and interpersonal loss; most victims with PD had had multiple life events. Events possibly dependent on the victim's own behavior had been much more common among the PD group, especially in the final week (70% vs. 23%). Age, gender, comorbid axis I diagnosis of alcoholism or depression, or PD cluster type B or C seemed to be less important factors in terms of excess events in the PD group. Thus, PD should be assessed as an important factor when analyzing the relationship between recent life events and suicide. Our findings suggest that interpersonal and job-related/financial problems may precede suicide closely among individuals with PD.

Psychosocial factors and completed suicide in personality disorders.

The aim of the present study was to investigate the relationships between personality disorders (PD) and various psychosocial factors in a random sample (n = 229) of suicides with psychological autopsy-based DSM-III-R diagnoses representing the total 1-year suicide population in Finland. Background social factors and social interaction factors for 56 suicide victims with a PD diagnosis were compared with those of 56 age- and sex-matched non-PD diagnosis victims. The groups were similar with regard to marital status, socio-economic status, parental divorce, broken home before the age of 16 years, parental suicide attempts, and proportion of subjects living with parents. The PD suicide victims had more commonly had a companion of the opposite sex, lived alone, and resided in an urban area, but had less often experienced parental psychiatric hospitalization during their childhood. Although the groups did not differ with regard to complaints of loneliness before suicide, the lonely PD suicide victims had experienced more interpersonal loss and/or conflict than the lonely non-PD suicide victims. The PD suicide victims were very similar with regard to psychosocial factors, irrespective of sex, age, Axis-I comorbidity, or the cluster type of the PD. Only living alone was more common in young PD suicide victims, and male PD subjects had less often had confidants or friends with whom they shared common interests.

Completed suicide and recent electroconvulsive therapy in Finland.

In the research phase of the National Suicide Prevention Project in Finland, all completed suicides in Finland (N = 1,397) within a 12-month period were comprehensively examined by using the psychological autopsy method. In this study, we examined the number of cases having received electroconvulsive therapy (ECT) during the 3 final months before suicide. Only two such cases (0.14% of all suicides) were found, a figure remarkably low considering the high prevalence of severe depression in the suicide population. In both of the two cases, the quality of treatment was questionable, and suicide occurred during a depressive relapse. The findings indirectly support earlier reports suggesting ECT to have a preventive effect concerning suicide. However, alternative explanations, such as low base rate of use of ECT in Finland during the study period, or withholding ECT from some patients because of comorbidity, as well as a combined effect of all the three factors, need also to be considered. Among all suicides, those within 3 months after ECT are rare, and the possible efficacy of ECT in preventing suicide warrants further study.

Panic disorder in completed suicide.

BACKGROUND: Patients with panic disorder are reportedly at increased risk of suicidal behavior, but in psychological autopsy studies of completed suicides, a current diagnosis of panic disorder has been rare or absent. The comorbidity and other clinical characteristics of panic disorder among suicides are not known. METHOD: On the basis of data from a psychological autopsy study of all suicides (N = 1397) in Finland occurring during 1 year, all victims with current DSM-III-R panic disorder were retrospectively identified and examined in terms of comorbidity, suicide methods, history of suicide attempts, treatment setting, and duration of panic disorder. RESULTS: Seventeen victims with current panic disorder, 1.2% of all suicides, were identified. The prevalence of panic disorder was higher among female (2.8%, 9 of 320) than male suicides (0.7%, 8 of 1077; p = .007). All victims with panic disorder suffered concurrent Axis I disorders, and 8 (47%) Axis II disorders. Major depression was diagnosed in 10 (59%), and substance dependence or abuse in 8 (47%) of the cases. The mean duration of panic disorder before suicide was 8 years. In most cases, the onset of panic disorder preceded comorbid Axis I disorders and previous suicide attempts. Most victims with panic disorder had a history of psychiatric treatment. CONCLUSION: Current panic disorder, and noncomorbid panic disorder in particular, seem to be rare among completed suicides. Suicide in persons with panic disorder is associated with superimposed major depression and substance abuse, and with personality disorders. For recognizing panic disorder patients at risk of suicide, the assessment and monitoring of the overall psychopathology are essential.

Suicide among subjects with personality disorders.

OBJECTIVE: There have been few psychological autopsy studies of suicide among individuals with personality disorders. The possible specificity of characteristics of suicide among such individuals has been little investigated. METHOD: A random sample of 229 subjects who committed suicide, representing all suicide victims in Finland within a 12-month period, were comprehensively examined by using the psychological autopsy method and were diagnosed according to DSM-III-R criteria. Within this random sample the authors investigated all subjects with axis II personality disorders (N = 67) and divided them into clusters B (N = 43), C (N = 23), and A (N = 1). Individuals with clusters B and C personality disorders were separately compared with sex- and age-matched suicide victims without personality disorder, in terms of sociodemographic characteristics, comorbid axis I and III syndromes, treatment histories, previous suicide attempts, communication of suicide intent, and suicide methods. RESULTS: All suicide victims with a personality disorder received at least one axis I diagnosis. In 95% this included a depressive syndrome, a psychoactive substance use disorder, or both. Individuals with cluster B personality disorders were more likely than comparison subjects to have psychoactive substance use disorders (79% versus 40%) and previous nonfatal suicide attempts (70% versus 37%) and were less likely to have axis III physical disorders (29% versus 50%). Subjects with cluster C personality disorders were not found to differ from the control subjects in any of the variables examined. CONCLUSIONS: Suicide victims with personality disorders were almost always found to have had current depressive syndromes, psychoactive substance use disorders, or both. Suicide victims with cluster B personality disorders differed from other suicide victims in several characteristics, while those with cluster C personality disorders did not.

Mental disorders in cancer suicides.

Mental disorders among suicide victims who had suffered from cancer were investigated using psychological autopsy data on all suicides in Finland over 1 year. Retrospective DSM-III-R consensus diagnoses were assigned to all 60 cancer suicides and to 60 age- and sex-matched comparison suicides without a cancer history. Depressive syndromes were equally common along cancer suicides (80%) and others (82%). Alcohol dependence and personality disorders were more frequent among noncancer suicides. Major depression and substance abuse were more common among victims with cancer in remission than in terminal stages. Only a small minority of cancer suicides seem to occur in the absence of mental disorders.

Suicide among female adolescents: characteristics and comparison with males in the age group 13 to 22 years.

OBJECTIVE: To characterize female suicides (n = 19) in an unselected nationwide youth suicide population aged 13 to 22 years (n = 116) and to compare them with male suicides with respect to variables indicating psychopathology and psychosocial functioning. METHOD: The data were collected in a psychological autopsy study of all suicides (N = 1,397) in Finland during a 12-month period. Data collection included interviews of next of kin and professionals and information from records after the suicide. RESULTS: Two thirds (68%) of the female victims had suffered from a mood disorder, and 73% had communicated their suicidal intent. Half (47%) of the female subjects had been in psychiatric care at some point in their lives, and 42% had been hospitalized. Compared with young male suicides, the young female victims more often had made previous suicide attempts (63% versus 30%), received more often a diagnosis of major depression (37% versus 14%), and had more often been in psychiatric care (47% versus 21%) during the year preceding the suicide. The females were more often incapable of working, and their psychosocial impairment was more severe during the final week. Alcohol abuse was almost as common among the female as the male victims (21% versus 26%). CONCLUSION: The results suggest that young females who commit suicide may have suffered from more severe psychopathology than young male victims. Substance abuse seems to be a major factor also in female suicides. Preventive efforts within psychiatric care are likely to reach a higher proportion of the young females than males at high risk for suicide.