Season of birth among patients with schizophrenia and their siblings: evidence for the procreational habits hypothesis.

OBJECTIVE: The birth rate of patients with schizophrenia during the winter and spring months is 5%-8% higher worldwide than the birth rate of the general population in the winter and spring months. Seasonal variation of births among the unaffected siblings of patients with schizophrenia has not been studied with adequate sample sizes. The authors investigated the seasonal variation of births among siblings of patients with schizophrenia in a large, nationwide, representative patient and sibling population. METHOD: Finnish patients with schizophrenia born from 1950 to 1969 (N=15,389) were identified from three nationwide health care registers. Unaffected siblings of these patients born in the same time period (N=37,819) were identified from the Finnish National Population REGISTER: The seasonal variation of births among patients and siblings were examined by using a log-linear model. Explanatory variables were sex, year of birth categorized into four 5-year groups, and seasonal variation, which was analyzed by fitting a short Fourier series to the monthly birth data. RESULTS: The odds for having been born during the winter-spring months were slightly higher among both siblings and patients in all birth-year groups. However, patients born from 1955 to 1959 showed prominent seasonal variation of births, but the magnitude of this variation remained unchanged among siblings. CONCLUSIONS: Seasonal variation of births among patients with schizophrenia may consist of two factors: 1) parental procreational habits causing a slight excess of births of both patients and unaffected siblings during the winter-spring months and 2) irregular environmental factors that considerably increase the magnitude of the seasonal variation of births among patients but not their siblings.

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.

Decreasing seasonal variation of births in schizophrenia.

BACKGROUND: Patients with schizophrenia have a winter-spring excess of births compared with the general population, the cause of which is unresolved. Fluctuations in the magnitude of the seasonal variation may provide clues to its aetiology. METHODS: All Finnish patients with schizophrenia born between 1950 and 1969 (N = 15892) were identified from two nationwide health-care registers. Their background demographic information was obtained from the Population Register Centre, which also provided monthly numbers of births in each municipality of Finland as multidimensional tables, with sex and year, month and place of birth as marginals. The incidence of schizophrenia was modelled using Poisson regression analysis, with sex, onset age, birth cohort, place of birth (urban/rural), trend and seasonal variation as explanatory variables. We also constructed a monthly time series and decomposed it into three components--seasonal, trend and remainder. RESULTS: Seasonal variation of births among patients born in the 1950s, especially between 1955 and 1959, was marked, but decreased among patients born in the 1960s. No interaction between place of birth or sex and seasonal variation was observed. The incidence was higher among the rural-born than the urban-born, but declined more slowly among the urban-born than the rural-born. CONCLUSIONS: The intensity of the factor causing the seasonal variation of births in schizophrenia may be decreasing. Urban birth may be emerging as a risk factor for schizophrenia in Finland, as elsewhere.

Suicides of alcohol misusers and non-misusers in a nationwide population.

Alcohol dependence is a risk factor for suicide, and in the general population alcohol consumption and suicide rates are known to be associated. We investigated victims with and without alcohol misuse among unselected completed suicides to explore the role of alcohol misuse in the suicidal process and final act. In a total 1-year (1987-1988) population of suicides in the National Suicide Prevention Project in Finland, alcohol-misusing and -non-misusing victims were compared. On the basis of informant interviews, 35% (n = 349) of included victims were classified as alcohol misusers and 65% (n = 648) as non-misusers. The misusers were more often younger, male, divorced or separated and had more often worked, but were recently unemployed. They had experienced more often recent adverse life events possibly dependent on their own behaviour, were far more likely to be alcohol-intoxicated at the time of suicide, and tended to die from drug overdose. Several characteristics of these predominantly male alcohol misusers indicated better earlier lifetime psychosocial adjustment compared to the non-misusers, but more adverse life events close to suicide. Alcohol misuse is likely to have a deteriorating influence on the life course of those who eventually succumb to suicide, and its adverse consequences are common in misusers during the final months.

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.

Decline in the incidence of schizophrenia in Finnish cohorts born from 1954 to 1965.

BACKGROUND: The declining incidence of schizophrenia observed in several countries is believed by many to merely reflect methodological problems in the studies performed. We report the first nationwide historical cohort study of changes in the incidence of schizophrenia, in which many of the previous methodological problems were overcome. METHODS: We used the Finnish Population Register to identify everyone born in Finland from 1954 to 1965. These persons were followed up from their 16th to their 26th birthdays, and all cases of schizophrenia (International Classification of Diseases, Eighth Revision and International Classification of Diseases, Ninth Revision code 295) that emerged were identified from the National Hospital Discharge Register, the Pension Register, and the Free Medicine Register. Persons for whom an age of onset could be defined were included in the analyses (n = 5645). We used the Poisson regression model to estimate the effects of age, sex, birth cohort, period of diagnosis, and season of birth on the incidence of schizophrenia. The relative importance of cohort and period were assessed using an age-period-cohort model. RESULTS: The incidence declined significantly in each successive cohort, from 0.79 to 0.53 per 1000 among males and from 0.58 to 0.41 per 1000 among females. The effects of cohort and period on the change were both significant. CONCLUSIONS: The incidence of schizophrenia has declined in Finland. This was partly caused by confounding factors, as reflected in the significant period effect. The significant birth cohort effect suggests that the intensity or frequency of one or more risk factors for schizophrenia has decreased.

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.

Age at onset and outcome in schizophrenia are related to the degree of familial loading.

BACKGROUND: Recent research suggests that high familial loading is associated with early onset of schizophrenia. Results concerning outcome have been controversial. METHOD: We assessed the relationship between familial loading, age at onset and outcome in all Finnish patients with schizophrenia born between 1950 and 1969. Patients and their first-degree relatives were identified using nationwide registers. Familial loading scores were calculated for schizophrenia and for combined psychotic disorders, and patients were accordingly classified into three groups: high (n = 761), intermediate (n = 14,247), and low familial loading (n = 725). Linear mixed models and the Cox proportional hazard model were used in the analyses. RESULTS: Onset was earliest, hospitalisation longest and risk of retirement in receipt of a disability pension highest in the group with high familial loading, with opposite extremes found in the group with low familial loading. CONCLUSIONS: High familial loading for schizophrenia is associated with early onset and poor outcome of schizophrenia.

Suicide attempts preceding completed suicide.

BACKGROUND: This study investigated three questions with major implications for suicide prevention: the sensitivity of the history of previous suicide attempt(s) as an indicator of suicide risk, the time interval from a preceding suicide attempt to the fatal one, and switching of suicide methods by those eventually completing suicide. METHOD: The lifetime history of suicide attempts and the methods the victims (n = 1397) used were examined in a nationwide psychological autopsy study comprising all suicides in Finland within a 12-month research period in 1987-1988. RESULTS: Overall, 56% of suicide victims were found to have died at their first suicide attempt, more males (62%) than females (38%). In 19% of males and 39% of females the victim had made a non-fatal attempt during the final year. Of the victims with previous attempts, 82% had used at least two different methods in their suicide attempts (the fatal included). CONCLUSIONS: Most male and a substantial proportion of female suicides die in their first suicide attempt, a fact that necessitates early recognition of suicide risk, particularly among males. Recognition of periods of high suicide risk on the grounds of recent non-fatal suicide attempts is likely to be important for suicide prevention among females. Subjects completing suicide commonly switch from one suicide method to another, a finding that weakens but does not negate the credibility of restrictions on the availability of lethal methods as a preventive measure.

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.