Risk Factors for Reattempt and Suicide Within 6 Months After an Attempt in the French ALGOS Cohort: A Survival Tree Analysis.

OBJECTIVE: Understanding the cumulative effect of several risk factors involved in suicidal behavior is crucial for the development of effective prevention plans. The objective of this study is to provide clinicians with a simple predictive model of the risk of suicide attempts and suicide within 6 months after suicide attempt. METHODS: A prospective observational cohort of 972 subjects, included from January 26, 2010, to February 28, 2013, was used to perform a survival tree analysis with all sociodemographic and clinical variables available at inclusion. The results of the decision tree were then used to define a simple predictive algorithm for clinicians. RESULTS: The results of survival tree analysis highlighted 3 subgroups of patients with an increased risk of suicide attempt or death by suicide within 6 months after suicide attempt: patients with alcohol use disorder and a previous suicide attempt with acute alcohol use (risk ratio [RR] = 2.92; 95% CI, 2.08 to 4.10), patients with anxiety disorders (RR = 0.98; 95% CI, 0.69 to 1.39), and patients with a history of more than 2 suicide attempts in the past 3 years (RR = 2.11; 95% CI, 1.25 to 3.54). The good prognosis group comprised all other patients. CONCLUSIONS: By using a data-driven method, this study identified 4 clinical factors interacting together to reduce or increase the risk of recidivism. These combinations of risk factors allow for a better evaluation of a subject's suicide risk in clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01123174.

Genome-Wide Association Study of Suicide Death and Polygenic Prediction of Clinical Antecedents.

OBJECTIVE: Death by suicide is a highly preventable yet growing worldwide health crisis. To date, there has been a lack of adequately powered genomic studies of suicide, with no sizable suicide death cohorts available for analysis. To address this limitation, the authors conducted the first comprehensive genomic analysis of suicide death using previously unpublished genotype data from a large population-ascertained cohort. METHODS: The analysis sample comprised 3,413 population-ascertained case subjects of European ancestry and 14,810 ancestrally matched control subjects. Analytical methods included principal component analysis for ancestral matching and adjusting for population stratification, linear mixed model genome-wide association testing (conditional on genetic-relatedness matrix), gene and gene set-enrichment testing, and polygenic score analyses, as well as single-nucleotide polymorphism (SNP) heritability and genetic correlation estimation using linkage disequilibrium score regression. RESULTS: Genome-wide association analysis identified two genome-wide significant loci (involving six SNPs: rs34399104, rs35518298, rs34053895, rs66828456, rs35502061, and rs35256367). Gene-based analyses implicated 22 genes on chromosomes 13, 15, 16, 17, and 19 (q<0.05). Suicide death heritability was estimated at an h2SNP value of 0.25 (SE=0.04) and a value of 0.16 (SE=0.02) when converted to a liability scale. Notably, suicide polygenic scores were significantly predictive across training and test sets. Polygenic scores for several other psychiatric disorders and psychological traits were also predictive, particularly scores for behavioral disinhibition and major depressive disorder. CONCLUSIONS: Multiple genome-wide significant loci and genes were identified and polygenic score prediction of suicide death case-control status was demonstrated, adjusting for ancestry, in independent training and test sets. Additionally, the suicide death sample was found to have increased genetic risk for behavioral disinhibition, major depressive disorder, depressive symptoms, autism spectrum disorder, psychosis, and alcohol use disorder compared with the control sample.

Suicide-related over-the-counter analgesic exposures reported to United States poison control centers, 2000-2018.

PURPOSE: To investigate suicide-related over-the-counter (OTC) analgesic medication exposures among individuals ≥6 years old reported to United States (US) poison control centers. METHODS: Data from the National Poison Data System for the years 2000-2018 were retrospectively analyzed. RESULTS: From 2000 to 2018, US poison control centers recorded 549 807 suicide-related cases involving OTC analgesics, including 327 781 cases (59.6%) admitted to the hospital and 1745 deaths (0.3%). Most cases involved a single substance (67.5%) and occurred among females (72.7%) and individuals 6-19 years old (49.7%). Overall, the rate of exposures increased significantly by 33.5% from 2000 to 2018, primarily driven by the increasing exposure rate among 6- to 19-year-old females. From 2000 to 2018, exposure rates for acetaminophen and ibuprofen increased, while that for acetylsalicylic acid decreased. Additionally, the proportion of cases resulting in a serious medical outcome or healthcare facility admission increased for all types of OTC analgesics. Acetaminophen and acetylsalicylic acid accounted for 48.0% and 18.5% of cases, respectively, and 64.5% and 32.6% of deaths, respectively. Both acetaminophen and acetylsalicylic acid had greater odds of healthcare facility admission (ORs 2.56 and 2.63, respectively) and serious medical outcomes (ORs 2.54 and 4.90, respectively) compared with ibuprofen. CONCLUSIONS: The rate of suicide-related OTC analgesic cases is increasing. Acetaminophen and acetylsalicylic acid cases are associated with greater morbidity and mortality. Prevention efforts should include implementing unit-dose packaging requirements and restrictions on package sizes and purchase quantities for acetaminophen and acetylsalicylic acid products to reduce access to large quantities of these analgesics.

The Impact of Suicide Prevention Act (2006) on Suicides in Japan.

Background: The Suicide Prevention Act was implemented in 2006 in Japan to promote various suicide prevention strategies. Aims: The present study examined the impact of the Suicide Prevention Act on recent suicide mortality rates in Japan. Method: Using an interrupted time-series design, we analyzed monthly mortality rates between January 1996 and December 2016. Death certificate data from vital statistics were obtained. Results: A total of 597,007 suicides (99.3% of all suicides) were analyzed. At the onset of the economic recession in 1998, a significant increase was observed in overall age-standardized mortality rates and sex-/age-specific populations, except for those aged 60 or older. The difference in trend between before and after implementation of the Suicide Prevention Act was not significant for overall or for any stratified populations. After the onset of the Tohoku earthquake and tsunami of 2011, mortality rates declined for overall and for sex-/age-specific populations. Limitations: No information was available on what could have led to each suicide. Conclusion: The decline in mortality rates may be due to a significant and recent natural disaster. Further studies are needed to clarify plausible mechanisms for the decline in suicide rates following the Tohoku disaster.

Economic Evaluation of Brief Cognitive Behavioral Therapy vs Treatment as Usual for Suicidal US Army Soldiers.

Importance: Brief cognitive behavioral therapy (BCBT) is a clinically effective intervention for reducing risk of suicide attempts among suicidal US Army soldiers. However, because specialized treatments can be resource intensive, more information is needed on costs and benefits of BCBT compared with existing treatments. Objective: To evaluate the cost-effectiveness of BCBT compared with treatment as usual for suicidal soldiers in the US Army. Design, Setting, and Participants: A decision analytic model compared effects and costs of BCBT vs treatment as usual from a US Department of Defense (DoD) perspective. Model input data were drawn from epidemiologic data sets and a clinical trial among suicidal soldiers conducted from January 31, 2011, to April 3, 2014. Data were analyzed from July 3, 2018, to March 25, 2019. Interventions: The strategies compared were treatment as usual alone vs treatment as usual plus 12 individual BCBT sessions. Treatment as usual could include a range of pharmacologic and psychological treatment options. Main Outcomes and Measures: Costs in 2017 US dollars, suicide attempts averted (self-directed behavior with intent to die, but with nonfatal outcome), suicide deaths averted, and incremental cost-effectiveness ratios, assuming a 2-year time horizon for treatment differences but including lifetime costs. Results: In the base-case analysis, BCBT was expected to avert approximately 23 to 25 more suicide attempts and 1 to 3 more suicide deaths per 100 patients treated than treatment as usual. Sensitivity analyses assuming a range of treatment effects showed BCBT to be cost saving in most scenarios. Using the federal discount rate, the DoD was estimated to save from $15 000 to $16 630 per patient with BCBT vs treatment as usual. In a worst-case scenario (ie, assuming the weakest plausible BCBT effect sizes), BCBT cost an additional $1910 to $2250 per patient compared with treatment as usual. Conclusions and Relevance: Results suggest BCBT may be a cost-saving intervention for suicidal active-duty soldiers. The costs of ensuring treatment fidelity would also need to be considered when assessing the implications of disseminating BCBT across the entire DoD.

Suicide Typologies in the United States Air Force: A Hierarchical Cluster Analysis.

OBJECTIVE: This study describes characteristics of United States Air Force (USAF) suicide decedents and determines subgroups. METHOD: Retrospective review of demographic, psychiatric, event-related, and psychosocial variables for USAF suicide decedents in the Suicide Event Surveillance System database was conducted between February 1999 and July 2009 (N = 376). Hierarchical cluster analysis was used to determine initial clusters and cluster centroids. RESULTS: Analyses identified three clusters. Cluster 1 (n = 149) individuals were mostly single or divorced, E-1-E-6 rank, living alone, and less likely to have psychiatric disorder diagnoses or engage with most helping resources. Cluster 2 (n = 126) decedents were mostly married, living with a partner, higher ranking, and least likely to communicate suicide intent. Cluster 3 (n = 101) individuals were mostly E-4-E-6 rank, with the highest rates of most psychiatric diagnoses, previous suicide-related events, engagement with multiple helping resources, communication of intent, and psychosocial precipitants. Clusters differed significantly in marital status, rank, psychiatric diagnoses, precipitants, service utilization, previous suicide-related events, risk factors, communication of intent, location and method of death, and residential status. CONCLUSIONS: This study identifies empirically based suicide typologies within a military decedent sample. While further research and replications of findings are needed, these typologies have clinical and policy implications for military suicide prevention.

Association of the Youth-Nominated Support Team Intervention for Suicidal Adolescents With 11- to 14-Year Mortality Outcomes: Secondary Analysis of a Randomized Clinical Trial.

Importance: The prevalence of suicide among adolescents is rising, yet little is known about effective interventions. To date, no intervention for suicidal adolescents has been shown to reduce mortality. Objective: To determine whether the Youth-Nominated Support Team Intervention for Suicidal Adolescents-Version II (YST) is associated with reduced mortality 11 to 14 years after psychiatric hospitalization for suicide risk. Design, Setting, and Participants: This post hoc secondary analysis of a randomized clinical trial used National Death Index (NDI) data from adolescent psychiatric inpatients from 2 US psychiatric hospitals enrolled in the clinical trial from November 10, 2002, to October 26, 2005. Eligible participants were aged 13 to 17 years and presented with suicidal ideation (frequent or with suicidal plan), a suicide attempt, or both within the past 4 weeks. Participants were randomized to receive treatment as usual (TAU) or YST plus TAU (YST). Evaluators and staff who matched identifying data to NDI records were masked to group. The length of NDI follow-up ranged from 11.2 to 14.1 years. Analyses were conducted between February 12, 2018, and September 18, 2018. Interventions: The YST is a psychoeducational, social support intervention. Adolescents nominated "caring adults" (mean, 3.4 per adolescent from family, school, and community) to serve as support persons for them after hospitalization. These adults attended a psychoeducational session to learn about the youth's problem list and treatment plan, suicide warning signs, communicating with adolescents, and how to be helpful in supporting treatment adherence and positive behavioral choices. The adults received weekly supportive telephone calls from YST staff for 3 months. Main Outcomes and Measures: Survival 11 to 14 years after index hospitalization, measured by NDI data for deaths (suicide, drug overdose, and other causes of premature death), from January 1, 2002, through December 31, 2016. Results: National Death Index records were reviewed for all 448 YST study participants (319 [71.2%] identified as female; mean [SD] age, 15.6 [1.3] years; 375 [83.7%] of white race/ethnicity). There were 13 deaths in the TAU group and 2 deaths in the YST group (hazard ratio, 6.62; 95% CI, 1.49-29.35; P < .01). No patients were withdrawn from YST owing to adverse effects. Conclusions and Relevance: The findings suggest that the YST intervention for suicidal adolescents is associated with reduced mortality. Because this was a secondary analysis, results warrant replication with examination of mechanisms. Trial Registration: ClinicalTrials.gov identifier: NCT00071617.

Suicidal behaviour among sexual-minority youth: a review of the role of acceptance and support.

Sexual-minority youth have a two to three times higher risk for suicidal behaviour than their peers. They also have increased mental health risk factors, such as depression and substance abuse, and are often victims of homophobia and discrimination. Available data are unable to provide a clear understanding of the psychosocial factors contributing to these unfavourable mental health indicators. In this Review, we assess current knowledge about the effect of variables, such as acceptance and support, as possible risk factors or protective factors for the development of suicidal behaviour among sexual-minority youth (we consider youth as those aged 13-25 years). 34 articles were eventually included in the review process; and we contextualised their content at three different levels (society, social network, and individual) before integrating the outcomes into a model. This Review shows how negative social environments (such as a non-acceptant school climate), inadequate support within the closest social network, and an absence of lesbian, gay, bisexual, transgender, intersex, queer or questioning support movements in communities contribute to the development of suicidality in young people. Furthermore, the unsupportive reactions of others can be internalised, manifesting as homophobic, biphobic, and transphobic patterns in the individual. To prevent suicidal behaviour, we suggest that all these aspects need to be taken into consideration when planning interventions.

Last Words: Are There Differences in Psychosocial and Clinical Antecedents Among Suicide Decedents Who Leave E-Notes, Paper Notes, or No Note?

OBJECTIVE: Only a minority of suicide decedents leave a suicide note. Typically, the notes are handwritten on paper; however, electronic suicide notes have been reported with increasing frequency. This emerging phenomenon remains generally under-researched. The aim of this study was to compare the psychosocial and clinical antecedents of suicide decedents who left E-notes with those who left paper notes or no notes. METHOD: The study was embedded in the Southwestern Ontario Suicide Study (SOSS). The SOSS was a three-year case series of consecutive deaths by suicide that occurred in the region between 2012 and 2014. Data on psychosocial and clinical antecedents were collected with a modified version of the Manchester questionnaire used in the UK. RESULTS: Of the 476 suicides files reviewed, 45.8% contained a suicide note. A total of 383 separate suicide notes were left: 74.3% were paper notes and 25.7% were E-notes. The results of the multivariate regression analyses indicate that the likelihood of leaving a suicide note was negatively associated with a history of admissions to a mental health unit, while the likelihood of leaving an E-note was negatively associated with age, positively associated with presence of a mental disorder, and negatively associated with history of hospital admissions. CONCLUSIONS: Future studies with larger samples need to consider the timing of the text messages, and appraise whether there was the intent of seeking help or rescue in the text messages.