Risk of suicide and self-harm in university students entering different university programs - a national register-based cohort study in Sweden.

PURPOSE: It is not known whether the elevated suicide risk in certain occupations, such as health care professionals, is partly attributable to a selection of individuals with prior vulnerability. We aimed to determine the risk of suicide and self-harm already in students entering different university programs. METHODS: We used national registers to identify 621,218 Swedish residents aged 18-39 years with registration for a university program 1993-2013. Outcomes were suicide and self-harm within three years. We applied logistic regression analyses to calculate odds ratios (OR) and 95% confidence intervals (CI) of risk of suicide and self-harm, with the Education program category as a reference. Results were adjusted for sex, age, time period and for history of hospitalization due to mental disorder or self-harm, as a measure of previous vulnerability. In the second step, we stratified results by sex. RESULTS: There was a higher risk of suicide (OR 2.4) in female nursing students and natural science students (OR 4.2) and of self-harm in female and male Nursing/Health care students (OR range 1.2 -1.7). Subcategorization into nursing students only strengthened the association with self-harm for both sexes. Prior vulnerability did not fully explain the increased risk. CONCLUSION: The elevated risk of suicide in nursing and health care occupations partly has its onset in vulnerability factors present before or emerging during university studies. Increased efforts in identifying and treating mental disorders and preventing self-harm in university students could be an important step in preventing future suicides.

Cross-cultural training program on mental health care for refugees - a mixed method evaluation.

BACKGROUND: Refugees tend to have a higher risk of mental ill-health and use mental health services less than the native-born population during their first 10 years in Sweden. Intercultural interactions between refugees and mental health professionals have been described as challenging. Cross-cultural training is proposed as one way to improve care for refugees. Evaluations of such training outcomes are sparse. The overall aim of this study was to evaluate Comprehensive Cross-Cultural Training for mental health care professionals in Stockholm, and to assess training outcomes for participants' perceived knowledge regarding mental health and care for newly arrived refugee patients, asylum seekers and undocumented refugees. In addition, we analysed the dimensionality of the pre- and post-training questionnaires used. METHODS: An embedded mixed-method design was applied. We used pre-and post-training questionnaires (n = 248) and conducted six focus group discussions (FGDs) with mental health professionals after training. Quantitative data was analysed by t-tests and factor analysis, qualitative data was analysed using thematic content analysis. RESULTS: Participants experienced gained knowledge and new perspectives in all aspects covered in the training. Training led to participants restructuring their existing knowledge. Those who had reported experience of refugee patients and working with interpreters pre-training in the past month, had higher ratings of perceived knowledge. Post-training, there were no significant changes in perceived knowledge between those with, and those without, experience of refugee patients and working with interpreters. Factor analysis resulted in 3 factors for the pre-training questionnaire, explaining 71% of the covariance, and 4 factors for the post-training questionnaire, explaining 78% of the covariance. Findings from the post-training FGDs, revealed that refugee patients were described as challenging. Also, that training promoted empathy towards refugees and strengthened participants' professional role. CONCLUSIONS: This cross-cultural training contributed to knowledge development and attitude changes. It was valuable regarding care providers' professional role. Additional outcomes of the training were that participants not only gained knowledge about refugee mental health care but also restructured their existing knowledge.

Columbia-Suicide Severity Rating Scale Screen Version: initial screening for suicide risk in a psychiatric emergency department.

BACKGROUND: Suicide screening is routine practice in psychiatric emergency (PE) departments, but evidence for screening instruments is sparse. Improved identification of nascent suicide risk is important for suicide prevention. The aim of the current study was to evaluate the association between the novel Colombia Suicide Severity Rating Scale Screen Version (C-SSRS Screen) and subsequent clinical management and suicide within 1 week, 1 month and 1 year from screening. METHODS: Consecutive patients (N = 18 684) attending a PE department in Stockholm, Sweden between 1 May 2016 and 31 December 2017 were assessed with the C-SSRS Screen. All patients (52.1% women; mean age = 39.7, s.d. = 16.9) were followed-up in the National Cause of Death Register. Logistic regression and receiver operating characteristic curves analyses were conducted. Optimal cut-offs and accuracy statistics were calculated. RESULTS: Both suicidal ideation and behaviour were prevalent at screening. In total, 107 patients died by suicide during follow-up. Both C-SSRS Screen Ideation Severity and Behaviour Scales were associated with death by suicide within 1-week, 1-month and 1-year follow-up. The optimal cut-off for the ideation severity scale was associated with at least four times the odds of dying by suicide within 1 week (adjusted OR 4.7, 95% confidence interval 1.5-14.8). Both scales were also associated with short-term clinical management. CONCLUSIONS: The C-SSRS Screen may be feasible to use in the actual management setting as an initial step before the clinical assessment of suicide risk. Future research may investigate the utility of combining the C-SSRS Screen with a more thorough assessment.

Patients' and clinicians' experiences of the DSM-5 Cultural Formulation Interview: A mixed method study in a Swedish outpatient setting.

This study is an evaluation of clinicians' and patients' experiences of the core Cultural Formulation Interview (CFI) in DSM-5. The CFI provides a framework for gathering culturally relevant information, but its final form has not been sufficiently evaluated. Aims were to assess the Clinical Utility (CU), Feasibility (F) and Acceptability (A) of the CFI for clinicians and patients, and to explore clinicians' experiences of using the CFI in a multicultural clinical setting in Sweden. A mixed-method design was applied, using the CFI Debriefing Instrument for Clinicians (N = 15) and a revised version of the Debriefing Instrument for Patients (N = 114) (DIC and DIP, scored from -2 to 2). Focus group interviews were conducted with clinicians. For patients (response rate 50%), the CU mean was 0.98 (SD = 0.93) and F mean 1.07 (SD = 0.83). Overall rating of the interview was 8.30 (SD = 1.75) on a scale from 0 and 10. For clinicians (response rate 94%), the CU mean was 1.14 (SD = 0.52), F 0.58 (SD = 0.93) and A 1.42 (SD = 0.44). From clinician focus-group interviews, the following themes were identified: approaching the patient and the problem in a new manner; co-creating rapport and understanding; and affecting clinical reasoning and assessment. Patients and clinicians found the CFI in DSM-5 to be a feasible, acceptable, and clinically useful assessment tool. The focus group interviews suggested that using the CFI at initial contact can help make psychiatric assessment patient-centred by facilitating patients' illness narratives. We argue for further refinements of the CFI.

Predicting suicide: A comparison between clinical suicide risk assessment and the Suicide Intent Scale.

BACKGROUND: How suicide risk should be assessed is under discussion with arguments for both actuarial and clinical approaches. The aim of the present study was to compare the predictive accuracy of a clinical suicide risk assessment to that of the Suicide Intent Scale (SIS) in predicting suicide within one year of an episode of self-harm with or without suicidal intent. METHODS: Prospective clinical study of 479 persons assessed in a psychiatric emergency department after an episode of self-harm. The clinical risk assessment and the SIS rating were made independently of each other. Suicides within one year were identified in the National Cause of Death Register. Receiver operating characteristic (ROC) curves were constructed, optimal cut-offs were identified and accuracy statistics were calculated. RESULTS: Of 479 participants, 329 (68.7%) were women. The age range was 18-95 years. During one-year follow up, 14 participants died by suicide. The area under the curve (AUC) for the clinical risk assessment and the SIS score were very similar, as were the accuracy statistic measures at the optimal cut-offs of the respective methods. The positive predictive value (PPV) of each assessment method was 6%. LIMITATIONS: The clinical suicide risk assessment is not standardized. The number of suicides is small, not allowing for stratification by e.g. gender or diagnosis. CONCLUSION: Predictive accuracy was similar for a clinical risk assessment and the SIS, and insufficient to guide treatment allocation.

A Comparison of Suicide Risk Scales in Predicting Repeat Suicide Attempt and Suicide: A Clinical Cohort Study.

OBJECTIVE: To compare the predictive accuracy of the Suicide Intent Scale (SIS), the Suicide Assessment Scale (SUAS), the Karolinska Interpersonal Violence Scale (KIVS), and the Columbia-Suicide Severity Rating Scale (C-SSRS) for suicide attempts and suicides within 3 and 12 months of an episode of self-harm. METHODS: This prospective multicenter cohort study included patients (N = 804) aged 18-95 years with a recent episode of self-harm assessed in psychiatric emergency settings from April 2012 to April 2016. Suicide attempts and suicides were identified in medical records and in the National Cause of Death Register. Receiver operating characteristic curves were constructed, and accuracy statistics were calculated. A sensitivity of at least 80% combined with a specificity of at least 50% were considered minimally acceptable. RESULTS: At least 1 suicide attempt was recorded for 216 participants during follow-up, and 19 participants died by suicide. The SUAS and C-SSRS were better than chance in classifying the 114 suicide attempts occurring within the first 3 months; a C-SSRS score ≥ 27 yielded a sensitivity/specificity of 79.8%/51.5% (P < .001). During 1-year follow-up, the SUAS and C-SSRS also performed better than chance, but no cutoff on either instrument gave a sensitivity/specificity of ≥ 80%/≥ 50%. The SIS was the only instrument that could classify suicides correctly. At 3 months, the area under the curve (AUC) was 0.94 (95% CI, 0.89-0.99), and a score ≥ 21 predicted suicide with a sensitivity/specificity of 100%/81.9%, based on only 4 suicides. At 1-year follow-up, the AUC was 0.74 (95% CI, 0.61-0.87), and a score ≥ 17 predicted suicide with a sensitivity/specificity of 72.2%/57.9%. CONCLUSIONS: Instruments that predicted nonfatal repeat suicide attempts did not predict suicide and vice versa. With the possible exception of the prediction of suicide by the SIS in a short time frame, the specificity of these instruments was low, giving them a limited relevance in the prediction of suicidal behaviors.

Swedish doctors choice of medical speciality and associations with cultural capital and perceived status: a cross-sectional study.

BACKGROUND: Many western countries have problems recruiting and retaining medical specialists. In Sweden there is a lack of primary care doctors and psychiatrists. Despite much research on the topic the shortage remains. We therefore set out to analyse choice of medical speciality using Bourdieu's theoretical concepts; cultural capital, social background and perceived status. METHODS: A cross-sectional questionnaire-based study of 399 alumni from the Medical School at Karolinska Institutet, Stockholm was performed. The response rate was 72% (n = 286); 262 of the respondents were in training to become specialists. Specialties were categorized as primary care, psychiatry, internal medicine, and surgical and hospital service specialties. To study the associations between medical specialties and cultural capital, we used multinomial regression analyses. Variables that showed a significant association with medical specialties were included in an adjusted multivariable model. These results were presented as odds ratios: the odds that a particular speciality is chosen in comparison to a choice of surgery as a speciality, based on perceptions of high status. RESULTS: The results were analysed using Bourdieu's theoretical concepts of cultural capital, in the form of educational capital and social prestige. We found distinctive differences in perceived status for the examined speciality groups, ranging from 70% high status for surgery down to 6% high status for geriatrics and primary care. Perceived status was also associated with respondents' own speciality choice, presented as an odds ratio. Our data did not show any associations between speciality choice and educational capital. We also included sociodemographic data. CONCLUSION: The field of medicine is according to Bourdieu an arena for power struggles. Knowledge of the distinctive differences in perceived status between medical specialties can be an asset particularly in relation to recruitment and retainment of specialist doctors. Our results could be used to identify specialities where perceptions of low status may be contributing to a shortage of specialists.

Prognoses after self-harm in youth: exploring the gender factor.

PURPOSE: Gender differences in youth self-harm are sparsely studied regarding long-term prognoses. We aimed to study the gender differences in effects of adolescent self-harm in early adult life in four domains: 1/family situation, 2/education and employment, 3/mental illness and suicidal behaviour, and 4/suicide and all-cause mortality. METHOD: A register-based cohort study including all Swedish residents aged 20 during 2001-2005 was performed. Exposure was self-harm at ages 10-20, and outcomes were death and suicide and past-year records of self-harm, marital status/children, education/employment, and mental health at age 30. We used logistic regression for dichotomous outcomes, and Cox regression models for time-dependent outcomes. An interaction term was introduced to detect significant gender effects, in which case we performed stratified analyses. RESULTS: Subjects with self-harm before age 20 had a poorer prognosis for all studied outcomes, and risk estimates were similar for men and women for most outcomes including suicide. Significant interaction terms (ITs) were found, revealing gender differences, for being married (pIT 0.0003; ORmen 0.6, ORwomen 0.9), being a parent (pIT < 0.0001; ORmen 0.7, ORwomen 1.1), receiving unemployment support (pIT < 0.0001; ORmen 2.4, ORwomen 1.8), and death from any cause (pIT 0.006; ORmen 10.6, ORwomen 7.4). CONCLUSIONS: Adolescent self-harm was associated with later life adversities and affected men more than women regarding prognoses for unemployment and certain aspects of the family situation. We found no gender difference for the effect of self-harm on the risk of suicide. Future suicide risk should not be underestimated in young self-harming women.

Short term risk of non-fatal and fatal suicidal behaviours: the predictive validity of the Columbia-Suicide Severity Rating Scale in a Swedish adult psychiatric population with a recent episode of self-harm.

BACKGROUND: The Columbia-Suicide Severity Rating Scale (C-SSRS) is a relatively new instrument for the assessment of suicidal ideation and behaviour that is widely used in clinical and research settings. The predictive properties of the C-SSRS have mainly been evaluated in young US populations. We wanted to examine the instrument's predictive validity in a Swedish cohort of adults seeking psychiatric emergency services after an episode of self-harm. METHODS: Prospective cohort study of patients (n = 804) presenting for psychiatric emergency assessment after an episode of self-harm with or without suicidal intent. Suicidal ideation and behaviours at baseline were rated with the C-SSRS and subsequent non-fatal and fatal suicide attempts within 6 months were identified by record review. Logistic regression was used to evaluate separate ideation items and total scores as predictors of non-fatal and fatal suicide attempts. Receiver operating characteristics (ROC) curves were constructed for the suicidal ideation (SI) intensity score and the C-SSRS total score. RESULTS: In this cohort, the median age at baseline was 33 years, 67% were women and 68% had made at least one suicide attempt prior to the index attempt. At least one non-fatal or fatal suicide attempt was recorded during follow-up for 165 persons (20.5%). The single C-SSRS items frequency, duration and deterrents were associated with this composite outcome; controllability and reasons were not. In a logistic regression model adjusted for previous history of suicide attempt, SI intensity score was a significant predictor of a non-fatal or fatal suicide attempt (OR 1.08; 95% CI 1.03-1.12). ROC analysis showed that the SI intensity score was somewhat better than chance in correctly classifying the outcome (AUC 0.62, 95% CI 0.57-0.66). The corresponding figures for the C-SSRS total score were 0.65, 95% CI 0.60-0.69. CONCLUSIONS: The C-SSRS items frequency, duration and deterrents were associated with elevated short term risk in this adult psychiatric cohort, as were both the SI intensity score and the C-SSRS total score. However, the ability to correctly predict future suicidal behaviour was limited for both scores.

Method of self-harm in adolescents and young adults and risk of subsequent suicide.

BACKGROUND: Self-harm is common in youth and an important risk factor for suicide. Certain self-harm methods might indicate a higher risk of suicide. The main aim of this study was to determine whether some methods of self-harm in adolescents (10-17 years) and young adults (18-24 years) are associated with a particularly high risk of suicide. A secondary aim was to ascertain how different self-harm methods might affect the probability of psychiatric follow-up. METHOD: Five Swedish registers were linked in a national population-based cohort study. All nonfatal self-harm events recorded in specialist health care, excluding psychiatry and primary care services, among 10-24 year olds between 2000 and 2009 were included. Methods were classified as poisoning, cutting/piercing, violent method (gassing, hanging, strangulation/suffocation, drowning, jumping and firearms), other and multiple methods. Hazard Ratios (HR) for suicide were calculated in Cox regression models for each method with poisoning as the reference. Odds Ratios (OR) for psychiatric inpatient care were determined in logistic regression models. Analyses were adjusted for important covariates and stratified by age group and treatment setting (inpatient/outpatient). RESULTS: Among adolescents with initial medical hospitalisation, use of a violent method was associated with a near eightfold increase in HR for suicide compared to self-poisoning in the adjusted analysis [HR 7.8; 95% confidence interval (CI) 3.2-19.0]. Among hospitalised young adult women, adjusted HRs were elevated fourfold for both cutting [4.0 (1.9-8.8)] and violent methods [3.9 (1.5-10.6)]. Method of self-harm did not affect suicide risk in young adult men. Adolescents using violent methods had an increased probability of psychiatric inpatient care following initial treatment for self-harm. CONCLUSIONS: Violent self-harm requiring medical hospitalisation may signal particularly high risk of future suicide in adolescents (both sexes) and in young adult women. For the latter group this is the case for cutting requiring hospitalisation as well.

Maternal suicide - Register based study of all suicides occurring after delivery in Sweden 1974-2009.

BACKGROUND: Recent research suggests that having a newborn child is associated with substantially reduced risk for maternal suicide. We studied postpartum suicides in a national cohort of mothers and the role of mental disorder, self-harm and delivery related factors. METHODS: We used a nested case-control design with data from Swedish registries. The cohort consisted of all women given birth in Sweden 1974-2009. Mothers who died by suicide during follow-up were considered cases (n = 1,786) and risk of suicide was estimated with proximity to delivery as the explanatory variable. In a second step, association between suicide during the first year following delivery (n = 145) and mental disorder, self-harm and delivery related variables risk factors were analyzed. RESULTS: The first postpartum year was associated with a lower risk of suicide, compared to later (RR 0.80, 95%CI 0.66-0.96), which was unaltered after adjustment for socio-economic status and history of self-harm (aRR 0.82, 95%CI 0.68-0.99). Compared to living mothers, suicide victims of the postpartum year more often had affective disorders (aRR 133.94, 95%CI 45.93-390.61), psychotic disorders (aRR 83.69, 95%CI 36.99-189.31) and history of self-harm (aRR 47.56, 95%CI 18.24-124.02). The aRR of stillbirth was 2.66 (95%CI 0.63-11.30). CONCLUSIONS: We found only a weak negative association between childbirth during the preceding year and suicide, when using mothers as controls. A severe mental disorder after delivery and a history of self-harm was strongly associated with increased risk of suicide in the postpartum year and may inform the clinical assessment postpartum.

Ongoing university studies and the risk of suicide: a register-based nationwide cohort study of 5 million young and middle-aged individuals in Sweden, 1993-2011.

OBJECTIVES: To investigate the risk of suicide, unnatural death and all-cause death in university students compared with non-students, taking previous educational attainment into account. DESIGN: Open cohort study of all residents aged 18-39 and living in Sweden at any time between 1 January 1993 and 31 December 2011. SETTING: We linked data from national registers and calculated person-years during university studies for three time periods (1993-1999, 2000-2005 and 2006-2011). Time as non-student was calculated and categorised according to attained educational level. Incidence rate ratios (IRR) with 95% CIs were calculated with Poisson regression models, controlling for age and period. PARTICIPANTS: The cohort consisted of 5 039 419 individuals, 51% men and 49% women. MAIN OUTCOME MEASURES: Incidence of suicide (International Classification of Diseases (ICD)-9: E950-E959, ICD-10: X60-X84) or death with undetermined intent (ICD-9: E980-E989, ICD-10: Y10-Y34), unnatural death (ICD-9: E800-E999 and ICD-10: V01-Y99) and all-cause death. RESULTS: A total of 7316 deaths due to suicide were identified, of which 541 were registered among university students. The risk of suicide was twofold during ongoing university studies compared with when having attained university education, IRR 2.37 (95% CI 2.07 to 2.72) in men and IRR 2.15 (95% CI 1.77 to 2.61) in women. CONCLUSIONS: Having ongoing university studies was associated with a higher risk of suicide compared with having attained university-level education. This finding highlights the importance of achieving a deeper understanding of suicidal behaviour during years at university. Further studies should assess risk factors for suicide and suicidal behaviour in university students.

Association between personality traits and future choice of specialisation among Swedish doctors: a cross-sectional study.

BACKGROUND: Medical students' choice of their future specialty is influenced by several factors, including working conditions and type of patient relations. The aim of this study was to investigate the association between the choice of specialty and personality traits. METHODS: This is a cross-sectional questionnaire-based study of 399 alumni from Karolinska Institutet Medical School who were assumed to undergo specialty training at the time of the survey in 2013. The Big Five Inventory was used to assess the personality traits extraversion, agreeableness, conscientiousness, neuroticism and openness to experience. Medical specialties were categorised as primary care, psychiatry, internal medicine and surgical and hospital service specialties. Adjustments were made for demographic factors and the method of selection for medical school admission. RESULTS: The response rate was 72% (n=289, of which 262 were in training to become specialists). Among these, surgeons scored lower in agreeableness than physicians in primary care, internal medicine and hospital services. Psychiatrists and hospital service physicians showed lower conscientiousness compared with surgeons. CONCLUSIONS: We found distinctive differences in personality traits between medical specialties even after adjusting for other potential explanatory variables. Since there are differences between specialties, for example, surgeons and psychiatrists, this supports previous findings that personality may affect medical students' specialty choice also in a Swedish setting.

Killing the mother of one's child: psychiatric risk factors among male perpetrators and offspring health consequences.

OBJECTIVE: To study possible psychiatric and criminological risk factors of intimate partner femicide (IPF) as well as the bereaved offspring's psychiatric morbidity and premature death. METHOD: We conducted a nested case-control study, based on Swedish national registries, including all perpetrators of IPF. We computed risk estimates relative to matched population controls, which were compared to those of non-IPF homicide offenders. Exposed children were matched to population controls and followed longitudinally up to 37 years. Offspring outcomes were psychiatric and substance use disorders (according to ICD) self-harm; violent crime; suicide; and premature, all-cause death. RESULTS: We identified 261 male IPF perpetrators and 494 bereaved children from 1973 through 2009. Multivariable logistic regression suggested that major mental disorder (adjusted odds ratio [OR] = 5.9; 95% CI, 3.3-10.6) and violent crime convictions (adjusted OR = 4.4; 95% CI, 2.7-7.2) were independent risk factors of IPF, but substance use disorders were not (aOR = 0.4; 95% CI, 0.2-1.0). Children exposed to IPF before age 18 years had elevated risks of major mental disorder (adjusted hazard ratio [HR] = 5.7; 95% Cl, 3.0-10.6), substance use disorders (adjusted HR = 5.8; 95% CI, 2.8-11.9) and self-harm (adjusted HR = 5.7; 95% CI, 3.0-11.1). Offspring 18 years or older at the IPF had an increased risk of completed suicide (adjusted HR = 4.3; 95% CI, 1.3-14.5). CONCLUSIONS: Previous major mental disorder and violent behavior were strong independent risk factors for IPF. Bereavement caused by IPF had significant associations with the offspring's future life, especially for those below 18 years of age at exposure. Our findings demonstrate the need of direct support to the exposed offspring by health care providers and social services.

Approaching the vulnerability of refugees: evaluation of cross-cultural psychiatric training of staff in mental health care and refugee reception in Sweden.

BACKGROUND: This study evaluates the outcomes of cross-cultural mental health training given to professionals in health care and refugee reception in Stockholm, Sweden. METHODS: A mixed method approach, with quantitative data from questionnaires (n = 232) and ten qualitative focus group interviews, was used. RESULTS: After training, the participants reported that the hindering effect of lack of knowledge on their work decreased significantly from 2.81 (SD1.22) before, to 2.29 (SD1.00) (p < 0.001). Focus group interviews contributed to an understanding of this. According to findings from focus group interviews, after training, the participants shifted from emphasising communication barriers towards empathy with refugees with mental ill-health. CONCLUSION: Training resulted in an increased experienced capacity among participants to understand the social vulnerability of newly-arrived refugees with mental distress. However, the lack of collaboration and the structural barriers between the different organisations were not affected.

Future risk of labour market marginalization in young suicide attempters--a population-based prospective cohort study.

BACKGROUND: Research on future labour market marginalization following suicide attempt at young age is scarce. We investigated the effects of suicide attempts on three labour market outcomes: unemployment, sickness absence and disability pension. METHODS: We conducted a prospective cohort study based on register linkage of 1,613,816 individuals who in 1994 were 16-30 years old and lived in Sweden. Suicide attempters treated in inpatient care during the 3 years preceding study entry, i.e. 1992-94 (N=5649) were compared with the general population of the same age without suicide attempt between 1973 and 2010 (n=1,608,167). Hazard ratios (HRs) for long-term unemployment (>180 days), sickness absence (>90 days) and disability pension in 1995-2010 were calculated by Cox regression models, adjusted for a number of parental and individual risk markers, and stratified for previous psychiatric inpatient care not due to suicide attempt. RESULTS: The risks for unemployment [HR 1.58; 95% confidence interval (CI) 1.52-1.64], sickness absence (HR 2.16; 2.08-2.24) and disability pension (HR 4.57; 4.34-4.81) were considerably increased among suicide attempters. There was a dose-response relationship between number of suicide attempts and the risk of disability pension, for individuals both with or without previous psychiatric hospitalizations not due to suicide attempts. No such relationship was present with regard to unemployment. CONCLUSIONS: This study highlights the strong association of suicide attempts with future marginalization from the labour market, particularly for outcomes that are based on a medical assessment. Studies that focus only on unemployment may largely underestimate the true detrimental impact of suicide attempt on labour market marginalization.

Unnatural deaths in a national cohort of people diagnosed with diabetes.

OBJECTIVE: To examine risk of unnatural death among people diagnosed with diabetes irrespective of disease type. RESEARCH DESIGN AND METHODS: We conducted a matched cohort study of the entire Swedish population using interlinked national registers. From the National Diabetes Register we identified 252,191 people diagnosed with diabetes (type 1 or 2) during 1996-2009. Each cohort member was matched for age, sex, and county of birth to five unaffected individuals randomly sampled from the Total Population Register. Mortality was examined with complete ascertainment, and risk ratios (RRs) for all unnatural deaths and for specific causes (suicide, accident, homicide, and iatrogenic effects) were estimated using conditional fixed-effects Poisson regression. RESULTS: Risk of any unnatural death was elevated versus the general population: 77.3 versus 32.1 per 10,000 (RR 2.2 [95% CI 2.1-2.4]), and these deaths occurred at a younger age in the diabetes cohort. Risk was increased for suicide (RR 3.4 [95% CI 3.0-3.8]), accident (RR 2.0 [95% CI 1.9-2.1]), homicide (RR 3.1 [95% CI 1.6-6.1]), and iatrogenic effects (RR 2.4 [95% CI 1.9-3.2]). It was greatly elevated for fatal poisoning from a variety of agents, including psychotropic drugs and "other and unspecified medication," as well as narcotics, alcohol, and carbon monoxide. Almost 9% of all fatal poisoning cases in the diabetes cohort were identified as overdoses of insulin or oral hypoglycemic drugs. CONCLUSIONS: Various causes of unnatural death, in particular deliberate and accidental poisonings, occur more frequently among diabetic patients. Before preventive strategies can be implemented, a deeper understanding of the risk factors and causal mechanisms explaining the marked elevations in risk is needed.

Comparison of communication skills between medical students admitted after interviews or on academic merits.

BACKGROUND: Selection of the best medical students among applicants is debated and many different methods are used. Academic merits predict good academic performance, but students admitted by other pathways need not be less successful. The aim of this study, was to compare communication skills between students admitted to medical school through interviews or on academic merits, respectively. METHODS: A retrospective cohort study. Communication skills at a surgical OSCE in 2008 were assessed independently by two observers using an evaluative rating scale. Correlations, t-tests and multivariate analyses by logistic regressions were employed. Academic merits were defined as upper secondary school grade point average (GPA) or scores from the Swedish Scholastic Assessment Test (SweSAT). RESULTS: The risk of showing unsatisfactory communicative performance was significantly lower among the students selected by interviews (OR 0.32, CI95 0.12-0.83), compared to those selected on the basis of academic merits. However, there was no significant difference in communication skills scores between the different admission groups; neither did the proportion of high performers differ. No difference in the result of the written examination was seen between groups. CONCLUSIONS: Our results confirm previous experience from many medical schools that students selected in different ways achieve comparable results during the clinical semesters. However, selection through interview seems to reduce the number of students who demonstrate inferior communication skills at 4th year of medical school.

Mental distress, alcohol use and help-seeking among medical and business students: a cross-sectional comparative study.

BACKGROUND: Stress and distress among medical students are thoroughly studied and presumed to be particularly high, but comparative studies including other student groups are rare. METHODS: A web-based survey was distributed to 500 medical students and 500 business students. We compared levels of study stress (HESI), burnout (OLBI), alcohol habits (AUDIT) and depression (MDI), and analysed their relationship with self-assessed mental health problems by logistic regression, with respect to gender. RESULTS: Medical students' response rate was 81.6% and that of business students 69.4%. Business students scored higher on several study stress factors and on disengagement. Depression (OR 0.61, CI95 0.37;0.98) and harmful alcohol use (OR 0.55, CI95 0.37; 0.75) were both less common among medical students. However, harmful alcohol use was highly prevalent among male students in both groups (medical students 28.0%, business students 35.4%), and among female business students (25.0%). Mental health problems in need of treatment were equally common in both groups; 22.1% and 19.3%, respectively, and was associated with female sex (OR 2.01, CI95 1.32;3.04), exhaustion (OR 2.56, CI95 1.60;4.10), lower commitment to studies (OR 1.95, CI95 1.09;3.51) and financial concerns (OR 1.81 CI95 1.18;2.80) CONCLUSIONS: Medical students may not be more stressed than other high achieving student populations. The more cohesive structure of medical school and a higher awareness of a healthy lifestyle may be beneficial factors.