[Suicide prevention in old age : Importance of depressive disorders and implications for the discussion on assisted suicide]. / Suizidprävention im Alter : Bedeutung depressiver Störungen und Implikationen für die Diskussion um den assistierten Suizid.

This article gives an overview of possibilities for suicide prevention in old age, with an emphasis on depression. A broad range of approaches are available, which are described differentiated into universal, selective and indicated strategies. In Germany the working group "Old people" of the National Suicide Prevention Program (NaSPro) has worked out these strategies in a differentiated way and with respect to the international discussions. The influence of the debate on assisted suicide and the influence of cognitive changes on suicidal ideation in old age are discussed. A further large need for concrete measures and also the presence of large gaps in the care structures are determined.

Suicide risk after psychiatric discharge: study protocol of a naturalistic, long-term, prospective observational study.

BACKGROUND: Suicide risk of psychiatric patients has proven to be strongly increased in the months after discharge from a psychiatric hospital. Despite this high risk, there is a lack of systematic research on the causes of this elevated suicide risk as well as a lack of treatment and intervention for patients at high risk after discharge. The main objective of this pilot study is, firstly, to examine the factors contributing to the elevated suicide risk and, secondly, to investigate whether an additional setting of care starting at discharge may reduce suicidality. METHODS: In this multi-centre pilot study, treatment as usual is complemented by an additional 18-month post-discharge setting of care for psychiatric patients at high risk for suicide. Two groups of patients differing in the amount of post-discharge personal contacts will be compared. One group of patients will be offered continuous personal contacts after discharge (months 1-6: monthly contacts; months 6-18: every 2 months) while another group of patients will receive contacts only at months 6, 12, and 18 after discharge. Data on suicidality, as well as associated with other symptoms, treatment, and significant events, will be collected. In the case of health-related severe events, the setting of care allows the patient to have the opportunity to connect with the doctor or therapist treating the patient. DISCUSSION: The results of this study will contribute to identifying critical factors raising suicide risk after discharge and will demonstrate the potential influence on suicide prevention of a setting of care with regular personal contact after discharge. TRIAL REGISTRATION: ZMVI1-2517FSB135 - funded by the German Federal Ministry of Health.

Epidemiology of suicide in Austria during 2000-2010: potential years of life lost: time for the national suicide prevention program.

BACKGROUND: This article investigates suicide rates from 2000 to 2010 in Austria, a country with now average rates that had started to decline in the mid-80s. RESULTS: Rates declined in the observed period, to an average of 26.1 per 100,000 persons for men, 8.2 for women, and 16.9 in the general population. The decrease was found in all age-groups, but more marked in women, with a reduction by 26.3 % compared with the previous decade than in men (20.0 % reduction). Hanging still is the most common method, 49.1 % for men and 35.0 % for women, although also on the decline. Furthermore, person years of lost life were calculated, also reflecting a decrease from 40,702 years in 2000 to 29,883 in 2010. Altogether, 372,551 years of life were lost by suicide in Austria in the period 2000-2010, 277,998 years among men and 94,553 years among women. CONCLUSIONS: Concerning the still observed increase in old age-groups and the huge amount of lost life years, it is argued that implementation of the National Suicide Prevention Programme for Austria is strongly needed.

Forty years of increasing suicide mortality in Poland: undercounting amidst a hanging epidemic?

BACKGROUND: Suicide rate trends for Poland, one of the most populous countries in Europe, are not well documented. Moreover, the quality of the official Polish suicide statistics is unknown and requires in-depth investigation. METHODS: Population and mortality data disaggregated by sex, age, manner, and cause were obtained from the Polish Central Statistics Office for the period 1970-2009. Suicides and deaths categorized as 'undetermined injury intent,' 'unknown causes,' and 'unintentional poisonings' were analyzed to estimate the reliability and sensitivity of suicide certification in Poland over three periods covered by ICD-8, ICD-9 and ICD-10, respectively. Time trends were assessed by the Spearman test for trend. RESULTS: The official suicide rate increased by 51.3% in Poland between 1970 and 2009. There was an increasing excess suicide rate for males, culminating in a male-to-female ratio of 7:1. The dominant method, hanging, comprised 90% of all suicides by 2009. Factoring in deaths of undetermined intent only, estimated sensitivity of suicide certification was 77% overall, but lower for females than males. Not increasing linearly with age, the suicide rate peaked at ages 40-54 years. CONCLUSION: The suicide rate is increasing in Poland, which calls for a national prevention initiative. Hangings are the predominant suicide method based on official registration. However, suicide among females appears grossly underestimated given their lower estimated sensitivity of suicide certification, greater use of "soft" suicide methods, and the very high 7:1 male-to-female rate ratio. Changes in the ICD classification system resulted in a temporary suicide data blackout in 1980-1982, and significant modifications of the death categories of senility and unknown causes, after 1997, suggest the need for data quality surveillance.

Predictors of suicide and suicide attempt in subway stations: a population-based ecological study.

Suicidal behavior on the subway often involves young people and has a considerable impact on public life, but little is known about factors associated with suicides and suicide attempts in specific subway stations. Between 1979 and 2009, 185 suicides and 107 suicide attempts occurred on the subway in Vienna, Austria. Station-specific suicide and suicide attempt rates (defined as the frequency of suicidal incidents per time period) were modeled as the outcome variables in bivariate and multivariate Poisson regression models. Structural station characteristics (presence of a surveillance unit, train types used, and construction on street level versus other construction), contextual station characteristics (neighborhood to historical sites, size of the catchment area, and in operation during time period of extensive media reporting on subway suicides), and passenger-based characteristics (number of passengers getting on the trains per day, use as meeting point by drug users, and socioeconomic status of the population in the catchment area) were used as the explanatory variables. In the multivariate analyses, subway suicides increased when stations were served by the faster train type. Subway suicide attempts increased with the daily number of passengers getting on the trains and with the stations' use as meeting points by drug users. The findings indicate that there are some differences between subway suicides and suicide attempts. Completed suicides seem to vary most with train type used. Suicide attempts seem to depend mostly on passenger-based characteristics, specifically on the station's crowdedness and on its use as meeting point by drug users. Suicide-preventive interventions should concentrate on crowded stations and on stations frequented by risk groups.

Declining autopsy rates and suicide misclassification: a cross-national analysis of 35 countries.

CONTEXT: Suicides are prone to misclassification during death ascertainment procedures. This problem has generated frequent criticism of the validity of suicide mortality statistics. OBJECTIVE: To employ an external measure of the validity of cause-of-death statistics (ie, national autopsy rates) and to examine potential misclassification of suicide across countries from Europe to Central and Northern Asia. DESIGN: Cross-national analysis. SETTING: Thirty-five countries. PARTICIPANTS: Aggregated mortality data. MAIN OUTCOME MEASURES: Data from 35 countries during the period from 1979 to 2007 were used to analyze the association of suicide rates with autopsy rates and death rates of undetermined and ill-defined causes, respectively. Analyses were cross-sectional and longitudinal. RESULTS: Cross-sectionally, a 1% difference in autopsy rates among nations was associated with a suicide rate difference of 0.49 per 100,000 population. Longitudinally, a 1% decrease in the autopsy rate aligned with a decrease of 0.42 per 100,000 population in the suicide rate. These cross-sectional and longitudinal associations were robust after adjustment for unemployment, degree of urbanization, and prevalence of undetermined or ill-defined deaths. Associations strengthened when analyses were confined to 19 European Union member countries. CONCLUSION: Autopsy rates may spatially and temporally affect the validity of suicide mortality statistics. Caution should be exercised in comparing international suicide rates and evaluating interventions that target suicide rate reduction.

Lithium in drinking water and suicide mortality.

BACKGROUND: There is some evidence that natural levels of lithium in drinking water may have a protective effect on suicide mortality. AIMS: To evaluate the association between local lithium levels in drinking water and suicide mortality at district level in Austria. METHOD: A nationwide sample of 6460 lithium measurements was examined for association with suicide rates per 100,000 population and suicide standardised mortality ratios across all 99 Austrian districts. Multivariate regression models were adjusted for well-known socioeconomic factors known to influence suicide mortality in Austria (population density, per capita income, proportion of Roman Catholics, as well as the availability of mental health service providers). Sensitivity analyses and weighted least squares regression were used to challenge the robustness of the results. RESULTS: The overall suicide rate (R(2) = 0.15, ß = -0.39, t = -4.14, P = 0.000073) as well as the suicide mortality ratio (R(2) = 0.17, ß = -0.41, t = -4.38, P = 0.000030) were inversely associated with lithium levels in drinking water and remained significant after sensitivity analyses and adjustment for socioeconomic factors. CONCLUSIONS: In replicating and extending previous results, this study provides strong evidence that geographic regions with higher natural lithium concentrations in drinking water are associated with lower suicide mortality rates.

Availability of mental health service providers and suicide rates in Austria: a nationwide study.

OBJECTIVE: Evidence shows that access to mental health services may have an impact on mental health outcomes such as suicide rates. This small-area analysis examined whether the availability of professionals providing mental health treatment in Austria had an effect on regional suicide rates. METHODS: A hierarchical Bayesian model accounting for spatially correlated random effects using an intrinsic conditional autoregressive prior that incorporated the neighborhood structure of districts and that assumed a Poisson distribution for the observed number of suicides was used to estimate the effects of access to mental health care (population density of general practitioners, psychiatrists, and psychotherapists) in Austria. RESULTS: Regional socioeconomic factors were correlated with the density of psychiatrists and psychotherapists. Only the number of psychotherapists per 10,000 population had a significant effect on suicide rates (relative risk [RR]=.97, 95% confidence interval [CI]=.94-.997, and absolute risk reduction [ARR]=-.62, CI=-1.20 to -.11); however, after adjustment for socioeconomic factors (in particular urbanicity as indicated by population density, average income, and proportion of non-Catholics), the observed effects were no longer significant. In the final model, only the socioeconomic component remained significant (RR=.94, CI=.88-.99), and ARR=-1.17, CI=-2.34 to -.05). CONCLUSIONS: The availability of specialized mental health service providers was associated with regional socioeconomic factors, and these factors appeared to be stronger predictors of suicide rates than the availability of providers. Therefore, suicide prevention efforts need to acknowledge that availability of services is only one aspect of access to care; a more influential factor is whether availability satisfies local demand.

Role of media reports in completed and prevented suicide: Werther v. Papageno effects.

BACKGROUND: Media reporting of suicide has repeatedly been shown to trigger suicidal behaviour. Few studies have investigated the associations between specific media content and suicide rates. Even less is known about the possible preventive effects of suicide-related media content. AIMS: To test the hypotheses that certain media content is associated with an increase in suicide, suggesting a so-called Werther effect, and that other content is associated with a decrease in suicide, conceptualised as a Papageno effect. Further, to identify classes of media articles with similar reporting profiles and to test for associations between these classes and suicide. METHOD: Content analysis and latent class analysis (LCA) of 497 suicide-related print media reports published in Austria between 1 January and 30 June 2005. Ecological study to identify associations between media item content and short-term changes in suicide rates. RESULTS: Repetitive reporting of the same suicide and the reporting of suicide myths were positively associated with suicide rates. Coverage of individual suicidal ideation not accompanied by suicidal behaviour was negatively associated with suicide rates. The LCA yielded four classes of media reports, of which the mastery of crisis class (articles on individuals who adopted coping strategies other than suicidal behaviour in adverse circumstances) was negatively associated with suicide, whereas the expert opinion class and the epidemiological facts class were positively associated with suicide. CONCLUSIONS: The impact of suicide reporting may not be restricted to harmful effects; rather, coverage of positive coping in adverse circumstances, as covered in media items about suicidal ideation, may have protective effects.

[The closeness to medical profession and the attitude towards euthanasia]. / Die Nähe zum medizinischen Beruf und die Einstellung zur aktiven Sterbehilfe.

Periodically debates on the legalization of active euthanasia are conducted in the Austrian media. In contrast to most European and North American countries, these debates are not based on local empirical data, because until now no studies on respective attitudes and values exist. In this study notion towards active euthanasia of (1) medical lays, (2) medical students and medical specialists in psychiatry, surgery and internal medicine are explored by means of a semistructured questionnaire. We found that increasing closeness to the medical profession is associated with an increasing refusal of active euthanasia. Among the medical specialists, specialists in internal medicine, who, after the legalization, would be most involved in decision-making processes as well as in the execution of active euthanasia, showed the greatest reservation concerning this question.

The gap between suicide characteristics in the print media and in the population.

BACKGROUND: Programmes to educate media professionals about suicide are increasingly established, but information about which suicide cases are most likely to be reported in the mass media is sparse. METHODS: We applied binomial tests to compare frequencies of social characteristics of all domestic suicides in the 13 largest Austrian print media in 2005 with frequencies of suicide characteristics in the population. Additionally, each reported suicide case was linked to its respective entry in the suicide database. We performed a logistic regression analysis, with presence of an article as outcome, and sex of the suicide case, age, religious affiliation, family status, conduction of an autopsy and location of the suicide as explaining variables. Time of the year and federal state where the suicide happened was controlled for. RESULTS: Binomial tests showed that suicides involving murder or murder attempt were over-represented in the media. Reporting on mental disorders was under-represented. In the regression analysis, the likelihood of a report was negatively associated with the age of suicide cases. Foreign citizenship was a further predictor of a suicide report. The methods of drowning, jumping, shooting and rare methods were more likely to be reported than hanging, which is the most frequent suicide method in Austria. CONCLUSIONS: Suicide characteristics in the media are not representative of the population. The identified discrepancies provide a basis for tailor-made education of mass media professionals.

Can media effects counteract legislation reforms? The case of adolescent firearm suicides in the wake of the Austrian firearm legislation.

To assess the impact of the Austrian firearm legislation (1997) on adolescent suicides, we investigated time trends in youth suicide prevalence (1986-2006) with Poisson regression. A temporary increase in firearm suicides after the reform was observed, followed by a continuous decrease. The hypothesis that media reporting triggered the short-term backlash effect is discussed.

Rural-urban differences in Austrian suicides.

OBJECTIVES: The answer to the question whether suicide rates are higher in urban than in rural areas may have changed over the years. This study analyzes the longitudinal trends of rural and urban suicides in Austria from 1970 to 2005. The most recent decade, 1995-2005 was also investigated cross-sectionally in terms of age groups, gender, suicide methods and family status. METHODS: Official suicide statistics were calculated in a Poisson regression model to determine trends in suicide rates according to gender in rural and urban regions as well as the ratios of rural- to urban-suicide rates. Population density levels were used as a measure of urbanization. Differences in suicide rates across the rural-urban categories were investigated in terms of genders, age groups, suicide methods and family status using Spearman correlations. RESULTS: The ratio of rural to urban suicide rates has continuously increased in both genders over the past 35 years, indicating a growing risk in rural areas. Suicide methods used in rural and urban areas vary significantly and suicide rates among men, but not women, were found to decrease with increasing urbanicity. CONCLUSION: In line with recent findings from other western countries, we showed a growing gap between rural and urban suicide rates. This suggests a need for rural-specific suicide prevention efforts, especially aimed at the male rural population.

Firearm legislation reform in the European Union: impact on firearm availability, firearm suicide and homicide rates in Austria.

BACKGROUND: The availability of firearms in homes and at aggregate levels is a risk factor for suicide and homicide. One method of reducing access to suicidal means is the restriction of firearm availability through more stringent legislation. AIMS: To evaluate the impact of firearm legislation reform on firearm suicides and homicides as well as on the availability of firearms in Austria. METHOD: Official statistics on suicides, firearm homicides and firearm licences issued from 1985 to 2005 were examined. To assess the effect of the new firearm law, enacted in 1997, linear regression and Poisson regressions were performed using data from before and after the law reform. RESULTS: The rate of firearm suicides among some age groups, percentage of firearm suicides, as well as the rate of firearm homicides and the rate of firearm licences, significantly decreased after a more stringent firearm law had been implemented. CONCLUSIONS: Our findings provide evidence that the introduction of restrictive firearmlegislation effectively reduced the rates of firearm suicide and homicide. The decline in firearm-related deaths seems to have been mediated by the legal restriction of firearm availability. Restrictive firearm legislation should be an integral part of national suicide prevention programmes in countries with high firearm suicide rates.

Trends in suicide rates of the elderly in Austria, 1970-2004: an analysis of changes in terms of age groups, suicide methods and gender.

BACKGROUND: Suicides of the elderly (persons aged 65 and older) make up a large proportion of total suicides. Since suicide rates of the elderly are highest in western populations, addressing them as a risk group in prevention plans has been recommended. In order to assess possible approaches to prevention strategies, this study examines high-risk groups of the elderly. METHODS: We examined official statistics on suicides that occurred in Austria between 1970-2004 (18,101 Suicides of the elderly). We analyzed time trends and differences in suicide methods as well as in age groups and both genders of the elderly. RESULTS: Three major high-risk groups were identified: elderly male suicides by firearms; elderly female suicides by poisoning, which occur more often with increasing age; and suicides of both genders by jumping from heights. CONCLUSION: Besides conducting treatment of psychiatric disorders of the elderly, restricting the means to commit suicide may help to prevent it among the elderly. Such specific prevention strategies should be implemented in national suicide prevention plans for the high-risk groups identified in this study.

Suicide by shooting is correlated to rate of gun licenses in Austrian counties.

OBJECTIVES: Shooting as method of suicide has increased considerably in Austria over recent decades and represented 23.5% of all suicides among men during the period 1990-2000. It is thought that the availability of guns could lead to their use in acts of suicide, and therefore we investigated the numbers of gun licenses (which constitutes ownership of guns and permission to carry a gun) in the nine Austrian counties and their correlation with suicides by shooting and other methods. METHODS: We studied registered suicides, including the method used, between 1990 and 2000 in Austria and the numbers of gun licenses held in the nine counties of Austria in the same period. RESULTS: We found a strong correlation between the average gun license rate for the period 1990-2000 and suicides by shooting (r = 0.967), and only very weak correlation, and for some of the years under investigation a negative correlation, with other methods of committing suicide (r = 0.117) and the suicide rate in general (r = 0.383). CONCLUSIONS: As shooting as a method of suicide has increased in Austria in recent decades, and is a highly lethal method, the finding that the shooting suicide rate is related to the extent of gun ownership deserves attention, especially as there is evidence that restriction of gun ownership is an important factor in suicide prevention.

Suicidality in bipolar disorders--psychoanalytic contribution.

This paper gives an overview of psychoanalytic contributions to the understanding of suicidal behavior in bipolar patients. Although little specific literature is available, many authors have contributed to the understanding of these patients' psychodynamics and suicidality in various papers. Different points of emphasis are described, among these are defensive strategies, narcissistic personality structure, and dealing with intense feelings such as object loss. Using detailed case descriptions, the inner world of bipolar patients as it relates to their suicidality, along with the appropriate psychoanalytically oriented approach to treatment, are highlighted.

Epidemiology of suicide in Austria 1990-2000: general decrease, but increased suicide risk for old men.

OBJECTIVES AND METHODS: The epidemiology of suicide in Austria, 1990-2000, was investigated. RESULTS: In comparison with 1980-1990, an overall decrease in the incidence of suicide was found. The annual averages for male, female, and total suicide rates were 32.2, 11.0, and 21.3, respectively, representing decreases of 17.6%, 25.7%, and 19.3%. Decreases were observed in all age groups except for males aged 80-84 years, where the suicide rate was 123.5 (15.1% increase), and for males aged 85 years or over, where the rate was 148.9 (25.4% increase). Hanging is still the most frequently used suicide method in Austria, despite steady decreases during recent decades. During the 1990s, hanging was used in 47.5% of male suicides and 34.8% of female cases. Shooting is the next most common method for male suicides (23.5% of cases) and has become more frequent for both sexes. CONCLUSIONS: The main findings reveal that the decrease in suicide incidence in Austria is greater for females than for males, reflecting the increased suicide risk within the oldest male age groups. This population subgroup should thus be a particular target for suicide-prevention efforts in Austria. A further aim within a national strategy for suicide prevention should be to stop the increased use of shooting as a suicide method.