Youth suicide attempts and the dose-response relationship to parental risk factors: a population-based study.

BACKGROUND: There is a lack of specific knowledge about the dose-response effect of multiple parental risk factors for suicide attempts among children and adolescents. The aim of this study was to determine the dose-response effect of multiple parental risk factors on an offspring's risk for suicide attempt. METHOD: We designed a population-based two-generation nested case-control study and used Danish register data. A population of 403 431 individuals born between 1983 and 1989 was sampled. Among these, 3465 (0.8%) were registered as having had a suicide attempt. Twenty controls were matched to each case and a link to the offspring's biological parents was established. RESULTS: There was a dose-response relationship between the number of exposures and the risk of suicide attempts, with the increased risk seeming to be a multiplicative effect. Parental suicide, suicide attempt, psychiatric illness and low level of income were all significant independent risk factors for offspring's suicide attempts. CONCLUSIONS: Knowledge of the effect of multiple risk factors on the likelihood of suicide attempts in children and adolescents is important for risk assessment. Dose-response effects of multiple parental risk factors are multiplicative, but it is rare for children and adolescents to be exposed to multiple parental risk factors simultaneously. Nevertheless, they should be considered along with the offspring's own multiple risk factors in determining the overall risk of a suicide attempt. Further research incorporating both parental and offspring's risk factors is indicated to determine the overall dose-response effect of multiple risk factors.

The measurement of suicidal ideation.

A four-item suicidal ideation subscale of the GHQ-28 has been used previously to assess suicidal ideation on the basis of its face validity. In order to further validate its use, this study compared scores on this scale with scores on a well-established suicidal intent scale. There was a significant correlation between scores of that subscale and the self-report component as well as the overall score of the suicidal intent scale, thereby confirming its validity in providing a standardized method for comparing suicidal ideation in different populations.

Psychosocial and pharmacological treatment of patients following deliberate self-harm: the methodological issues involved in evaluating effectiveness.

Development of effective treatments for patients following deliberate self-harm (self-poisoning or self-injury) is a very important element in suicide prevention. The randomized controlled trial (RCT) is the mainstay of evaluation of treatments. In a systematic review of the literature, the effectiveness of treatments based on RCTs was examined and the quality of the RCTs was assessed. Twenty trials were identified, and where possible, these were grouped on the basis of similarities among the types of treatment. In this paper, we examine the methodological aspects of the trials and consider what may be learned that will assist in the design of future studies in this field. The methodological quality of the trials was reasonable, but most trials included too few participants to detect clinically important differences in rates of repeated self-harm. In planning future trials, the following major issues should be addressed: investigators should perform power calculations to determine the number of subjects necessary to detect clinically important effects, provide information on method of randomization and interventions, use standard measures of outcome, and focus on homogeneous subgroups of patients. Improving the methodology of future studies in this field will be essential if sound evidence is to be obtained which can inform effective service provision for deliberate self-harm patients.

Mental health literacy: an impediment to the optimum treatment of major depression in the community.

BACKGROUND: Mental health literacy refers to the knowledge and beliefs about mental disorders which aid their recognition, management and prevention. This study examined the mental health literacy and experience of depression in a random and representative community population. METHODS: The experience of depression and mental health literacy of 3010 subjects from a random and representative population were determined on the basis of responses to the mood module of the PRIME-MD and questions about a vignette of a person with features of major depression. RESULTS: Those with major depression had significantly more personal experience of depression than those with other depressions and those who were not depressed, but there were few significant differences between the groups in terms of mental health literacy. Of those with major depression, 40% considered anti-depressants helpful, but 40% also considered they were harmful. CONCLUSIONS: There is a considerable impediment to the recognition and management of major depression and a need for further community education programs.

Suicidal ideation and health-related quality of life in the community.

OBJECTIVE: To examine the health-related quality of life of people with suicidal ideation in the general community. DESIGN: A Health Omnibus Survey of a random, representative sample of the South Australian population in 1998, conducted by experienced interviewers. SUBJECTS: 3010 people over the age of 15 years. OUTCOME MEASURES: The survey included questions about utilisation of health services and the Short-form Health-related Quality of Life (SF-36) and Assessment of Quality of Life (AQoL) instruments. Suicidal ideation was determined in response to a direct question. RESULTS: 79 (2.6%) subjects reported suicidal ideation in the past two weeks. Compared with those without suicidal ideation, subjects with suicidal ideation reported significantly greater use of general practitioners, psychiatrists, psychologists, social workers and outpatient clinics (P<0.001), community health services and other counsellors (P<0.01), and more hospital admissions (P<0.05). Those subjects also scored significantly poorer on all subscales of both instruments (P<0.001), to the extent that they were below the 4th percentile on the role-emotional and mental health dimensions of the SF-36 and the social relationships, psychological wellbeing and overall scores of the AQoL. CONCLUSIONS: Suicidal ideation is associated with poor health-related quality of life. These results in a random and representative community sample add support to the need to improve targeting of those with suicidal ideation on a population basis with a view to earlier intervention.

The media and suicide: a cautionary view.

There is now unequivocal statistical evidence of an association between some media portrayals of suicide and further subsequent suicide. However, it is a weak association, and it is probably of far less importance than our need to address basic principles of good mental health management. Rather than prescribe to the media how to report suicide, its potentially positive effects should be addressed.

Major depression and its associated morbidity and quality of life in a random, representative Australian community sample.

OBJECTIVE: The objective of this study is to describe health services utilisation and morbidity, including health-related quality of life, in those with major depression in a random and representative sample of the population. METHOD: Data were gathered in a Health Omnibus Survey of the South Australian population. Major depression was delineated on the basis of responses to the Primary Care Evaluation of Mental Disorders. Information about use of health services and absence from usual functioning was collated, and two measures of health-related quality of life, the Short-form Health Status Questionnaire and the Assessment of Quality of Life were also administered. Results of those with major depression were compared with those who had other depressive syndromes and those who had no depression. RESULTS: Those with major depression reported significantly greater use of all health services and poorer functioning in terms of carrying out their normal duties. Similarly, their health-related quality of life was significantly poorer than those with other depressive syndromes, which in turn was significantly poorer than those who were not depressed. Only one-fifth of those with major depression were currently taking antidepressants. CONCLUSIONS: These results are consistent with international studies. In addition to the potential for alleviating the depressive symptomatology of individuals, it is evident that even a modest improvement in functioning with appropriate treatment would have the potential to benefit the Australian community by one billion dollars a year.

The privilege and responsibility of suicide prevention.

Each year about a million people worldwide take their lives, and a further unknown number, but probably no less than 20 million, attempt suicide. In addition, for every person who engages in suicidal behavior, another five or six will be associated with them in some way, making a conservative total of 100 million people worldwide who are affected each year--and to whom we have some degree of responsibility. There is no one approach to suicide prevention, and probably more so than for any other human condition, we are privileged to be able to collaborate with many different disciplines in our endeavors. However, there is a considerable responsibility to ensure that whatever our own area of expertise and interest may be, we should apply universal principals of objective analysis to these diverse contributions. This is addressed by examining research from four broad areas. First, there are studies that irrevocably bring together the sociological and biological approaches to suicide. Second, there are reports that support the notion of the universality of suicide. Third, despite considerable attention paid to the media, its influence on suicide is very limited. And finally, although there have been pessimistic reviews, there are persuasive data from innovative research designs that have documented that we can prevent suicide.

Mental health status of the South Australian population.

OBJECTIVE: To determine, by the use of a telephone survey, the mental health status of SA adults (18+ years) using the GHQ-28, SF-12 and self-report as indicators of mental health, and to examine risk factors for mental health morbidity. SAMPLE: A random representative sample of South Australian adults selected from the Electronic White Pages. Overall, 2,501 interviews were conducted (74.0% response rate). RESULTS: Overall, 19.5% of respondents had a mental health problem as determined by the GHQ-28, 11.8% as determined by the mental health component summary score of the SF-12 and 11.9% self-reported a mental health condition. The percentage of people with a mental health problem who had used a psychologist or a psychiatrist in the previous 12 months was 9.6% for people diagnosed by the GHQ-28, 16.2% by SF-12 and 23.7% for self-report. The logistic regression analyses undertaken to describe people with a mental health problem as determined by the GHQ-28 and to describe people who visited a psychologist or psychiatrist produced different age categories, demographic and co-morbidity indicators. Variables found in both analyses included living in the metropolitan area, being economically inactive and being a high user of health services. CONCLUSIONS: One in five South Australian adults has a mental problem. Although the prevalence is higher for younger age groups, older adults are more likely to visit a psychologist or a psychiatrist. IMPLICATIONS: Telephone interviewing produces robust indicators of the prevalence of mental health problems and is a cost-effective way of identifying prevalence estimates or tracking changes over time.

Suicidal ideation in a random community sample: attributable risk due to depression and psychosocial and traumatic events.

OBJECTIVE: To determine the attributable risk for suicidal ideation of depression and psychosocial and traumatic events in a random and representative population. METHOD: Data were gathered from a random and representative sample of 2501 South Australians. Suicidal ideation and clinical depression were determined by the general health questionnaire (GHQ-28) and the short-form health survey (SF-12) respectively, and information regarding psychosocial stressors and traumatic events was collated. These data were subjected to univariate and multivariate analyses to determine the population-attributable risks for suicidal ideation. RESULTS: Overall, 5.6% of men and 5.3% of women had suicidal ideation. Univariate analyses demonstrated a significant attributable risk for suicidal ideation for depression and the majority of the psychosocial and traumatic events. Multivariate analysis demonstrated that clinical depression remained significantly associated with suicidal ideation, with a population-attributable risk of 46.9%. Because of the small number of people in the population who experience both suicidal ideation and specific events, multivariate analysis could not be applied to individual events. However, even when the psychosocial events were summed, they no longer remained significantly associated with suicidal ideation, whereas the summation of traumatic events remained significant, with a population-attributable risk of 38.0%. CONCLUSIONS: These results confirm the importance of traumatic events as significant factors in contributing to suicidal ideation. However, of even greater importance is that they indicate, unequivocally, the magnitude of the contribution of clinical depression to suicidal ideation, with the population-attributable risk of depression indicating that elimination of mood disorders would reduce suicidal ideation by up to 46.9%.

Pre-Durkheim suicidology.

Durkheim is generally regarded as the founder of the scientific study of suicide. However, even a cursory review of 18th- and 19th-century literature reveals an increasingly sophisticated scientific approach to suicide, culminating in the encyclopedic research of Morselli in 1879 and the critical review of Tuke in 1892, works that lose nothing in comparison with Durkheim's Le Suicide of 1897. This review, while in no way drawing Durkheim's role as a founder of scientific sociology into question, indicates that his position in regard to the study of suicide does warrant reconsideration.

A double-blind, multicentre study to assess the tolerability and efficacy of paroxetine compared with amitriptyline in the treatment of depressed patients in Australian general practice.

OBJECTIVE: This study compared the tolerability and efficacy of paroxetine and amitriptyline in the treatment of depression in general practice. METHODS: In this double-blind, multicentre study conducted in the general practice, patients with depression (Montgomery Asberg Depression Rating Scale [MADRS] score > or = 20) who were regarded as requiring antidepressant therapy were randomly assigned to receive paroxetine (20 mg, n = 184) or amitriptyline (50-100 mg, n = 191) once daily for 9 weeks. RESULTS: More patients completed treatment with paroxetine than with amitriptyline (71.1% vs 56.1%, p = 0.009). Depression rating scores (MADRS and Clinical Global Impression [CGI]) were improved with both agents, but at week 9, paroxetine achieved more favourable scores compared with amitriptyline on MADRS (p=0.019), CGI severity of depression (p=0.044), and CGI efficacy index (p = 0.038). CONCLUSIONS: Depressed patients treated in general practice respond more quickly and are more likely to complete the treatment regimen with paroxetine than with amitriptyline.