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.

Suicide Immediately After Discharge From Psychiatric Inpatient Care: A Cohort Study of Nearly 2.9 Million Discharges.

OBJECTIVE: The risk of suicide is elevated after discharge from a psychiatric hospital. This study aimed to investigate how recent suicidal behavior affects the risk of suicide in patients with different psychiatric diagnoses immediately after discharge. METHODS: Registers with national coverage were linked to create a study cohort including all individuals discharged from psychiatric hospitals in Sweden from 1973 through 2009. Hazard ratios for discharge diagnoses were calculated. The risk of suicide within 30 days after discharge in each diagnostic category when suicidal behavior had been registered within 30 days before admission was estimated. RESULTS: A total of 3,695 suicides occurred after 2,883,088 discharges. If recent suicidal behavior was registered, the risk of completed suicide increased prominently in all diagnostic categories, but particularly for schizophrenia (hazard ratio [HR] = 8.9; 95% CI, 6.4-12.4) and other nonorganic psychosis (HR = 6.8; 95% CI, 5.1-9.0). Patients suffering from depression had the highest overall risk of suicide postdischarge (HR = 3.0; 95% CI, 2.7-3.3). This finding applied especially to male patients with depression (HR = 4.5; 95% CI, 4.0-5.0) or with reaction to crisis (HR = 3.6; 95% CI 3.0-4.4). CONCLUSIONS: A distinct elevation of the risk of suicide was seen in all diagnostic groups if a recent self-harm event had occurred, particularly among patients with psychotic disorders. Overall, the immediate risk of suicide after discharge was high regardless of recent suicidal behavior. The findings in this study have relevance for clinical decisions about immediate after-care and treatment in connection with discharge from psychiatric inpatient care.

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.

Interpersonal violence and the prediction of short-term risk of repeat suicide attempt.

In this multi-center cohort study, suicide attempters presenting to hospital (N = 355, 63% women) were interviewed using the Karolinska Interpersonal Violence Scale (KIVS) and followed-up by medical record review. Main outcome was non-fatal or fatal repeat suicide attempt within six months. Also, repeat attempt using a violent method was used as an additional outcome in separate analyses. Data were analyzed for the total group and for men and women separately. Repeat attempts were observed within six months in 78 persons (22%) and 21 (6%) of these used a violent method. KIVS total score of 6 or more was associated with repeat suicide attempt within six months (OR = 1.81, CI 1.08-3.02) and predicted new attempts with a sensitivity of 62% and a specificity of 53%. A three-fold increase in odds ratio was observed for repeat attempt using a violent method (OR = 3.40, CI 1.22-9.49). An association between exposure to violence in adulthood and violent reattempt was seen in women (OR = 1.38, CI 1.06-1.82). The overall conclusions are that information about interpersonal violence may help predict short-term risk for repeat suicide attempt, and that structured assessment of interpersonal violence may be of value in risk assessment after attempted suicide.

Suicide risk after nonfatal self-harm: a national cohort study, 2000-2008.

OBJECTIVE: To study the short-term risk of suicide after nonfatal deliberate self-harm and its association with coexisting mental disorders and with the method of self-harm used. METHOD: We used linked Swedish national registers to design a cohort study with 34,219 individuals (59% females) who were admitted to hospital in 2000-2005 after deliberate self-harm (ICD-10-defined). They were followed for 3-9 years. The studied outcome was completed suicide; Cox regression models yielded hazard ratios (HRs) for suicide risk. Temporal patterns were plotted with Kaplan-Meier survival curves, calculated separately for each mental disorder and for the method used at the previous self-harm event. RESULTS: 1,182 subjects committed suicide during follow-up (670 males and 512 females). Coexisting bipolar disorder (in males, adjusted HR = 6.3; 95% confidence interval [CI], 3.8-10.3; in females, adjusted HR = 5.8; 95% CI, 3.4-9.7) and nonorganic psychotic disorder (in males, adjusted HR = 5.1; 95% CI, 3.5-7.4; in females, adjusted HR = 4.6; 95% CI, 2.8-7.7) implied the highest risk of suicide after previous self-harm. Hanging as index self-harm method was a strong predictor of later suicide in both males (adjusted HR = 5.3; 95% CI, 4.0-7.0) and females (adjusted HR = 4.5; 95% CI, 2.5-8.1). Of those with bipolar disorder who used a method other than poisoning at the index event, 20.4% had already committed suicide after 3-9 years. CONCLUSION: Individuals with severe mental disorders (affective and psychotic disorders) have a poor prognosis in the first years after hospital admission due to self-harm. The risk of subsequent suicide is higher after attempts by hanging and other self-injury methods (vs self-poisoning). Aftercare for those with a self-harm episode should focus on treatment of the mental disorder present at the time of the episode.

Suicide after release from prison: a population-based cohort study from Sweden.

OBJECTIVE: Released prisoners have high suicide rates compared with the general population, but little is known about risk factors and possible causal pathways. We conducted a population-based cohort study to investigate rates and risk factors for suicide in people previously imprisoned. METHOD: We identified individuals released from prison in Sweden between January 1, 2005, and December 31, 2009, through linkage of national population-based registers. Released prisoners were followed from the day of release until death, emigration, new incarceration, or December 31, 2009. Survival analyses were conducted to compare incidence rates and psychiatric morbidity with nonconvicted population controls matched on gender and year of birth. RESULTS: We identified 38,995 releases among 26,985 prisoners (7.6% female) during 2005-2009. Overall, 127 suicides occurred, accounting for 14% of all deaths after release (n = 920). The mean suicide rate was 204 per 100,000 person-years, yielding an incidence rate ratio of 18.2 (95% CI, 13.9-23.8) compared with general population controls. Previous substance use disorder (hazard ratio [HR] = 2.1; 95% CI, 1.4-3.2), suicide attempt (HR = 2.5; 95% CI, 1.7-3.7), and being born in Sweden versus abroad (HR = 2.1; 95% CI, 1.2-3.6) were independent risk factors for suicide after release. CONCLUSIONS: Released prisoners are at high suicide risk and have a slightly different pattern of psychiatric risk factors for suicide compared with the general population. Results suggest appropriate allocation of resources to facilitate transition to life outside prison and increased attention to prisoners with both a previous suicide attempt and substance use disorder.

Attempted suicide in bipolar disorder: risk factors in a cohort of 6086 patients.

OBJECTIVE: Bipolar disorder is associated with high risk of self-harm and suicide. We wanted to investigate risk factors for attempted suicide in bipolar patients. METHOD: This was a cohort study of 6086 bipolar patients (60% women) registered in the Swedish National Quality Register for Bipolar Disorder 2004-2011 and followed-up annually 2005-2012. Logistic regression was used to calculate adjusted odds ratios for fatal or non-fatal attempted suicide during follow-up. RESULTS: Recent affective episodes predicted attempted suicide during follow-up (men: odds ratio = 3.63, 95% CI = 1.76-7.51; women: odds ratio = 2.81, 95% CI = 1.78-4.44), as did previous suicide attempts (men: odds ratio = 3.93, 95% CI = 2.48-6.24; women: odds ratio = 4.24, 95% CI = 3.06-5.88) and recent psychiatric inpatient care (men: odds ratio = 3.57, 95% CI = 1.59-8,01; women: odds ratio = 2.68, 95% CI = 1.60-4.50). Further, those with many lifetime depressive episodes were more likely to attempt suicide. Comorbid substance use disorder was a predictor in men; many lifetime mixed episodes, early onset of mental disorder, personality disorder, and social problems related to the primary group were predictors in women. CONCLUSION: The principal clinical implication of the present study is to pay attention to the risk of suicidal behaviour in bipolar patients with depressive features and more severe or unstable forms of the disorder.