Risk factors for suicide and undetermined death among in-patient alcoholics in Scotland.

Approximately 32,000 patients, representing all those discharged alive from inpatient psychiatric care for alcoholism in Scottish hospitals between 1974 and 1983, were traced for up to 10 years by means of a national record-linkage study in order to ascertain the frequency of suicide and undetermined deaths. The cumulative mortality from these causes was 1.17% at 5 years and 2.01% at 10 years. Several risk factors were investigated, using survival analysis techniques. Sex, age, social class (males only) and marital status were not found to be useful predictors, but the different secondary diagnoses recorded at discharge were associated with major variations in outcome. Attention is drawn to the prognostic importance of a secondary diagnosis of both affective disorders and personality disorders, and some implications of the findings are noted concerning attempts to construct population models linking alcoholism, demographic characteristics and suicide.

Association of age and social class with suicide among men in Great Britain.

STUDY OBJECTIVE: The aim was to investigate suicide and "undetermined" deaths by age, economic activity status, and social class in Great Britain among males of working age. DESIGN: The study was a cross sectional analysis of Registrar General's data for England and Wales around 1981, repeated for around 1971, and for Scotland around 1971 and 1981. MEASUREMENTS AND MAIN RESULTS: For England and Wales around 1971, suicide and undetermined death rates showed a progressive increase with age and a markedly higher rate in the lower social classes. A significant interaction effect was identified in the central age groups of the lower occupational categories. This interaction was confirmed in the remaining three data sets, notwithstanding some differences in the profile of age specific mortality. Other findings included a higher standardised mortality ratio for the economically inactive, who also showed an earlier peak in age specific mortality, and a relative concentration of undetermined as compared to suicide deaths in the lower social classes, but not all these further results were fully replicated. CONCLUSIONS: There is a concentration of suicide and undetermined deaths in the middle age groups of the lower social classes. Plausible explanations include both the social drift and the social genesis hypotheses, the latter including the effects of long term unemployment.

The construction and selection of predictive scales, with special reference to parasuicide.

Issues concerning the use of predictive and screening instruments include the difficulties posed by temporal changes in the base rates for the behaviour of interest, the possible advantages of using three rather than the customary two risk categories, and the desirability of specifying in advance the proportional sizes of the risk subgroups. A method is proposed for constructing and assessing tripartite risk scales, and a new scale for predicting the repetition of parasuicide, with the results of a prospective validation study, is reported.

Suicide among hospital-treated alcoholics in Scotland, 1974-83.

Two cohorts of suicide (and undetermined deaths) in Scotland for the quinquennia 1974-78, 1979-83 were investigated. A national record linkage exercise was carried out relating the deaths to admissions for alcoholism in the preceding 5 years (minimum) to 10 years (maximum). No differences were found between the cohorts in socio-demographic or clinical characteristics at the time of initial admission. The survival time as measured from either first admission or from last discharge to death was appreciably longer in the second quinquennium. This improvement might reflect changes in the patterns of services provided for alcoholics, especially the increased emphasis on the extra-mural care.

Affective disorders among women in the general population and among those referred to psychiatrists. Clinical features and demographic correlates.

In a study comparing depressive disorders detected in a field survey (n = 90) with patients referred to a specialist treatment setting (n = 63), the clinical features and demographic correlates of 'cases' of affective disorders proved to be similar. However, those in treatment settings appeared to have more people achieving definite case status. Hospital-referred cases were also more likely than community cases to be older and single, and this difference persisted even after controlling for chronicity of symptoms.

Long term trends in parasuicide and unemployment in Edinburgh, 1968-87.

Aggregate- and individual-level trends in parasuicide and unemployment among men and women resident in Edinburgh during the years 1968-87 are reported. During the first half of the period unemployment and parasuicide rates increased in parallel (r = 0.91, P less than 0.001 among men; r = 0.82, P less than 0.01 among women). However, while unemployment continued to rise after 1977, parasuicide rates tended to fall (r = -0.83, P less than 0.001 among men; r = -0.38, NS among women). It could be shown that the reversed relationship between parasuicide and unemployment after 1976 was not due to changes over time in the validity of the local unemployment rate as a marker of economic conditions. Suggested explanations for the falling parasuicide rate in Edinburgh include the possibility of a "threshold" effect and the influence of other (non-economic) factors. The rate of parasuicide among the unemployed fell, especially after 1973, while the rate among the employed rose until 1976-7, thereafter tending to fall. The relative risk (rate among the unemployed/rate among the employed) declined until 1979, since when it has fluctuated at about 10. The highest rate of parasuicide was consistently found among the long-term unemployed.

Self-esteem, life stress and psychiatric disorder.

Using a special subsample from a survey of women in Edinburgh investigations were carried out into (a) which types of life event are associated with lowered self-esteem; (b) the role of life events and self-esteem in onset of psychiatric disorder; and (c) the additional significance of prior psychiatric consultation in determining onset. Stressors involving impaired relationships with others were the only ones clearly associated with lowered self-esteem. Minor psychiatric illness was predicted by stress of uncertain outcome, and, to a lesser extent, by impaired relationship stress. Onset of major depression was best predicted by an interaction between total stress experienced and low self-esteem. There was evidence that such onset involves a pre-existing low level of self-esteem on which life stress impinges, rather than life stress generating low self-esteem and then onset. A small group of subjects characterised by low self-esteem, prior psychiatric consultation and maladaptive coping seemed to be fluctuating in and out of psychiatric illness irrespective of stress.

Alcoholic and non-alcoholic liver disease in relation to alcohol consumption in Scotland, 1978-84. Part I: Epidemiology of liver diseases.

A common strategy in epidemiological studies linking alcohol consumption in the general population with liver cirrhosis mortality is to use non-specific cirrhosis mortality rates in which alcoholic and non-alcoholic causes of death are not distinguished. Evidence is presented from Scottish mortality data for 1979 to 1984 that the two forms of cirrhosis have quite different epidemiological profiles. Similar findings emerge from morbidity data. The two forms of disease should be distinguished in future studies in which liver cirrhosis is used as a proxy for consumption, despite the manifest shortcomings of currently available data.

Repetition of parasuicide: an epidemiological and clinical study.

The dramatic clinical presentation of parasuicide tends to deflect attention from the repetitive pattern of this behaviour in many patients. In an epidemiological study of annual cohorts of parasuicides for 1972, 1977, and 1982 admitted to the Regional Poisoning Treatment Centre, Edinburgh, it was found that for certain subgroups of the population 'repeaters' were actually commoner than 'first-ever' patients, and a number of risk factors were identified, of which social class was particularly important. The clinical characteristics of patients distinguished by their frequency of repetition were also described, with special attention to the stability of these differentiating features over time. It is suggested that the habitual repeater requires closer study, and that the factors which lead to initiation into a parasuicidal 'career' are not necessarily those which conduce to repetition.

Recent clinical and epidemiological trends in parasuicide in Edinburgh and Oxford: a tale of two cities.

This is a report of clinical and epidemiological trends in parasuicide in Edinburgh and Oxford over the period of 1976 to 1984. Rates of parasuicide declined in both cities, but more markedly among women than men. Male rates tended to be higher in Edinburgh and female rates higher in Oxford. Age-specific rates were similar for the two cities in 1983-84, with peak rates for females among 15-19 year olds and those for males among 20-24 year olds in Edinburgh and 25-34 year olds in Oxford. Parasuicide incidence was higher in lower social class groups and among the unemployed in both cities. During the study period there was a massive decline in barbiturate overdoses, a more modest decline in minor tranquillizer overdoses but, in Oxford, a marked increase in self-poisoning with paracetamol. By the end of the study period the proportion of patients receiving a diagnosis of drug addiction had doubled in Edinburgh, although it had remained fairly constant in Oxford. There were differences in patterns of aftercare offered to patients in the two cities; these almost certainly reflect differing clinical policies.

Hospital-treated and general-population morbidity from affective disorders. Comparison of prevalence and inception rates.

In this study, we compare the rates of psychiatric disorders found among women in a random sample of the general population with those of patients referred to specialist services. Both these groups were drawn from the same geographical area. The ratio of prevalence rates is less than the ratio between inception rates in the two groups. When only those with affective disorders were considered, the results revealed that the point prevalence in the treated-disorders group was only 1% of the community-group prevalence, while the inception into care in the former group was nearly 6% of that in the latter. Single women and older women were over-represented in the hospital sample.

Suicide, age and marital status.

A new data set concerning suicide in relation to marital status for Scotland, 1973-83, is presented. The effects of age-standardization on marital status rates and of marital status standardization on age-specific rates are both elucidated. The difficulties of drawing conclusions from marital status rates for suicide are outlined. Nevertheless, the data suggest that the importance of the widowed state has been underestimated and that it appears that the relative risk for suicide associated with divorce has probably been decreasing among Scottish men over the study period.

Self-appraisal, anxiety and depression in women. A prospective enquiry.

Depressive illness is known to be associated with low self-evaluation, but it has been suggested that there may be a reciprocal connection as well, such that low self-appraisal (in the absence of illness) makes the subsequent onset of depression more likely. A prospective study, using a community sample of 376 women, provided data about clinical state over a period of 18 months, and self-appraisal questionnaire scores were determined on two occasions separated by 6 months. There was no evidence that low self-evaluation predicted future episodes of depressive illness, except in women who reported previous psychological episodes for which they had sought medical help, and, even for those with previous episodes, much of the predictive power of low self-esteem was accounted for by individuals who were subsequently recognised to have been in the early stages of illness. Conversely, there was little evidence that prior episodes predicted future illness in people with high self-esteem. One explanation of the findings is that recurrent episodes of illness cause progressive impairment of self-appraisal, but other possibilities are also considered. Women who had recovered from illnesses detected at the first interview still had significantly less self-confidence 6 months later than those who were well throughout.