Therapeutic alliance and change in suicide ideation among psychiatric inpatients at risk for suicide.

BACKGROUND: Therapeutic alliance is thought to be essential in the treatment of suicidality. Surprisingly, studies about the association between therapeutic alliance and change in suicide ideation over the course of treatment are sparse and reported inconsistent results. Furthermore, theoretically important moderators were rarely explored empirically. METHODS: We investigated the association between therapeutic alliance and change in suicide ideation (difference between intake and discharge), unadjusted and adjusted for potential confounding variables (diagnoses, sociodemographics etc.) in a sample of 351 inpatients treated in a psychiatric department specialized in crisis intervention and suicide prevention. We also explored if the association was moderated by suicide ideation at intake, history of suicide attempts, and borderline personality disorder (BPD). We ran sensitivity analyses for different diagnostic subgroups, history of suicide attempts, and a quantitative measure of BPD symptoms. RESULTS: We found a moderate association between therapeutic alliance and change in suicide ideation (r = 0.30, p < 0.01). This association remained robust after accounting for potentially confounding variables. Suicide ideation at intake, history of suicide attempts, and BPD were not statistically significant moderators. Sensitivity analyses led to similar results. LIMITATIONS: Therapeutic alliance was assessed only at the end of treatment and causality cannot be inferred from our study method. CONCLUSIONS: Therapeutic alliance was a robust correlate of improvement in suicide ideation among psychiatric inpatients at risk for suicide, independent from diagnostic groups and other patient characteristics. Our results support the crucial role of therapeutic alliance in the treatment of patients at risk for suicide.

God Bless You? The Association of Religion and Spirituality with Reduction of Suicide Ideation and Length of Hospital Stay among Psychiatric Patients at Risk for Suicide.

OBJECTIVE: Religion and spirituality (R&S) were protective against suicidal behavior in the majority of studies. In prospective studies, R&S were associated with improved outcome for patients with depression, a main risk factor for suicide. Thus, R&S may also improve recovery from suicidal crisis, but related data is lacking. METHOD: We explored how aspects of R&S were associated with reduction of suicide ideation and length of hospital stay among 351 patients admitted to a psychiatric crisis intervention ward specialized in suicide prevention. We analyzed the results separately by gender and sexual orientation due to the known specific effects of R&S in these groups. RESULTS: Overall, there were only small and non-significant associations between R&S and reduction of suicide ideation and length of hospital stay. For heterosexual men, some R&S variables were associated with less optimal outcome. Contrary to our hypothesis, R&S were not less or even more beneficial for sexual minority than heterosexual patients. CONCLUSIONS: Religion and spirituality were not or only weakly associated with improvement of suicide ideation and shorter hospital stay. Further studies are needed to account for selection biases and other limitations in our study. Based on our findings, R&S may not be major sources to recover from suicidal crisis in a psychiatric setting.

The Gender-Specific Associations Between Religion/Spirituality and Suicide Risk in a Sample of Austrian Psychiatric Inpatients.

Most studies have found religion/spirituality to be protective against suicide risk, with a stronger effect among women. To understand this effect, theories of suicide and clinical samples are needed, but related studies are lacking. We applied two established suicide models in 753 psychiatric inpatients. Religion/spirituality correlated protectively with components of the suicide models, with stronger associations among women. The protective effect emerged especially for the capability aspect of suicide among men and for the motivational aspect among women, suggesting very different causal mechanisms, but this has to be replicated with longitudinal studies.

Sexual orientation differences in treatment expectation, alliance, and outcome among patients at risk for suicide in a public psychiatric hospital.

BACKGROUND: Sexual minority (SM) individuals (gay, lesbian, bisexual, or otherwise nonheterosexual) are at increased risk for mental disorders and suicide and adequate mental healthcare may be life-saving. However, SM patients experience barriers in mental healthcare that have been attributed to the lack of SM-specific competencies and heterosexist attitudes and behaviors on the part of mental health professionals. Such barriers could have a negative impact on common treatment factors such as treatment expectancy or therapeutic alliance, culminating in poorer treatment outcomes for SM versus heterosexual patients. Actual empirical data from general psychiatric settings is lacking, however. Thus, comparing the treatment outcome of heterosexual and SM patients at risk for suicide was the primary aim of this study. The secondary aim was to compare treatment expectation and working alliance as two common factors. METHODS: We report on 633 patients from a suicide prevention inpatient department within a public psychiatric hospital. Most patients were at risk for suicide due to a recent suicide attempt or warning signs for suicide, usually in the context of a severe psychiatric disorder. At least one indicator of SM status was reported by 21% of patients. We assessed the treatment outcome by calculating the quantitative change in suicide ideation, hopelessness, and depression. We also ran related treatment responder analyses. Treatment expectation and working alliance were the assessed common factors. RESULTS: Contrary to the primary hypothesis, SM and heterosexual patients were comparable in their improvement in suicide ideation, hopelessness, or depression, both quantitatively and in treatment responder analysis. Contrary to the secondary hypothesis, there were no significant sexual orientation differences in treatment expectation and working alliance. When adjusting for sociodemographics, diagnosis, and length of stay, some sexual orientation differences became significant, indicating that SM patients have better outcomes. CONCLUSIONS: These unexpected but positive findings may be due to common factors of therapy compensating for SM-specific competencies. It may also be due to actual presence of SM competencies - though unmeasured - in the department. Replication in other treatment settings and assessment of SM-specific competencies are needed, especially in the field of suicide prevention, before these findings can be generalized.

Real-Time Monitoring of Non-linear Suicidal Dynamics: Methodology and a Demonstrative Case Report.

In recent years, a number of different authors have stressed the usefulness of non-linear dynamic systems approach in suicide research and suicide prevention. This approach applies specific methods of time series analysis and, consequently, it requires a continuous and fine-meshed assessment of the processes under consideration. The technical means for this kind of process assessment and process analysis are now available. This paper outlines how suicidal dynamics can be monitored in high-risk patients by an Internet-based application for continuous self-assessment with integrated tools of non-linear time series analysis: the Synergetic Navigation System. This procedure is illustrated by data from a patient who attempted suicide at the end of a 90-day monitoring period. Additionally, future research topics and clinical applications of a non-linear dynamic systems approach in suicidology are discussed.

Nothing like Christmas--suicides during Christmas and other holidays in Austria.

BACKGROUND: Contrary to the myth that suicides increase around Christmas, multiple studies reveal that suicide rates decrease towards Christmas and return back to normal or even peak in the beginning of the new year. We aimed to replicate this effect for Austria. METHODS: The analyses were based on the official suicide statistics 2000-13 using Poission regression and Bayesian changepoint analysis. We also investigated changes of suicide rates during other major holidays and weekends. Seasonal effects were controlled for by using restricted control periods. RESULTS: Suicide rates declined before Christmas and were minimal on December 24th, remained low until the end of the year, peaked on New Year's day, but remained at average level in New Year's week. In contrast, suicide rates increased in the week after Easter and on Mondays/Tuesdays after weekends. No significant effects were found in the week after Whitsun and summer holidays. CONCLUSION: Compared with other holidays, Christmas time is clearly associated with fewer suicides in Austria, too, and may even counteract the 'broken promise' effect. This finding may help clarifying common myths in suicide prevention and may enhance the proper timing of preventive efforts.

The railway suicide death of a famous German football player: impact on the subsequent frequency of railway suicide acts in Germany.

BACKGROUND: The railway suicide of Robert Enke, an internationally respected German football goal keeper, sent shockwaves throughout the world of football. We analyzed its impact on the frequency of subsequent railway suicide acts (RS). METHODS: Two analytic approaches were performed applying German Railway Event database Safety (EDS) data: first, an inter-year approach comparing the incidence of RS during a predefined "index period" with identical time windows in 2006 to 2008; second, an intra-year approach comparing the number of RS 28 days before and after the incidence. To analyze a possible "compensatory deficit", the number of RS in the subsequent first quarter of 2010 was compared with the identical time windows in the preceding three years. Incidence ratios with 95% confidence intervals were estimated by Poisson regression. Findings were controlled for temperature. FINDINGS: Compared to the preceding three years, the incidence ratio (IR) of the number of RS in the index period increased by 1.81 (1.48-2.21; p<0.001), leading to an overall percentage change of 81% (48-121%; p<0.001). Comparing the number of suicides 28 days before and after the incidence revealed an even more pronounced increase of IR (2.2; 1.6-3.0). No modifications of these associations were observed by daytime, by location of the suicide and fatality. No compensatory deficit occurred in the post-acute period. INTERPRETATION: The substantial increase of RS in the aftermath of the footballer's suicide death brought about copycat behavior in an unforeseen amount, even though the media reporting was largely sensitive and preventive measures were taken.

Increasing railway suicide acts after media coverage of a fatal railway accident? An ecological study of 747 suicidal acts.

BACKGROUND: While coverage of a celebrity suicide in the mass media may trigger copycat suicides, evidence for the effect of media reports of non-prominent suicides is moderate. Diversification of current media may raise further doubts as to whether their influence on suicidal acts is still present. We examined whether widespread media coverage of a railway accident, in which several people were killed while investigating a presumed railway suicide, subsequently increased the number of railway suicides. METHODS: The daily incidence of railway suicides was derived from the national accident registry on the German railway net. We estimated incidence ratios by Poisson regression, adjusting for relevant confounders (eg, outdoor temperature, unemployment rate), for the 2 months following the accident (predefined index period) and predefined control periods (preceding 2 years of the same period and 1 month before/after the index period). RESULTS: The mean number of railway suicides per day in the index period increased significantly to 2.66 (95% CI 2.19 to 3.13) compared to 1.94 (95% CI 1.78 to 2.10) during both control periods. Fully adjusted Poisson regression showed a 44% daily increase in railway suicides in the index period compared to the control periods (incidence ratio 1.44, 95% CI 1.02 to 2.03). A maximum of eight suicides per day was reached about 1 week after the accident. CONCLUSIONS: Non-fictional media coverage of a fatal accident appears to affect subsequent railway suicide numbers. Supposedly, media reports drew attention to railways as a means of suicide.