The Value of Routine Mid-Trimester Ultrasound in Low-Risk Pregnancies at Primary Care Level

This study investigated the effect of routine second-trimester ultrasound scanning on obstetric management and pregnancy outcomes. This was an open cluster; randomised; controlled trial. Clusters of women with low-risk pregnancies presenting in the second trimester were randomised to receive an ultrasound scan followed by usual antenatal care; or to an unscanned control group undergoing conventional antenatal care only. Out of the 962 women randomised; follow-up was successful for 804 (83.6); with 416 allocated to the ultrasound scan group and 388 controls. There were no significant differences between the ultrasound scan group and the control group in terms of prenatal hospitalisa- tion; mode of delivery; miscarriage; perinatal mortality rate and low birthweight rate. Ultrasound dating was associated with a lower rate of induction of labour for post-term pregnancy (1.4vs. 3.6; P=0.049). However; ultrasound scanning in low-risk pregnancies was not associated with improvements in pregnancy outcome

A randomized controlled trial of postcrisis suicide prevention.

OBJECTIVE: This study tested the hypothesis that professionals' maintenance of long-term contact with persons who are at risk of suicide can exert a suicide-prevention influence. This influence was hypothesized to result from the development of a feeling of connectedness and to be most pertinent to high-risk individuals who refuse to remain in the health care system. METHODS: A total of 3,005 persons hospitalized because of a depressive or suicidal state, populations known to be at risk of subsequent suicide, were contacted 30 days after discharge about follow-up treatment. A total of 843 patients who had refused ongoing care were randomly divided into two groups; persons in one group were contacted by letter at least four times a year for five years. The other group-the control group-received no further contact. A follow-up procedure identified patients who died during the five-year contact period and during the subsequent ten years. Suicide rates in the contact and no-contact groups were compared. RESULTS: Patients in the contact group had a lower suicide rate in all five years of the study. Formal survival analyses revealed a significantly lower rate in the contact group (p=.04) for the first two years; differences in the rates gradually diminished, and by year 14 no differences between groups were observed. CONCLUSIONS: A systematic program of contact with persons who are at risk of suicide and who refuse to remain in the health care system appears to exert a significant preventive influence for at least two years. Diminution of the frequency of contact and discontinuation of contact appear to reduce and eventually eliminate this preventive influence.

An integrated approach to estimating suicide risk.

It is ironic that if we had a perfect predictive instrument we would not be able to recognize it because it could never be validated by its critical outcome criterion. Though some exceptions could occur, we would be obliged to take all available measures to prevent a suicidal outcome in cases where suicide was predicted. After the crisis we could have no way of knowing with certainty whether the person would have suicided or not. Even if we accepted the reality that people are not either 0% or 100% likely to suicide, and developed a perfect scale to estimate degree of risk, we would still be unable to validate it in individual cases. If it indicated "moderate" risk of 2.5-5.0%, for example, and no intervention were offered, we would have to observe one suicide in every 20-40 persons assessed at this level of risk to demonstrate its validity. The key to assessment is obtaining information, primarily regarding present or anticipated pain and the threshold of pain tolerance in the individual involved. Since different persons communicate in a variety of ways--verbal, nonverbal, symbolic, metaphoric, etc., eclecticism in approach is essential. For some clinicians communication will be facilitated most by one style; for others, a different method would be most effective. Thus, the "best" approach is the one that works best given the unique characteristics of the persons involved and under the conditions existing at the time. My own bias is that every assessment, whatever the approach, must include some form of direct inquiry regarding suicidal intent, and that the final decision in this regard must be a subjective and intuitive judgment. Contrary to possible assumptions in the legal world, accurate assessment does not necessarily mean safety. It can serve as a guide to the degree of risk that may be involved in a treatment program, but even low risk management measures may have an adverse outcome without implications of negligence or carelessness. There has been no mention here of biological markers of suicide, which are of much current interest but still in an investigational stage. Similarly, rational suicide has not been mentioned, though our aging population and the status of AIDS are making this issue progressively more important. The principles involved in assessment of risk are the same as with other forms of suicide, however. Finally, we can only presume that more precise assessment will operate to reduce suicidal deaths.(ABSTRACT TRUNCATED AT 400 WORDS)

Models of suicide risk: nice persons.

The hypotheses are advanced that: (1) certain types of persons at risk for suicide represent identifiable clinical models, and (2) that such models provide relatively homogeneous samples from which specific high-risk indicators can be derived for clinical application to others who represent that model. Nine-hundred and eighty-six psychiatric inpatients representing the "Nice Persons" model, including 35 suicides, were randomly divided into an index and a validation set. Statistical analysis of the index set (N = 579), using a screening procedure followed by linear discriminant and linear logistic procedures, identified 11 high-risk indicators from 184 prospectively determined variables. When applied to the independent validation set (N = 407), the 11 indicators identified the suicides in that set with a sensitivity of 46% and specificity of 88%. Though not statistically significant, this level of efficiency is clinically of considerable potential value. Most importantly, the hypothesis is testable and is shown to deserve further development.

Empirical indicators of near-term suicide risk.

In practice, clinicians estimating the likelihood of suicide are most concerned with short-term risk. To address this issue, an analysis of prospective data from 3,005 psychiatric patients at risk for suicide was carried out, focusing on 38 persons who committed suicide within 60 days of evaluation. Nine high-risk variables were identified: prior psychiatric hospitalization, contemplation of hanging or jumping, presence of suicidal impulses, divorced, a threat of financial loss, feeling a burden to others, unable to cry or severe crying, severe or moderate ideas of persecution or reference, and a negative or mixed reaction to the patient by the interviewer. Four or more of these characteristics identified the suicides with a sensitivity of 79% and a specificity of 81%.

Development of a clinical instrument to estimate suicide risk.

This report details the development of an empirical suicide risk scale for adults hospitalized due to a depressive or suicidal state. The authors studied 2,753 such subjects prospectively regarding 101 psychosocial variables. In a 2-year follow-up, 136 (4.94%) of the subjects had committed suicide. Rigorous statistical analysis, including a validation procedure, identified 15 variables as significant predictors of suicidal outcome. These were translated into a paper-and-pencil scale that gives an estimated risk of suicide within 2 years. Such an instrument can provide a valuable supplement to clinical judgment and a quantitative expression of suicide risk.

Preliminary field-testing of a risk estimator for suicide.

A 15-item suicide risk estimator, empirically derived from a prospective study of 2,753 suicidal persons, was given a field trial in five clinical settings. Two hundred ninety subjects were included. Volunteer crisis workers needed an average of 4.5 minutes to complete the instrument, and rated its ease of administration 2.5 on a 5-point scale. When compared with clinical ratings, the instrument estimated suicide risk slightly higher than did the interviewers. Scale items that differed from the raters' intuition tended to be omitted more than others. The trial provided valuable information needed to prepare for a large scale evaluation.

Suicide risk factors in alcohol abuse.

The "clinical model" approach to estimating suicide risk assumes that persons sharing specific attributes will also share certain indicators of vulnerability to suicide. This would warrant an empirically derived risk assessment scale applicable only to persons with those attributes. Nine hundred seventy eight persons at risk for suicide who met our criteria for alcohol abuse were interviewed at length and followed for two years, during which 53 (5.5 percent) committed suicide. Eleven variables which best differentiated those who suicided from those who did not in an index set were then applied to an independent validation set. Clinical implications of the findings are discussed.

The psychopathology of suicide: a clinical model approach.

The author hypothesizes that certain types of persons at high risk for suicide constitute definable clinical models, that the process of arriving at a suicidal outcome involves elements unique to each model, and that these elements can be considered manifestations of psychopathology. This approach is investigated using two models: "Males Under Forty" and "Stable with Forced Change." The results indicate statistically reliable differences between the models in the distributions of estimated risks for persons who subsequently committed suicide compared with those who did not. The implications of the associated highrisk variables as reflections of psychopathologic processes are considered.

New approaches to crisis intervention.

Constant efforts to improve crisis services have led to many innovative programs. Some have proven their feasibility and become established procedures. Others are now in a developing stage and still others represent new approaches. A survey of 50 suicide prevention and crisis services around the world provides evidence of a trend toward a broadening range of services, a more active case-finding approach, greater visibility, increased integration into the community care system, and creative leadership by newer and smaller centers as well as the well-established ones. This is being accomplished without relinquishing the traditional respect for anonymity, ever-present availability, and a nonjudgmental regard for each person's need.

Starting a therapy group in a suicide prevention and crisis center.

This report outlines the experience of one center in establishing a group therapy program, discussing the "readiness" of the center, reservations of the governing board, qualifications and number of group leaders, composition of the group, time-place-duration of meetings, "open" versus "closed" structure, vagaries of obtaining participants, integration with the 24-hour telephone crisis service, problems of confidentiality, and dealing with the suicide of a group member.

Estimation of suicide risk by the use of clinical models.

This report details some preliminary experience in the use of clinical models to develop scales for the estimation of suicide risk. A cohort was drawn for each of two models: Stable with Forced Change (N = 333) and Alienated (N = 566). A set of postulated discriminators regarding suicide was examined with negative results. Available data revealed 12 items for the Stable with Forced Change model and 20 items for the Alienated model that discriminated between the suicides and the nonsuicides at a .05 level of confidence. That only 4 items were common to both supports the idea that the models represent different populations in regard to vulnerability to suicide and thus require independent lethality scales.

Suicide prevention for high-risk persons who refuse treatment.

A program was developed to exert a suicide prevention influence on high-risk persons who decline to enter the health care system. There were 3,006 patients admitted to a psychiatric in-patient service because of a depressive or suicidal state who were contacted to determine if the post-discharge plan was followed. Half of those who refused their treatment program were contacted by telephone or letter on a set schedule. The contact was limited to expressing interest in the person's well-being. Mortality in the contact group was compared with the no-contact subjects and with the subjects who had accepted treatment, after 1, 2, 3, and 4 years. Suicidal deaths were found to diverge progressively in the three groups, the treatment subjects showing the highest rates, the no-contact group coming next, and the contact subjects showing the lowest. The observed divergence between the contact and no-contact groups provides tentative evidence that a high-risk population for suicide can be identified and that a system-atic approach to reducing that risk can be applied.