Impulsive suicide attempts among young people-A prospective multicentre cohort study in Sweden.

BACKGROUND: We aimed to compare the prevalence of impulsive suicide attempts (ISA) among young adults and those over 25 who present at hospital in connection with attempted suicide. We also aimed to identify factors associated with ISA in young adults and to assess medical severity as well as the probability of repeated suicide attempts in this age group. METHOD: A prospective multicentre cohort study included hospital known cases of suicide attempt (N = 666). The prevalence of ISA was compared between young adults (18-25) and adults aged > 26. We used logistic regression models to identify factors associated with ISA, associations of ISA with high medical severity and prediction of new fatal or non-fatal suicide attempts within 6 months. RESULTS: 43.7% of the young patients had made an ISA, and 30.2% among those aged > 26 (p = 0.001). Among the young, substance use disorder was associated with ISA; crude odds ratio (OR) 2.0 (1.0-4.2), and adjusted OR 2.1 (0.99-4.4). Affective disorder and unemployment/ sickness absence implied lower odds of ISA. ISA resulted in injuries of high medical severity as often as more planned attempts and non-fatal or fatal repetition within 6 months was equally common (30%) in both groups. LIMITATIONS: The study was set in psychiatric emergency services, which limits the generalizability. CONCLUSIONS: Clinicians should acknowledge that suicide attempts among youth often occur without previous planning and may result in medically severe injuries. The probability of new fatal or non-fatal suicide attempts should be kept in mind also after an impulsive suicide attempt.

Risk factors for suicide in bipolar disorder: a cohort study of 12 850 patients.

OBJECTIVE: Bipolar disorder carries a high risk of suicide. Identification of risk factors is important. The aim of this study was to study risk factors for suicide in a large cohort of men and women with bipolar disorder. METHOD: A prospective cohort study using clinical data from the Swedish National Quality Register for Bipolar Affective Disorder (BipoläR). The outcome variable was suicide captured in the Cause of Death Register between 2004 and 2014. Hazard ratios (HR) were calculated using Cox proportional hazards models. RESULTS: Of 12 850 persons (4844 men and 8006 women) with bipolar disorder, 90 (55 men and 35 women) died by suicide during the follow-up period (between 1 and 10 years). Male sex (HR 2.56), living alone (HR 2.45), previous suicide attempts (HR 4.10), comorbid psychiatric disorder (HR 2.64), recent affective episodes (HR 2.39), criminal conviction (HR 4.43), psychiatric inpatient care (HR 2.79), and involuntary commitment (HR 3.50) were significant risk factors for suicide. Several of the statistically significant risk factors for suicide in bipolar disorder differed between men and women. CONCLUSIONS: Risk factors for suicide in bipolar disorder include factors associated with suicide in general, but also diagnosis-specific factors.

Suicide in obsessive-compulsive disorder: a population-based study of 36 788 Swedish patients.

The risk of death by suicide in individuals with obsessive-compulsive disorder (OCD) is largely unknown. Previous studies have been small and methodologically flawed. We analyzed data from the Swedish national registers to estimate the risk of suicide in OCD and identify the risk and protective factors associated with suicidal behavior in this group. We used a matched case-cohort design to estimate the risk of deaths by suicide and attempted suicide in individuals diagnosed with OCD, compared with matched general population controls (1:10). Cox regression models were used to study predictors of suicidal behavior. We identified 36 788 OCD patients in the Swedish National Patient Register between 1969 and 2013. Of these, 545 had died by suicide and 4297 had attempted suicide. In unadjusted models, individuals with OCD had an increased risk of both dying by suicide (odds ratio (OR)=9.83 (95% confidence interval (CI), 8.72-11.08)) and attempting suicide (OR=5.45 (95% CI, 5.24-5.67)), compared with matched controls. After adjusting for psychiatric comorbidities, the risk was reduced but remained substantial for both death by suicide and attempted suicide. Within the OCD cohort, a previous suicide attempt was the strongest predictor of death by suicide. Having a comorbid personality or substance use disorder also increased the risk of suicide. Being a woman, higher parental education and having a comorbid anxiety disorder were protective factors. We conclude that patients with OCD are at a substantial risk of suicide. Importantly, this risk remains substantial after adjusting for psychiatric comorbidities. Suicide risk should be carefully monitored in patients with OCD.

Mental illness and suicide after self-harm among young adults: long-term follow-up of self-harm patients, admitted to hospital care, in a national cohort.

BACKGROUND: Self-harm among young adults is a common and increasing phenomenon in many parts of the world. The long-term prognosis after self-harm at young age is inadequately known. We aimed to estimate the risk of mental illness and suicide in adult life after self-harm in young adulthood and to identify prognostic factors for adverse outcome. METHOD: We conducted a national population-based matched case-cohort study. Patients aged 18-24 years (n = 13 731) hospitalized after self-harm between 1990 and 2003 and unexposed individuals of the same age (n = 137 310 ) were followed until December 2009. Outcomes were suicide, psychiatric hospitalization and psychotropic medication in short-term (1-5 years) and long-term (>5 years) follow-up. RESULTS: Self-harm implied an increased relative risk of suicide during follow-up [hazard ratio (HR) 16.4, 95% confidence interval (CI) 12.9-20.9). At long-term follow-up, 20.3% had psychiatric hospitalizations and 51.1% psychotropic medications, most commonly antidepressants and anxiolytics. There was a six-fold risk of psychiatric hospitalization (HR 6.3, 95% CI 5.8-6.8) and almost three-fold risk of psychotropic medication (HR 2.8, 95% CI 2.7-3.0) in long-term follow-up. Mental disorder at baseline, especially a psychotic disorder, and a family history of suicide were associated with adverse outcome among self-harm patients. CONCLUSION: We found highly increased risks of future mental illness and suicide among young adults after self-harm. A history of a mental disorder was an important indicator of long-term adverse outcome. Clinicians should consider the substantially increased risk of suicide among self-harm patients with psychotic disorders.

Combining the Suicide Intent Scale and the Karolinska Interpersonal Violence Scale in suicide risk assessments.

BACKGROUND: High suicide intent, childhood trauma, and violent behavior are risk factors for suicide in suicide attempters. The aim of this study was to investigate whether the combined assessment of suicide intent and interpersonal violence would provide a better prediction of suicide risk than an assessment of only suicide intent or interpersonal violence. METHODS: This is a cohort study involving 81 suicide attempters included in the study between 1993 and 1998. Patients were assessed with both the Suicide Intent Scale (SIS) and the Karolinska Interpersonal Violence Scale (KIVS). Through the unique personal identification number in Sweden, patients were linked to the Cause of Death Register maintained by the Swedish National Board of Health and Welfare. Suicides were ascertained from the death certificates. RESULTS: Seven of 14 patients who had died before April 2013 had committed suicide. The positive predictive value for the Suicide Intent Scale alone was 16.7 %, with a specificity of 52 % and an area under the curve of 0.74. A combined assessment with the KIVS gave higher specificity (63 %) and a positive predictive value of 18.8 % with an AUC of 0.83. Combined use of SIS and KIVS expressed interpersonal violence as an adult subscale gave a sensitivity of 83.3 %, a specificity of 80.3 %, and a positive predictive value of 26 % with an AUC of 0.85. The correlation between KIVS and SIS scores was not significant. CONCLUSIONS: Using both the the SIS and the KIVS combined may be better for predicting completed suicide than using them separately. The nonsignificant correlation between the scales indicates that they measure different components of suicide risk.

Age-specific suicide mortality following non-fatal self-harm: national cohort study in Sweden.

BACKGROUND: Possible age-related differences in risk of completed suicide following non-fatal self-harm remain unexplored. We examined associations between self-harm and completed suicide across age groups of self-harming patients, and whether these associations varied by violent index method, presence of mental disorder, and repeated self-harm. METHOD: The design was a cohort study with linked national registers in Sweden. The study population comprised individuals aged ⩾10 years hospitalized during 1990-1999 due to non-fatal self-harm (n = 53 843; 58% females) who were followed for 9-19 years. We computed hazard ratios (HRs) across age groups (age at index self-harm episode), with time to completed suicide as outcome. RESULTS: The 1-year HR for suicide among younger males (10-19 years) was 14.6 [95% confidence interval (CI) 4.1-51.9] for violent method and 8.4 (95% CI 1.8-40.0) for mental disorder. By contrast, none of the three potential risk factors increased the 1-year risks in the youngest females. Among patients aged ⩾20 years, the 1-year HR for violent method was 4.6 (95% CI 3.8-5.4) for males and 10.4 (95% CI 8.3-13.0) for females. HRs for repeated self-harm during years 2-9 of follow-up were higher in 10- to 19-year-olds (males: HR 4.0, 95% CI 2.0-7.8; females: HR 3.7, 95% CI 2.1-6.5). The ⩾20 years age groups had higher HRs than the youngest, particularly for females and especially within 1 year. CONCLUSIONS: Violent method and mental disorder increase the 1-year suicide risk in young male self-harm patients. Further, violent method increases suicide risk within 1 year in all age and gender groups except the youngest females. Repeated self-harm may increase the long-term risk more in young patients. These aspects should be accounted for in clinical suicide risk assessment.

High interleukin-6 and impulsivity: determining the role of endophenotypes in attempted suicide.

The dysregulation of inflammation has been associated with depression and, more recently, with suicidal behaviors. The reports regarding the relationship between interleukin-6 (IL-6) and suicide attempts are inconsistent. Personality traits such as impulsivity and aggression are considered endophenotypes and important factors that underlie suicidal behaviors. The aim of the current study was to assess whether plasma and cerebrospinal fluid (CSF) levels of IL-6 are associated with personality traits among suicide attempters. We assessed the relationships among personality traits, IL-6 and violent suicide attempts. The plasma and CSF levels of IL-6 were measured in suicide attempters (plasma=58, CSF=39) using antibody-based immunoassay systems. Personality domains were assessed using the Karolinska Scale of Personality (KSP). IL-6 levels in plasma and CSF were used to predict personality domains via regression models. Plasma IL-6 was significantly and positively correlated with extraversion as well as the KSP subscales impulsivity and monotony avoidance. CSF IL-6 was positively correlated with monotony avoidance. Violent suicide attempts tended to be associated with high plasma IL-6 levels. Plasma and CSF levels of IL-6 were not significantly associated with each other. These results indicate that impulsivity and the choice of a violent suicide attempt method might be related to higher levels of IL-6 in individuals who attempt suicide. The neuroinflammation hypothesis of suicidal behavior on the basis of elevated IL-6 levels might be partly explained by the positive association between IL-6 and impulsivity, which is a key element of the suicidal phenotype.

The ethics of doing nothing. Suicide-bereavement and research: ethical and methodological considerations.

BACKGROUND: Valuable trauma-related research may be hindered when the risks of asking participants about traumatic events are not carefully weighed against the benefits of their participation in the research. METHOD: The overall aim of our population-based survey was to improve the professional care of suicide-bereaved parents by identifying aspects of care that would be amenable to change. The study population included 666 suicide-bereaved and 377 matched (2:1) non-bereaved parents. In this article we describe the parents' perceptions of their contacts with us as well as their participation in the survey. We also present our ethical-protocol for epidemiological surveys in the aftermath of a traumatic loss. RESULTS: We were able to contact 1410 of the 1423 eligible parents; eight of these parents expressed resentment towards the contact. Several participants and non-participants described their psychological suffering and received help because of the contact. A total of 666 suicide-bereaved and 377 non-bereaved parents returned the questionnaire. Just two out of the 1043 answered that they might, in the long term, be negatively affected by participation in the study; one was bereaved, the other was not. A significant minority of the parents reported being temporarily negatively affected at the end of their participation, most of them referring to feelings of sadness and painful memories. In parallel, positive experiences were widely expressed and most parents found the study valuable. CONCLUSIONS: Our findings suggest, given that the study design is ethically sound, that suicide-bereaved parents should be included in research since the benefits clearly outweigh the risks.

Offspring death and subsequent psychiatric morbidity in bereaved parents: addressing mechanisms in a total population cohort.

BACKGROUND: It is unclear if psychiatric morbidity among parents bereaved of a child is related to major loss in general or if the cause of death matters. Whether such a link is consistent with a causal explanation also remains uncertain. METHOD: We identified 3,114,564 parents through linkage of Swedish nationwide registers. Risk of psychiatric hospitalization was assessed with log-linear Poisson regression and family-based analyses were used to explore familial confounding. RESULTS: A total of 3284 suicides and 14,095 any-cause deaths were identified in offspring between 12 and 25 years of age. Parents exposed to offspring suicide had considerably higher risk of subsequent psychiatric hospitalization than unexposed parents [relative risk (RR) 1.90, 95% confidence interval (CI) 1.72-2.09], higher than parents exposed to offspring non-suicide death relative to controls (RR 1.18, 95% CI 1.11-1.26). We found no risk increase among stepfathers differentially exposed to biologically unrelated stepchildren's death or suicide, and the relative risk was notably lower among full siblings differentially exposed to offspring death or suicide. CONCLUSIONS: Parental psychiatric hospitalization following offspring death was primarily found in offspring suicide. Familial (e.g. shared genetic) effects seemed important, judging from both lack of psychiatric hospitalization in bereaved stepfathers and attenuated risk when bereaved parents were contrasted to their non-bereaved siblings. We conclude that offspring suicide does not 'cause' psychiatric hospitalization in bereaved parents.

Parental schizophrenia and increased offspring suicide risk: exploring the causal hypothesis using cousin comparisons.

BACKGROUND: Little is known about suicide risk among offspring of parents hospitalized for schizophrenia and the mechanisms behind this association. METHOD: We applied a nested case-control design based on linkage of Swedish population-based registers. Among 12- to 30-year-old offspring, we identified 68 318 offspring with suicidal behavior (attempted and completed suicide) and their parents. Five healthy control-parent pairs were matched to each suicidal case-parent pair and conditional logistic regression used to obtain odds ratios (ORs). Further, to disentangle familial confounding from causal environmental mechanisms, we compared the population-based suicide risk with the risk found within full-cousins and half-cousins differentially exposed to parental schizophrenia. RESULTS: Offspring of parents with schizophrenia had significantly increased suicide risk after accounting for socio-economic status, parental suicidal behavior and offspring mental illness [OR 1.68, 95% confidence interval (CI) 1.53-1.85]. Suicide risks in offspring of schizophrenic mothers and fathers were similar in magnitude; so were risks across different developmental periods. Importantly, offspring suicide risk remained essentially unchanged across genetically different relationships; offspring of siblings discordant for schizophrenia had equivalent risk increases within full-cousins (OR 1.96, 95% CI 1.66-2.31) and half-cousins (OR 1.69, 95% CI 1.17-2.44). CONCLUSIONS: Parental schizophrenia was associated with increased risk of offspring suicidal behavior, independent of gender of the schizophrenic parent, and persisting into adulthood. The suicide risk in offspring remained at a similar level when comparing genetically different relationships, which suggests that at least part of the association is due to environmental mechanisms. These findings should inspire increased attention to suicidal ideation and prevention efforts in offspring of parents with schizophrenia.

Familial clustering of suicide risk: a total population study of 11.4 million individuals.

BACKGROUND: Research suggests that suicidal behaviour is aggregated in families. However, due to methodological limitations, including small sample sizes, the strength and pattern of this aggregation remains uncertain. METHOD: We examined the familial clustering of completed suicide in a Swedish total population sample. We linked the Cause of Death and Multi-Generation Registers and compared suicide rates among relatives of all 83 951 suicide decedents from 1952-2003 with those among relatives of population controls. RESULTS: Patterns of familial aggregation of suicide among relatives to suicide decedents suggested genetic influences on suicide risk; the risk among full siblings (odds ratio 3.1, 95% confidence interval 2.8-3.5, 50% genetic similarity) was higher than that for maternal half-siblings (1.7, 1.1-2.7, 25% genetic similarity), despite similar environmental exposure. Further, monozygotic twins (100% genetic similarity) had a higher risk than dizygotic twins (50% genetic similarity) and cousins (12.5% genetic similarity) had higher suicide risk than controls. Shared (familial) environmental influences were also indicated; siblings to suicide decedents had a higher risk than offspring (both 50% genetically identical but siblings having a more shared environment, 3.1, 2.8-3.5 v. 2.0, 1.9-2.2), and maternal half-siblings had a higher risk than paternal half-siblings (both 50% genetically identical but the former with a more shared environment). Although comparisons of twins and half-siblings had overlapping confidence intervals, they were supported by sensitivity analyses, also including suicide attempts. CONCLUSIONS: Familial clustering of suicide is primarily influenced by genetic and also shared environmental factors. The family history of suicide should be considered when assessing suicide risk in clinical settings or designing and administering preventive interventions.

The development of the Suicidal Patient Observation Chart (SPOC): Delphi study.

Constant observation is a method used to insure the safety of suicidal inpatients. It involves structure and control as well as flexibility and the development of a relationship between the observer and the patient. It has been found that important observations may go unnoticed by the observer or fail to be communicated to the multidisciplinary team because of a lack of sufficient training and systematic documentation. We therefore conducted a Delphi survey to collect opinions on what would be important to observe during constant observation of suicidal patients. A panel of experienced clinicians, service users and researchers reached consensus on 37 of 40 observation items (92%). Of these, 28 were rated as the most important. As a result, we developed a form for systematic observer documentation in clinical practice, the Suicidal Patient Observation Chart. The Suicidal Patient Observation Chart includes the 28 items and covers 24 separate observation periods.

Performance-based self-esteem and burnout in a cross-sectional study of medical students.

OBJECTIVES: To examine levels of burnout among medical students and test the hypothesis that high performance-based self-esteem is associated with burnout. Further to study associations between burnout and self-rated health. DESIGN: Cross-sectional survey, of medical students at 1st, 3rd and 6th year of medical school, N = 342, 59.1% women. MEASURES: Burnout was monitored by the Oldenburg Burnout Inventory (OLBI), comprising Exhaustion and Disengagement dimensions. Performance-based self-esteem (PBSE) was assessed by the PBSE-scale (PBSS) and self-rated health by SRH-5. RESULTS: The response rate was 90.4%. Females were more exhausted than males and sixth year students were most disengaged. High performance-based self-esteem was present in 41.7% of the respondents and poor health in 10.7%. Performance-based self-esteem had significant and moderate correlations with both burnout dimensions. Logistic regression showed a positive association between poor health and Exhaustion. CONCLUSIONS: Exhaustion among medical students was significantly associated with poor health, and deserves attention from teachers. Performance-based self-esteem was higher than in other populations and associated with both burnout dimensions, but not with poor health. Further research on study environment and burnout is needed, and the reasons for female students' higher exhaustion levels should be further investigated.

Resource use and costs associated with patients treated for depression in primary care.

We investigated medical resource consumption, productivity loss and costs associated with patients treated with antidepressants for depression in primary care in Sweden. Patients on treatment for depression were followed naturalistically for six-months, and data on patients' characteristics, daily activity and resource-use were collected. The total cost per patient was estimated at euro 5,500 (95%CI euro 5,000-6,100) over six months in 2005 prices. Direct costs were estimated at euro 1,900 (euro 1,700-2,200), 35% of total costs, and indirect costs at euro 3,600 (euro 3,100-4,100), 65% of total costs. The cost for antidepressants represented only 4% of the total costs. We conclude that the burden of depression is high, both to the individual as well as to wider society, and there seems to be a particular need for therapies that have the potential to improve productivity in depressed patients.

The mission is remission: health economic consequences of achieving full remission with antidepressant treatment for depression.

The aim of the present study was to determine the magnitude of the impact of treating depression to full remission on cost and health-related quality of life. In a naturalistic longitudinal survey recordings of resource use and quality of life were carried out among depressed patients treated with antidepressant therapy in 56 Swedish primary care clinics. We found that a total of 52% of the patients achieved full remission during the study period. Remitting patients had, on average, three outpatient visits less than non-remitting patients (p < 0.01), 22 fewer sick leave days (p = 0.01), which translated into a significantly lower total cost (Euro 2700) compared with non-remitting patients (p < 0.01). Health-related quality-of-life scores improved by 40% for remitting patients when compared with non-remitting ones (p < 0.01). We conclude that remission has a substantial health economic impact on patients treated for depression, which further strengthens the importance of aiming for full remission in the treatment of depression.

Attitudes towards suicide and suicidal patients among medical students.

Medical students' attitudes towards suicide and suicidal patients were studied. The aim was also to determine whether attitudes differ between students in the beginning and end of studies. A questionnaire including own attitudes on death and suicide and psychosocial circumstances was filled in by 63% of first and final year students (306 of 485). The calculation included a factor analysis on items describing the attitudes to suicidal patients. Attitudes towards patients became influenced by the knowledge of mental disorders and by biological aspects of behaviour during the education. Final year students more often consider suicide to be an expression of psychiatric disease and thought that people trying to commit suicide were not responsible for their own actions. Thirty-four percent and 44% (ns) in the first and last years, respectively, reported suicidal ideas some time in their lives. Students with such a history of suicide thoughts were less optimistic about the possibility to help. Ongoing depressive/anxious symptoms were prevalent in 36/305 (12%) of students, but did not seem to affect their attitudes to patients. Female students had sought psychological/psychiatric help more often than males (26% and 10%, P < 0.01).

Burden of illness and suicide in elderly people: case-control study.

OBJECTIVES: To study the association between physical illness and suicide in elderly people. DESIGN: Case-control with illness determined from interviews with relatives of people who committed suicide and with control participants and from medical records. SETTING: Gothenburg and two surrounding counties (210 703 people aged 65 years and over). PARTICIPANTS: Consecutive records of people who had committed suicide and had undergone forensic examination (46 men, 39 women) and living control participants from the tax register (84 men, 69 women). MAIN OUTCOME MEASURES: Physical illness rated in 13 organ systems according to the cumulative illness rating scale-geriatrics; serious physical illness (organ category score 3 or 4); overall score for burden of physical illness. RESULTS: Visual impairment (odds ratio 7.0, 95% confidence interval 2.3 to 21.4), neurological disorders (3.8, 1.5 to 9.4), and malignant disease (3.4, 1.2 to 9.8) were associated with increased risk for suicide. Serious physical illness in any organ category was an independent risk factor for suicide in the multivariate regression model (6.4, 2.0 to 20.0). When the sexes were analysed separately, serious physical illness was associated with suicide in men (4.2, 1.8 to 9.5) as was high burden of physical illness (2.8, 1.2 to 6.5). Such associations were not seen in women, possibly because of the small sample size. CONCLUSIONS: Visual impairment, neurological disorders, and malignant disease were independently associated with increased risk of suicide in elderly people. Serious physical illness may be a stronger risk factor for suicide in men than in women.

Parasuicides without follow-up.

The aim of this project was to approach subjects who committed parasuicide but did not primarily receive or accept a recommendation for care through the regular routines after referral to a general hospital. Three hundred and twenty-nine consecutive parasuicides in 10- to 89-year-olds (162 men and 167 women) were studied. One hundred were subsequently hospitalized in the departments of psychiatry, 130 were followed up at outpatient facilities, and 96 left without any follow-up. A psychiatric liaison consultation was made in 57% of the total sample. The 96 subjects without follow-up were compared with the subjects who received follow-up. The sample was somewhat younger and included slightly more men. They were single in 54% and unemployed in 43% of the cases. According to the DSM-IV, 27% had a concurrent depression. According to the CAGE questions, 57% had indication of substance addiction. Fifty-four per cent had currently low global functioning, less than 50 points on the GAF. They had not been in contact with psychiatric care previously to the same extent as the others. About 34% of these who did not receive or rejected follow-up initially after a second approach agreed to follow-up when contacted by the project team, referring them to appropriate authorities such as social welfare offices, family counselling, or psychosocial staff within psychiatry or primary care. This may imply that the group delineated is at risk for eventual suicide and that the acceptance of follow-up should be interpreted as an indication that a substantial number needs help and can be successfully encountered by means of a case manager approach.

Management of suicide attempts in Italy and Sweden. A comparison of services offered to consecutive samples of suicide attempters.

The aim of the study was to compare the management of suicide attempts by patients in Sweden and Italy with a view to providing a perspective on differences in treatment. Two consecutive samples of suicide attempters from Huddinge (n=97) and Padua (n=100) were studied in terms of sociodemographic characteristics, previous care, referral, medical and psychiatric care, hospitalization, aftercare, and short-term compliance. In Italian somatic management of acute suicidal crises, there are more physicians specializing in anesthesia or internal medicine working in ambulances and emergency wards, and there is a heavier emphasis on somatic care. Swedish management procedures seem to entail more medical examinations and biohumoral tests. Moreover, the procedures at the Swedish hospital give priority to early psychiatric intervention, and admission to psychiatric inpatient care is more frequent. However, it is not normal practice in emergency psychiatric care at either of the centers for specialists to serve in the immediate liaison consultation. There are differences in assessment and treatment between the two countries that may provide a perspective on their procedures, implying that current procedures for managing patients belonging to groups identified as "high-risk" in terms of suicide may be modified.

Anabolic androgenic steroids and suicide.

Eight medicolegally examined cases of suicide, in 21- to 33-year-old males, with a history of current or discontinued use of anabolic androgenic steroids (AAS) are described, five of which were approached by means of systematic interviews with survivors. Five suicides were committed during current use of AAS, and two following 2 and 6 months of AAS withdrawal. In one case it was unclear whether the suicide was committed during current use or after recent discontinuation. In five cases family members had noted depressive symptoms associated with AAS withdrawal. After prolonged use, four persons had developed depressive syndromes. Two subjects exhibited hypomania-like symptoms during the time immediately preceding the suicide. Four subjects had recently committed acts of violence while using AAS. In some cases these acts exacerbated the subjects' problems in personal relationships or at work, which in turn seem to have precipitated the suicides. Only one of them had experienced suicidal ideation before starting to use AAS. In all cases examined by psychological autopsy, risk factors of suicidality likely to be independent of the use of AAS were present. In conclusion, this study presents data suggesting that psychiatric symptoms and conflicts resulting from long-term use of AAS may contribute to completed suicide in certain predisposed individuals.