Reasons for Attempted Suicide in Europe: Prevalence, Associated Factors, and Risk of Repetition.

To examine the prevalence of specific reasons for attempted suicide, factors associated with them, and whether reasons for attempted suicide influence risk of repetition. As part of the Monitoring Suicide in Europe (MONSUE) project, data on 4,683 suicide attempters from nine European countries were collected. Independence tests were used to study the influence of age, gender, and other factors on reported reasons. We examined risk of repetition using logistic regression analysis. Interpersonal conflict was common for all patients except those widowed, living alone, or retired. Mental health problems were prevalent among over 45 year-olds, patients unable to work, and patients with a history of at least three suicide attempts. Financial difficulties were cited more often by patients who were 45-64 years old, divorced or separated, living with children only, and unemployed. Close bereavement/serious illness and own physical illness were associated with those over 65 years of age. Two reasons for suicide attempt, interpersonal conflict and mental health problems, were associated with increased risk of repetition independent of other factors. Suicide attempters have a multitude of problems of varying prevalence depending on age, gender, and other factors. They present a range of clinical profiles that require a multidisciplinary response.

[Suicidal behavior: a psychiatric emergency situation, suicide prevention: a psychiatric obligation]. / Suizidalität: ein psychiatrischer Notfall, Suizidprävention: eine psychiatrische Verpflichtung.

In German psychiatry suicidal behavior is seen as sign of a psychiatric crisis in a person in the context of psychopathology, psychodynamics and psychosocial situation. Psychiatric disorders are found in up to 90% of people who commit suicide and the time span following the decision to commit suicide is often very short, within 24 h. Suicide prevention is a central duty and obligation in psychiatry and psychotherapy. This article gives an overview on the current state of knowledge on suicide from a clinical point of view.

How to adjust media recommendations on reporting suicidal behavior to new media developments.

This study examines the inclusion of preventive factors and new media developments in media recommendations on suicide reporting. Of the 193 member states of the United Nations screened for media recommendations, information was available for 74 countries. Similarities and differences in their contents were analyzed by cluster analysis. Results indicate that of these 74 countries, 38% have national suicide prevention programs, 38% have media recommendations, and 25% have press codes including suicide reporting. Less than 25% of the media recommendations advise against mentioning online forums, suicide notes, pacts, clusters, hotspots, details of the person, and positive consequences. No more than 15% refer to self-help groups, fictional and online reporting. We conclude that media recommendations need to be revised by adding these preventive factors and by including sections on new media reporting.

[Transcranial magnetic stimulation for comorbid depression in anorexia]. / Transkranielle Magnetstimulation gegen komorbide Depression bei Anorexie.

A 24-year-old anorexic patient with cormobid symptoms of depression was treated for depression with repetitive transcranial magnetic stimulation (rTMS) rather than with psychopharmacotherapy, due to her poor physical condition. The depressive symptomatology significantly improved in correlation with two rTMS cycles but occurred again within 2 weeks. A third successful cycle was then followed by a maintenance rTMS protocol with the patient going into remission from depression. This case illustrates that rTMS may be considered as a therapeutic option for comorbid depression in anorectic patients.

The factorial structure of the Suicide Intent Scale: a comparative study in clinical samples from 11 European regions.

Although the Suicide Intent Scale (SIS) is a widely used instrument in research on suicidal behavior, comparative research on the latent structure of the SIS has been neglected. To determine whether a general factor model of the SIS is supported, alternative factor models of the SIS were evaluated comparatively in 11 clinical samples. The SIS was applied as part of a structured clinical interview to patients after an episode of non-fatal suicidal behavior. The samples were drawn from 11 study centers within the frame of the WHO/EURO multicenter study on suicidal behavior. Three different two-factor and two three-factor models of the SIS were examined in each sample using principal component analysis with orthogonal Procrustes rotation. The factorial structure of the 'subjective part' of the SIS (items 9-14) was strongly supported, whereas an acceptable model fit for the 'objective part' was not found. Possible future revisions of 'objective' SIS items may be worth consideration. As a limitation, the results of the study might not generalize to other samples that use different definitions of non-fatal suicidal behavior.

[Epidemiology of suicide in older persons]. / Epidemiologie von Suizidalität im Alter.

The suicide risk in Germany increases with age. The suicide rates follow the so called "Hungarian" pattern. Especially the percentage of older females among all suicides has increased unproportionally in recent years in relation to their percentage in the population. Every second suicide of a female is today a suicide of a female older than 60 years. The main suicide method among older persons is hanging. Suicide attempts are rare among older persons; however, the rates are increasing among the oldest age groups. The suicide attempts of older persons are committed with a higher lethality and show rarely appellative components. Suicide attempt methods are often poisoning with pharmaceuticals. In total the suicide and suicide attempt rates among elderly are underestimated due to indirect methods (passive reactions, e.g. noneating). Reasons for suicides and suicide attempts among older persons are often psychic illnesses (mostly depression), motives often include loss of partners, loss of the social network, fear of the consequences of somatic illnesses and loss of freedom of action. Thus, often the social situation of older persons with suicide attempts changed before suicide was attempted.

[Changes in the frequency of suicidal behaviour after a 2-year intervention campaign]. / Veränderung der Häufigkeit suizidaler Handlungen nach zwei Jahren "Bündnis gegen Depression".

BACKGROUND: Insufficient treatment of depression is one of the most important causes of suicide. The Nuremberg Alliance against Depression (funded by the German Ministry of Education and Research) tried to improve the quality of care for patients suffering from depression. This multilevel programme focussed on close cooperation with general practitioners, a public relation campaign about depression, involvement of other professional groups, and reinforcement of self-help activities. METHODS: The project was realised in the city of Nuremberg, Germany in 2001-2002. Changes in the frequency of suicidal acts (successful and attempted suicides) compared to a baseline (2000) and a control region (Wuerzburg, Germany) were prospectively defined as the main outcome criterion. RESULTS: The frequency of suicidal acts decreased significantly (-21.7%) compared to the control region. This reduction was mainly due to a lower rate of suicide attempts. CONCLUSIONS: Many other regions in Germany and Europe followed the Nuremberg model project and have initiated regional alliances against depression.

[Cycloid psychoses as atypical manic-depressive disorders. Results of a family study]. / Sind zykloide Psychosen atypische manisch-depressive Erkrankungen? Ergebnisse einer Familienuntersuchung.

BACKGROUND: Whereas a growing body of evidence suggests that cycloid psychoses have to be separated from schizophrenic psychoses, their relations to bipolar affective disorder are less clear. PATIENTS AND METHODS: In a controlled family study, we recruited 46 patients with cycloid psychosis (CP), 33 with manic-depressive illness (MDI), and 27 controls. Three hundred fifty-six of 389 living first-degree relatives were personally examined by experienced psychiatrists blinded to the diagnosis of the index proband. RESULTS: The relatives of CP patients showed significantly lower morbidity risk of functional psychoses than relatives of patients with MDI in Kaplan-Meier life table calculation. The morbidity risk for functional psychoses in relatives of patients with CP did not differ significantly from that in relatives of controls. CONCLUSION: These results suggest that CP are etiologically different from bipolar affective psychoses and cannot be integrated into the spectrum of bipolar affective disorders. The findings provide further evidence for a nosological independence of CP.

Cycloid psychoses are not part of a bipolar affective spectrum: results of a controlled family study.

BACKGROUND: Whereas a growing body of evidence suggests that cycloid psychoses have to be separated from schizophrenic psychoses, their relations to bipolar affective disorder are less clear. To further clarify this issue a controlled family study was undertaken. METHODS: All living and traceable adult first-degree relatives of 45 cycloid psychotic, 32 manic-depressive and 27 control probands were personally examined by an experienced psychiatrist blind to the diagnosis of the index proband. Data about not traceable relatives were collected by the "Family-History"-Method. A catamnestic diagnosis was established for each of the 431 relatives blind to family data. Age-corrected morbidity risks were calculated using the life-table method. RESULTS: Relatives of cycloid psychotic patients showed a significantly lower morbidity risk for endogenous psychoses in general and manic-depressive illness compared to relatives of patients with manic-depressive illness. The familial morbidity risk for cycloid psychoses was low and did not differ significantly in both proband groups. Relatives of cycloid psychotic patients however did not differ significantly from relatives of controls regarding familial morbidity. LIMITATIONS: Our time-consuming methodical procedure implicated a relatively small number of participants due to restricted personnel resources. The restriction to hospitalised probands could possibly cause a limited representativity of the study sample. CONCLUSIONS: Our results suggest that cycloid psychoses are aetiologically different from manic-depressive illness and could not be integrated into a spectrum of bipolar affective disorders. The findings provide further evidence for a nosological independence of cycloid psychoses.

Influence of cerebral oxygenation following severe head injury on neuropsychological testing.

Despite recent advances in the management of severe head injury the mortality and morbidity remains high. Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) are crucial parameters for the correct management at the intensive care unit, due to their therapeutic and prognostic importance. In addition, regional brain tissue oxygenation (ptiO2) seems to be of importance. While different studies demonstrated the impact of cerebral hypoxia on outcome (mortality), no data are available focusing on morbidity (neuropsychological deficits). Therefore, our study is carried out to demonstrate a possible relationship between amount of cerebral oxygenation during acute stage after severe head injury and neuropsychological outcome. Besides ICP and CPP, ptiO2 was monitored in 40 severely head injured patients during the ICU stay from the day of admission until day 10. Monitoring data were stored and amount of hypoxic episodes were calculated. Besides outcome using the Glasgow Outcome Scale neuropsychological testing was performed 2-3 years after injury. Analysing the quality of brain tissue oxygenation, a relationship to the performance in neuropsychological tests could be found. Patients with low brain tissue oxygenation had a worse outcome in neuropsychological testing, especially concerning intelligence and memory. Associated with these deficits patients showed a reduced performance in their profession. Our data suggest a possible predictive value of brain tissue oxygen on morbidity analysing neurocognitive function after head injury. This may implicate monitoring and treatment of cerebral hypoxia.

Treatment of patients with severe burn injuries: the impact of schizophrenia.

Four patients treated in one ward of a psychiatric clinic were admitted to our burn unit within 2 months due to severe burn injuries. The patients showed signs of a self-mutilation epidemic. All four patients were female and the mean age was 28 years. The psychiatric diagnosis was schizophrenia in all patients (ICD 10: F20.9). The ignition of flammable liquid was the most common method and the mean burned TBSA was 33%. The mean severity score (ABSI) was 8 and the median hospital stay was 50 days. All patients were characterised by a prolonged hospital stay in comparison to patients without additional psychiatric pathology (median 31 days). This prolonged stay was based on a delayed wound healing, more operations, extended time for mobilisation and difficulties in co-operation. It is possible that in patients with schizophrenia, changes in nutrition, activity, sleep and drug use could influence their immune system profoundly. Anxiety and depression is also associated with the impairment of cellular and humoural immunity. Poor sleep reduces the production of an anabolic endocrine environment and sleep disturbances can interfere with macrophage and lymphocyte functions. Poor appetite leads to malnutrition, which is also capable of producing delayed wound healing. On the other hand, apathy and a general lack of motivation interfere with therapeutic strategies, because poor appetite and weight loss often occurs after neuroleptic withdrawal, which is correlated with clinical decompensation. Moreover, this "self-destructive" behaviour, which is acting on the immune system, might make a patient more susceptible to infection. All these aspects and side effects of schizophrenia combine to make the treatment of burned patients with schizophrenia a very special and difficult task.

Repetition of suicidal behaviour in elderly Europeans: a prospective longitudinal study.

The aim of this study was to assess any predictive factors for repeated attempted suicide and completed suicide in a 1-year follow-up on a sample of elderly European suicide attempters (60 years and over). From 1990 to 1993, 63 subjects completed the first interview and were recontacted after 1 year. At follow-up, eight subjects (12.7%) had taken their lives and seven (11.1%) had repeated at least one suicide attempt. On comparison of repeaters and non-repeaters, differences emerged in terms of death of the father in childhood and for mean Suicidal Intent Score. At the end of follow-up period, repeaters reported a more frequent desire to repeat suicidal behaviour and judged their mental health and social assistance received to be worse. Suicides and non-repeaters differed especially in relation to death of father during childhood and number of contacts with General Practitioner. Interpretation of the results must take into account the smallness of the test sample, the difficulties in obtaining complete data for the follow-up interview, the lack of a control group and a diagnosis formulated in a hospital consultation setting. The study confirms, however, the high risk of repetition of suicidal behaviour in the elderly. In old age suicidal ideation is often sustained over long periods of time and requests for help are addressed to relatives and GPs. An interesting finding is the more frequent death of the father during childhood among repeaters.

Exposure to prenatal infections, genetics and the risk of systematic and periodic catatonia.

The meaning of heterogeneity in schizophrenia and the impact of genetic and environmental factors on etiology are a matter of continuous debate in psychiatric research. Different clinical and birth history variables were investigated in a sample of 68 patients with chronic catatonic schizophrenia according to DSM III-R, classified into Leonhard's systematic schizophrenia (n = 32) and periodic catatonia (n = 36). Parental transmission of the disease was evident in 44% of the periodic catatonia cases compared to one case in systematic catatonia (3%; p = 0.0003). In systematic catatonia, 34% of the index cases were exposed to prenatal infections compared to 8% in periodic catatonia (p = 0.008). Using logistic regression analysis exposure to gestational maternal infections predicted diagnosis of systematic catatonia at p = 0.008, and parental psychosis predicted diagnosis of periodic catatonia in the index cases at p = 0.0001. The latter finding is substantiated by the recent mapping of a periodic catatonia-susceptibility locus on chromosome 15q15 with evidence for autosomal dominant transmission. These findings support the hypothesis that distinct schizophrenia phenotypes are based on different etiological mechanisms.

Carbohydrate-deficient transferrin is elevated in catabolic female patients.

Serum carbohydrate-deficient transferrin (CDT) is currently widely used as a biochemical marker of alcohol misuse. However, various recent studies have questioned the diagnostic value of this parameter and reported low levels of both specificity and sensitivity, especially in women. Thus, we sought to identify sub-groups of female individuals in which CDT is elevated independently of alcohol consumption. Significantly increased CDT levels were found in catabolic disease states due to psychiatric disorders distinct from alcoholism. None of those patients reported frequent alcohol consumption. CDT therefore appears also to be increased by metabolic processes distinct from alcohol degradation. Possible biochemical mechanisms of this phenomenon are discussed. As a consequence of these findings, the measurement of CDT alone is not suitable to screen for alcohol misuse in catabolic subjects.

Repetition of attempted suicide among teenagers in Europe: frequency, timing and risk factors.

BACKGROUND: Adolescents in many countries show high rates of suicide attempts and repetitions of attempts as a common feature. Attempted suicide is the best predictor of future suicide. Repetition of attempts further increases the risk of suicide. The present study sought to identify patterns and risk factors for repetition of attempts in older teenagers. METHODS: Data were collected by uniform procedures in a longitudinal follow-up study in seven European centres participating in the WHO/EURO Multicentre Study on Suicidal Behaviour. Information on attempted suicide in the 15-19-year age group during the period 1989-1995 was analysed. RESULTS: A total of 1,720 attempts by 1,264 individuals over a mean follow-up period of 204 weeks (SD 108.9) were recorded. When life-table analysis was performed, 24% of the individuals who had previously attempted suicide made another attempt within one year after the index attempt, compared with 6.8% of the "first-evers", with no major gender difference. Cox regression analysis revealed that previous attempted suicide (OR 3.3, 95% CI 2.4-4.4) and use of "hard" methods (OR 1.5, 95% CI 1.1-2.1) were both significantly associated with repetition of attempted suicide. Stepwise Cox regression analysis showed that a history of previous attempted suicide was the most important independent predictor of repetition (OR 3.2, 95% CI 2.4-4.4). CONCLUSION: For young suicide attempters, follow-up and adequate aftercare are very important if repetition and risk of suicide are to be reduced. This applies particularly to those who have already made more than one attempt.

Attempted and completed suicide in older subjects: results from the WHO/EURO Multicentre Study of Suicidal Behaviour.

OBJECTIVE: The authors present an analysis of findings for the 65 years and over age group from the WHO/EURO Multicentre Study of Suicidal Behaviour (1989-93). METHODS: Multinational data on non-fatal suicidal behaviour is derived from 1518 subjects in 16 European centres. Local district data on suicide were available from 10 of the collaborating centres. RESULTS: Stockholm (Sweden), Pontoise (France) and Oxford (UK) had the highest suicide attempts rates. In most centres, the majority of elderly who attempted suicide were widow(er)s, often living alone, who used predominantly voluntary drug ingestion. Non-fatal suicidal behaviour decreased with increasing age, whereas suicide rates rose. The ratio between fatal and non-fatal behaviours was 1:2, that for males/females almost 1:1. In the years considered, substantial stability in suicide and attempted suicide rates was observed. As their age increased, suicidal subjects displayed only a limited tendency to repeat self-destructive acts. Moreover, there was little correlation between attempted suicide and suicide rates, which carries different clinical implications for non-fatal suicidal behaviour in the elderly compared with younger subjects in the same WHO/EURO study.

Towards the genetic basis of periodic catatonia: pedigree sample for genome scan I and II.

In a genome-wide linkage study, we mapped two major susceptibility loci for periodic catatonia, a phenotype with qualitative disturbances of the psychomotor sphere and a morbidity risk of 26.9% in first-degree relatives of index cases, to chromosome 15q15, and to chromosome 22q13 using nonparametric as well as parametric (autosomal dominant model) analyses. The study included 12 multiplex pedigrees with 135 individuals, among them 57 affected persons. A second genome scan is in progress investigating four families with 21 affected individuals, aiming to confirm linkage results. Age at onset patterns as well as the clinical outcome were similar among affected individuals in both sets of families. Within the pedigrees we observed no physical diseases segregating with periodic catatonia. Under the assumption of genetic homogeneity, the statistical power to detect LOD scores > or = 2.0 was 98.5% in the first set of families, and 57.9% in the second set. Thus, the panel of multiplex pedigrees segregating periodic catatonia seems to represent a homogenous clinical sample, and possesses sufficient statistical power to delineate and confirm linkage to major genetic loci for periodic catatonia.

Mass media, cultural attitudes, and suicide. Results of an international comparative study.

Many studies indicate that the suicidal behavior in a society is affected by the suicide stories publicized. Cultural valuations appear in the way media present self-destruction. The reflection of sociocultural attitudes toward suicide can be observed and analyzed in these texts. In this research, reports about suicide (n = 2203) in the years from 1981 and 1991 taken from daily newspapers were gathered--three central and regional papers in each country. A content analysis was performed of the suicide reports in Hungary (n = 244), Japan (n = 684), the United States (n = 265), Germany (former West n = 458, former East n = 60), Austria (n = 405), and Finland (n = 81), on the basis of the following variables: mentioning of the name, personal data, prominence of the suicidal person, qualification of the suicide, methods, motives, positive or negative consequences, alternatives, and the expression(s) used to refer to the act. After a coding process, an analysis was conducted as to whether any significant differences existed in the rate of the several characteristics in the countries from the point of view of the possible imitation-identification and of the cultural differences are the most important findings interpreted.

Recommended care for young people (15-19 years) after suicide attempts in certain European countries.

Data on recommended care for young people aged 15-19 years after attempted suicide from nine European research centres during the period 1989-1992 were analysed in terms of gender, history of previous suicide attempt and methods used. Altogether 438 suicide attempts made by 353 boys and 1,102 suicide attempts made by 941 girls were included. Analyses of the total data from all centres showed that young people with a history of previous suicide attempt and those using violent methods had significantly higher chance of being recommended aftercare than first-time attempters or those choosing self-poisoning. There were no significant differences of being recommended care between genders. Logistic regression analyses of the material were performed and the results were similar. Both having previous attempted suicide (odds ratio 2.0, 95% CI 1.53-2.61) and using "hard" methods (odds ratio 1.71, 95% CI 1.49-1.96) were significantly associated with increased possibility of being recommended aftercare. When individual centres were analysed, large disparities of recommended care after suicide attempts were found and there were no uniform criteria of recommending care for young suicide attempters in Europe.