Nordic region suicide trends 2000-2018; sex and age groups.

BACKGROUND AND AIM: Overall, suicide rates in the Nordic region, Denmark, Finland, Iceland, Norway and Sweden, have declined in the past 40 years. The aim of this study was to determine trends in suicide mortality from 2000 to 2018. METHODS: Data were obtained from official suicide statistics for men and women, 15 years and older. Gender and age groups in four calendar periods were analyzed using Joinpoint Estimated Regression Coefficient. RESULTS: The crude regional suicide rate was 17.1, 2000-2004, decreased to 14.1 per 100,000 inhabitants in 2015-2018. Age-standardized rates are 13.6-11.3. The crude rate decreased by 19.5% (16.3% age-standardized), 19.3% for males and 20.5% for females. The largest decrease was found in Finland (34.9%), the smallest in Norway (1.4%). In males, the exception was an increased suicide rate among all Icelandic except 15-24-year olds, and in 45-64 year-old Norwegians. Among females, an increase was seen among 15-24-year olds in all countries except Iceland, in all age groups in Norway, and in 25-44-year olds in Sweden. In males, a decline of the suicide rated lower than 10% was noted in 25-44 olds in Norway and in 15-64 year-olds in Sweden. DISCUSSION: A robust decrease was observed in the overall regional suicide rate in recent years. Exceptions are rising rates in Icelandic males, in Norwegian females, and the youngest female groups in all except Iceland. The small decline among middle-aged males in Norway and Sweden is of concern.

A Public Mental Health Study Among Iraqi Refugees in Sweden: Social Determinants, Resilience, Gender, and Cultural Context.

This public mental health study highlights the interactions among social determinants and resilience on mental health, PTSD and acculturation among Iraqi refugees in Sweden 2012-2013. Objectives: The study aims to understand participants' health, resilience and acculturation, paying specific attention to gender differences. Design: The study, using a convenience sampling survey design (N = 4010, 53.2% men), included measures on social determinants, general health, coping, CD-RISC, selected questions from the EMIC, PC-PTSD, and acculturation. Results: Gender differences and reported differences between life experiences in Iraq and Sweden were strong. In Sweden, religious activity was more widespread among women, whereas activity reflecting religion and spirituality as a coping mechanism decreased significantly among men. A sense of belonging both to a Swedish and an Iraqi ethnic identity was frequent. Positive self-evaluation in personal and social areas and goals in life was strong. The strongest perceived source of social support was from parents and siblings, while support from authorities generally was perceived as low. Self-rated health was high and the incidence of PTSD was low. A clear majority identified multiple social determinants contributing to mental health problems. Social or situational and emotional or developmental explanations were the most common. In general, resilience (as measured with CD-RISC) was low, with women's scores lower than that of men. Conclusions: Vulnerability manifested itself in unemployment after a long period in Sweden, weak social networks outside the family, unsupportive authorities, gender differences in acculturation, and women showing more mental health problems. Though low socially determined personal scores of resilience were found, we also identified a strong level of resilience, when using a culture-sensitive approach and appraising resilience as expressed in coping, meaning, and goals in life. Clinicians need to be aware of the risks of poorer mental health among refugees in general and women in particular, although mental health problems should not be presumed in the individual patient. Instead clinicians need to find ways of exploring the cultural and social worlds and needs of refugee patients. Authorities need to address the described post-migration problems and unmet needs of social support, together comprising the well-established area of the social determinants of health.

Safe but isolated - an interview study with Iraqi refugees in Sweden about social networks, social support, and mental health.

BACKGROUND: Problems with social networks and social support are known to be associated with mental ill-health in refugees. Social support after migration promotes resilience. AIM: To study how Iraqi refugees who arrived in Sweden after the year 2000 perceived their social networks and social support, and to relate the observed network characteristics and changes to the refugees' mental health and well-being. METHOD: Semi-structured interviews with 31 refugees, including questions on background and migration experiences, a biographical network map, and three health assessment scales. The findings were analysed with descriptive statistics and content thematic analysis. RESULTS: The respondents' networks were diminished. Social support was continued to be provided mainly by family members and supplemented by support from authorities. The main themes of the refugee experience of post-migration challenges were weakened social networks, barriers to integration and challenges to cultural and religious belonging. Failed reunion and worrying about relatives was described as particularly painful. Negative contacts with authority persons were often seen as humiliating or discriminating. Acquiring a new cultural belonging was described as challenging. At the same time, changing family and gender roles made it more difficult to preserve and develop the culture of origin. Traumatic experiences and mental health problems were common in this group. Family issues were more often than integration difficulties associated with mental health problems. CONCLUSION: In order to strengthen post-migration well-being and adaptation, authorities should support the refugees' social networks. Clinicians need to address post-migration problems and challenges, including the meaning and function of social networks.

"On Nomadic Shores Inward": Harry Martinson's Journey to Late-Life Suicide.

The aim of this study was to explore the unconscious dimensions of suicide as conveyed by the Swedish writer Harry Martinson, who took his life in 1978, four years after having received the Nobel Prize in Literature. A psychoanalytically informed "listening" to Martinson comprised a close reading of his writings, reflection on my total response to the material, the application of psychoanalytic hypotheses on severe depression and suicide-nearness, and the study of biographical sources. The dramatic fluctuations of Martinson's self-regard were noted, as was the juxtaposition of opposites in his poetry: darkness that seeps through observations of the beauty of nature and man or the reverse, a gleam of love that defuses the cruelty of the world. Martinson's drive to communicate with himself and others by talking and writing, to find auxiliary objects compensating for the traumatic losses of his childhood, and to realize mature love in adulthood was understood as a counterforce to self-destructiveness and threatening narcissistic disintegration. Pressured by negative reactions to the Nobel, which overlay decades of envy and political critique from colleagues, whose support he coveted, Martinson's aggressivity-reflecting the near soul-murder of his early life-exploded in his suicide.

Skepticism towards the Swedish vision zero for suicide: interviews with 12 psychiatrists.

BACKGROUND: The main causes of suicide and how suicide could and should be prevented are ongoing controversies in the scientific literature as well as in public media. In the bill on public health from 2008 (Prop 2007/08:110), the Swedish Parliament adopted an overarching "Vision Zero for Suicide" (VZ) and nine strategies for suicide prevention. However, how the VZ should be interpreted in healthcare is unclear. The VZ has been criticized both from a philosophical perspective and against the background of clinical experience and alleged empirical claims regarding the consequences of regulating suicide prevention. This study is part of a larger research project in medical ethics with the overarching aim to explore whether the VZ is ethically justifiable. The aim is to enrich the normative discussion by investigating empirically how the VZ is perceived in healthcare. METHODS: Interviews based on a semi-structured interview guide were performed with 12 Swedish psychiatrists. The interviews were analysed with descriptive qualitative content analysis aiming for identifying perceptions of the Vision Zero for Suicide as well as arguments for and against it. RESULTS: Though most of the participants mentioned at least some potential benefit of the Vision Zero for Suicide, the overall impression was a predominant skepticism. Some participants focused on why they consider the VZ to be unachievable, while others focused more on its potential consequences and normative implications. CONCLUSIONS: The VZ was perceived to be impossible to realize, nonconstructive or potentially counterproductive, and undesirable because of potential conflicts with other values and interests of patients as well as the general public. There were also important notions of the VZ having negative consequences for the working conditions of psychiatrists in Sweden, in increasing their work-related anxiety and thwarting the patient-physician relationship.

Challenges of Combining Perspectives.

BACKGROUND: Asylum seekers have increased risk of suicide and suicidal behavior, with differences related to origin, gender, and age. There are barriers to communication in clinical encounters between asylum seekers and clinicians. There is insufficient knowledge about how communication in the clinical encounter affects the suicide risk in female asylum seekers. AIMS: To explore the documented communication between female asylum-seeking suicide attempters and clinicians and how it affects treatment. METHOD: The medical records of 18 asylum-seeking women who had attempted suicide were analyzed with content analysis. RESULTS: Communication between patients and clinicians was affected by: the unbearable realities of the women; difficulties for clinicians in decoding languages of distress, and understanding trauma and subjective meanings of suicide; challenges of combining patients' and clinicians' perspectives; and a sense of shared powerlessness. LIMITATIONS: The medical records did not give direct access to the patient's experience, only to the patient as documented by the clinician. CONCLUSION: The results suggest that clinicians working with asylum seekers who have attempted suicide need to develop an understanding of social and cultural factors and of trauma issues. A question for further study is how an enhanced integration of context and subjectivity in psychiatric practice would equip clinicians for the specific challenges encountered.

Encountering the Body at the Site of the Suicide: A Population-Based Survey in Sweden.

Encountering the body of a child who died by suicide at the site of death is believed to be especially harmful for bereaved parents. We investigated the association between encountering the body at the site of the suicide and psychological distress in 666 suicide-bereaved parents. Parents who had encountered their child's body at the site of the suicide (n = 147) did not have a higher risk of nightmares (relative risk [RR] 0.95, 95% confidence interval [CI] 0.67-1.35), intrusive memories (RR 0.97, 95% CI 0.84-1.13), avoidance of thoughts (RR 0.97, 95% CI 0.74-1.27), avoidance of places or things (RR 0.91, 95% CI 0.66-1.25), anxiety (RR 0.93, 95% CI 0.64-1.33), or depression (RR 0.94, 95% CI 0.63-1.42) compared with parents who had not encountered the body (n = 512). Our results suggest that losing a child by suicide is sufficiently disastrous by itself to elicit posttraumatic responses or psychiatric morbidity whether or not the parent has encountered the deceased child at the site of death.

Psychosis and Suicide.

BACKGROUND: The life time risk of suicide among patients with long term psychosis is 5-15%. Suicide prevention in this group is a major clinical challenge. AIMS: To capture specific characteristics of suicidal communication and critical events preceding suicide in patients with psychosis. METHODS: Medical records were examined and a life event inventory applied to a one-year cohort of 21 cases of suicide in the clinical group in Stockholm county. RESULTS: In most cases direct or indirect verbal communication of suicidal thoughts were documented before the suicide. Three months preceeding death, 20 of the 21 subjects had described one or more negative critical experiences, typically physical illness, loss of contact with an important other, loss of "home", and intolerable side effects of medication. In most cases the suicide appeared to be the culmination of prolonged suffering and suicidal deliberations. CONCLUSIONS: Suicide prevention among patients with psychosis requires sensitivity, active listening, and responsiveness on the part of the care person to the patient's explicit suicidal communication and perceptions of care-related or other incidents or interactions, even when conveyed in an odd manner or with little emotion. To prevent suicide, attentive and long-term planning in collaboration with the patient is essential.

Assessment and treatment of asylum seekers after a suicide attempt: a comparative study of people registered at mental health services in a Swedish location.

BACKGROUND: Even though asylum seekers are considered vulnerable to mental ill-health, knowledge of their suicidal behaviour is limited. The aim of this study was to improve our understanding of factors that influence the clinical assessment of asylum seekers who have attempted suicide compared to the assessment of non-asylum seekers. METHODS: The study focused on 88 asylum seekers registered for suicide attempts in mental health services 2005-2009, who were matched for age and gender and compared with 88 suicide attempters with Swedish personal identity numbers. The medical records were analysed with a quantitative protocol, focusing on social risk and protective factors, health history, current clinical picture as well as the assessment procedure, diagnostics, patterns of treatment and follow-up in this clinical group. Data was analysed using the chi-square test, Fisher's exact probability test, and the Mann-Whitney U test. RESULTS: As in earlier studies, asylum seekers were more traumatized, had different social risk factors and received different diagnoses than the controls. Asylum seekers were referred to less specialized follow-up after treatment, in spite of their health history and of previous and current clinical pictures indicating a similar or--in the case of the female asylum seekers--more serious mental health condition. Female asylum seekers also received more intense and prolonged in-patient treatment than female controls. Asylum seekers appeared to have social networks more often than the control group. However, there was less documentation of the social context, previous suicidal behaviour, and on suicide in the family and close environment of the asylum-seeking men. Information on suicidal intent was lacking in a majority of both groups. The time relation of the suicide attempt and the asylum process suggested the importance of the asylum decision, as well as the possible role of earlier mental health problems and premigration stress, for the suicidal behaviour. CONCLUSIONS: The groups had different sets of risk factors and clinical pictures. There was a lack of early and thorough exploration of suicide intent for both groups, and of contextual and subjective factors for the asylum seekers. Differences in follow-up indicate unequal access to care.

Lack of Trust in the Health-Care System After Losing a Child to Suicide.

BACKGROUND: Lack of trust in the health-care system after losing a child to suicide may prevent bereaved parents from seeking professional treatment when needed, thus diminishing their chances of recovery. AIMS: This is the first large study to aim at evaluating the incidence of lack of trust in the health-care system and associated variables in suicide-bereaved parents. METHOD: This nationwide population-based survey included 569 parents who lost a child to suicide 2-5 years earlier and a matched comparison group of 326 nonbereaved parents. Using a study-specific questionnaire, we asked bereaved and nonbereaved parents if they trusted the health-care system and measured psychological and background variables. RESULTS: Prevalence of lack of trust in the health-care system differed between the bereaved (46.5%) and the nonbereaved parents (18.3%), giving a relative risk of 2.5 (95% CI = 2.0-3.3). After multivariable modeling, high scores of depression, living in big cities, and being single were identified as variables associated with lack of trust in suicide-bereaved parents. CONCLUSION: Suicide-bereaved parents show lack of trust in the health-care system. We present possible effect modifiers that may be considered in professional interventions aiming at influencing suicide-bereaved parents' level of trust.

Suicide-bereaved siblings' perception of health services.

The authors investigated suicide-bereaved siblings' reported reasons for seeking or not seeking professional support, their reported satisfaction when receiving it, and their recommendations to health services when meeting suicide-bereaved siblings. Using qualitative content analysis of 18 interviews with suicide-bereaved siblings, the authors found that the perception of health services as being helpful was influenced by both the participants' and by the deceased siblings' experiences with health services. They conclude that the bereaved sibling's and the deceased sibling's unmet needs may generate negative attitudes toward health services, which reduces the likelihood of seeking professional help as well as medication acceptance in some cases.

Suicide mortality trends in the Nordic countries 1980-2009.

BACKGROUND AND AIM: The Nordic countries provide a suitable setting for comparing trends in suicide mortality. The aim of this report is to compare suicide trends by age, gender, region and methods in Denmark, Finland, Iceland, Norway and Sweden 1980-2009. METHODS: Suicide statistics 1980-2009 were analyzed for men and women aged 15 years and above and the age group 15-24 years. Regional suicide rates in 2009 were presented in maps. RESULTS: The suicide rates across the Nordic countries declined from 25-50 per 100,000 in 1980 to 20-36 in 2009 for men and from 9-26 in 1980 to 8-11 in 2009 for women. The rates in Finland were consistently higher than those of the other countries. A significant increase of suicides in young women in Finland and Norway and a lack of a decline among young women in Sweden were noted. The male- female ratio of suicide converged to approximately 3:1 across the region during the study period. Rural areas in Finland, Norway and Sweden saw the highest suicide rates, whereas the rates in the capital regions of Denmark, Norway and Sweden were lower than the respective national rates. CONCLUSIONS: We hold that the overall decline of suicide rates in the Nordic countries reflects the socio-economic development and stability of the region, including the well-functioning healthcare. The increasing rates in Finland and Norway and the unchanged rate in Sweden of suicide in young women are an alarming trend break that calls for continued monitoring.

[The European Psychiatric Association (EPA) guidance on suicide treatment and prevention]. / Az Európai Pszichiátriai Szövetség (European Psychiatric Association, EPA) úmutatója az öngyilkosság kezelésére és megelözésére.

UNLABELLED: Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. Suicidal crisis: Acute intervention should start immediately in order to keep the patient alive. DIAGNOSIS: An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential. TREATMENT: Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. TREATMENT with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. TREATMENT with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. TREATMENT team: Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. Family: The suicidal person independently of age should always be motivated to involve family in the treatment. Social support: Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks. SAFETY: A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. Training of personnel: Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.

Suicide-nearness assessed with PORT, the Percept-genetic Object-Relation Test: A replication and a reliability study.

To determine the reliability and validity of a previously identified "suicide cluster" in the Percept-genetic Object-Relation Test (PORT), which test documents subliminal perception of object-relation pictures, 20 suicide attempters and 70 controls were investigated. The correspondence between scores assigned by two judges was 95%-100%. The suicide-cluster signs in PORT, notably "lack of attachment relationships" and "Motor activity," were significant. Differences between the results of this and the previous study are discussed as is the role of psychiatric disorder in suicide.

Primo Levi's loneliness: psychoanalytic perspectives on suicide-nearness.

To elucidate suicide-nearness, the perspectives of the death drive and narcissism are applied to the writings of Primo Levi. Emerging themes are Levi's struggle to maintain his self-regard from his year as a prisoner in Auschwitz and onward, and his observations on xenophobia, violence, and the need for love. The gradual increase of depressive content in Levi's work is noted, as are his identifications with others who succumbed in the Holocaust or took their lives after surviving it. The conflict between the wish for peace and the need for love is seen as impossible to resolve under the threat of extermination and as reemerging in the prevailing sense of loneliness that Levi described.

Depression, anxiety, and psychological defense in attempted suicide: a pilot study using PORT.

Depressive affect, anxiety, and psychological defenses were studied in the presented research with PORT, a projective test that exploits subliminal perception of object-relation images. Protocols of 20 hospitalized suicide attempters were compared to those of 20 matched controls, 34 previously studied nonsuicidal depressed patients, 18 patients with panic attack, and 32 patients with borderline and psychotic disorders. The suicide attempters were anxious; their defenses resembled those seen in borderline pathology; depressive reactions were limited in symbolic content; reality testing was poor. The closeness between depression and anxiety in suicidality is further discussed throughout this article. A constellation of signs using the PORT test was hypothesized to be a marker for suicidality. The test is deemed useful for future research on suicide.