Long-term psychosocial effects of persistent chronic illness. A follow-up study of Finnish adolescents aged 16 to 32 years.

Adolescents reporting persistent chronic illness at ages 16, 22, and 32 years (n = 296, limiting in daily life n = 52, non-limiting n = 244) were compared with those without any chronic illness (n = 401) in their life situation, psychosocial well-being and health habits at age 32 years. The data were drawn from a follow-up survey of a Finnish urban age cohort from age 16 until age 32 years. The group of persistent chronic illnesses included allergies (n = 249, 84%), non-allergic skin conditions (n = 10), migraine (n = 29), diabetes mellitus (n = 5), and others (n = 9). Results indicated that adults with persistent chronic illness limiting their daily life reported more depression and lower self-esteem than those with non-limiting chronic illness or healthy controls. Daily smoking was more common among females with any chronic illness than among healthy controls. No significant differences were found between adults with any persistent chronic illness (mainly non-severe allergic conditions) and healthy controls in psychosocial well-being. More attention in health care should be paid to psychological well-being in persons with limiting chronic illness. The study also raises the question how to improve health habit counselling within health care among females with chronic illness.

Paternal remarriage as a modifier of proneness to depression in young adulthood.

BACKGROUND: The remarriage of a parent is a major event experienced by many children. Its role in children's depressive symptoms was examined in a follow-up study of a cohort from the age of 16 to 22 years. METHODS: The study population consisted of young people who had experienced parental divorce in childhood (N=356). Associations between a parent's remarriage and potential modifying factors in adolescence (atmosphere at home, school performance, dating behavior, life-events, the importance of siblings, and socioeconomic status) and depressive symptoms at 22 years of age were studied. RESULTS: A poor atmosphere at home at 16 years and father's remarriage (but not mother's) in childhood were associated with subsequent depression. Girls whose father had not remarried, but boys whose father had remarried, were more depressive than others. Dating behavior in adolescence modified proneness to depression in these groups. CONCLUSION: The findings indicate the importance of the father in adolescent development after divorce and that the processes involved may differ by gender.

Completed suicide among adolescents with no diagnosable psychiatric disorder.

The characteristics of male adolescent suicide victims with (n = 84) and without (n = 8) a diagnosable psychiatric disorder were compared. Using psychological autopsy methods--interviews with victims' family members and health care professionals, and review of records (e.g., medical, school, police)-data were collected on all adolescent suicides in Finland during a 12-month period. Compared with adolescents with a psychiatric disorder, those with no disorder tended to come from less disturbed families, had shown less antisocial behavior, and had less frequently utilized health care and social services. Adolescents with no disorder more often communicated suicidal thoughts for the first time just before the suicide, and difficulties with the law (discipline problems) were more common precipitants than among those with a disorder. It was concluded that the process leading to suicide seems to be relatively short among male adolescents with no diagnosable psychiatric disorder. Communication of suicidal intent and problems with discipline are among the few clinical warning signs.

Psychosocial development among adolescents with visual impairment.

The psychosocial development of adolescents with visual impairment was studied in a group of 54 adolescents (40 boys, 14 girls) attending Finnish regular schools. Mean age was 14.0 (SD 0.87). The control group consisted of normally sighted adolescents of the same age level (N=385, 172 boys, 213 girls). Data were collected with self-report questionnaires. Results indicated that the adolescent group with visual impairment did not differ from the control group in the frequency of depression, distress symptoms or in their relations with parents and siblings. Adolescents with visual impairment less often had many friends and dates with other young people than those without visual impairment. They also reported more often feelings of loneliness and difficulties in making friends. Self-esteem, school achievement and social skills were lower in girls with visual impairment than in the control girls. In summary, our results showed that the psychosocial developmental outcomes of many adolescents with visual impairment were similar to their peers without visual impairment. However, some adolescents with visual impairment, especially girls, need more support in their psychosocial development.

Recent life events and suicide in personality disorders.

This study investigates the relationships between personality disorders, recent life events, and comorbid axis I disorders in suicide. Life events during the last week and last 3 months before suicide of 56 suicide victims with a DSM-III-R axis II personality disorder (PD) were compared with those of 56 age- and sex-matched comparison suicides with evidence of no PD. These victims were from a random sample of suicides representing a total 1-year nationwide suicide population in Finland. Life events had been more common among PD victims, particularly job problems, family discord, financial trouble, unemployment, and interpersonal loss; most victims with PD had had multiple life events. Events possibly dependent on the victim's own behavior had been much more common among the PD group, especially in the final week (70% vs. 23%). Age, gender, comorbid axis I diagnosis of alcoholism or depression, or PD cluster type B or C seemed to be less important factors in terms of excess events in the PD group. Thus, PD should be assessed as an important factor when analyzing the relationship between recent life events and suicide. Our findings suggest that interpersonal and job-related/financial problems may precede suicide closely among individuals with PD.

Psychosocial factors and completed suicide in personality disorders.

The aim of the present study was to investigate the relationships between personality disorders (PD) and various psychosocial factors in a random sample (n = 229) of suicides with psychological autopsy-based DSM-III-R diagnoses representing the total 1-year suicide population in Finland. Background social factors and social interaction factors for 56 suicide victims with a PD diagnosis were compared with those of 56 age- and sex-matched non-PD diagnosis victims. The groups were similar with regard to marital status, socio-economic status, parental divorce, broken home before the age of 16 years, parental suicide attempts, and proportion of subjects living with parents. The PD suicide victims had more commonly had a companion of the opposite sex, lived alone, and resided in an urban area, but had less often experienced parental psychiatric hospitalization during their childhood. Although the groups did not differ with regard to complaints of loneliness before suicide, the lonely PD suicide victims had experienced more interpersonal loss and/or conflict than the lonely non-PD suicide victims. The PD suicide victims were very similar with regard to psychosocial factors, irrespective of sex, age, Axis-I comorbidity, or the cluster type of the PD. Only living alone was more common in young PD suicide victims, and male PD subjects had less often had confidants or friends with whom they shared common interests.

Suicide among subjects with personality disorders.

OBJECTIVE: There have been few psychological autopsy studies of suicide among individuals with personality disorders. The possible specificity of characteristics of suicide among such individuals has been little investigated. METHOD: A random sample of 229 subjects who committed suicide, representing all suicide victims in Finland within a 12-month period, were comprehensively examined by using the psychological autopsy method and were diagnosed according to DSM-III-R criteria. Within this random sample the authors investigated all subjects with axis II personality disorders (N = 67) and divided them into clusters B (N = 43), C (N = 23), and A (N = 1). Individuals with clusters B and C personality disorders were separately compared with sex- and age-matched suicide victims without personality disorder, in terms of sociodemographic characteristics, comorbid axis I and III syndromes, treatment histories, previous suicide attempts, communication of suicide intent, and suicide methods. RESULTS: All suicide victims with a personality disorder received at least one axis I diagnosis. In 95% this included a depressive syndrome, a psychoactive substance use disorder, or both. Individuals with cluster B personality disorders were more likely than comparison subjects to have psychoactive substance use disorders (79% versus 40%) and previous nonfatal suicide attempts (70% versus 37%) and were less likely to have axis III physical disorders (29% versus 50%). Subjects with cluster C personality disorders were not found to differ from the control subjects in any of the variables examined. CONCLUSIONS: Suicide victims with personality disorders were almost always found to have had current depressive syndromes, psychoactive substance use disorders, or both. Suicide victims with cluster B personality disorders differed from other suicide victims in several characteristics, while those with cluster C personality disorders did not.

Social factors in suicide.

BACKGROUND: The study objective was to investigate the age-related variation of social factors in suicide. METHOD: Age-related variations in marital status, living arrangements, employment and social interaction were investigated in an entire 12-month suicide population in Finland (n = 1067); these findings were compared with appropriate census data. RESULTS: Several social factors varied across age groups among suicides, with some age-related sex differences. Compared with the general population, the suicides were more commonly never married (especially men aged 30-39 years), divorced, and widowed (especially women aged 60-69 years); living alone was more frequent among the suicides, as was living with parents among male suicides aged 25-39 years. A history of psychiatric admission was especially common among young male suicides who had never married or were living with parents. Living alone was particularly frequent among middle-aged male suicides who had misused alcohol. CONCLUSIONS: While most of the age-related variation in social factors found in suicide seems to parallel the natural variation of these factors in the general population, some social findings in suicide might be related to the victims' psychopathology and excessive alcohol use.

Mental disorders in cancer suicides.

Mental disorders among suicide victims who had suffered from cancer were investigated using psychological autopsy data on all suicides in Finland over 1 year. Retrospective DSM-III-R consensus diagnoses were assigned to all 60 cancer suicides and to 60 age- and sex-matched comparison suicides without a cancer history. Depressive syndromes were equally common along cancer suicides (80%) and others (82%). Alcohol dependence and personality disorders were more frequent among noncancer suicides. Major depression and substance abuse were more common among victims with cancer in remission than in terminal stages. Only a small minority of cancer suicides seem to occur in the absence of mental disorders.

Parental divorce, self-esteem and depression: an intimate relationship as a protective factor in young adulthood.

This study investigated whether an intimate relationship in young adulthood protects young people from depression in the presence of risk factors (parental divorce, low self-esteem in adolescence). The data were drawn from a follow-up survey of adolescents from the age of 16-22 (n = 1656). The prevalence of depression was highest among persons from divorced families who had reported low self-esteem at the age of 16 and who in young adulthood lacked an intimate relationship. An intimate relationship was found to protect young adults with the risk factor of earlier low self-esteem from depression irrespective of family background. The pattern was similar in both sexes.

Suicide among female adolescents: characteristics and comparison with males in the age group 13 to 22 years.

OBJECTIVE: To characterize female suicides (n = 19) in an unselected nationwide youth suicide population aged 13 to 22 years (n = 116) and to compare them with male suicides with respect to variables indicating psychopathology and psychosocial functioning. METHOD: The data were collected in a psychological autopsy study of all suicides (N = 1,397) in Finland during a 12-month period. Data collection included interviews of next of kin and professionals and information from records after the suicide. RESULTS: Two thirds (68%) of the female victims had suffered from a mood disorder, and 73% had communicated their suicidal intent. Half (47%) of the female subjects had been in psychiatric care at some point in their lives, and 42% had been hospitalized. Compared with young male suicides, the young female victims more often had made previous suicide attempts (63% versus 30%), received more often a diagnosis of major depression (37% versus 14%), and had more often been in psychiatric care (47% versus 21%) during the year preceding the suicide. The females were more often incapable of working, and their psychosocial impairment was more severe during the final week. Alcohol abuse was almost as common among the female as the male victims (21% versus 26%). CONCLUSION: The results suggest that young females who commit suicide may have suffered from more severe psychopathology than young male victims. Substance abuse seems to be a major factor also in female suicides. Preventive efforts within psychiatric care are likely to reach a higher proportion of the young females than males at high risk for suicide.

The last appointment before suicide: is suicide intent communicated?

OBJECTIVE: The authors' goal was to determine whether people who committed suicide within 4 weeks after having made contact with a health care professional communicated their intent to commit suicide during that final contact. METHOD: Using data from a nationwide psychological autopsy study of all suicides in Finland that occurred in 1 year, the authors examined the 571 cases of suicide victims whose last appointment with a health care professional took place up to 28 days before suicide, including 100 cases of victims who had appointments on the day of suicide. RESULTS: Suicide intent was reportedly discussed in only 22% of the cases; it was particularly uncommon in general practice and nonpsychiatric specialist settings. CONCLUSIONS: The majority of patients who commit suicide do not seem to communicate their intent to do so during their last appointment.

Age-related variation in recent life events preceding suicide.

Recent life events as reported by the next of kin were explored in male and female suicide victims to see how these factors varied across age groups by decade of age. The study population comprised all 1022 suicide victims aged 20 years and older in Finland during a 12-month period who had life event data assessed as reliable by the interviewing mental health professionals. Age-related patterns of variation of life events were found: separation, serious family arguments, financial trouble, job problems, unemployment, and residence change were more common among younger victims, whereas somatic illness and retirement were more common among older victims. Mean number of life events, greater among men than women, tended to decline gradually across the age range. In terms of sex differences, somatic illness was more common among elderly men, while separation, financial trouble, and unemployment were more common among younger men. Most life events among younger age groups were possibly dependent upon the victims' own behavior. Logistic regression indicated association between specific life events and alcohol misuse: separation, serious family arguments, financial trouble and unemployment were especially related to alcohol misuse. Violent suicide method lacked association with life events, being commoner only among males and those not having misused alcohol. Age- and sex-specific control groups and multidimensional life event interview schedules are needed to further investigate the relative risk of life events in suicide.

Mental disorders and suicide prevention.

In the research phase of the National Suicide Prevention Project, all suicides (n = 1397) in Finland between March 1987 and April 1988 were examined retrospectively using the psychological autopsy method. Careful retrospective diagnostic evaluation of the victims according to DSM-III-R criteria was done by weighing and integrating all available information. A series of studies addressing the mental disorders among suicide victims, the treatment received before death and the life events is now reviewed. Among a random sample of suicide victims from the natiowide suicide population, at least one psychiatric diagnosis was made for 93% of the victims. The most prevalent disorders were depressive syndromes (66%) and alcohol dependence/abuse (43%). The prevalence of major depression was higher among women than among men. Major depression as the principal diagnosis was more common among the elderly suicides. Among adolescent victims, depressive syndromes were also the most prevalent disorders. Adjustment disorders were common (25%) among male adolescent suicides. The majority of suicide victims of all ages suffered from comorbid mental disorders. Among suicide victims who had had contact with a health carer before death, inadequacy of treatment for mental disorders seems to have been common. Of the major depressive victims only 3% were found to have received adequate psychopharmacological treatment, and only 7% received weekly psychotherapy by a trained therapist. The analysis of the massive database collected in the research phase of the National Suicide Prevention Project in Finland is still ongoing, and the implications of the findings for suicide prevention will be refined during the research process. The necessity to improve recognition and treatment for comorbid depressive disorders in all age groups seems evident already.

Mental disorders in elderly suicide.

The purpose of this study was to investigate the prevalence and comorbidity of current mental disorders defined by DSM-III-R among elderly suicide victims and to compare them with the mental disorders among younger victims. Using a psychological autopsy method, we collected comprehensive data on all suicides in Finland during 1 year. Retrospective Axis I-III consensus diagnoses were assigned to a random sample consisting of 43 victims aged 60 years or over and 186 victims aged under 60 from the nationwide suicide population. At least one Axis I diagnosis was made for 91% of the elderly victims. Major depression as the principal diagnosis was more common among the elderly victims. Almost all elderly female victims were major depressives. Psychiatric comorbidity was more common among elderly male than among elderly female victims. More of the elderly victims (88%) than the younger (36%) received Axis III diagnoses. Suicide among the elderly without a diagnosable mental disorder and somatopsychiatric comorbidity seems to be rare.

Suicide in major depression in different treatment settings.

BACKGROUND: Whether suicide victims having suffered from major depression differ in their characteristics and treatment of depression received in various settings prior to death has been unknown. METHOD: From a random sample representing all completed suicides in Finland within a 12-month period, cases with a best estimate diagnosis of current unipolar DSM-III-R major depression (N = 71) were comprehensively analyzed using the method of psychological autopsy. Suicide victims with major depression were classified according to treatment setting, and the victims in different settings--psychiatric care (N = 32), medical care (N = 27), and no contact with health care (N = 12)--were compared. RESULTS: The sex distribution of suicides who had major depression was equal within psychiatric care; but in medical care or without contact with health care, 77% (30 of 39) were men (p = .018). Significantly more victims in psychiatric than in medical care had communicated to attending personnel their intent to commit suicide (59% [19 of 32] vs. 19% [5 of 27], p = .004). Antidepressants were received by 60% of victims in psychiatric care but only 16% in medical care (p = .002). CONCLUSION: Suicide victims with major depression differ in sex distribution and communication of suicide intent among treatment settings, which may complicate the ability to generalize research findings, particularly from psychiatric to medical care. Promoting suicide prevention in major depressive disorders would seem to require improving not only the quality of treatment within psychiatric care, but also basic skills in recognizing and treating depression in medical care, especially for male patients.

Differences in recent life events between alcoholic and depressive nonalcoholic suicides.

The purpose of this study was to investigate the main differences in recent life events preceding suicide between alcoholic and depressive nonalcoholic suicide victims, how much these differences were sex- and age-dependent, and how social support varied between these groups. Using the psychological autopsy method, retrospective best-estimate diagnoses by DSM-III-R criteria were assigned to a randomized 16.4% sample (n = 229) of suicide victims drawn from a 1-year total nationwide suicide population (n = 1,397) in Finland. Life events during the last 3 months (32 items) and social support (6 items) of 75 suicide victims with alcohol abuse/dependence diagnoses were compared with those of 69 nonalcoholic depressive victims. Among male suicides, the alcoholics had experienced more separations and family discord, financial trouble, and unemployment, whereas the depressives had experienced more somatic illness. Among females, adverse interpersonal events had been common in both alcoholic and depressive victims. Among the alcoholics, unlike the depressives, the number of adverse interpersonal life events had not diminished with increasing age. Living alone had been twice as common among the alcoholic suicides and, in these cases, recent separation, unemployment, and financial trouble were remarkably common, suggesting a concurrent stressor effect. Our results confirm and extend the earlier findings of excess interpersonal stressors among alcoholic suicides compared with depressive suicides. The findings suggest that multiple adverse life events and living alone need to be taken into account in clinical practice when assessing psychosocial stress and suicidal danger in alcoholism.

Suicide in bipolar disorder in Finland.

OBJECTIVE: The authors examined suicides of persons with bipolar disorder in aspects relevant to suicide prevention, including clinical features, treatment contacts, adequacy of treatment received, communication of suicidal intent, and suicide methods. METHODS: All suicide victims with DSM-III-R bipolar I disorder among all 1,397 suicides in Finland within a 12-month period were carefully studied using the psychological autopsy method and were compared to suicide victims with unipolar major depression. RESULTS: Thirty-one bipolar I victims were identified. Most suicides of persons with bipolar disorder occurred during a major depressive episode (79%), but in some cases it occurred during a mixed state (11%) or even during or immediately after remission of psychotic mania (11%). Men had a higher rate of comorbid alcoholism, a lesser mean age, and shorter treatment histories than women. Although 74% of the victims were receiving psychiatric care at the time of suicide, and 39% had even explicitly communicated their intent to health care personnel during the last 3 months, only 11% of those who were depressed had received adequate doses of antidepressants and none had received ECT. Only 32% of the bipolar patients were prescribed lithium. In comparison to unipolar depressed suicide victims, the bipolar victims had more divorces, longer treatment histories, and more frequent hospitalizations. CONCLUSIONS: Although late suicides were common among both male and female bipolar victims, suicide seemed to occur earlier among males. Most bipolar victims had had a recent psychiatric treatment contact, but few had received adequate treatment immediately before death. Suicide victims with unipolar and bipolar disorders differed in marital status and treatment history.

Psychosocial stressors more common in adolescent suicides with alcohol abuse compared with depressive adolescent suicides.

OBJECTIVE: Relationships between stressors and psychiatric diagnoses were studied among 13- to 19-year-old adolescent suicide victims with alcohol abuse/dependence (N = 14), depressive disorders (N = 18), and the remainder (N = 21). METHOD: The study included all adolescent suicides (N = 53) during a nationwide psychological autopsy study of suicides in Finland during a 12-month period (N = 1397). The data were collected through interviews with the victims' parents and health care personnel and from official records. RESULTS: Interpersonal separations and difficulties regarding discipline or the law were common recent stressors among the alcohol abuse victims, and interpersonal conflicts and somatic illness among those with depressive disorders. Compared with the depressive victims, an unstable earlier family history was more common among the alcohol abusers. The accumulation of stressors and weakened parental support during the previous year were also more frequently found in the alcohol abuse victims. CONCLUSIONS: The results indicate that specific psychosocial stressors may be critical for suicidal adolescents with different diagnoses. In the evaluation of suicidal adolescent substance abusers, particularly recent interpersonal separations and family support need to be carefully weighed. Disruptions in the adolescent's interpersonal relationships, excess accumulation of stress, and lacking support from the family may be warning signs of suicide potential and indications for additional social support, for more intensive treatment, or for a change in the treatment setting.