The association of childhood trauma with suicidality in adult psychiatric patients: The mediating role of NSSI and the moderating role of self-esteem.

BACKGROUND: The contribution of specific childhood trauma subtypes to suicidal thoughts and the associated mechanisms remains unclear, particularly in psychiatric patients. METHODS: Face-to-face interviews were conducted with 449 psychiatric patients aged 18-73. Childhood trauma, self-esteem, nonsuicidal self-injury (NSSI), and suicidality were assessed retrospectively. Regression and moderated mediation model were employed to examine these relationships. RESULTS: Emotional and sexual abuse were independently associated with suicidality. Female patients reported higher levels of emotional and sexual abuse, lower self-esteem, and a heightened risk of suicide. Self-esteem moderated the links between childhood trauma and NSSI, as well as between NSSI and suicidality. NSSI served as a mediator between childhood trauma and suicidality. CONCLUSIONS: Suicide prevention in mentally ill patients should involve targeted programs addressing specific childhood trauma. Additionally, psychological interventions to enhance self-esteem and assist individuals engaging in NSSI behavior are crucial.

Sleep quality of adult psychiatric outpatients at Chris Hani Baragwanath Academic Hospital.

Background: Sleep disorders are increasingly prevalent among the general population and individuals with mental disorders. However, little research has focused on the sleep quality of psychiatric patients beyond depression, despite its relevance in diagnostic criteria. Aim: This study aimed to assess overall sleep quality in psychiatric outpatients and to assess for an association with socio-demographic variables. Setting: This study took place at the adult psychiatric outpatient department of Chris Hani Baragwanath Academic Hospital. Methods: A cross-sectional study design was employed to evaluate overall sleep quality using the self-administered Pittsburgh Sleep Quality Index (PSQI), a validated tool. The PSQI yields a global score ranging from 0 to 21, with scores of 5 or greater indicating poor sleep quality. Eligibility was determined through structured clinical interviews and data obtained from participant records. Results: Poor sleep quality was found in 50% of participants. Sleep quality did not differ significantly based on sex or age. Subscale analysis revealed reduced sleep duration and efficiency, nocturnal disturbances and daytime dysfunction. Additionally, 38% of participants required pharmacological intervention for sleep issues, despite lacking a diagnosis of primary or comorbid sleep disorders. Conclusion: Half of the psychiatric outpatients experienced poor sleep quality, irrespective of socio-demographic factors, psychiatric diagnosis, symptom remission or medication type. Contribution: This study highlights the importance of addressing sleep disturbances as comorbid conditions in psychiatric patients. Comprehensive evaluation and management of sleep quality can lead to improved patient outcomes and quality of life.

Acceptability, feasibility, and user satisfaction of a virtual reality relaxation intervention in a psychiatric outpatient setting during the COVID-19 pandemic.

Background: The COVID-19 pandemic was particularly difficult for individuals with mental disorders. Due to governmental restrictions, face-to-face offers for psychiatric outpatients like therapies, psychoeducational groups or relaxation courses were limited. Virtual reality (VR) might be a new possibility to support these patients by providing them with a home-based relaxation tool. Objective: The aim of this study was to evaluate the acceptability, feasibility, and user satisfaction of a supportive therapy-accompanying, relaxation VR intervention in psychiatric outpatients during the COVID-19 pandemic in Germany. Methods: The four-weeks VR intervention consisted of regular watching of relaxing videos in the participants' home environment. Sociodemographics, feasibility (frequency of use, user-friendliness), satisfaction (Client Satisfaction Questionnaire-8), depressive symptoms (Patient Health Questionnaire-9), quality of life (abbreviated World Health Organization Quality of Life assessment), and credibility and expectancy (Credibility Expectancy Questionnaire-8) were measured in an intention-to-treat (ITT) analysis and a per-protocol (PP) analysis of completers. Results: In total, N = 40 patients participated in the study. Most of the participants in the ITT analysis (n = 30, 75.0%) used the VR device three or 4 weeks. A majority of the N = 29 completers (PP: n = 18, 62.1%) used it all 4 weeks. Most participants used the device two or more times a week (ITT: n = 30, 83.3%; PP: n = 26, 89.7%) and described the user-friendliness as rather or very easy (ITT: n = 33, 91.7%; PP: n = 26, 89.7%). User satisfaction was high (ITT: 19.42, SD = 4.08; PP: M = 20.00, SD = 4.19) and did not correlate with participants' sex or age (all p < 0.05). Depressive symptoms and psychological quality of life improved significantly from pre-to post-intervention (ITT and PP, all p < 0.05). Higher pre-intervention credibility significantly correlated with a better outcome of satisfaction (ITT and PP), depressive symptoms, physical, psychological, and social quality of life (PP; all p < 0.05). Conclusion: A supportive therapy-accompanying VR relaxation intervention is feasible and acceptable in a psychiatric outpatient setting. Due to the high satisfaction and user-friendliness, VR can be an easy to implement relaxation tool to support psychiatric outpatients. Clinical trial registration: https://clinicaltrials.gov/, DRKS00027911.

Telemedicine treatment of patients with mental disorders during and after the first COVID-19 pandemic lockdown in Germany - an observational study on feasibility and patient satisfaction.

INTRODUCTION: In response to the COVID-19 pandemic, a general lockdown was enacted across Germany in March 2020. As a consequence, patients with mental health conditions received limited or no treatment in day hospitals and outpatient settings. To ensure continuity of care, the necessary technological preparations were made to enable the implementation of telemedical care via telephone or video conferencing, and this option was then used as much as possible. The aim of this study was to investigate the satisfaction and acceptance with telemedical care in a heterogeneous patient group of psychiatric outpatients in Germany during the first COVID-19 lockdown. METHODS: In this observational study, patients in ongoing or newly initiated outpatient psychiatric therapy as well as those who had to be discharged from the day clinic ahead of schedule received telemedical treatment via telephone. Data collection to assess the patients' and therapists' satisfaction with and acceptance of the telemedical care was adjusted to the treatment setting. RESULTS: Of 60 recruited patients, 57 could be included in the analysis. 51.6% of the patients and 52.3% of their therapists reported that the discussion of problems and needs worked just as well over the phone as in face-to-face consultations. In the subgroup of patients who were new to therapy due to being discharged from hospital early, acceptance was higher and telemedicine was rated as equally good in 87.5% of contacts. Both patients and therapists felt that telemedicine care during lockdown was an alternative for usual therapy in the outpatient clinic and that the option of telemedicine care should continue for the duration of the coronavirus pandemic. DISCUSSION: The results show a clear trend towards satisfaction with and acceptance of telemedicine care in a heterogeneous group of unselected psychiatric patients. Although the number of patients is small, the results indicate that the mostly positive results of telemedicine concepts in research projects can probably be transferred to real healthcare settings. CONCLUSIONS: Telemedicine can be employed in healthcare for psychiatric patients either an alternative treatment option to maintain continuity of care or as a potential addition to regular care.

Prevalence of Prolonged Grief Disorder and Related Clinical Factors Among Turkish Psychiatric Outpatients During the COVID-19 Pandemic.

Prolonged grief disorder (PGD), a new diagnosis in some classification systems, has gained prominence due to the high mortality rates observed during the Covid-19 pandemic. Herein, the prevalence of PGD (diagnosed with structured clinical interviews), death-related features, and associated clinical factors were investigated among outpatient psychiatric patients who lost a first-degree relative within the past 12-24 months. PGD was diagnosed in 30/68 patients (44.1%). PGD development did not differ based on cause of death (Covid-19-related vs. other causes) but was associated with higher age of the bereaved, younger age of the deceased, and degree of kinship. Higher rates of depression, insomnia, and anxious attachment were also observed in PGD patients. Finally, the unexpectedness of death predicted the development of PGD. Due to the high prevalence of PGD among psychiatric patients, clinicians should be aware of the disorder, monitor grief processes in high-risk patients, and consider PGD in treatment planning.

Sexual risk behavior among individuals seeking outpatient mental health services: Associations with childhood emotional neglect and identity dysfunction.

This study was developed to examine sexual risk behavior among patients seeking community-based mental health services, including associations with psychological distress, identity dysfunction, and childhood emotional neglect. A mediation model was examined regarding identity dysfunction mediating the link between emotional neglect and sexual risk behavior. A total of 245 outpatients completed questionnaires regarding perceived risky sexual behavior, psychological distress, identity dysfunction, and emotional neglect. Sexual risk behavior was found to be a prevalent issue among individuals seeking outpatient mental health services, with 13% reporting engagement in unsafe sexual practices at least some of the time. Mediation analysis revealed that childhood emotional neglect was indirectly linked with sexual risk behavior through the mediating effect of identity dysfunction. Thus, findings suggest a pathway to sexual risk behaviors through perceived childhood emotional neglect and identity dysfunction. Clinical attention to identity-related vulnerability among this population may be warranted in aiming to mitigate risk-taking associated with sexual practices.

Psychometric evaluation of the 9-item Concise Health Risk Tracking - Self-Report (CHRT-SR9) (a measure of suicidal risk) in adolescent psychiatric outpatients in the Texas Youth Depression and Suicide Research Network (TX-YDSRN).

BACKGROUND: This study evaluated the psychometric properties of the 9-item Concise Health Risk Tracking Self-Report (CHRT-SR9), a measure of suicidality, in adolescent psychiatric outpatients. METHODS: Altogether, 933 depressed or suicidal adolescents (12-20 years of age), receiving treatment at psychiatric outpatient clinics in Texas, completed the 16-item CHRT-SR at baseline and one month later. CHRT-SR9 was extracted from CHRT-SR16 using multigroup confirmatory factor analysis. Sex and age measurement invariance, classical test theory, item response theory (IRT), and concurrent validity analyses (against the suicidal ideation Item 9 of Patient Health Questionnaire-Adolescent (PHQ-A)) were conducted. RESULTS: The CHRT-SR9 demonstrated excellent model fit with four factors (pessimism, helplessness, despair, and suicidal thoughts). Measurement invariance was upheld. Acceptable item-total correlations (0.56-0.80) and internal consistency (Spearman-Brown 0.78-0.89) were revealed. IRT analyses showed a unidimensional instrument with excellent item performance. Using the CHRT-SR9 total score as a measure of overall suicidality and comparing it against levels of PHQ-A Item 9, the mean (standard deviation) of CHRT-SR9 total score was 8.64 (SD = 5.97) for no-risk (0 on Item 9), 17.05 (SD = 5.00) for mild, 23.16 (SD = 5.05) for moderate, and 26.96 (SD = 5.24) for severe-risk (3 on Item 9). Significant differences (p-value<0.0001) indicated that CHRT-SR9 total score distinguished between levels of suicidal risk. Furthermore, CHRT-SR9 was sensitive to change over a one-month period. LIMITATIONS: Whether CHRT-SR9 predicts actual suicidal attempts in adolescents is not well defined. CONCLUSION: The CHRT-SR9 is an easy-to-administer, user-friendly self-report with good psychometric qualities which makes it an excellent screening measure of suicidal risk in adolescent psychiatric outpatients.

Positive Orientation and Psychological Distress: An Examination with Psychiatric Outpatients

@#Introduction: This research was conducted to extend the theoretical construct of positive orientation (PO) to psychiatric outpatients. This research also examined the effect of PO on alleviating stress, anxiety, and depression among psychiatric outpatients. Methods: This cross-sectional survey recruited 301 psychiatric outpatients online. As these respondents have a short attention span, short measures were used to measure PO-related variables (life satisfaction, optimism, self-esteem) and indicators of psychological distress (depression, anxiety, and stress). These outpatients are at the legal age to provide consent for themselves (M = 30.12, SD= 8.11). The majority of them have been identified as male (80.07%). Similarly, the ethnic distribution was unequal, with the majority of these outpatients identified as Malay (85.05%), followed by those who were identified as Chinese (7.31%), Indian (4.32%), and from other ethnic groups (3.32%). Results: Generalized structured component analysis (GSCA) supported that satisfaction with life, optimism, and self-esteem reflect the construct of PO. Furthermore, PO predicted depression, anxiety, and depression negatively. Conclusion: It is possible to replicate the construct of PO with psychiatric outpatients using single item measures for life satisfaction, optimism, and self-esteem. PO is beneficial to psychiatric outpatients as it reduces the severity of depression, anxiety, and stress.

Corrigendum: Acceptability, feasibility, and user satisfaction of a virtual reality relaxation intervention in a psychiatric outpatient setting during the COVID-19 pandemic.

[This corrects the article DOI: 10.3389/fpsyt.2023.1271702.].

Initial adherence by psychiatric outpatients in a general hospital and relevant personal factors.

BACKGROUND: Initial adherence is a predictor of long-term adherence and thus is a crucial metric to explore and support. This study aimed to investigate initial adherence by psychiatric outpatients and relevant personal factors. METHODS: The study surveyed psychiatric outpatients using a 30-day timely return visit rate (TRVR) after the first visit to indicate initial adherence. All participants agreed to engage in the self-designed survey and assessments of the Eysenck Personality Questionnaire (EPQ) and Symptoms Checklist-90 (SCL-90). Clients who missed timely return visits received telephone follow-up to determine the main reasons. RESULTS: The overall TRVR was 59.4, and 40.6% of clients missed return visits. Logistic regression analysis revealed risk factors for initial adherence were work, tense family atmosphere, negative attitudes towards medication, higher EPQ psychoticism score, and lower SCL-90 phobic anxiety score. The main reasons given for non-timely return visits were improvement suggesting lack of need for a return visit, various barriers, no improvement, and side effects. CONCLUSION: Psychiatric outpatients had poor initial adherence related to multiple dimensional factors, including job, family, personality characteristics, mental status, and thoughts about mental illness and treatments.

Adapting to a major crisis: Sleep and mental health during two lockdowns.

The present study aimed at investigating the impact of the pandemic on sleep and mental health in healthy individuals (n = 78) as well as in psychiatric outpatients (n = 30) during the first and the second lockdown in Germany, in March and November 2020, respectively. Sleep quality and anxiety were worse in patients compared with controls during both lockdowns. Further, patients but not controls exhibited higher levels of depression and overall psychiatric symptomatology during the second lockdown. No differences were found in the perceived threat evoked by the pandemic. The data suggest that healthy individuals adapt flexibly to the difficult situation over the time course of the pandemic, whereas psychiatric patients seem to get worse, indicating difficulties in adapting to stressful circumstances.

The COVID-19 Pandemic: A Longitudinal Study on the Emotional-Behavioral Sequelae for Children and Adolescents with Neuropsychiatric Disorders and Their Families.

This study aimed to investigate the immediate and short-term impact of the pandemic on the psychological well-being of Italian children and adolescents with psychiatric disorders and their families. Overall, 56 patients aged 6-18 (M = 13.4 years, SD = 2.77) and their parents were evaluated during the COVID-19 lockdown (T0) and after 4 months (T1). An ad hoc data sheet, Youth Self-Report 11-18 (YSR), Child Behavior Checklist 6-18 (CBCL), and Depression Anxiety Stress Scale-21 (DASS-21) were administered. Patients, mainly suffering from internalizing disorders, overall demonstrated a good adaptation to the pandemic context. Moreover, patients with behavioral disorders showed a greater psychological discomfort at both T0 and T1 compared to patients with internalizing disorders. Over time, patients presented an improvement on the emotional side, as proven by a significant decrease in internalizing and post-traumatic stress problems. Finally, no significant differences were found in the emotional-behavioral profile of patients according to the means of conducting neuropsychiatric interventions during the lockdown (i.e., in person/remotely/interrupted), thus allowing us to exclude important negative effects caused by the transition to remote therapy. Concerning parents, an inverse relationship emerged between the DASS-21 scores and the level of resilience, which therefore represents a protective factor against psychological maladjustment. Over time, an improvement in the psychological well-being of parents was observed, as shown by a significant decrease in mothers' anxiety and fathers' stress.

Depressive symptoms and health-related quality of life in a heterogeneous psychiatric sample: conditional indirect effects of pain severity and interference.

BACKGROUND: Few studies have examined clinically relevant mechanisms that underlie the association between two important indices of recovery- depression severity and health-related quality of life (HRQOL) in psychiatric outpatients. This study aimed to explicate the roles of pain interference and pain severity as mediating and moderating mechanisms in the relationship between depressive symptoms and HRQOL. METHODS: Data from 290 outpatients diagnosed with schizophrenia (n = 102), depressive (n = 98), and anxiety (n = 90) disorders were examined. Participants completed a set of questionnaires that queried their sociodemographic statuses, current pain severity and interference levels, depression severity levels, and HRQOL. Subsequently, mediation and moderation analyses were conducted. RESULTS: Analyses revealed that pain interference fully mediated the relationship between depressive symptoms and physical (34% of the total effect) but not mental HRQOL. At high pain levels (+ 1 SD from mean), depressive symptoms may interfere with physical quality of life through pain interference, but this was not present at low pain levels (- 1 SD from mean). CONCLUSIONS: Prolonged pain symptoms could negatively influence psychiatric recovery beyond the physical aspect of HRQOL. These results thus imply a need to detect and manage severe physical pain complaints at the acute stage in psychiatric outpatients.

Sluggish Cognitive Tempo in Adults Referred for an ADHD Evaluation: A Psychometric Analysis of Self- and Collateral Report.

Objective: Sluggish cognitive tempo (SCT) symptoms uniquely contribute to psychiatric and functional outcomes in child samples; however, the psychometric properties of SCT measures among adult outpatients are unknown. Method: Adults (n = 124) presenting for an ADHD evaluation provided self- and collateral report of SCT symptoms. Results: The SCT scale had good internal consistency and yielded three factors across raters: Slow/Daydreamy, Sleepy/Sluggish, and Low Initiation/Persistence. SCT scores exhibited convergent validity with ADHD symptoms across raters. Individuals with ADHD received higher SCT ratings than those without ADHD via collateral report, a pattern that was similar when comorbidity was considered. SCT was associated with poorer functioning after accounting for ADHD symptoms with some differential effects based on reporting source. Conclusion: Findings support the internal consistency and validity of a three-factor SCT scale among adult outpatients. Differential results between self- and collateral report demonstrate the importance of multiple reporters of SCT in clinical settings.

Children with Psychopathology and Their Parents Facing the Covid-19 Pandemic: A Case-Control Study.

OBJECTIVE: This case-control study aimed to explore the effects of the COVID-19 outbreak on the mental well-being of pediatric psychiatric outpatients and their families, comparing them with children/adolescents and their parents from the general population. METHOD: The case group consisted of 168 subjects: 56 patients (6-18 years old) with psychiatric disorders, and their 112 parents. The healthy control group included 189 subjects: 63 children and adolescents with no psychopathologies, and their 126 parents. Both groups were assessed during the first COVID-19 lockdown in Italy (T0) and 4 months later (T1), by administering the CBCL6-18 and DASS-21. RESULTS: Patients showed a good adaptation to the pandemic situation, while the children/adolescents in the healthy sample showed a greater variation in their general habits and a higher prevalence of stress symptoms during the lockdown. The patients' parents likewise had fewer stress-related symptoms than caregivers in the healthy control group, both during the lockdown and 4 months later. At T0, patients' mothers reported higher anxiety levels than mothers in the healthy group, while at T1 fathers of healthy children scored higher on the DASS-21 anxiety and stress scales than patients' fathers. As concerns changes over time (T0-T1) in the parents' psychological well-being, a general improvement was detected in both groups. CONCLUSIONS: The pandemic and quarantine measures were confirmed as significant stressors for all children and adolescents, and negatively affected their parents' adaptation. The findings of this study point to the need for preventive interventions to support the mental health of all parents and their children in uncertain and stressful times.

Love of life and its association with well-being in Iranian psychiatric outpatients.

Aim: The aims of this study were as follows: (a) to investigate the psychometric properties of the Love of Life Scale (LLS); (b) to explore sex differences in LLS scores; (c) to explore LLS correlations with spiritual health and psychological well-being; and (d) to compare the mean LLS score with previous studies. Design: A cross-sectional study. Methods: A sample of 191 Iranian psychiatric outpatients was recruited from clinics at the School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), which is affiliated with the Iran University of Medical Sciences. They responded to the Farsi versions of the LLS, the Spiritual Well-Being Scale (SWS) and the World Health Organization-five Well-Being Index (WHO-5). Results: Cronbach alpha for the LLS was 0.95, and a principal component analysis (PCA) of the LLS items extracted one component labelled "Love of life." The sex difference in LLS scores was not significant. All the correlations between the scales were statistically significant and positive. Patients who had high scores for their love of life had better spiritual health and psychological well-being. Discussion: The present sample obtained a lower mean LLS score than college students from eight countries except one. Further research should explore predictors of the love of life.

Patient-reported well-being: psychometric properties of the world health organization well-being index in specialised community mental health settings.

The Five-item World Health Organization Well-being Index (WHO-5) is an increasingly used measure of generic well-being, but there is no evidence to support whether outpatients consider the questionnaire valuable. As the WHO-5 has not yet been psychometrically evaluated in specialised community mental health settings, an evaluation of its validity seems warranted. The aim of this cross-sectional study was to examine the psychometric properties of the WHO-5 in this type of setting. Data was collected from an outpatient center (N = 191 adults). Results indicate that the questionnaire was feasible to administer (n = 57 patients), it reported low mean Burden-scores and high Positive-Value scores, and had excellent internal consistency. No evidence of floor or ceiling effects was found. Results supported the unidimensional structure of the questionnaire. Significant differences were found concerning patients' diagnoses, with patients with schizophrenia diagnoses reporting higher scores and patients with depression and personality disorders reporting lower ones. When comparing the WHO-5 total score and patients' attitudes toward medication, negative correlations were observed with psychological reactance, as well as positive aspects of psychiatric medication. The present study demonstrates that the WHO-5 is feasible to administer and has robust psychometric properties in specialised community mental health centres.

Perfectionism and Prospective Near-Term Suicidal Thoughts and Behaviors: The Mediation of Fear of Humiliation and Suicide Crisis Syndrome.

BACKGROUND: Perfectionism has been linked to suicide. According to the Narrative-Crisis Model of suicide, individuals with trait vulnerabilities are prone to develop a certain mindset, known as a Suicidal Narrative, which may precipitate the Suicide Crisis Syndrome (SCS), culminating in suicide. The purpose of this study was to investigate the association between perfectionism (trait vulnerability), fear of humiliation (component of the Suicidal Narrative), SCS, and prospective near-term suicidal thoughts and behaviors (STB). METHODS: Adult psychiatric outpatient participants (N = 336) were assessed at baseline with the Suicidal Narrative Inventory for perfectionism and fear of humiliation. The questions used to assess perfectionism were adapted from the Multidimensional Perfectionism Scale. The severity of the SCS was calculated using the Suicide Crisis Inventory. STB were assessed at baseline and after one month using the Columbia Suicide Severity Rating Scale. Serial mediation analyses were conducted using PROCESS version 3.3 in SPSS. RESULTS: While the direct effect of perfectionism on prospective STB was not significant (b = 0.01, p = 0.19), the indirect effect of perfectionism on STB, through serial mediation by fear of humiliation and the SCS, was significant (indirect effect p = 0.007, 95% CI [0.003,0.013]). The indirect effect was not significant for models that did not include both mediators. LIMITATIONS: Variables were assessed at one time only. CONCLUSION: Perfectionism did not directly modulate STB. Perfectionism may be related to suicidal behavior through fear of humiliation, leading to the SCS. These results support the Narrative-Crisis Model of suicide and clarify the role of perfectionism in the etiology of suicide.

Mortality and suicide rates in patients discharged from forensic psychiatric wards in Japan.

BACKGROUND: Japanese forensic mental health services for patients with psychiatric disorders under the Medical Treatment and Supervision Act was initiated in 2005; however, the prognosis of those patients is not well-known, particularly regarding mortality and suicide. This study aimed to evaluate the all-cause mortality and suicide rate in forensic psychiatric outpatients who had been discharged from forensic psychiatric wards in Japan. METHODS: Participants included 966 patients who had been discharged from forensic psychiatric wards. Data were collected from July 15, 2005 to July 15, 2018 at 29 of the 33 forensic psychiatric wards in Japan. Only the patients who provided written informed consent were included. We and collaborators at each forensic psychiatric ward identified demographic data of participants from the medical records for the inpatient treatment period. The reintegration coordinators, who belonged to the Ministry of Justice, investigated the prognosis of the participants during the outpatient treatment order period. We then connected demographic data and participants' prognosis for analysis. The crude rates (CRs) and standardized mortality ratios (SMRs) were calculated to analyze all-cause mortality and suicide rates. Univariate analysis was performed to examine the factors associated with all-cause mortality and suicide rates using the Cox proportional hazards ratio model. RESULTS: The participants included 3.3 times as many men (n=739) compared to women (n=227), and their combined mean age was 47.3 (SD=12.9). The most common primary psychiatric diagnosis was psychotic disorders (81.3%). The mean follow-up period was 790.2 days (SD=369.6). The total observation period was 2091.2 person-years. The CR for all-cause death was 812.9 per 100,000 person-years (95% CI [426.5, 1199.4]), while the SMR for all-cause death was 2.2 (95% CI [1.3, 3.5]). The CR for completed suicide was 478.2 per 100,000 person-years (95% CI [181.8, 774.6]). The suicide SMR was 17.9 (95% CI [8.6, 32.9]) overall, 7.7 (95% CI [2.5, 18.0]) for men, and 79.4 (95% CI [25.8, 185.2]) for women. Univariate analysis showed that women had higher completed suicide risk than men (hazard ratio=3.599, 95% CI [1.041, 12.445]). CONCLUSION: The all-cause mortality and completed suicide rates were higher in participants than observed in the general population consistent with the results of previous international studies.