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Research into patient suicide indicates that it has an impact on the psychiatrists involved, but leaves a number of unanswered questions about which elements of the experience are most likely to cause problems, who is most at risk, what is the clinical or professional significance of any effect on the psychiatrist and how other professionals are affected. Despite these uncertainties, it is clear that a response is needed, with three bodies responsible in different ways for coordinating one: the relevant mental health trust, as employer; the Royal College of Psychiatrists, as the professional representative body; and the National Confidential Inquiry into Suicide and Safety in Mental Health, as mediator of social and professional impact.
Charles Baudelaire’s notion of the flaneur – a figure who mingles with crowds and street scenes but also observes and documents the sights from a distance – captures well the early life of John Kennedy Toole and the character of Ignatius Reilly at the center of his famous novel. Ignatius is modeled upon a colleague of Toole’s at a small college in Lafayette, Louisiana, a scholar of Medieval culture and history who came from New Orleans. It also traces the novel’s publication history and extraordinary success in the Spanish-speaking world, as well as the tragic end to young novelist’s life by suicide.
This chapter is based on descriptions of three mentally disordered offenders. The first had a history of severe traumatization and the second suffered from a psychotic illness. They were both sent to prison and both committed suicide. The third suffered from Asperger syndrome and was sent to a secure psychiatric facility. I argue that the two deaths arose from a prescientific, retributive response to crime that was wholly inappropriate in these individuals. In the case of the trauma victim, the system responded by inflicting further trauma on her. The tragic outcome in the psychotic offender arose from the application of a legal definition of insanity that does not allow for complex clinical realities. I conclude that these cases point to a need to move from a retributive response to crime to one based on achieving the best outcomes for victims, offenders, and society. Legal concepts and definitions of insanity should be dropped. Instead, we should adopt an approach that is therapeutic rather than punitive in all cases where mental disorder has been a necessary causal factor in the commission of the offence.
The two instruments the state uses to maintain order are the corrective and the preventive. Those who reject the notion of moral responsibility either prefer to abandon punishment in favor of preventive techniques or seek to justify (nonretributive) punishment. Although I think punishment is essentially retributive and cannot be justified, I also think we must, if possible, avoid yielding to the preventive worldview. We must distinguish the lengths to which we are willing to go with incompetent or irrational individuals who are dangerous from the lengths to which we are willing to go with rational and competent offenders. My view is that borrowing from punishment its harsh methods we maintain the dignity of competent offenders when we subject them to these methods with the aim of leading them to abandon the defective motivational traits that resulted in the crime. I call this approach correction rather than punishment, because it lacks the retributive element that makes punishment punishment. Here I suggest how this view might be defended if we start, as Fichte does, from the assumption that those who violate any law deserve to be made outlaws; in current terminology, to be subjected to preventive detention and preventive techniques generally.
Suicide is a global public health problem, but very few theories have been developed for its etiology and effective prevention. Presented in this article is a comprehensive and parsimonious theory explaining the socio-psychological mechanism prior to suicidal behavior. Strain, resulting from conflicting and competing pressures in an individual’s life, is hypothesized to precede suicide. The strain theory of suicide (STS) proposes four sources of strain leading to suicide: (1) value strain from differential values; (2) aspiration strain from the discrepancy between aspiration and reality; (3) deprivation strain from the relative deprivation, including poverty; and (4) coping strain from deficient coping skills in the face of a crisis. This new model is built on previous notions of anomie (Durkheim, 1897/1951), strain theories of deviance (Merton, 1957) and crime (Agnew, 1992), although suicide is not a major target for explanation in those theories. Future research with rigorous quantitative data needs to be conducted to further test STS on a more comprehensive level.
This study investigates suicide risk in late childhood and early adolescence in relation to a family-centered intervention, the Family Check-Up, for problem behavior delivered in early childhood. At age 2, 731 low-income families receiving nutritional services from Women, Infants, and Children programs were randomized to the Family Check-Up intervention or to a control group. Trend-level main effects were observed on endorsement of suicide risk by parents or teachers from ages 7.5 to 14, with higher rates of suicide risk endorsement in youth in the control versus intervention condition. A significant indirect effect of intervention was also observed, with treatment-related improvements in inhibitory control across childhood predicting reductions in suicide-related risk both at age 10.5, assessed via diagnostic interviews with parents and youth, and at age 14, assessed via parent and teacher reports. Results add to the emerging body of work demonstrating long-term reductions in suicide risk related to family-focused preventive interventions, and highlight improvements in youth self-regulatory skills as an important mechanism of such reductions in risk.
Women suffering from first onset postpartum mental disorders (PPMD) have a highly elevated risk of suicide. The current study aimed to: (1) describe the risk of self-harm among women with PPMD and (2) investigate the extent to which self-harm is associated with later suicide.
We conducted a register-based cohort study linking national Danish registers. This identified women with any recorded first inpatient or outpatient contact to a psychiatric facility within 90 days after giving birth to their first child. The main outcome of interest was defined as the first hospital-registered episode of self-harm. Our cohort consisted of 1 202 292 women representing 24 053 543 person-years at risk.
Among 1554 women with severe first onset PPMD, 64 had a first-ever hospital record of self-harm. Women with PPMD had a hazard ratio (HR) for self-harm of 6.2 (95% CI 4.9–8.0), compared to mothers without mental disorders; but self-harm risk was lower in PPMD women compared to mothers with non-PPMD [HR: 10.1, (95% CI 9.6–10.5)] and childless women with mental disorders [HR: 9.3 (95% CI 8.9–9.7)]. Women with PPMD and records of self-harm had a significantly greater risk for later suicide compared with all other groups of women in the cohort.
Women with PPMD had a high risk of self-harm, although lower than risks observed in other psychiatric patients. However, PPMD women who had self-harmed constituted a vulnerable group at significantly increased risk of later suicide.
Rates and risk factors for suicidal behaviour require updating and comparisons among mood disorders.
To identify factors associated with suicidal risk in major mood disorders.
We considered risk factors before, during and after intake assessments of 3284 adults with/without suicidal acts, overall and with bipolar disorder (BD) versus major depressive disorder (MDD), using bivariate comparisons, multivariable regression modelling and receiver operating characteristic (ROC) analysis.
Suicidal prevalence was greater in BD versus MDD: ideation, 29.2 versus 17.3%; attempts, 18.8 versus 4.78%; suicide, 1.73 versus 0.48%; attempts/suicide ratio indicated similar lethality, 10.9 versus 9.96. Suicidal acts were associated with familial BD or suicide, being divorced/unmarried, fewer children, early abuse/trauma, unemployment, younger onset, longer illness, more dysthymic or cyclothymic temperament, attention-deficit hyperactivity disorder (ADHD), substance misuse, mixed features, hospital admission, percentage time unwell, less antidepressants and more antipsychotics and mood stabilisers. Logistic regression found five independent factors: hospital admission, more depression at intake, BD diagnosis, onset age ≤25 years and mixed features. These factors were more associated with suicidal acts in BD than MDD: percentage time depressed/ill, alcohol misuse, >4 pre-intake depressions, more dysthymic/cyclothymic temperament and prior abuse/trauma. ADHD and total years ill were similar in BD and MDD; other factors were more associated with MDD. By ROC analysis, area under the curve was 71.3%, with optimal sensitivity (76%) and specificity (55%) with any two factors.
Suicidal risks were high in mood disorders: ideation was highest with BD type II, attempts and suicides (especially violent) with BD type I. Several risk factors for suicidal acts differed between BD versus MDD patients.
Declaration of interest
No author or immediate family member has financial relationships with commercial entities that might appear to represent potential conflicts of interest with the information presented.
Trans and gender diverse (TGD) young people worldwide experience high rates of poor mental health; however, these rates were unknown in Australia. In addition, how negative life events affect the mental health of TGD young people has been largely unexplored.
This paper reports on novel mental health findings of Trans Pathways, the largest study ever conducted in Australia with trans (transgender) and gender diverse young people (N = 859; aged 14–25 years). The study was an anonymous online cross-sectional survey undertaken in 2016. Logistic and linear regression models were used to test associations between mental health outcomes and negative life experiences.
TGD young people in Australia experience high levels of mental distress, including self-harming (79.7%), suicidal thoughts (82.4%), and attempting suicide (48.1%). Three in four participants had been diagnosed with depression and/or anxiety (74.6% and 72.2%, respectively). Many TGD young people had been exposed to negative experiences such as peer rejection (89.0%), precarious accommodation (22.0%), bullying (74.0%), and discrimination (68.9%). Most poor mental health outcomes were associated with negative experiences. The strongest associations were found for precarious accommodation and issues within educational settings. For example, participants with a prior suicide attempt were almost six times more likely to have experienced issues with accommodation, including homelessness.
The current results highlight the urgent need for better mental health care and provide insight into areas for targeted mental health interventions. These findings are pertinent for clinicians working with trans young people and wider society.
To investigate the association between suicide death and serum cholesterol levels as measured at times close to suicide death.
We conducted a nested case-control study of 41 cases of suicide deaths and 205 matched controls with serum total cholesterol (TC) levels till 3 years before suicide death in a large cohort of Japanese workers.
Individuals in the lowest versus highest tertile/predefined category of TC in a Japanese working population had a three- to four-fold greater risk of suicide death. Each 10 mg/dl decrement of average TC was associated with an 18% increased chance of suicide death (95% confidence interval, 2–35%). Similar results were found for TC levels at each year.
These results suggest that a low serum TC level in recent past is associated with an increased risk of suicide death.
To follow-up a cohort of older people who self-harmed, their carer, and general practitioner (GP) and examine their reflections on the self-harm, care experiences, and outcomes.
Qualitative in-depth interviews.
Two teaching hospitals and associated community services.
Twelve-month follow-up of participants aged 80 or older who self-harmed, their nominated carers, and GPs.
A geriatric psychiatrist gathered data through patient and carer interviews using a narrative inquiry approach and from medical records. Interviews were audio recorded and transcribed. N-VIVO facilitated data organization for thematic analysis. Questionnaires sent to the patient’s GP examined their perspectives and aspects of care relating to the self-harm.
Nineteen patients (63% baseline sample), 29 carers (90.6%), and 11 GPs (36.7%) were available at follow-up. Themes emerging from patients were “denial and secrets;” “endless suffering;” “more invalidation;” “being heard;” and “miserable in care.” Themes from carer interviews were “denial and secrets;” “patient’s persistent wish to die;” “abandonment by clinicians;” “unending burden for the carer;” and “distress regarding placement.” General practitioner themes were “the problem is fixed;” “the troops have arrived;” and “I understand.”
Factors contributing to self-harm persisted at follow-up. Positive and negative responses were identified in the older person’s system, highlighting areas for potential intervention. A conceptual framework for understanding self-harm in the very old was derived that emphasized the importance of understanding individual needs, the interpersonal context of the older person, and carer burden. Interventions should improve communication, facilitate shared understanding of perspectives, and provide support at all levels.
Studies on the individual gender-specific risk and familial co-aggregation of suicidal behaviour in autism spectrum disorder (ASD) are lacking.
We conducted a matched case-cohort study applying conditional logistic regression models on 54 168 individuals recorded in 1987–2013 with ASD in Swedish national registers: ASD without ID n = 43 570 (out of which n = 19035, 43.69% with ADHD); ASD + ID n = 10 598 (out of which n = 2894 individuals, 27.31% with ADHD), and 270 840 controls, as well as 347 155 relatives of individuals with ASD and 1 735 775 control relatives.
The risk for suicidal behaviours [reported as odds ratio OR (95% confidence interval CI)] was most increased in the ASD without ID group with comorbid ADHD [suicide attempt 7.25 (6.79–7.73); most severe attempts i.e. requiring inpatient stay 12.37 (11.33–13.52); suicide 13.09 (8.54–20.08)]. The risk was also increased in ASD + ID group [all suicide attempts 2.60 (2.31–2.92); inpatient only 3.45 (2.96–4.02); suicide 2.31 (1.16–4.57)]. Females with ASD without ID had generally higher risk for suicidal behaviours than males, while both genders had highest risk in the case of comorbid ADHD [females, suicide attempts 10.27 (9.27–11.37); inpatient only 13.42 (11.87–15.18); suicide 14.26 (6.03–33.72); males, suicide attempts 5.55 (5.10–6.05); inpatient only 11.33 (9.98–12.86); suicide 12.72 (7.77–20.82)]. Adjustment for psychiatric comorbidity attenuated the risk estimates. In comparison to controls, relatives of individuals with ASD also had an increased risk of suicidal behaviour.
Clinicians treating patients with ASD should be vigilant for suicidal behaviour and consider treatment of psychiatric comorbidity.
Much of suicide research focuses on suicide attempt (SA) survivors. Given that more than half of the suicide decedent population dies on their first attempt, this means a significant proportion of the population that dies by suicide is overlooked in research. Little is known about persons who die by suicide on their first attempt–and characterizing this understudied population may improve efforts to identify more individuals at risk for suicide.
Data were derived from the National Violent Death Reporting System, from 2005 to 2013. Suicide cases were included if they were 18–89 years old, with a known circumstance leading to their death based on law enforcement and/or medical examiner reports. Decedents with and without a history of SA were compared on demographic, clinical, and suicide characteristics, and circumstances that contributed to their suicide.
A total of 73 490 cases met criteria, and 57 920 (79%) died on their first SA. First attempt decedents were more likely to be male, married, African-American, and over 64. Demographic-adjusted models showed that first attempt decedents were more likely to use highly lethal methods, less likely to have a known mental health problem or to have disclosed their intent to others, and more likely to die in the context of physical health or criminal/legal problem.
First attempt suicide decedents are demographically different from decedents with a history of SA, are more likely to use lethal methods and are more likely to die in the context of specific stressful life circumstances.
Very little clinical work or research to date has focused on the prioritization of suicidal imagery intervention in the stabilization of risk. Current Cognitive Behavioural Therapy Suicide Prevention (CBT-SP) does not specifically address suicidal imagery as a priority intervention. This paper prioritizes imagery modification as the central task of therapy with the suicidal client. This is a single subject case review describing specific imagery interventions used to destabilize the comforting component of suicidal images, de-glamourize the suicidal image as a problem-solving method and the reconstruction of new images to offset the emotional grasp of both ‘flash-forward’ violent suicidal images and suicidal ‘daydreaming’ rumination. It is hypothesized that when suicidal images become less emotionally charged, the desire to act upon suicide decreases. Focusing on imagery intervention as a priority aims to stabilize risk in a more clinically specific and targeted way. Rob is a 19-year-old depressed young man with chronic suicidal ideation/images with repeated suicide attempts. All GP referrals are of a crisis nature since the age of 16. He was referred to a CBT clinician with specific training and experience in CBT-SP who proposed the following brief imagery intervention. Socialization to treatment rationale was pivotal at the outset to help facilitate strong therapeutic alliance, ‘buy-in’ to the intended de-glamourization of suicide planning/daydreaming/rumination and the effects of intrusive ‘flash-forward’ images on emotional well-being. Therapy was facilitated weekly, supported by telephone contact, on an out-patient basis in the HSE (Health Service Executive) Irish Adult Mental Health service. The care plan and interventions were supported by access to the 24-hour acute Adult Mental Health services, as required. There was no requirement for direct client engagement with the acute services. Rob engaged with five treatments of CBT-SP imagery intervention and full stabilization of risk to self by suicide was achieved. At the time of writing, Rob is alive, has no engagement with the services and no further GP referral requests for intervention. Despite Rob leaving therapy before full completion, brief targeted suicidal imagery intervention was observed to stabilize the risk of suicidal behaviour. This young man has completed his schooling, engaged in ‘life’ planning rather than ‘death’ planning and has not required further intervention from this service. Further research is required to engage frontline clinicians on the merits of suicidal imagery assessment in routine clinical practice.
Key learning aims
(1)To assess for imagery and violent day dreaming in suicidal patients.
(2)Conceptualizing suicidal rumination and daydreaming as being a maladaptive problem-solving technique in overcoming psychological pain.
(3)Use of suicide-specific assessment.
(4)Ask about the presence of suicidal imagery as part of routine mental health assessment with the suicidal client.
This study aimed to evaluate the risk of suicidal ideation and behavior associated with vortioxetine treatment in adults with major depressive disorder (MDD).
Suicide-related events were evaluated post hoc using 2 study pools: one short-term pool of 10 randomized, placebo-controlled studies (6–8 weeks) and another long-term pool that included 3 open-label extension studies (52 weeks). Evaluation of suicide-related events was performed using Columbia-Suicide Severity Rating Scale (C-SSRS) scores and treatment-emergent adverse events (TEAEs) data.
At baseline, the percentage of patients reporting any C-SSRS ideation or behavior events in short-term studies was similar between placebo (14.7%), vortioxetine (19.8%, 13.0%, 11.2%, and 13.7% for 5-, 10-, 15-, and 20-mg groups, respectively), and duloxetine active reference (13.2%) and did not change throughout the 6- to 8-week treatment period for placebo (17.0%), vortioxetine (19.3%, 13.5%, 12.6%, and 15% for 5-, 10-, 15-, and 20-mg groups, respectively), or duloxetine (11.3%). The incidence of suicide-related events for TEAEs in the short-term pool was 0.4% for placebo, 0.2% or 1.0% for vortioxetine 5 mg or 10 mg, and 0.7% each for vortioxetine 15 mg and 20 mg, as well as duloxetine. After 52-week treatment with vortioxetine, suicidal ideation based on C-SSRS was 9.8%, C-SSRS suicidal behavior was 0.2%, and the incidence of suicide-related events based on TEAEs was <1%. There were no completed suicides in any study.
Vortioxetine is not associated with increased risk of suicidal ideation or behavior in MDD patients.
The 2008 economic recession was associated with an increase in suicide internationally. Studies have focused on the impact in the general population with little consideration of the effect on people with a mental illness.
To investigate suicide trends related to the recession in mental health patients in England.
Using regression models, we studied suicide trends in mental health patients in England before, during and after the recession and examined the demographic and clinical characteristics of the patients. We used data from the National Confidential Inquiry into Suicide and Safety in Mental Health, a national data-set of all suicide deaths in the UK that includes detailed clinical information on those seen by services in the last 12 months before death.
Between 2000 and 2016, there were 21 224 suicide deaths by patients aged 16 or over. For male patients, following a steady fall of 0.5% per quarter before the recession (quarterly percent change (QPC) 2000–2009 –0.46%, 95% CI –0.66 to –0.27), suicide rates showed an upward trend during the recession (QPC 2009–2011 2.37%, 95% CI –0.22 to 5.04). Recession-related rises in suicide were found in men aged 45–54 years, those who were unemployed or had a diagnosis of substance dependence/misuse. Between 2012 and 2016 there was a decrease in suicide in male patients despite an increasing number of patients treated. No significant recession-related trends were found in women.
Recession-associated increases in suicide were seen in male mental health patients as well as the male general population, with those in mid-life at particular risk. Support and targeted interventions for patients with financial difficulties may help reduce the risk at times of economic hardship. Factors such as drug and alcohol misuse also need to be considered. Recent decreases in suicide may be related to an improved economic context or better mental healthcare.
Declaration of interest
N.K. is supported by Greater Manchester Mental Health NHS Foundation Trust. L.A. chairs the National Suicide Prevention Strategy Advisory Group at the Department of Health (of which N.K. is also a member) and is a non-executive Director for the Care Quality Commission. N.K. chairs the National Institute for Health and Care Excellence (NICE) depression in adults guideline and was a topic expert member for the NICE suicide prevention guideline.
Restricting access to lethal means is an effective suicide prevention strategy. However, there is little discussion in the literature about the potential contribution of prescribing practices on discharge from inpatient psychiatric care (which has been established as a high-risk period for suicide) to suicide deaths by overdose of prescribed medication. This study aimed to assess the quantity, toxicity and potential lethality of psychotropic medication being prescribed on discharge from psychiatric care to those with and without indices of suicidality.
Patient demographic, clinical and prescription data were collected from 50 randomly selected charts following discharge from inpatient psychiatric care. Psychotropic medications (dose × duration) on discharge were converted to their equivalent doses of neuroleptics, antidepressants and anxiolytics to rate toxicity and potential lethality, using the Maudsley Prescribing Guidelines. Mood stabilizing medications were also documented.
39% of prescriptions analysed contained toxic and potentially fatal doses of either neuroleptic or antidepressant equivalent medication.
Patient discharge from inpatient psychiatric care presents a golden opportunity to moderate access to potentially fatal psychotropic medication. Iatrogenic provision of lethal means for suicide during a period of increased risk and in a group at increased suicide risk may impact suicide prevention efforts and requires further in-depth research. Current prescribing practices may be a missed opportunity to intervene in this regard.
To investigate cases of suicide in which there was no healthcare contact, by looking at history of help-seeking and evidence of previous mental health vulnerability. To identify any life events associated with suicide for which individuals did not seek help.
Previous research has suggested that non-consultation is the main barrier to suicide prevention among men. Estimates suggest approximately 22% of men who die by suicide have not consulted their GP in the year before their death. Little is known about the lifetime pattern of engagement with services among these individuals and whether or not this may influence their help-seeking behaviour before death.
Coroner records of suicide deaths in Northern Ireland over 2 years were linked to general practice (GP) records. This identified 63 individuals who had not attended health services in the 12 months before death. Coroner’s data were used to categorise life events associated with the male deaths. Lifetime mental health help-seeking at the GP was assessed.
The vast majority of individuals who did not seek help were males (n=60, 15% of all suicide deaths). Lack of consultation in the year before suicide was consistent with behaviour over the lifespan; over two-thirds had no previous consultations for mental health. In Coroner’s records, suicides with no prior consultation were primarily linked to relationship breakdown and job loss. These findings highlight the limitations of primary care in suicide prevention as most had never attended GP for mental health issues and there was a high rate of supported consultation among those who had previously sought help. Public health campaigns that promote service use among vulnerable groups at times of crisis might usefully be targeted at those likely to be experiencing financial and relationship issues.