Deliberate self-harm (DSH) is related to suicide and DSH repetition is common. DSH hospital presentations are often self-poisonings with medicinal agents. While older age and male sex are known risk factors for suicide, it is unclear how these factors are related to the nature and severity of medicinal self-poisoning (SP). Such knowledge can guide prevention strategies emphasizing detecting and treating mental illness and controlling access to means.
Medicinal SP presentations by 18,383 residents of Ontario, Canada, aged 12 years and older, who presented to a hospital emergency department in that province between April 1, 2001-March 31, 2002 were characterized by the agents taken, identification of deliberate intent and medical severity.
We found distinct age-sex differences in the nature and severity of medicinal SP. In youths, aged 12-17, about 40% of presentations involved analgesics, typically not prescribed and most often the acetaminophen agent-group. Females aged 12-64 were identified as deliberate more often than their male counterparts and this pattern occurred in most agent-groups, even among those who took antidepressants. The acetaminophen agent-group was most consistently associated with medical severity and this effect was strongest among female youths. Although medicinal SP was less frequent in the elderly, these presentations tended to be more medically serious and less often identified deliberate.
The high proportion of medicinal SP in youths involving agents typically not prescribed and the medical severity of the acetaminophen agent-group underscore how prevention strategies must extend beyond controlling access to antidepressants. Despite a higher risk for suicide, males and the elderly may not have their deliberate intent detected and therefore, may not receive appropriate treatment. The emergency department can serve as important link to mental health care and usage patterns can provide feedback about the need for system-level enhancements and DSH surveillance.
Assertive community treatment appears to have limited impact on the risk of suicide in persons with severe and persistent mental illness (SPMI). This exploratory prospective study attempts to understand this observation by studying the contribution of suicidality to the occurrence of crisis events in patients with SPMI. Specifically, an observer-rated measure of the need for hospitalization, the Crisis Triage Rating Scale, was completed at baseline, crisis occurrence, and resolution to determine how much the level of suicidality contributed to the deemed level of crisis. Second, observer-ratings of suicidal ideation, the Modified Scale for Suicide Ideation, and psychopathology and suicidality, Brief Psychiatric Rating Scale, were measured at baseline, crisis occurrence, and resolution. A self-report measure of distress, the Symptom Distress Scale, was completed at baseline, crisis occurrence, and resolution. Finally, the patients' crisis experiences were recorded qualitatively to compare with quantitative measures of suicidality. Almost 40% of the subjects experienced crisis events and more than a quarter of these events were judged to be severe enough to warrant the need for hospitalization. Our findings suggest that elevation of psychiatric symptoms is a major contributor to the crisis occurrences of individuals with SPMI; although the risk of suicide may have to be conceived as somewhat separate from crisis occurrence.
This paper gives a description of a psychosocial/psychoeducational group intervention for individuals with a history of recurrent suicide attempts. The intervention was conceived to reduce the risk of future suicidal behavior and to modify the client's psychopathology. Three features are felt to make the intervention unique from others described in the literature. First, the intervention is targeted at both men and women from an inner-city population who are often underhoused, underemployed, and undereducated. 24 of 48 clients (50%) lived alone, and 24 of those (92%) were living in subsidized housing; 33% lived in supportive housing, and one lived on the street at the time of assessment. 48% had a high-school education or less. Second, the principles of our approach stressed client validation and participation in the development and delivery of the therapy. Our frame of reference was to name ourselves as professionals with a set of skills and access to some kinds of information and clients as the experts on the experience in their lives. Third, the group content incorporated a multimodal approach to meet the varied needs of the clients. Future reports will discuss the empirical evaluation of this intervention; however, the development of specific, targeted approaches for unique individuals with recurrent suicide attempts is clearly needed.
Hospital separation data are used to study suicidal behaviour; however, there is little information about the appropriateness of these data for research and planning activities. The study purpose is to examine how consistently hospital separation E-code data reflect suicidal behaviours. Expert clinicians reviewed medical records of individuals who had a separation for self-poisoning to determine whether the self-poisoning was deliberate. Agreement among clinicians was evaluated and latent class analysis performed to derive a summary estimate of the prevalence of deliberate self-poisoning. This estimate was then compared to the prevalence of deliberate self-poisoning based on the external cause of injury (E-codes). Clinicians estimated the prevalence to be 63% higher than the E-code based prevalence. Much larger discrepancies were apparent among older age groups, those whose care was primarily medical in nature and those with a longer length of hospital stay. In acute care settings, self-poisonings among the elderly may not receive adequate attention and/or documentation. Estimating the prevalence of admissions for suicidal behaviour using hospital separation data is of questionable validity, particularly among older age groups.
The prevalence of borderline personality disorder (BPD) in outpatient clinics varies greatly (7%-27%) depending on the setting and methodology. We examined the cross-sectional rate of BPD in a general adult outpatient university clinic using a 2-phase procedure: (1) we screened all registered patients with the self-report SCID-II-PQ and (2) we administered the Revised Diagnostic Interview for Borderlines (DIB-R). Sixty-six percent (239/360) of the clinic patients completed the screening: About 72.4% (173/239) (95% confidence interval [CI] = 66.7%, 78.1%) were positive for BPD on the Structured Clinical Interview for DSM-IV Personality Disorders-Patient Questionnaire (SCID-II-PQ), and 22.6% (54/239) (95% CI = 17.3%, 27.9%) were positive for BPD on the DIB-R. Our BPD rate was somewhat higher than recent semistructured interview studies (9%-18%). We believe this is due, in part, to our cross-sectional design and our decision not to exclude acute Axis I disorders. Mostly, however, we believe that our 22.6% incidence of BPD arises from the high morbidity of our sample. Demographic data from 130 of 131 DIB-R completers reveal the following: mean age was 40.2 years, 75.4% were female, most patients were unable to work, and they averaged 3.8 lifetime hospitalizations.
This qualitative study investigated the repeated use of the emergency department (ED) by men with a history of suicidal behaviour and substance abuse to understand the needs and barriers to care for this high-risk group. Identification of common themes from interviews with patients and health care workers can serve as a basis for improved ED-based interventions.
Using semistructured interviews, patients, ED staff and family physicians were asked about needs of the aformentioned group. Twenty-five patients were interviewed and completed questionnaires regarding their substance use, aggression, parasuicidal behaviour, alexithymia and childhood trauma. In addition, 27 staff members were interviewed. Interviews were tape-recorded, transcribed and qualitatively analyzed using an iterative coding process.
Of the 25 patients, 23 (96%) had a mood or anxiety disorder and 18 (75%) had borderline personality disorder. One-half of the patients scored high and another quarter scored moderate on alexithymia testing. The ED was viewed as a last resort despite seeking help. Frustration was felt by both patients and staff regarding difficult communication, especially during an acute crisis.
The ED plays an important role in the provision of care for men with recurrent suicidal behaviour and substance abuse. Some of the diagnoses and problems faced by these patients are beyond the purview of the ED; however, staff can identify mutual goals for crisis interventions, allow for frequent communication and seek to de-escalate situations through the validation of the stress patients are experiencing.
Suicide rates are often high in rural areas. Despite the strong association between deliberate self-harm (DSH) and suicide, few have studied rural residence and DSH. Self-poisonings dominate DSH hospital presentations. We investigate a previously reported association between rural residence and medical severity (defined as a subsequent medical/surgical inpatient stay) among emergency department presentations for medicinal self-poisoning (SP) to determine whether differences in agents taken, mental health service use or hospital-level resources explain the relationship.
A cohort of n=16,294 12-64-year olds presenting with SP to hospital emergency departments in Ontario, Canada, in 2001/2002 was linked to their service records over time.
The rural-medical severity association was best explained by differences in hospital resources; presenting to hospitals providing inpatient psychiatric services appeared to reduce medical/surgical inpatient stays in favor of psychiatric ones. Among those with a recent psychiatric admission, more intensive ambulatory psychiatric contact may be protective of a psychiatric inpatient stay subsequent to the SP presentation. Compared to nonrural residents, deliberate intent was identified less often in rural residents, particularly males.
The rural-medical severity association was best explained by disparities in the delivery systems serving rural and nonrural residents, important to rural suicide prevention efforts.
Narcissistic personality (NP) has been implicated as a potential vulnerability factor for late-life suicide. The present study investigated whether NP increases vulnerability to suicidal ideation and behavior among geriatric depression day-hospital patients.
Using a retrospective database analysis, the authors examined demographic data, diagnostic information, and scores on self-report (Geriatric Depression Scale [GDS]) and clinician-rated depression measures (Hamilton Rating Scale for Depression [HAM-D]), for 608 geriatric psychiatry patients 65 years or older.
Of the 538 patients meeting study inclusion criteria, 20 had NP, defined as either narcissistic personality disorder (n = 13) or narcissistic personality traits (n = 7). Patients with NP were rated significantly higher on the HAM-D suicide item than those without NP, controlling for age, sex, depression (GDS), and cognitive functioning.
Findings suggest that NP may be a clinical marker of elevated suicide risk among depressed older adults. Clinicians are advised to assess the presence of self-pathology and its potential impact upon psychological functioning in depressed older patients, and to incorporate discussions of life transitions into therapeutic work with those at-risk for suicide.
General hospital psychiatric services are able to provide leadership and coordinate the development of suicide prevention programs for individuals serviced in general hospital settings. We completed this literature review to suggest priorities for programming.
Our procedure was to update the review by Gunnell and Frankel that guided priorities for Health of the Nation, the national suicide prevention strategy in the UK. We completed a search, using the terms suicide prevention and control, of all English-language research and clinical trials conducted between January 1, 1994, and May 1, 2004.
We identified 82 papers. Of these, 48 were excluded and the remaining 34 were grouped by secondary care setting categories. We found no articles on screening tools for predicting risk of suicide, 16 articles on interventions for individuals with suicidal behaviour, 14 articles on the treatment of major psychiatric disorders, 1 article and 1 published abstract on discharge from hospital, and 2 articles on reducing access to means.
Based on a review of each category, we make several program and policy recommendations, including regularly updating clinical assessment skills, using guidelines for assessment of patients following a suicide attempt, assessing the risk of suicide 24 to 48 hours before discharge from hospital, and incorporating education about reducing access to means into routine psychiatric care.
People with borderline personality disorder (BPD) are at high risk for attempting suicide. There are some data to suggest that risk factors for suicide attempts change over time. We conducted a prospective cohort study to examine risk factors for suicide attempts in a treated sample of patients with BPD.
One hundred eighty participants with BPD were followed over a year-long course of dialectical behaviour therapy or general psychiatric management and then for 2 more years in naturalistic follow-up. Participants were assessed for suicidal and self-injurious behaviours at baseline, every 4 months over the 1-year treatment phase, and every 6 months over a 2-year follow-up period. Participants were classified as suicide or non-suicide attempters based on their behaviour at the end of the 1-year treatment phase and after the 2-year follow-up period. Groups were then compared on baseline clinical and demographic variables.
Nearly 26% of participants made a suicide attempt during the 1-year treatment phase, while 16.7% reported a suicide attempt over the 2-year follow-up period. Baseline number of suicide attempts during the 4 months prior to study and severity of childhood sexual abuse predicted suicide attempts during the treatment year. Similarly, baseline suicide attempts, severity of childhood sexual abuse, and number of hospitalizations in the 4 months prior to study entry predicted suicide attempts during the 2-year follow-up.
Risk factors for suicide attempts in this treated sample of patients with BPD were fairly stable, largely non-modifiable, and unrelated to psychopathology or psychosocial functioning at baseline.