Does Response on the PHQ-9 Depression Questionnaire Predict Subsequent Suicide Attempt or Suicide Death?

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessPreventing Suicide Begins With Regular AssessmentsLinda M. RichmondLinda M. RichmondSearch for more papers by this authorPublished Online:17 May 2019https://doi.org/10.1176/appi.pn.2019.4b18AbstractPatients with psychotic disorders who indicated suicidal thoughts on a brief questionnaire were four times more likely to attempt suicide in the next 90 days, a study shows. So why aren’t more patients being asked about suicidal ideation?Psychiatrists who don’t conduct formal assessments of suicidality at every patient visit are missing an important way to track treatment outcomes and keep patients safe.The study by Gregory E. Simon, M.D., M.P.H., and colleagues shows that individuals with psychotic disorders are able and willing to articulate suicidal thoughts: Patients who reported frequent thoughts of self-harm were four times more likely to attempt suicide within 90 days.In fact, simply having patients with a psychotic disorder complete the Patient Health Questionnaire (PHQ-9) at every visit can strongly predict who will attempt suicide in the next 90 days, according to a study published in the March issue of Psychiatric Services by Gregory E. Simon, M.D., M.P.H., senior investigator at Kaiser Permanente Washington Health Research Institute and psychiatrist at Washington Permanente Medical Group, and colleagues.“Individuals with psychotic disorders have by far the highest suicide rate of any mental health condition,” Simon said. In fact, more than 1 in 4 individuals with psychotic disorders attempt suicide and more than 1 in 20 die by suicide. Risk is especially high after the first onset of symptoms and soon after psychiatric hospitalization.“There are a lot of outdated notions about people with psychotic disorders: There’s this idea that maybe they are not as able or willing to communicate their thoughts of self-harm, or perhaps they are not as self-aware,” Simon said. This study refutes that idea.For the study, Simon and colleagues identified nearly 6,000 adults with a diagnosis of schizophrenia spectrum psychosis or unspecified psychosis using electronic health records from seven large integrated health systems. They tracked nearly 33,000 outpatient visits for these patients and their responses to the PHQ-9 and tallied any subsequent completed suicide attempts over the next year.The researchers found that patients reporting frequent thoughts of death and self-harm, as indicated in response to item 9 of the PHQ-9, were four times more likely to attempt suicide within 90 days than patients reporting no such thoughts. Considering patients’ prior-year responses to item 9—not just the current response—improved detection of risk: 60% of those who attempted suicide had reported thoughts of death and self-harm within the past year.The results were similar to a 2016 study by Simon and colleagues of 500,000 patients who completed the PHQ-9 during primary care and outpatient mental health visits. “The PHQ-9 was developed to assess depression, but we’ve found it also works to identify suicide risk and other mental health conditions,” Simon said. In fact, Kaiser Permanente has chosen to implement use of the PHQ-9 across its entire health system and requires clinicians to use it at every mental health outpatient appointment and for primary care providers to give it to patients at least once a year.If a patient indicates thoughts of self-harm or death, physicians are instructed to follow up with the Columbia-Suicide Severity Rating Scale. Part of these physicians’ salaries hinges upon how well they adhere to established protocols when patients report having such thoughts of death or self-harm, Simon explained.Assessments: Key to Good Mental Health CareWhile it may not be the norm in many practice settings, Simon said that conducting brief formal assessments at every visit is what good mental health care is all about. In addition, having a formal process in place requiring the use of the PHQ-9 at every visit helps to keep clinicians from forgetting to ask. “I am a believer in standard processes that scale to large populations. If you’re going to a primary care doctor and the doctor never measures your blood pressure, would you keep going? No. But somehow that’s OK in mental health care.”Many psychiatrists don’t ask, in part because they don’t feel comfortable managing suicidal patients and the risk that entails, said Maria A. Oquendo, M.D., Ph.D., APA past president and the Ruth Meltzer Professor of Psychiatry and chair of the Department of Psychiatry at the Perelman School of Medicine at the University of Pennsylvania. Most medication management appointments are set for 10 to 15 minutes. “The system is not set up for management of these patients without major disruptions to the workflow,” she said.Oquendo recommends that group practices and clinics establish clear written protocols, such as a decision tree, for clinicians to follow when a patient becomes suicidal, including making available to primary care providers a list of consulting psychiatrists they can call as the need arises. “The more that there is a system in place, the more likely it is that physicians will feel more comfortable screening for suicidality.”Assessment doesn’t end with self-report questionnaires, however. “If you ask and the patient says ‘no,’ it doesn’t mean the patient is not at risk for suicide,” said Jill Harkavy-Friedman, Ph.D., vice president of research at the American Foundation for Suicide Prevention. “Providers should also consider important social risk factors for suicidal behavior, such as their current health, other mental health conditions, life stressors they are experiencing, relationships status, history of child abuse, and their access to lethal means.”Why Don’t Patients Disclose Suicidal Ideation?About 4 out of 10 suicide attempts in the Psychiatric Services study by Simon and colleagues occurred among patients who responded they weren’t thinking “at all” about death or self-harm within the year prior to the attempt. A study in the November 2018 Psychiatric Services by Julie E. Richards, M.P.H., a research associate of the Kaiser Permanente Washington Health Research Institute, and colleagues shed some light on why: Mental health patients who did not disclose suicidal ideation on the PHQ-9, yet went on to attempt suicide less than two months later said they were either not experiencing suicidal ideation at the time of screening or else feared the outcome of disclosure.Specifically, such patients said they feared stigma, overreaction, and loss of autonomy. Interviews also revealed instances of heavy episodic drinking at the time of the suicide attempt, particularly when suicide was completely unplanned.The researchers concluded that nonjudgmental listening and expressions of caring without overreaction among providers may help patients overcome their fear of reporting suicidal ideation. Screening to identify heavy episodic drinking may also help identify individuals who make unplanned suicide attempts.The study by Simon and colleagues was supported by funding from the National Institute of Mental Health. ■“Self-Reported Suicidal Ideation as a Predictor of Suicidal Behavior Among Outpatients With Diagnoses of Psychotic Disorders” can be accessed here. “Risk of Suicide Attempt and Suicide Death Following Completion of the Patient Health Questionnaire Depression Module in Community Practice” is available here. “Understanding Why Patients May Not Report Suicidal Ideation at a Health Care Visit Prior to a Suicide Attempt: A Qualitative Study” is posted here. ISSUES NewArchived

Recent research has highlighted that psychotic experiences are far more prevalent than psychotic disorders and associated with the full range of mental disorders. A particularly strong association between psychotic experiences and suicidal behavior has recently been noted. To provide a quantitative synthesis of the literature examining the longitudinal association between psychotic experiences and subsequent suicidal ideation, suicide attempts, and suicide deaths in the general population. We searched PubMed, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO from their inception until September 2017 for longitudinal population studies on psychotic experiences and subsequent suicidal ideation, suicide attempts, and suicide death. Two authors searched for original articles that reported a prospective assessment of psychotic experiences and suicidal ideation, suicide attempts, or suicide death in general population samples, with at least 1 follow-up point. Two authors conducted independent data extraction. Authors of included studies were contacted for information where necessary. We assessed study quality using the Newcastle-Ottawa Quality Assessment Scale. We calculated pooled odds ratios using a random-effects model. A secondary analysis assessed the mediating role of co-occurring psychopathology. Psychotic experiences and subsequent suicidal ideation, suicide attempts, and suicide death. Of a total of 2540 studies retrieved, 10 met inclusion criteria. These 10 studies reported on 84 285 participants from 12 different samples and 23 countries. Follow-up periods ranged from 1 month to 27 years. Individuals who reported psychotic experiences had an increase in the odds of future suicidal ideation (5 articles; n = 56 191; odds ratio [OR], 2.39 [95% CI,1.62-3.51]), future suicide attempt (8 articles; n = 66 967; OR, 3.15 [95% CI, 2.23-4.45]), and future suicide death (1 article; n = 15 049; OR, 4.39 [95% CI, 1.63-11.78]). Risk was increased in excess of that explained by co-occurring psychopathology: suicidal ideation (adjusted OR, 1.59 [95% CI, 1.09-2.32]) and suicide attempt (adjusted OR, 2.68 [95% CI, 1.71-4.21]). Individuals with psychotic experiences are at increased risk of suicidal ideation, suicide attempts, and suicide death. Psychotic experiences are important clinical markers of risk for future suicidal behavior.

Counseling on access to lethal means is highly recommended for patients with suicide risk, but there are no formal evaluations of its impact in real-world settings. Evaluate whether lethal means assessment reduces the likelihood of suicide attempt and death outcomes. Quasi-experimental design using an instrumental variable to overcome confounding due to unmeasured patient characteristics that could influence provider decisions to deliver lethal means assessment. Kaiser Permanente Colorado, an integrated health system serving over 600,000 members, with comprehensive capture of all electronic health records, medical claims, and death information. Adult patients who endorsed suicide ideation on the Patient Health Questionnaire-9 (PHQ-9) depression screener administered in behavioral health and primary care settings from 2010 to 2016. Provider documentation of lethal means assessment in the text of clinical notes, collected using a validated Natural Language Processing program. Main outcome was ICD-9 or ICD-10 codes for self-inflicted injury or suicide death within 180days of index PHQ-9 event. We found 33% of patients with suicide ideation reported on the PHQ-9 received lethal means assessment in the 30days following identification. Lethal means assessment reduced the risk of a suicide attempt or death within 180days from 3.3 to 0.83% (p = .034, 95% CI = .069-.9). Unmeasured suicide prevention practices that co-occur with lethal means assessment may contribute to the effects observed. Clinicians should expand the use of counseling on access to lethal means, along with co-occurring suicide prevention practices, to all patients who report suicide ideation.

In March 2004 the U.S. Food and Drug Administration (FDA) warned physicians and patients regarding increased risk of suicide with 10 newer antidepressant drugs. Available data leave considerable uncertainty regarding actual risk of suicide attempt and death by suicide during antidepressant treatment. The authors used population-based data to evaluate the risk of suicide death and serious suicide attempt in relation to initiation of antidepressant treatment. Computerized health plan records were used to identify 65,103 patients with 82,285 episodes of antidepressant treatment between Jan. 1, 1992, and June 30, 2003. Death by suicide was identified by using state and national death certificate data. Serious suicide attempt (suicide attempt leading to hospitalization) was identified by using hospital discharge data. In the 6 months after the index prescription of antidepressant treatment, 31 suicide deaths (40 per 100,000 treatment episodes) and 76 serious suicide attempts (93 per 100,000) were identified in the study group. The risk of suicide attempt was 314 per 100,000 in children and adolescents, compared to 78 per 100,000 in adults. The risk of death by suicide was not significantly higher in the month after starting medication than in subsequent months. The risk of suicide attempt was highest in the month before starting antidepressant treatment and declined progressively after starting medication. When the 10 newer antidepressants included in the FDA advisory were compared to older drugs, an increase in risk after starting treatment was seen only for the older drugs. The risk of suicide during acute-phase antidepressant treatment is approximately one in 3,000 treatment episodes, and risk of serious suicide attempt is approximately one in 1,000. Available data do not indicate a significant increase in risk of suicide or serious suicide attempt after starting treatment with newer antidepressant drugs.

To examine the association between thoughts of death or self-harm reported on item 9 of the Patient Health Questionnaire (PHQ) depression module and the risk of suicide attempt or suicide death over the following 2 years. In 4 health care systems participating in the Mental Health Research Network, electronic records identified 509,945 adult outpatients completing 1,228,308 PHQ depression questionnaires during visits to primary care, specialty mental health, and other outpatient providers between January 1, 2007 and December 31, 2012. 9,203 nonfatal suicide attempts were identified using health system records of inpatient or outpatient encounters for self-inflicted injury. 484 suicide deaths were identified using cause-of-death codes from state mortality data. Cumulative hazard of suicide attempt during 2 years ranged from approximately 0.5% among those reporting thoughts of death or self-harm "not at all" to 3.5% among those reporting such thoughts "nearly every day." Cumulative hazard of suicide death during 2 years ranged from approximately 0.04% among those responding "not at all" to 0.19% among those responding "nearly every day." The excess hazard associated with thoughts of death or self-harm declined with time, but remained 2- to 5-fold higher for at least 18 months. Nevertheless, 39% of suicide attempts and 36% of suicide deaths within 30 days of completing a PHQ occurred among those responding "not at all" to item 9. In community practice, response to PHQ item 9 is a strong predictor of suicide attempt and suicide death over the following 2 years. For patients reporting thoughts of death or self-harm, suicide prevention efforts must address this enduring vulnerability.

Individuals with substance use disorders (SUD) are at risk for suicide, but no studies have assessed whether routinely administered screeners for suicidal ideation accurately identify outpatients with SUD who are at risk for suicide attempt or death. Data from more than 186,000 visits by over 55,000 patients with mental health and SUD diagnoses receiving care in 7 health systems were analyzed to determine whether responses to item 9 of the 9-item Patient Health Questionnaire, which assesses frequency of thoughts of death and self-harm, are associated with suicide outcomes after an outpatient visit. Odds of suicide attempt or death were computed using generalized estimating equations. In bivariate analyses, a nearly 5-fold risk was observed for patients answering "nearly every day" relative to "not at all" among individuals who made a suicide attempt within 90 days (4.9% vs 1.1%; χ2 = 1151, P < 0.0001). At nearly half of visits (46%) followed by a suicide attempt within 90 days, patients responded "not at all." In logistic models, compared to "not at all," all other responses were associated with higher odds of suicide attempt or death within 90 days. Fully adjusted models attenuated results but odds of suicide attempt (AOR = 3.24, CI: 2.69-3.91) and suicide death (AOR = 5.67, CI: 2.0-16.1) remained high for those reporting "nearly every day." In people with SUD, increasing Patient Health Questionnaire item 9 response predicts increased risk of subsequent suicidal behavior and should prompt intervention. However, clinicians should realize that those reporting "not at all" are not immune from subsequent suicide risk.

To investigate the associations between psychiatric diagnosis in late adolescence in an unselected population and subsequent suicide attempt and suicide during 36-year follow-up. A total of 49,321 Swedish men conscripted for compulsory military training in 1969/1970, born 1949-1951, were screened for psychiatric disorder and, if detected, diagnosed by a psychiatrist according to ICD-8. Data on suicides and suicide attempts 1971-2006 were collected in national registers. At conscription examination, 11.7% of the cohort received a psychiatric diagnosis. Among those, increased risks of suicide 1971-2006 [HR = 2.7 (2.2-3.2), 624 cases] and suicide attempt 1973-2006 [HR = 3.5 (3.1-4.0), 1170 cases] were found. The increased relative risks persisted during the follow-up period 19-36 years after examination [1989-2006 suicide HR = 2.1 (1.6-2.7), 308 cases, and 1989-2006 suicide attempt HR = 2.6 (2.1-3.1), 484 cases]. The dominant diagnostic groups, neurosis and personality disorder, were significantly associated with suicide and suicide attempt in the early as well as the late follow-up period. Psychiatric diagnoses made in late adolescence predicted subsequent suicide and suicide attempt over a 36-year follow-up period. The increased relative risks were not limited to young adulthood but were also evident 18-36 years after conscription examination.

BackgroundSuicide remains the 10th-ranked most frequent cause of death in the United States, accounting for over 40,000 deaths per year. Nonfatal suicide attempts lead to over 200,000 hospitalizations and 600,000 emergency department visits annually. Recent evidence indicates that responses to the commonly used Patient Health Questionnaire (PHQ9) can identify outpatients who are at risk of suicide attempt and suicide death and that specific psychotherapy or Care Management programs can prevent suicide attempts in high-risk patients. Motivated by these developments, the NIMH-funded Mental Health Research Network has undertaken a multisite trial of two outreach programs to prevent suicide attempts among outpatients identified by routinely administered PHQ9 questionnaires.Methods/designOutpatients who are at risk of suicide attempt are automatically identified using data from electronic health records (EHRs). Following a modified Zelen design, all those identified are assigned to continued usual care (i.e., no contact) or to be offered one of two population-based outreach programs. A Care Management intervention includes systematic outreach to assess suicide risk, EHR-based tools to implement risk-based care pathways, and care management to facilitate recommended follow-up. A Skills Training intervention includes interactive online training in Dialectical Behavior Therapy skills, supported by reminder and reinforcement messages from a skills coach. Each intervention supplements, rather than replaces, usual care; participants may receive any other services normally available. Interventions are delivered primarily by secure messaging through EHR patient portals. Suicide attempts and deaths following randomization are identified using state vital statistics data and health system EHR and insurance claim data. Primary evaluation will compare risk of suicide attempt or death over 18 months according to the initial assignment, regardless of intervention participation. Recruitment is underway in three health systems (Group Health Cooperative, HealthPartners, and Kaiser Permanente Colorado). Over 2500 participants have been randomized as of 1 March 2016, with enrollment averaging approximately 100 per week.DiscussionAssessing the effectiveness of population-based suicide prevention requires adherence to the principles of pragmatic trials: population-based enrollment, accepting variable treatment participation, assessing outcomes using health record data, and analyses based on intent-to-treat.Trial registrationClinicalTrials.gov registration #NCT02326883, registered on 23 December 2014.

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessData Refute Link Between Suicide, AntidepressantsJim RosackJim RosackPublished Online:20 Jan 2006https://doi.org/10.1176/pn.41.2.0018Researchers in Washington state have found that the risk of suicide and serious suicide attempts is highest in the 30 days before patients begin taking an antidepressant medication, rather than the month following initiation of drug therapy. With continued antidepressant use, the researchers said, risk of suicide death remains fairly constant through the first six months of treatment, while risk of a suicide attempt serious enough to result in hospitalization steadily decreases.The new report involved an in-depth review of computerized health plan records at Seattle-based Group Health Cooperative (GHC). Between January 1, 1992, and June 30, 2003, researchers led by Gregory Simon, M.D., M.P.H., identified 65,103 GHC patients who received 82,285 prescriptions for new antidepressant treatment (many patients were prescribed trials of more than one antidepressant). Within that population, during the six months following initiation of new antidepressant treatment, 31 suicide deaths occurred, and patients were hospitalized for a serious suicide attempt 76 times.The report, funded by grants from the National Institute of Mental Health, appears in the January American Journal of Psychiatry.Suicide and serious suicide attempts are "tragic but fortunately rare events," said Simon, an assistant professor of psychiatry at the University of Washington and a staff physician and researcher at GHC's Center for Health Studies."We don't find any evidence to support the widely held belief that suicide risk increases when people start taking antidepressant medications," Simon told Psychiatric News. "What we did find was that suicide risk actually decreases when people start taking antidepressants."Simon added that the results "do not mean that there may not be individuals who somehow have adverse reactions to these medications, but certainly on average, risk goes down [for patients on medication]."Simon and his colleagues used GHC computerized pharmacy records and outpatient visit and hospital discharge data for all GHC health plan members during the study period. Mortality records were created for each study year by linking GHC membership rolls with state and national death-certificate data. Mortality data were included for every GHC member during the 10.5-year period, regardless of whether the member remained covered by GHC at the time of death.All episodes of antidepressant treatment (the "index prescription") were identified, which represented a new outpatient prescription for an antidepressant medication to any patient who had no record of any antidepressant prescription filled in the previous six months. These patients were diagnosed with unipolar major depressive disorder, dysthymia, or depressive disorder not otherwise specified during the 30 days prior to or following the prescription of the antidepressant.Medication Clearly Reduces RiskPatients meeting those criteria were predominantly female (69.5 percent) and ranged in age from 5 to 105. Of the 82,285 episodes of antidepressant treatment, 5,107 (6.2 percent) were in patients aged 17 or younger.In addition to the 31 suicide deaths (a rate of 40 per 100,000 treatment episodes) and 76 serious attempts (93 per 100,000) identified in the six months following the index prescription, the researchers identified 73 suicide attempts (93 per 100,000) that resulted in hospitalization in the three months prior to an index prescription. The majority of those attempts occurred in the seven days preceding the index prescription, indicating that some patients were put on medication specifically in response to the attempt, Simon said (see chart on page 18).Black-Box WarningsEarly warnings of a potential association between antidepressant medications and increased risk of suicidal thoughts and behaviors came in a March 2004 Public Health Advisory issued by the Food and Drug Administration (FDA). That advisory included only newer antidepressants, primarily the SSRIs and SNRIs. The black-box warnings ordered by the FDA in October 2005 were expanded to include all antidepressants marketed in the United States.Simon and his colleagues separated the 82,285 episodes of antidepressant prescriptions into older versus newer prescriptions to determine if the number of suicide deaths or serious suicide attempts differed between the different antidepressant classes."We found no evidence of any higher risk, or a specific risk, associated with use of newer antidepressants," said Simon. "If anything, our data say there should be more concern associated with the older drugs."For patients taking newer antidepressants, risk of a serious suicide attempt was still highest in the month before the index prescription. For those patients taking older medications, risk was not statistically significantly different in the month before compared with the month after index prescription. Once on medication, both groups' risk declined significantly as medication was continued out to six months.The researchers had received previous NIMH grants to look at specific outcomes measures pertaining to antidepressant medications. However, Simon said, they had not looked at how risk of suicide or serious suicide attempt differed before initiation of medication therapy compared with risk after medication was begun."When this controversy arose," Simon said, "we already had a large dataset readily available." However, he continued, an observational study such as this one has inherent limits and cannot clearly establish or refute a causal relationship between antidepressants and suicide risk."In the ideal world, what we'd like to do is conduct a true experiment—to do a large, randomized, controlled trial," Simon explained. "But the difficulty is, if you are looking for something that is inherently fairly rare, you would have to have over 300,000 patients to have the study statistically sufficiently powered to detect a difference."An added difficulty, he said, occurs when trying to separate out the risk of suicide death for adults versus children and adolescents. In the data analyzed by Simon and his colleagues, "adolescents constituted a small portion" and accounted for three suicide deaths and 17 serious attempts. Risk of serious suicide attempt was four times as high in adolescents as in adults, but the pattern over time was similar in the two groups.Further research is "clearly needed," the researchers concluded. Until then, "closer monitoring of antidepressant treatment is needed, but warnings regarding suicide precipitated by antidepressants may do more to discourage effective treatment than to improve the quality of follow-up care.""Suicide Risk During Antidepressant Treatment" is posted at<www.ajp.psychiatryonline.org/cgi/content/full/163/1/41>.▪ Am J Psychiatry 2005 163 41 ISSUES New Archived

Suicidal behavior is a leading cause of injury and death worldwide, and previous cross-sectional studies have demonstrated that nonmedical use of prescription drugs (NMUPD) was associated with suicidality. However, there is not any study in China having examined the longitudinal relationships between NMUPD, suicidal ideation, and suicidal attempts, as well as explored the potential mediating effects of depressive symptoms. To determine whether baseline NMUPD was associated with subsequent suicidal ideation and attempts while controlling for depressive symptoms and to determine whether the increased risks were mediated by depressive symptoms. In this longitudinal study, a total of 3273 students in randomly selected schools in Guangzhou were surveyed from 2009 to 2010 (response rate, 96.8%) and followed up at 1 year (2011-2012; retention rate, 96.1%). The dates of data analysis were October 9, 2015, to October 15, 2015; additional data analysis occurred March 23, 2016, to March 29, 2016. Suicidal ideation, suicidal attempts, NMUPD, depressive symptoms, and alcohol-related problems. Overall, 3273 adolescents (mean [SD] age, 13.7 [1.0] years) were recruited for this study. The final results showed that after controlling for sociodemographic information (including sex, age, household socioeconomic status, and living arrangements), baseline depressive symptoms, baseline alcohol-related problems, baseline suicidal ideation, and baseline suicidal attempts, baseline opioids misuse (adjusted odds ratio [AOR], 2.31; 95% CI, 1.30-4.11), sedatives misuse (AOR, 4.46; 95% CI, 1.54-7.94), and nonmedical use of any prescription drug (AOR, 1.97; 95% CI, 1.21-3.23) were positively associated with suicidal ideation at follow-up. Additionally, baseline opioid misuse (AOR, 3.39; 95% CI, 1.33-5.63) and nonmedical use of any prescription drug (AOR, 2.91; 95% CI, 1.26-3.71) were also associated with subsequent suicidal attempts after controlling for sex, age, household socioeconomic status, living arrangements, depressive symptoms, alcohol-related problems, suicidal ideation, and suicidal attempts at baseline. There were significant standardized indirect effects of baseline opioids misuse on subsequent suicidal ideation (standardized β estimate = 0.020; 95% CI, 0.010-0.030) and suicidal attempts (standardized β estimate = 0.009; 95% CI, 0.004-0.015) through depressive symptoms; the standardized indirect effect of baseline sedatives misuse on subsequent suicidal ideation through depressive symptoms was also significant (standardized β estimate = 0.016; 95% CI, 0.005-0.026). In this study, NMUPD at baseline was associated with subsequent suicidal ideation and attempts. These findings support that proper surveillance systems with the potential to reduce adolescent suicidality should be established to control and supervise suicidality and NMUPD among Chinese adolescents.

Between-visit changes in suicidal ideation and risk of subsequent suicide attempt.

Bipolar disorder is associated with elevated risk of suicide attempts and deaths. Key aims of the International Society for Bipolar Disorders Task Force on Suicide included examining the extant literature on epidemiology, neurobiology and pharmacotherapy related to suicide attempts and deaths in bipolar disorder. Systematic review of studies from 1 January 1980 to 30 May 2014 examining suicide attempts or deaths in bipolar disorder, with a specific focus on the incidence and characterization of suicide attempts and deaths, genetic and non-genetic biological studies and pharmacotherapy studies specific to bipolar disorder. We conducted pooled, weighted analyses of suicide rates. The pooled suicide rate in bipolar disorder is 164 per 100,000 person-years (95% confidence interval = [5, 324]). Sex-specific data on suicide rates identified a 1.7:1 ratio in men compared to women. People with bipolar disorder account for 3.4-14% of all suicide deaths, with self-poisoning and hanging being the most common methods. Epidemiological studies report that 23-26% of people with bipolar disorder attempt suicide, with higher rates in clinical samples. There are numerous genetic associations with suicide attempts and deaths in bipolar disorder, but few replication studies. Data on treatment with lithium or anticonvulsants are strongly suggestive for prevention of suicide attempts and deaths, but additional data are required before relative anti-suicide effects can be confirmed. There were limited data on potential anti-suicide effects of treatment with antipsychotics or antidepressants. This analysis identified a lower estimated suicide rate in bipolar disorder than what was previously published. Understanding the overall risk of suicide deaths and attempts, and the most common methods, are important building blocks to greater awareness and improved interventions for suicide prevention in bipolar disorder. Replication of genetic findings and stronger prospective data on treatment options are required before more decisive conclusions can be made regarding the neurobiology and specific treatment of suicide risk in bipolar disorder.

To evaluate demographic and clinical predictors of suicide attempt and suicide death in a population-based sample of people treated for bipolar disorder (BD). Computerized records were used to identify 32,360 individuals treated for BD at two large prepaid health plans. Suicide attempts were identified using computerized records of outpatient visit diagnoses and hospital discharge diagnoses. Suicide deaths were identified using state death certificate data. Overall event rates were 1.06 per 1,000 person-years for suicide death, 5.6 per 1,000 person-years for suicide attempt leading to hospitalization, and 13.9 per 1,000 person-years for suicide attempt not leading to hospitalization. Men had a significantly lower rate of suicide attempt [hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.56-0.83] but a higher rate of suicide death (HR 2.70, 95% CI 1.69-4.31). Suicide attempts were significantly more frequent among younger patients, but suicide deaths did not vary significantly by age. Substance use comorbidity was significantly related to risk of suicide attempt (HR 2.53, 95% CI 2.07-3.09) but not to risk of suicide death (HR 1.02, 95% CI 0.54-1.93). Comorbid anxiety disorder was associated with significantly higher risk of both suicide attempt (HR 1.40, 95% CI 1.14-1.72) and suicide death (HR 1.81, 95% CI 1.09-2.99). Among people treated for BD, risk of suicide death is significantly related to male sex and comorbid anxiety disorder. The predictors of suicide death differ markedly from predictors of suicide attempt.

Adolescents and young adults represent the high-risk group for first onset of both DSM-IV mental disorders and lifetime suicide attempt (SA). Yet few studies have evaluated the temporal association of prior mental disorders and subsequent first SA in a young community sample. We examined (a) such associations using a broad range of specific DSM-IV mental disorders, (b) the risk of experiencing the outcome due to prior comorbidity, and (c) the proportion of SAs that could be attributed to prior disorders. During a 10-year prospective study, data were gathered from 3021 community subjects, 14–24 years of age at baseline. DSM-IV disorders and SA were assessed with the Munich-Composite International Diagnostic Interview. Cox models with time-dependent covariates were used to estimate the temporal associations of prior mental disorders with subsequent first SA. Most prior mental disorders showed elevated risk for subsequent first SA. Highest risks were associated with posttraumatic stress disorder (PTSD), dysthymia, and nicotine dependence. Comorbidity elevated the risk for subsequent first SA, and the more disorders a subject had, the higher the risk for first SA. More than 90% of SAs in the exposed group could be attributed to PTSD, and over 30% of SAs in the total sample could be attributed to specific phobia. Several DSM-IV disorders increase the risk for first SA in adolescents and young adults. Several promising early intervention targets were observed, e.g., specific phobia, nicotine dependence, dysthymia, and whether a young person is burdened with comorbid mental disorders.

Anticipating Suicide Will Be Hard, But This Is Progress.