Common Risk Factors For Suicide Research Articles

Role of machine learning algorithms in suicide risk prediction: a systematic review-meta analysis of clinical studies

ObjectiveSuicide is a complex and multifactorial public health problem. Understanding and addressing the various factors associated with suicide is crucial for prevention and intervention efforts. Machine learning (ML) could enhance the prediction of suicide attempts.MethodA systematic review was performed using PubMed, Scopus, Web of Science and SID databases. We aim to evaluate the performance of ML algorithms and summarize their effects, gather relevant and reliable information to synthesize existing evidence, identify knowledge gaps, and provide a comprehensive list of the suicide risk factors using mixed method approach.ResultsForty-one studies published between 2011 and 2022, which matched inclusion criteria, were chosen as suitable. We included studies aimed at predicting the suicide risk by machine learning algorithms except natural language processing (NLP) and image processing.The neural network (NN) algorithm exhibited the lowest accuracy at 0.70, whereas the random forest demonstrated the highest accuracy, reaching 0.94. The study assessed the COX and random forest models and observed a minimum area under the curve (AUC) value of 0.54. In contrast, the XGBoost classifier yielded the highest AUC value, reaching 0.97. These specific AUC values emphasize the algorithm-specific performance in capturing the trade-off between sensitivity and specificity for suicide risk prediction.Furthermore, our investigation identified several common suicide risk factors, including age, gender, substance abuse, depression, anxiety, alcohol consumption, marital status, income, education, and occupation. This comprehensive analysis contributes valuable insights into the multifaceted nature of suicide risk, providing a foundation for targeted preventive strategies and intervention efforts.ConclusionsThe effectiveness of ML algorithms and their application in predicting suicide risk has been controversial. There is a need for more studies on these algorithms in clinical settings, and the related ethical concerns require further clarification.

An analysis of suicides among first responders ─ Findings from the National Violent Death Reporting System, 2015–2017

Introduction: First responders, including law enforcement officers (LEOs), firefighters, emergency medical services (EMS) clinicians, and public safety telecommunicators, face unique occupational stressors and may be at elevated risk for suicide. This study characterized suicides among first responders and identifies potential opportunities for additional data collection. Methods: Using suicides identified from the three most recent years of National Violent Death Reporting System data with industry and occupation codes from the NIOSH Industry and Occupation Computerized Coding System (2015–2017), decedents were categorized as first responders or non-first responders based on usual occupation. Chi-square tests were used to evaluate differences in sociodemographic and suicide circumstances between first and non-first responders. Results: First responder decedents made up 1% of all suicides. Over half of first responders (58%) were LEOs, 21% were firefighters, 18% were EMS clinicians, and 2% were public safety telecommunicators. Compared to non-first responder decedents, more first responders served in the military (23% vs. 11%) and used a firearm as the method of injury (69% vs. 44%). Among first responder decedents for whom circumstances were known, intimate partner problems, job problems, and physical health problems were most frequent. Some common risk factors for suicide (history of suicidal thoughts, previous suicide attempt, alcohol/substance abuse problem) were significantly lower among first responders. Selected sociodemographics and characteristics were compared across first responder occupations. Compared to firefighters and EMS clinicians, LEO decedents had slightly lower percentages of depressed mood, mental health problems, history of suicidal thoughts, and history of suicide attempts. Conclusions: While this analysis provides a small glimpse into some of these stressors, more detailed research may help inform future suicide prevention efforts and interventions. Practical application: Understanding stressors and their relation to suicide and suicidal behaviors can facilitate suicide prevention among this critical workforce.

Methods of attempted suicide and risk factors in LGBTQ+ youth

BackgroundThis study aimed to identify patterns of attempted suicide methods and risk factors in lesbian, gay, bisexual, transgender, queer and other gender/sexual minority (LGBTQ+) youth by comparing them to non-LGBTQ+ youth. MethodsA total of 9281 Chinese college students completed the study, 8313 participants were included in the analysis of which 1032 were LGBTQ+ youth and 7281 were non-LGBTQ+ youth. Sociodemographic information was collected along with several scales and self-report items. This included anxiety scores using the Generalized Anxiety Disorder (GAD)-7, depression scores using the Patient Health Questionnaire (PHQ)-9, mania score using the Altman Self-Rating Mania (ASRM), Childhood Trauma Questionnaire (CTQ), and Intimate Partner Violence (IPV) victimization using the World Health Organization's definition. Self-report items were used to further collect history of non-fatal self-injurious behaviors, parents' related risk factors, history of suicide attempts, and methods of attempted suicide. ResultsThe prevalence of attempted suicide in LGBTQ+ youth was 4.2%, which in comparison was more than four times higher than non-LGBTQ+ youth. LGBTQ+ youth 19–22 years old were at a significantly higher risk of attempting suicide than non-LGBTQ+ youth. The most common method of attempted suicide was cutting of the wrist, followed by jumping from a high height. There were some common suicide risk factors that were similar between LGBTQ+ and non-LGBTQ+ youth, such as living in a rural area, having a history of a psychiatric disorder, and having a history of non-fatal self-injurious behaviors. The associated increased risk factors for LGBTQ+ youth were having a higher score for CTQ-emotional abuse and CTQ-sexual abuse. LimitationThe causality of risk factors to attempted suicide cannot be assumed due to the cross-sectional nature of the survey. Also, due to the relatively small sample size within the subgroups, we did not assess LGBTQ+ youth separately according to the different sexuality groups. ConclusionLGBTQ+ youth showed a higher prevalence of attempted suicide when compared to their heterosexual peers. Emotional and sexual abuse showed higher rates among LGBTQ+ youth, the cumulative effects of childhood trauma might explain the difficulties in developing healthy coping styles.

Adolescent firearm suicide risk patterns: A latent class analysis using U.S. National Violent Death Reporting System surveillance data, 2007–2017

ObjectivesSuicide is the second leading cause of death among adolescents in the United States, and a substantial proportion are committed with a firearm. This study identifies risk patterns among adolescent firearm suicides and examines how demographic factors relate to these patterns. MethodsA latent class analysis was conducted using US National Violent Death Reporting System data, years 2007–2017. Adolescent firearm suicide decedents ages 10–17 years were included in the primary analyses (n = 2139). Factors used to identify risk patterns fell under the categories of mental health, relationship or other social problems, and substance use. Demographic factors examined in relation to risk patterns were age, race/ethnicity, and sex. ResultsThree risk patterns emerged: low problems (i.e., a low probability of all risk factors included in the model; n = 1075; 50.26%); high mental health problems and history of suicidal behavior, ideation, and suicide attempts (n = 742, 34.69%); and high problems at school (n = 322, 15.05%). Compared to White adolescents, Black adolescents had decreased odds of being in the “high mental health and suicidal behavior” class, compared to being in the “low problems” class (AOR, 0.53, 95% CI: 0.36, 0.79). A post hoc analysis identified four risk patterns for non-firearm suicides (n = 3319), with mental health problems featuring more prominently compared to firearm suicide patterns. ConclusionsFindings indicate that half of adolescent firearm suicides are characterized by a low probability of having common risk factors for suicide. This emphasizes the importance of universal safe storage practices among firearm-owning parents. Results also indicate a need for more research on the risk factors unique to Black adolescents.

Suicide prevention in psychiatric patients.

An increased risk of suicide has been reported for psychiatric patients. In several world regions, an underlying psychiatric disorder is reported in up to 90% of people who die from suicide, though this rate seems to be considerably lower in low- and middle-income countries. Major psychiatric conditions associated with suicidality are mood disorders, alcohol and substance use disorders, borderline personality disorder, and schizophrenia. Comorbidity between different disorders is frequently associated with a higher suicide risk. A history of suicide attempts, feelings of hopelessness, impulsivity and aggression, adverse childhood experiences, severe psychopathology, and somatic disorders are common risk factors for suicide among psychiatric patients. Stressful life events and interpersonal problems, including interpersonal violence, are often triggers. A comprehensive and repeated suicide risk assessment represents the first step for effective suicide prevention. Particular attention should be paid during and after hospitalization, with the first days and weeks after discharge representing the most critical period. Pharmacological treatment of mood disorders and schizophrenia has been shown to have an anti-suicidal effect. A significant reduction of suicidal thoughts and behavior has been reported for cognitive behavioral therapy and dialectical behavior therapy. Brief interventions, including psychoeducation and follow-ups, are associated with a decrease in suicide deaths. Further development of suicide prevention in psychiatric patients will require a better understanding of additional risk and protective factors, such as the role of a person's decision-making capacity and social support, the role of spiritual and religious interventions, and the reduction of the treatment gap in mental health care.

The prevalence of severe depression in Iranian older adult: a meta-analysis and meta-regression

BackgroundDepression is one of the most common psychiatric disorders in the older adult and one of the most common risk factors for suicide in the older adult. Studies show different and inconsistent prevalence rates in Iran. This study aims to determine the prevalence of severe depression in Iranian older adult through a meta-analysis approach.MethodsThe present meta-analysis was conducted between January 2000–August 2019. Articles related to the subject matter were obtained by searching Scopus, Sciencedirect, SID, magiran, Barakat Knowledge Network System, Medline (PubMed), and Google Scholar databases. The heterogeneity of the studies was evaluated using I2 index and the data were analyzed in Comprehensive Meta-Analysis software.ResultsIn a study of 3948 individuals aged 50–90 years, the overall prevalence of severe depression in Iranian older adult was 8.2% (95% CI, 4.14–6.3%) based on meta-analysis. Also, in order to investigate the effects of potential factors (sample size and year of study) on the heterogeneity of severe depression in Iranian older adult, meta-regression was used. It was reported that the prevalence of severe depression in Iranian older adult decreased with increasing sample size and increasing years of the study, which is significantly different (P < 0.05).ConclusionConsidering the high prevalence of severe depression in Iranian older adult, it is necessary for health policy makers to take effective control measures and periodic care for the older adult.

Seasonality of Suicides among Victims Who Are under the Influence of Alcohol.

Introduction: Suicide is one of the most frequent causes of death. According to the World Health Organization (WHO), each year, over eight hundred thousand people worldwide die as a result of suicide. The most common risk factors for suicide are depressive disorders and alcohol dependence. Alcohol can directly influence a decision about suicide, or be a factor facilitating this decision. The aim of the study was to analyse the seasonality of suicides among persons under the influence of alcohol. Material and Methods: Data for analysis were obtained from the Department of Forensic Medicine (DFM) of the Medical University of Warsaw. A retrospective analysis was performed on 317 victims of suicides by hanging, those which were entered into the registry of deaths kept by the DFM in the years 2009–2013. The analysis took into account the age and sex of victims, initial cause of death, date of post-mortem examination, autopsy result and alcohol concentration in the blood or muscles of the victims. Statistical analysis was performed using IBM SPSS Statistics version 20. Results: In the analysis, a spring peak of suicides was found for men, and an autumn peak was revealed for women. In addition, a significant correlation was observed between the age of victims and the concentration of alcohol; the older the victims, the higher the alcohol concentration. However, this correlation was reported only in the spring months. Conclusions: The results of the analysis seem to be consistent with seasonal patterns observed in other studies, and they indicate the occurrence of suicide seasonality. In order to improve the strategies of suicide prevention, it is necessary to identify factors which are related to the seasonal variation of suicidal behaviours, as well as to gain knowledge about the mechanisms behind this phenomenon.

Self-harm hospitalised morbidity and mortality risk in Australia using a matched population-based cohort

IntroductionPrior and repeated self-harm hospitalisations are common risk factors for suicide. However, few studies have accounted for pre-existing comorbidities and prior hospital use when quantifying the burden of self-harm.&#x0D; Objectives and ApproachTo quantify hospitalisation in the 12 months preceding and re-hospitalisation and mortality risk in the 12 months post a self-harm hospitalisation. A population-based matched cohort study of individuals ≥18 years using linked hospitalisation and mortality records from four Australian states. Self-harm was identified using a principal diagnosis of injury (S00-T75 or T79) and an external cause of self-harm (X60-X84). The index self-harm hospitalisation was identified and 12-month pre- and post-index injury health service use was examined. The non-injured comparison cohort was randomly selected from the electoral roll and was matched 1:1 on age, gender, and postcode of residence. Comorbidities were identified using diagnosis classifications with a 1-year lookback. Negative binomial regression was used to quantify associations between self-harm and counts of hospital admissions 12-months post the index hospitalisation using rate ratios and 95%CIs.&#x0D; ResultsThere were 11,597 individuals with a self-harm hospitalisation in New South Wales, South Australia, Queensland or Tasmania with a matched comparison. Mean age was 38.6 years (SD=14.9) and 57.6% were female. The self-harm cohort had a higher proportion of Charlson comorbidities, mental health diagnoses, alcohol misuse and drug-related dependence than their matched counterparts. The self-harm cohort experienced a higher proportion of health service use in the 12-months preceding (20.5% vs 10.1%) and post (21.2% vs 10.6%) the index admission and a higher mortality rate (2.9% vs 0.3%) than their matched counterparts. The adjusted rate ratios (ARR) for hospital readmission were highest for females (ARR: 2.86; 95% CI: 2.33-3.52) and individuals aged 55-64 years (ARR: 3.96; 95%CI: 2.79-5.64).&#x0D; Conclusion/ImplicationsImproved hospitalisation burden quantification for self-harm can inform resource allocation for intervention and after care services for individuals at-risk of repeated self-harm. Better assessment of at-risk self-harm behaviour, appropriate referrals and improved post-discharge care, focusing on care continuity is needed.

Factors contributing to cancer-related suicide: A study of root-cause analysis reports.

Vast efforts are directed toward curing or prolonging the life of patients with cancer. However, less attention is given to mental health aspects of cancer care, and there is elevated incidence of death by suicide in this population. Evaluating Root Cause Analyses (RCAs) of cancer-related suicides may further our understanding of system-level factors that may contribute to suicide in patients with cancer and highlight strategies to mitigate this risk. We searched the Veterans Health Administration National Center for Patient Safety RCA database for cancer-related suicides between 2002 and 2017 to evaluate the context of the suicides and identify root causes and suggested actions. These variables were coded by consensus and evaluated using descriptive statistics. We identified 64 RCA reports involving cancer-related suicide; 100% were males of older age. Many suicides occurred during treatment with palliative intent (44%, N=28). Depression (59%, N=38), medical comorbidities (59%, N=38), and pain (47%, N=30) were common suicide risk factors identified. Most suicides occurred within 7days of a medical visit (67%, N=43), especially within the first 24hours (41%, N=26). Root causes included a need to improve recognition of triggers for assessment and interdisciplinary communication. This analysis uncovers opportunities to mitigate risk of death by suicide among patients with cancer. Suggested actions include use of comprehensive cancer centers and development of a distress checklist using information from the National Comprehensive Cancer Network Guidelines. Further studies should assess additional factors that may increase the risk of other adverse mental health outcomes in this population.

A pilot project to identify individuals who died from suicide and visited an ED before death

Objective: To explore the use of ED syndromic surveillance data to retrospectively identify individuals who died from suicide and visited an ED before death in order to improve suicide surveillance and inform planning and prevention efforts in Salt Lake County, Utah.Introduction: In 2015, suicide was the 8th leading cause of death in Salt Lake County, Utah, and has recently been identified as a priority public health issue. For suicide, suicide ideation and suicide attempts surveillance, Salt Lake County Health Department staff use National Violent Death Reporting System (NVDRS) mortality data to monitor historical trends and vital records mortality data and ESSENCE ED encounter morbidity data to monitor trends and populations in real time. To improve surveillance and better identify populations at higher risk of suicide, we tested whether we could retrospectively identify residents who died from suicide and visited an ED in the year before death.Methods: Data for all ESSENCE ED encounters from January 1, 2016, through June 30, 2017, were downloaded from the National Syndromic Surveillance Program BioSense platform. Salt Lake County residents who died from suicide from January 1, 2017, through June 30, 2017, were linked to this ESSENCE dataset using date of birth and zip code. We performed chart reviews of the matched patients’ ED encounters and collected sociodemographic (name, residence, race, ethnicity, marital status, military service, sexual orientation), socioeconomic status (education, occupation) and suicide risk factor data (social isolation, addiction, physical health, relationship, financial, job, school, criminal, civil legal problems, eviction or housing problem, recent suicide or other death of family/friend, current depressed mood, current or recent mental health diagnosis and/or treatment, current alcohol or other substance use disorder, perpetrator or victim of interpersonal violence, history of abuse, and history of suicide ideation, plan and attempt). We used descriptive epidemiology to describe risk factors and circumstances.Results: Fifteen Salt Lake County residents who died from suicide from January 1, 2017, through June 30, 2017, matched individuals in the ESSENCE ED dataset by date of birth and zip code. Upon chart review, 14/15 matched by medical record number; the remaining patient was excluded due to medical record number mismatch. Ultimately, 13% (14/105) of Salt Lake County residents who died from suicide from January 1, 2017, through June 30, 2017, were identified in ESSENCE as having visited an ED in the year before death. Among them, they visited an ED a total of 30 times. Based on chart review of 13/14 of these individuals, the most common suicide risk factors or circumstances were physical health problem (62%), current mental health diagnosis (62%), history of suicidal thoughts (54%) and current depressed mood (54%). The correlation between risk factors identified from ESSENCE and those identified from NVDRS was moderate (r= 0.57).Conclusions: It is possible to identify individuals who died from suicide and visited an ED before death. We are encouraged by the result that common risk factors found via chart review are similar to those we have found in our historical analyses of NVDRS suicide data. This risk factor information adds valuable context to real-time surveillance of suicide, suicide ideation and suicide attempts. Next steps in this pilot are to complete the final chart review and develop and test triage note search queries to monitor suicide and suicidal thoughts and behavior and identify populations who have these common risk factors and may be at higher risk for suicide. It should be noted that during this work, several facilities’ data feeds dropped and the quantity of data decreased dramatically. That we were still able to identify 13% of our residents who died from suicide in ESSENCE despite the large loss of data suggests the true percentage is likely to be much higher once facilities are re-onboarded. This gives us confidence that we will be able to develop a reliable ESSENCE query for suicide risk factors specific to our residents.

Socio-economic status and risk for suicide by immigration background in Norway: A register-based national study

The relative importance of socio-economic factors on risk for suicide in the immigrant population may differ from that for the native population; however, few studies have addressed this issue on a national basis. With a nested case-control design and data from Norwegian population registers we identified 11,409 suicide cases in the years 1992–2012 and 191,785 sex-birthdate-matched controls. The influence of socio-economic factors on the risk for completed suicide was assessed through conditional logistic regression. Among 11,409 suicides, 1139 (10%) were individuals with an immigration background of either themselves or their parent(s). Suicide cases, as well as the controls, with an immigration background differed in several aspects of their socio-economic status from those without such a background. Being single or separated, divorced or widowed, was, however, associated with an increased risk of suicide regardless to the subjects’ immigration background. Low level of education and low annual income significantly increased the risk for suicide in almost all the study subgroups. Living in the capital area was associated with a reduced risk of suicide in first-generation immigrants but an increased risk in native Norwegians. In conclusion, persons with an immigration background, as well as native Norwegians, shared most common risk factors for suicide, but the strength of associations between socio-economic factors and risk for suicide can differ by immigration background.

Self-harm hospitalised morbidity and mortality risk using a matched population-based cohort design.

Prior and repeated self-harm hospitalisations are common risk factors for suicide. However, few studies have accounted for pre-existing comorbidities and prior hospital use when quantifying the burden of self-harm. The aim is to quantify hospitalisation in the 12 months preceding and re-hospitalisation and mortality risk in the 12 months post a self-harm hospitalisation. A population-based matched cohort using linked hospital and mortality data for individuals ⩾18 years from four Australian jurisdictions. A non-injured comparison cohort was matched on age, gender and residential postcode. Twelve-month pre- and post-index self-harm hospitalisations and mortality were examined. The 11,597 individuals who were hospitalised following self-harm in 2009 experienced 21% higher health service use in the 12 months pre and post the index admission and a higher mortality rate (2.9% vs 0.3%) than their matched counterparts. There were 133 (39.0%) deaths within 2 weeks of hospital discharge and 342 deaths within 12 months of the index hospitalisation in the self-harm cohort. Adjusted rate ratios for hospital readmission were highest for females (2.86; 95% confidence interval: [2.33, 2.52]) and individuals aged 55-64 years (3.96; 95% confidence interval: [2.79, 5.64]). Improved quantification of the burden of self-harm-related hospital use can inform resource allocation for intervention and after-care services for individuals at risk of repeated self-harm. Better assessment of at-risk self-harm behaviour, appropriate referrals and improved post-discharge care, focusing on care continuity, are needed.

A large-scale survey of inpatient suicides: comparison between medical and psychiatric settings

Suicide is one of the common severe accidents occurring in hospitals. This study aimed to investigate inpatient suicides simultaneously in medical and psychiatric settings in a large number of hospitals and to examine the prevalence of common suicide risk factors, related symptoms in inpatients who had died by suicide and the differences in inpatient suicides between both settings. We conducted a survey of hospitals in Japan that belonged to the nationwide standard-setting and accrediting body. The questionnaire covered the: 1) presence or absence of inpatient suicides in each hospital from 2012 to 2015; 2) number of inpatient suicides; 3) method, location, and timing of inpatient suicides; and 4) characteristics of inpatients who died by suicide. In total, 529 hospitals reported 262 inpatient suicides during the 3-year period: 131 were in medical settings and 131 were in psychiatric settings. The prevalence of common suicide risk factors was frequent in inpatient suicides. Inpatients had characteristics and suicide risk factors specific to those settings such as worsening of physical health in medical settings. Therefore, recognizing common suicide risk factors and understanding differences in inpatient suicides between both settings are important to prevent inpatient suicides.

Tracking search engine queries for suicide in the United Kingdom, 2004–2013

ObjectivesFirst, to determine if a cyclical trend is observed for search activity of suicide and three common suicide risk factors in the United Kingdom: depression, unemployment, and marital strain. Second, to test the validity of suicide search data as a potential marker of suicide risk by evaluating whether web searches for suicide associate with suicide rates among those of different ages and genders in the United Kingdom. Study designCross-sectional. MethodsSearch engine data was obtained from Google Trends, a publicly available repository of information of trends and patterns of user searches on Google. The following phrases were entered into Google Trends to analyse relative search volume for suicide, depression, job loss, and divorce, respectively: ‘suicide’; ‘depression + depressed + hopeless’; ‘unemployed + lost job’; ‘divorce’. Spearman's rank correlation coefficient was employed to test bivariate associations between suicide search activity and official suicide rates from the Office of National Statistics (ONS). ResultsCyclical trends were observed in search activity for suicide and depression-related search activity, with peaks in autumn and winter months, and a trough in summer months. A positive, non-significant association was found between suicide-related search activity and suicide rates in the general working-age population (15–64 years) (ρ = 0.164; P = 0.652). This association is stronger in younger age groups, particularly for those 25–34 years of age (ρ = 0.848; P = 0.002). ConclusionsWe give credence to a link between search activity for suicide and suicide rates in the United Kingdom from 2004 to 2013 for high risk sub-populations (i.e. male youth and young professionals). There remains a need for further research on how Google Trends can be used in other areas of disease surveillance and for work to provide greater geographical precision, as well as research on ways of mitigating the risk of internet use leading to suicide ideation in youth.

Suicidal Behavior in Relatives or Associates Moderates the Strength of Common Risk Factors for Suicide.

The prevalence and odds ratios of different suicide risk factors were compared in three pairs of decedents: 80 suicides and 25 injury decedents with blood relatives with suicidal behavior history (biologically exposed); 259 suicides and 126 injury decedents with unrelated acquaintances with suicidal behavior history (socially exposed); and 471 suicides and 523 injury decedents with neither relatives nor acquaintances with suicidal behavior history (unexposed). Negative life events and high psychological stress were more common in socially exposed suicides than in other suicides. The adjusted odds ratios of most established suicide risk factors were higher in unexposed decedents than in biologically or socially exposed decedents, suggesting that the predictive value of established risk factors wanes in individuals who have been exposed to suicidal behavior in family or friends.

Suicide rate after induced abortion decreased in Finland after Current Care Guidelines

Background A register-based study showed that women with a recent induced abortion have more than three-fold risk for suicide compared to non-pregnant women in 1987-1994. This suggests rather common risk factors for suicide and induced abortion than harmful effects of induced abortion on mental health. The increased risk was recognised in national unofficial guidelines on abortion treatment right after the study was published. The same was true for official Current Care Guidelines for induced abortion, which …

A Comparison of Suicides and Undetermined Deaths by Poisoning among Women: An Analysis of the National Violent Death Reporting System

The study compared the prevalence of common suicide risk factors between poisoning deaths classified as injuries of undetermined intent or suicides among women. Data were derived from the 2003–10 National Violent Death Reporting System. Multiple logistic regression assessed the factors associated with 799 undetermined deaths (relative to 3,233 suicides). Female decedents with lower education, a substance use problem, and a health problem were more likely to be classified as undetermined death. Older women, those with an intimate partner problem, financial problem, depressed mood, mental health problem, attempted suicide, and disclosed intent to die were less likely to be classified as undetermined death. The present study raises the possibility that many (perhaps most) undetermined female poisoning deaths are suicides.

Combat experience and the acquired capability for suicide

Rising suicide rates are an increasing concern among military personnel. The interpersonal-psychological theory of suicide proposes that three necessary factors are needed to die by suicide: feelings that one does not belong with other people, feelings that one is a burden on others or society, and an acquired capability to overcome the fear and pain associated with suicide. The current study tests the theory's proposal that acquired capability may be particularly influenced by military experience, because combat exposure may cause habituation to fear of painful experiences such as suicide. Utilizing clinical and nonclinical samples of military personnel deployed to Iraq, results of the current study indicate that a greater range of combat experiences predicts acquired capability above and beyond depression and post-traumatic stress disorder symptoms, previous suicidality, and other common risk factors for suicide. Combat experiences did not, however, predict perceived burdensomeness or thwarted belongingness. The authors discuss how combat experiences might serve as a mechanism for elevating suicide risk and implications for clinical interventions and suicide prevention efforts.

Child Suicide, Family Environment, and Economic Crisis

Suicide among children is considered to be a rare event, although it is still one of the leading causes of death in children younger than 15 years of age worldwide (Pelkonen & Marttunen, 2003; Vajani, Annest, Crosby, Alexander, & Mille, 2007). Compared to other age groups, the prevalence of suicide in children is more likely to be underestimated (Beautrais, 2001; Crepeau-Hobson, 2010; Fortune & Hawton, 2007; McClure, 2001). Possible reasons for this underestimation may be the social stigma and shame surrounding suicide in general, the reluctance by officials or coroners to determine a verdict of suicide in a child, disparities in death classification systems, and/or the misconception that children are precluded from engaging in suicidal acts due to cognitive immaturity (Crepeau-Hobson, 2010; Schmidt, Muller, Dettmeyer, & Madea, 2002; Shaw, Fernandes, & Rao, 2005; Pritchard & Hansen, 2005). However, research has indicated that, from the age of 8 on, children understand the concept of suicide (Mishara, 1998; Fortune & Hawton, 2007) and are capable of carrying it out. Research in adolescent and youth suicide is growing. While previous studies provided a broad overview of the phenomenon, few focused specifically on suicide in children. There appears to be some empirical support for the notion that children may be less exposed to common suicide risk factors, such as mental illness and substance abuse, and less likely to display predictive factors, such as prior suicidal behavior (Beautrais, 2001; Groholt, Ekeberg, Wichstrom, & Haldorsen, 1998; Pelkonen & Marttunen, 2003; Schmidt et al., 2002). Groholt et al. (1998) suggested that the low suicide incidence in children might be related to fewer risk factors rather than to their resilience to these risk factors. Interpersonal family conflicts, especially parent-child conflicts, are important suicide risk factors in children and younger adults and appear more frequently compared to older adults. Beautrais (2001) reported that 70.5% of child suicides aged 9–14 years had a family conflict as a triggering factor. Furthermore, it has been reported that parental divorce or a stepparent in the family increases the risk of suicidal behaviors in children and adolescents (Pelkonen & Marttunen, 2003; Samm et al., 2010). A growing body of research indicates that the risk of child and adolescent suicide and attempted suicides increases when family psychopathology is involved, such as parental mental health problems or a history of suicidal behavior (King, 2009). However, the existence and impact of shared genetic risk factors, the level of influence of an adverse family environment, and whether these influences can be mediated remain unknown in the context of child suicide (Brent & Mann, 2006; King, 2009). It also appears that the family environment – parenting style, physical abuse, and parental mental health problems – can be greatly influenced by economic pressure (Yoder & Hoyt, 2005). Since the beginning of the global financial crisis, several editorials and papers have indicated the possible impact the economic recession may have on morbidity (Catalano, 2009; Uutela, 2010), mortality (Simms, 2009), and, more specifically, suicide (Gunnell, Platt, & Hawton, 2009). Indeed, based on past experiences and from a public health perspective, it is very important to notify professionals and politicians about the possible consequences (Stuckler, Basu, Suhrcke, Coutts, &McKee, 2009). Meanwhile, speculations continue about eventual scenarios, as it is too early to see the impact the global financial crisis might have on overall suicide mortality and morbidity rates. The effects of an economic recession on children, general child mortality and morbidity, violence against children, schooling, quality of care, and emotional well-being also need to be considered (Harper, Jones, McKay, & Espey, 2009). Yet, how much do we know about the possible fallouts of an economic crisis on children, their suicidal behaviors, and child suicides? The impact of an economic recession can be measured both on an aggregated and an individual level. In a recent paper, Apter, Bursztein, Bertolote, Fleischmann, and Wassermann (2009) considered that turmoil following rapid changes in the economy has been

Suicidal risk factors and completed suicide: meta-analyses based on psychological autopsy studies

The purpose of the present review is to evaluate the effects of common risk factors for suicide by meta-analyses using data extracted from studies based on the psychological autopsy method. We focused on five common risk factors of suicide: substance-related disorders, mood disorders, adverse marital status, adverse employment status, and self-harm behaviors. A total of 24 articles were identified from MEDLINE in which the crude odds ratio (OR) could be calculated for the above five risk factors through 30 April 2007, using such search keywords as "suicide," "psychological autopsy," and "case-control study." Overall, both substance-related disorders [OR = 5.24; 95% confidence interval (CI) = 3.30-8.31] and mood disorders [OR = 13.42; 95% CI = 8.05-22.37] were strongly associated with suicidal risk. Suicidal attempt and deliberate self-harm, which can directly lead to completed suicide, have been shown to be very strongly associated with suicidal risk [OR = 16.33; 95% CI = 7.51-35.52]. Effects of social factors such as adverse marital and employment status were relatively small. As substance-related disorders and mood disorders were strongly associated with an increased risk of completed suicide, the comorbidity of these two disorders should be paid a maximum attention. The effective prevention of suicide depends on whether we can successfully incorporate these personal factors as well as social factors into an adequate multi-factorial model.