Nonfatal Suicidal Behavior Research Articles

Chronic Pain Among Suicide Decedents, 2003 to 2014: Findings From the National Violent Death Reporting System.

More than 25 million adults in the United States have chronic pain. Chronic pain has been associated with suicidality, but previous studies primarily examined nonfatal suicidal behaviors rather than suicide deaths associated with chronic pain or the characteristics of such deaths. To estimate the prevalence of chronic pain among suicide decedents in a large multistate sample and to characterize suicide decedents with and without chronic pain. Retrospective analysis of National Violent Death Reporting System (NVDRS) data. The NVDRS links death certificate, coroner or medical examiner, and law enforcement data collected by investigators, who often interview informants who knew the decedent to gather information on precipitating circumstances surrounding the suicide. Information is abstracted by using standard coding guidance developed by the Centers for Disease Control and Prevention. 18 states participating in the NVDRS. Suicide decedents with and without chronic pain who died during 1 January 2003 to 31 December 2014. Demographic characteristics, mechanism of death, toxicology results, precipitating circumstances (mental health, substance use, interpersonal problems, life stressors), and suicide planning and intent. Of 123181 suicide decedents included in the study, 10789 (8.8%) had evidence of chronic pain, and the percentage increased from 7.4% in 2003 to 10.2% in 2014. More than half (53.6%) of suicide decedents with chronic pain died of firearm-related injuries and 16.2% by opioid overdose. The results probably underrepresent the true percentage of suicide decedents who had chronic pain, given the nature of the data and how they were captured. Chronic pain may be an important contributor to suicide. Access to quality, comprehensive pain care and adherence to clinical guidelines may help improve pain management and patient safety. None.

Nonfatal Suicidal Behaviors in the Administrative Records of Activated U.S. Army National Guard and Army Reserve Soldiers, 2004–2009

Objective: The U.S. Army suicide rate increased sharply during the wars in Iraq and Afghanistan. There is limited information about medically documented, nonfatal suicidal behaviors among soldiers in the Army’s Reserve Component (RC), which is composed of the Army National Guard and Army Reserve. Here we examine trends and sociodemographic correlates of suicide attempts, suspicious injuries, and suicide ideation among activated RC soldiers. Methods: Data come from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Historical Administrative Data Study (HADS), which integrates administrative records for all soldiers on active duty for the years 2004 through 2009 (n = 1.66 million). Results: We identified 2,937 unique RC soldiers on active duty with a nonfatal suicidal event documented at some point during the HADS study period. There were increases in the annual incidence rates of suicide attempts (71 to 204/100,000 person-years) and suicide ideation (326 to 425/100,000 person-years). Incidence rates for suspicious injuries also generally increased but were more variable. Using hierarchical classification rules, we identified the first instance of each soldier’s most severe behavior (suicide attempt versus suspicious injury versus suicide ideation). For each of those suicide- or injury-related outcomes, we found increased risk among those who were female, younger, non-Hispanic White, less educated, never married, and lower-ranking enlisted. These sociodemographic associations significantly differed across outcomes, although the patterns were similar. Conclusion: Results provide a broad overview of nonfatal suicidal trends in the RC during the period 2004 through 2009. They also demonstrate that integration of multiple administrative data systems enriches analysis of the predictors of such events.

Substance use and suicidal ideation and behaviour in low- and middle-income countries: a systematic review

BackgroundUnderstanding relationships between substance use and suicidal ideation and behaviour (SIB) has important public health implications for suicide prevention in low- and middle-income countries (LMICs), where 75% of suicides occur. This systematic review explored the associations between substance use and SIB in LMICs.MethodsWe searched five databases using a combination of keywords for substance use, SIB and LMICs to identify English-written quantitative studies published between January 2006 and February 2016. Data were extracted to provide an overview of what is known about the topic, highlight gaps in the literature, and explore the implications of current knowledge for suicide prevention. Studies included in the review were assessed for methodological quality using the Scottish Intercollegiate Guidelines Network checklist.ResultsAnalysis of included studies (N = 108) demonstrated a consistent positive association between substance use and SIB across all substances (i.e. alcohol, tobacco, cannabis, illicit drugs, non-medical use of prescription drugs), all substance use dimensions (i.e. intoxication, use, and pathological use) and all SIB dimensions (i.e. suicidal ideation, non-fatal suicidal behaviour, and suicide). Most of the available research evidence comes from upper-middle-income countries, only 22% comes from lower-middle-income and low-income countries. Most studies focused on alcohol and tobacco, while neglecting substances such as cannabis, opioids, sedatives, stimulants, misuse of prescription medication, inhalants, and hallucinogens. Most of the studies employed a cross-sectional design, were conducted within a risk-factor paradigm, and provided little information about the potential interaction between variables.ConclusionsPublic health suicide prevention policy and research in LMICs should take account of the fact that: substance use is a potentially modifiable risk factor; assessment and management of substance use is integral to the care of at-risk patients; reducing consumption and hazardous use of substances in LMICs is important for suicide prevention; and research needs to be expanded to include more theory driven research that focuses on all substance use dimensions and SIB dimensions, while employing more sophisticated statistical methods.

Suicidal Ideation and Attempts Among Students in Grades 8, 10, and 12 - Utah, 2015.

Suicidal thoughts and behaviors among youths are important public health concerns in Utah, where the suicide rate among youths consistently exceeds the national rate and has been increasing for nearly a decade (1). In March 2017, CDC was invited to assist the Utah Department of Health (UDOH) with an investigation to characterize the epidemiology of fatal and nonfatal suicidal behaviors and identify risk and protective factors associated with these behaviors, among youths aged 10-17 years. This report presents findings related to nonfatal suicidal behaviors among Utah youths. To examine the prevalence of suicidal ideation and attempts among Utah youths and evaluate risk and protective factors, data from the 2015 Utah Prevention Needs Assessment survey were analyzed. Among 27,329 respondents in grades 8, 10, and 12, 19.6% reported suicidal ideation and 8.2% reported suicide attempts in the preceding 12 months. Significant risk factors for suicidal ideation and attempts included being bullied, illegal substance or tobacco use in the previous month, and psychological distress. A significant protective factor for suicidal ideation and attempts was a supportive family environment. UDOH, local health departments, and other stakeholders are using these findings to develop tailored suicide prevention strategies that address multiple risk and protective factors for suicidal ideation and attempts. Resources such as CDC's Preventing Suicide: A Technical Package of Policy, Programs, and Practices (2) can help states and communities identify strategies and approaches using the best available evidence to prevent suicide, which include tailored strategies for youths.

Suicide among men in Ghana: The burden of masculinity

ABSTRACTIn Ghana, some studies have reported a high rate for both fatal and non-fatal suicidal behaviors among men. The current study aimed at understanding the psychosocial circumstances involved in male suicides. We interviewed between two to seven close relations of each of 12 men who died by suicide. Interpretative phenomenological analysis of data indicates that experiences of shame related to loss of economic control, breach of patriarchal norms, and threats to sexual competence contributed to the suicides. Addressing socioeconomic issues, creating opportunities for men to disclose their emotions, and identifying sources of these emotions may help prevent suicide among men.

Quantification of 5-HT1A and 5-HT2A receptor Binding in Depressed Suicide Attempters and Non-Attempters

Objective: To determine serotonin system abnormalities related to major depression or previous suicidal behavior.Methods: [11C]WAY100635, [18F]altanserin and positron emission tomography were used to compare 5-HT1A and 5-HT2A binding in MDD patients divided into eight past suicide attempters (>4yrs prior to scanning) and eight lifetime non-attempters, and both groups were compared to eight healthy volunteers.Results: The two receptor types differed in binding pattern across brain regions from each other, but there were no differences in binding between healthy volunteers and the two depressed groups or between depressed suicide attempters and non-attempters. No effects of depression severity or lifetime aggression were observed for either receptor.Conclusion: Limitations of this study include small sample size and absence of high lethality suicide attempts in the depressed attempter group. No trait-like binding correlations with past suicide attempt or current depression were observed. Given the heterogeneity of nonfatal suicidal behavior, a larger sample study emphasizing higher lethality suicide attempts may find the serotonin biological phenotype seen in suicide decedents.

Difference in the prevalence of non-fatal suicidal behaviours in patients with unipolar and bipolar depression in China: a meta-analysis

Difference in the prevalence of non-fatal suicidal behaviours in patients with unipolar and bipolar depression in China is rarely reported. We conducted a meta-analysis to examine this difference. Major Chinese and English literature databases were searched online to collect studies comparing the prevalence of non-fatal suicidal behaviours of patients with unipolar and bipolar depression. The quality of the included studies was assessed according to the matching principle. Risk difference (RD) of prevalence rates of non-fatal suicidal behaviours between patients with unipolar and bipolar depression was calculated. A total of 16 studies, containing 1678 cases with unipolar depression and 1069 cases with bipolar depression, were included. Differences in rates of suicidal ideation and attempt were not statistically significant between patients with unipolar and bipolar depression, but rates of overall non-fatal suicidal behaviours in patients with unipolar depression was significantly higher than those with bipolar depression (RD: 0.28, 95% CI: 0.20, 0.36). In summary, the rate of overall non-fatal suicidal behaviours of patients with unipolar depression is higher than that of patients with bipolar depression in China.

Sexual Orientation Discordance and Nonfatal Suicidal Behaviors in U.S. High School Students

Studies among adults have documented association between sexual orientation discordance and some suicide risk factors. However, studies examining sexual orientation discordance and nonfatal suicidal behaviors in youth are rare. This study examines the association between sexual orientation discordance and suicidal ideation/suicide attempts among a nationally representative sample of U.S. high school students. Using sexual identity and sex of sexual contact measures from the 2015 national Youth Risk Behavior Survey (n=6,790), a sexual orientation discordance variable was constructed describing concordance and discordance (agreement and disagreement, respectively, between sexual identity and sex of sexual contacts). Three suicide-related questions (seriously considered attempting suicide, making a plan about how they would attempt suicide, and attempting suicide) were combined to create a two-level nonfatal suicide risk variable. Analyses were restricted to students who identified as heterosexual or gay/lesbian, who had sexual contact, and who had no missing data for sex or suicide variables. The association between sexual orientation discordance and nonfatal suicide risk was assessed using logistic regression. Analyses were performed in 2017. Approximately 4.0% of students experienced sexual orientation discordance. High suicide risk was significantly more common among discordant students compared with concordant students (46.3% vs 22.4%, p<0.0001). In adjusted models, discordant students were 70% more likely to have had suicidal ideation/suicide attempts compared with concordant students (adjusted prevalence ratio=1.7, 95% CI=1.4, 2.0). Sexual orientation discordance was associated with increased likelihood of nonfatal suicidal behaviors. Discordant adolescents may experience unique stressors that should be considered when developing and implementing suicide prevention programs.

Mental Health Symptomatology and Exposure to Non-Fatal Suicidal Behavior: Factors That Predict Vulnerability and Resilience Among College Students

Despite efforts to identify risk factors following exposure to completed suicide, research has paid less attention to the associations between exposure to non-fatal suicide behavior (NFSB) and mental health symptomatology—factors that may underlie one’s susceptibility to future suicidal thoughts and behaviors. This study examined differences in mental health symptomatology among 192 college students exposed to NFSB and 202 exposed to general stressors. Results indicated that students exposed to NFSB had significantly higher levels of depression and anxiety compared to those exposed to a variety of other stressors but not NFSB. Furthermore, among those exposed, a number of risk and protective factors emerged in relation to psychological sequelae, such as emotional stability, social support, and the quality of the relationship between the exposed and suicidal individual. These findings highlight the importance of enhancing provisions of support for those exposed to NFSB.

Trends and repetition of non-fatal suicidal behaviour: analyses of the Gold Coast University Hospital's Emergency Department.

There was a significant increase in the age-standardised rates of NFSB for males (incidence Rate Ratio = 1.05; 95% confidence interval (CI): 1.04-1.07) and females (iRR = 1.06; 95% CI: 1.04-1.07). Age-specific rates showed significant increases for all age groups, except 25-34 and 55+ for females. Different types of poisoning were the predominant method of NFSB (poisoning only - 61.7% of episodes), followed by cutting (23%). Within the first year after the index episode, 13.4% of subjects repeated NFSB. Multivariate Cox regression model showed that sex, age and method predicted repetition. The increasing trends of NFSB and relatively high repetition rates emphasise the need for preventative actions. Monitoring of NFSB at the ED level should be further extended in Australia.

Antidepressants and suicidal behaviour in late life: a prospective population-based study of use patterns in new users aged 75 and above

PurposeTo investigate associations between antidepressant use patterns and risk of fatal and non-fatal suicidal behaviours in older adults who initiated antidepressant therapy.MethodA national population-based cohort study conducted among Swedish residents aged ≥ 75 years who initiated antidepressant treatment. Patients who filled antidepressant prescriptions between January 1, 2007 and December 31, 2013 (N = 185,225) were followed until December 31, 2014. Sub-hazard ratios of suicides and suicide attempts associated with use patterns of antidepressants, adjusting for potential confounders such as serious depression were calculated using the Fine and Gray regression models.ResultsDuring follow-up, 295 suicides and 654 suicide attempts occurred. Adjusted sub-hazard ratios (aSHRs) were increased for both outcomes in those who switched to another antidepressant (aSHR for suicide 2.42, 95% confidence interval 1.65 to 3.55, and for attempt 1.76, 1.32 to 2.34). Elevated suicide risks were also observed in those who concomitantly filled anxiolytics (1.54, 1.20 to 1.96) and hypnotics (2.20, 1.69 to 2.85). Similar patterns were observed for the outcome suicide attempt. Decreased risk of attempt was observed among those with concomitant use of anti-dementia drugs (0.40, 0.27 to 0.59).ConclusionSwitching antidepressants, as well as concomitant use of anxiolytics or hypnotics, may constitute markers of increased risk of suicidal behaviours in those who initiate antidepressant treatment in very late life. Future research should consider indication biases and the clinical characteristics of patients initiating antidepressant therapy.

Rural/Urban Disparities in Adolescent Nonfatal Suicidal Ideation and Suicide Attempt: A Population‐Based Study

Adolescent suicide rates exhibit stark geographic disparities, with rates highest in rural areas. The causes of this disparity remain unclear. We investigated whether adolescent nonfatal suicidal ideation and attempt-leading risk factors for suicide-demonstrate the same rural/urban disparity. Using adolescent data from the 2011-2014 waves of the population-representative California Health Interview Survey (CHIS; N=4,616), we estimated associations between residence in a rural area and suicidal ideation and suicide attempt, as well as access to psychological care. Survey-weighted logistic regression models controlled for individual- and family-level covariates. Results showed that rural adolescents were, compared to urban adolescents, substantially less likely to report recent suicidal ideation (OR=0.25, 95% confidence interval [CI]=0.10, 0.61) and suicide attempt (OR=0.17, 95% CI=0.05, 0.66). Suicidal youths in rural and urban areas were equally likely, however, to report receiving psychological care. In this study, rural adolescents in California reported lower rates of nonfatal suicidal behavior compared to urban peers. This pattern contrasts with rates of adolescent suicide fatality, which are higher in rural areas. Results suggest that reducing geographic disparities in youth suicide may require multifaceted public health approaches, in addition to better identification and treatment for high-risk adolescents.

Neighborhood Characteristics and Adolescent Suicidal Behavior: Evidence from a Population-based Study.

Research on the relationship between neighborhood characteristics and adolescents' risk of nonfatal suicidal behavior is scarce. We used California survey data to examine associations between measures of objective neighborhood quality (levels of violent crime, property crime, and socioeconomic disadvantage) and subjective neighborhood quality (perceptions of neighborhood safety and social cohesion) and adolescents' self-reported suicidal ideation and suicide attempt. Objective measures of neighborhood quality were unrelated to adolescents' risk of suicidal behavior. However, adolescents who perceived their neighborhoods to be less safe and less cohesive were 20%-45% more likely than nonsuicidal peers to report suicidal ideation and attempt.

The Burden of Suicide in Rural Bangladesh: Magnitude and Risk Factors.

The aim of the paper is to quantify the burden and risk factors of fatal and non-fatal suicidal behaviors in rural Bangladesh. A census was carried out in seven sub-districts encompassing 1.16 million people. Face-to-face interviews were conducted at the household level. Descriptive analyses were done to quantify the burden and Poisson regression was run to determine on risk factors. The estimated rates of fatal and non-fatal suicide were 3.29 and 9.86 per 100,000 person years (PY) observed, respectively. The risk of suicide was significantly higher by 6.31 times among 15–17 and 4.04 times among 18–24 olds compared to 25–64 years old. Married adolescents were 22 times more likely to commit suicide compared to never-married people. Compared to Chandpur/Comilla district, the risk of suicide was significantly higher in Narshingdi. Students had significantly lower risk of non-fatal suicidal behavior compared to skilled laborers. The risk of non-fatal suicidal behavior was lower in Sherpur compared to Chandpur/Comilla. Among adolescents, unskilled laborers were 16 times more likely to attempt suicide than students. The common methods for fatal and non-fatal suicidal behaviors were hanging and poisoning. Suicide is a major public health problem in Bangladesh that needs to be addressed with targeted interventions.

Socio-Economic Position and Suicidal Ideation in Men.

People in low socio-economic positions are over-represented in suicide statistics and are at heightened risk for non-fatal suicidal thoughts and behaviours. Few studies have tried to tease out the relationship between individual-level and area-level socio-economic position, however. We used data from Ten to Men (the Australian Longitudinal Study on Male Health) to investigate the relationship between individual-level and area-level socio-economic position and suicidal thinking in 12,090 men. We used a measure of unemployment/employment and occupational skill level as our individual-level indicator of socio-economic position. We used the Index of Relative Socio-Economic Disadvantage (a composite multidimensional construct created by the Australian Bureau of Statistics that combines information from a range of area-level variables, including the prevalence of unemployment and employment in low skilled occupations) as our area-level indicator. We assessed suicidal thinking using the Patient Health Questionnaire (PHQ-9). We found that even after controlling for common predictors of suicidal thinking; low individual-level and area-level socio-economic position heightened risk. Individual-level socio-economic position appeared to exert the greater influence of the two; however. There is an onus on policy makers and planners from within and outside the mental health sector to take individual- and area-level socio-economic position into account when they are developing strategic initiatives.

Prevalence of exposure to suicide: A meta-analysis of population-based studies

Those exposed to suicide are at increased risk of adverse outcomes including mental illness, impaired social functioning, and fatal and non-fatal suicidal behavior. However, it is unclear how many people are exposed to suicide in the general community. This first meta-analysis of population-based studies aimed to provide pooled estimates of past-year and lifetime prevalence of exposure to suicide among family, friends/peers, and all relationships. In addition, the study examined prevalence of exposure to suicide by age group: adolescents and adults. Systematic searches of the literature in Embase, Medline and PsycINFO identified eighteen studies that were included in the analysis. Pooled past-year prevalence was 4.31% (CI: 2.50 to 6.58) and life-time prevalence 21.83% (CI: 16.32 to 27.90). Both past-year and lifetime prevalences of exposure to suicide among friends and peers were significantly higher than the prevalence of exposure within families; there were no differences in the prevalence of exposure to suicide between adolescents and adults. Heterogeneity was highly significant. Future research should be conducted with large national representative samples and use standardised assessment instruments. Given the increased risks of adverse outcomes among those exposed to suicide, the high rate of exposure to suicide reported here has important ramifications for public health and mental health service delivery.

Life stress and suicidal ideation in Australian men - cross-sectional analysis of the Australian longitudinal study on male health baseline data.

BackgroundSuicide is a leading cause of death in Australian males aged 18 to 55. Non-fatal suicidal behaviours and thoughts are indicators of increased risk for future suicide. Suicidal behaviour is complex and multi-determined. Research supports the involvement of stressful life events in suicide and suicidal behaviour, however the evidence regarding suicidal thoughts is less developed. This study investigates stressful life events in relation to suicidal ideation in a large cohort of adult males recruited into Ten to Men, the Australian Longitudinal Study on Male Health.MethodsBaseline data from a national cohort of 13, 884 males aged 18–55 years on suicidal behaviour, psychiatric disorder and life events was used. Multivariable logistic regressions were conducted with current suicidal ideation as the outcome and 12 month life events, 12 month depression, anxiety and harmful/hazardous alcohol use, and socio-demographics as covariates. Further logistic regression models investigated the relative risk of life stress alone, depression/alcohol/anxiety alone and co-occurring life stress and depression/alcohol/anxiety.ResultsIn multivariable models there was an independent contribution to suicidal ideation for six of 24 life events (ORs 1.27–1.95), 12 month depression (OR 4.49) harmful alcohol use (OR 1.38) and anxiety disorders (OR 1.27). Life events co-occurring with depression (OR 10.3) was higher risk than either alone (depression OR 6.6; life stress OR 2.6). There was a lesser effect for co-occurrence in the anxiety and harmful alcohol use models.ConclusionLife events appear to be related to suicidal ideation independent of depression, anxiety and harmful alcohol use in adult males, however if life events occur in the context of depression that risk is substantially increased.

Use of emergency department electronic medical records for automated epidemiological surveillance of suicide attempts: a French pilot study.

The aim of this study was to determine whether an expert system based on automated processing of electronic health records (EHRs) could provide a more accurate estimate of the annual rate of emergency department (ED) visits for suicide attempts in France, as compared to the current national surveillance system based on manual coding by emergency practitioners. A feasibility study was conducted at Lyon University Hospital, using data for all ED patient visits in 2012. After automatic data extraction and pre-processing, including automatic coding of medical free-text through use of the Unified Medical Language System, seven different machine-learning methods were used to classify the reasons for ED visits into "suicide attempts" versus "other reasons". The performance of these different methods was compared by using the F-measure. In a test sample of 444 patients admitted to the ED in 2012 (98 suicide attempts, 48 cases of suicidal ideation, and 292 controls with no recorded non-fatal suicidal behaviour), the F-measure for automatic detection of suicide attempts ranged from 70.4% to 95.3%. The random forest and naïve Bayes methods performed best. This study demonstrates that machine-learning methods can improve the quality of epidemiological indicators as compared to current national surveillance of suicide attempts.

Factors Related to Suicide in LGBT Populations.

There is evidence of heightened vulnerability to nonfatal suicidal behaviors among LGBT populations yet a paucity of studies into fatal behaviors. The specific aim of this article was to identify factors related to suicide in LGBT individuals in Australia. The psychological autopsy (PA) method with a matched case-control study design was used. PA interviews were conducted with 27 next-of-kin of an LGBT person that had died by suicide. Three living LGBT controls per suicide case, matched by age and gender, were also interviewed. The key factors relating to suicide in LGBT people were a lack of acceptance by family and self (reflected in higher internalized homophobia and shame), negative feelings about own sexuality/gender, and dissatisfaction with appearance. LGBT people who died by suicide also tended to go through coming out milestones 2 years earlier than controls. There was a higher prevalence of aggressive behaviors and a more predominant history of physical and sexual abuse. Additionally, there was greater incidence of depression and anxiety and alcohol and substance use disorders. Specific predictive factors for suicide in LGBT populations in Australia were identified, including significantly poorer mental health outcomes and more violence across an array of measures.

Ethics in Community-Based Research with Vulnerable Children: Perspectives from Rwanda.

A “risk of harm” protocol to identify youth in need of immediate emergency assistance in a study on mental health and HIV in Rwanda among 680 youth ages 10–17 is described. Cases are presented that describe the experience in using this protocol to ensure safety of participants, with ethical and logistical challenges considered. Among the population of the study, 3.2% were deemed “risk of harm.” The most prevalent presenting problem was non-fatal suicidal behavior (91% of risk of harm cases), with 36% having a history of a reported previous attempt. Challenges included: acute food insecurity/significant poverty; lack of support/adequate supervision from family members; family violence; alcohol abuse; and HIV-related stigma. Development of a “risk of harm” protocol and collaboration between study staff, community leadership, health authorities, and health workers are critical to ensuring participants’ safety in research among vulnerable populations.