Violent Suicide Research Articles

Constitution of "The Already Dying": The Emergence of Voluntary Assisted Dying in Victoria.

In June 2019 Victoria became the first state in Australia to permit "voluntary assisted dying" (VAD), with its governance detailed in the Voluntary Assisted Dying Act 2017 (Vic) ("VAD Act"). While taking lead from the regulation of medically assisted death practices in other parts of the world, Victoria's legislation nevertheless remains distinct. The law in Victoria only makes VAD available to persons determined to be "already dying": it is expressly limited to those medically prognosed to die "within weeks or months." In this article, we discuss the emergence of the Victorian legislation across key formative documents. We show how, in devising VAD exclusively for those "already at the end of their lives", the Victorian state mobilizes the medico-legal category of the already dying. We argue that this category functions to negotiate a path between what are seen as the unacceptable alternatives of violent suicide on the one hand, and an unlimited right to die on the other. Further, we argue that the category of the already dying operates to make medical practitioners the gatekeepers of this new life-ending choice and effectively limits the realization of autonomy at the end of life.

Completed Suicide With Violent and Non-violent Methods by the Elderly in Rural China: A Psychological Autopsy Study.

Background: Late-life suicide is a severe public health problem in rural China; however, knowledge regarding the specific characteristics and risk factors for completed suicide via violent and non-violent methods among elderly individuals in rural China is limited.Methods: Subjects aged 60 years or older were selected from rural areas in Shandong, Hunan, and Guangxi provinces in China. This study was a 1:1 matched case-control design conducted by using the psychological autopsy method.Results: According to the univariate analyses, the presence of mental disorder, higher degree of depression, loneliness, lack of social support, hopelessness, impulsivity, and increased quantity of life events were associated with suicide in both violent and non-violent methods. For violent suicide, another risk factor was the lack of pesticides at home. For non-violent suicide, other risk factors were not currently married, family suicide history, and alcohol use disorder (P < 0.05). Variables that remained in the logistic regression model were the severity of depressive symptoms for both violent and non-violent suicide. For non-violent suicide, the degree of hopelessness was another independent risk factor. In addition, violent suicides were more likely to lack pesticides at home, choose the spring season and have an increased quantity of life events than those who died by suicide via non-violent methods.Conclusion: The major risk factor for both violent and non-violent suicide was the severity of depressive symptoms. Suicide prevention measures that focus on depression among this vulnerable population are urgently needed. Moreover, the characteristics of suicides via violent methods differed from those via non-violent methods among elderly individuals. Suicide prevention efforts should be tailored to the specific characteristics of the different suicide methods utilized by older adults in rural areas.

Evolución y diferencias en las tasas de suicidio en Perú por sexo y por departamentos, 2017-2019

IntroductionAnnual suicide rates are increasingly notably worldwide due to various accompanying risk factors. The objective of this study is to know the suicide mortality rates and their distribution between the years 2017 and 2019. MethodsThe national death registries of the Ministry of Health of Peru were analysed, calculating the regional death rates from suicides adjusted for age and gender using the standardisation recommended by the World Health Organization. ResultsA total of 1,666 cases of suicide were identified (69.3% males); the age group with the highest frequency was that of 20 to 29 years (27.8%); the mean age at suicide was higher in males (37.49±18.96 vs. 27.86±15.42; p<0.001). Hanging was the most common suicide method among both males (58.87%) and females (48.14%). For males, hanging was followed by poisoning (22.6%) and firearms (4.59%); for females, by poisoning (38.75%) and firearms (0.59%). The suicide rate increased from 2017 (1.44/100,000 inhabitants) to 2019 (1.95). The highest rates were identified in the departments of Arequipa, Moquegua and Tacna. ConclusionsIn recent years, there has been an increase in the number of suicide cases and the rates by department, with the highest number of cases reported in males. Males tend to use more violent suicide methods. The risk factors in the vulnerable populations that were identified in this study need to be known.

Comparing County Level Suicide, Violent Suicide, and Transportation Accident Mortality Rates Between Longitude-Based Partitions of United States Time Zones

Misalignments between circadian rhythms and societal demands are associated with behavioral dysregulation, morbidity and mortality. One hour phase differences in exposure key light zeitgebers exist between Western and Eastern extremes within timezones. We thus hypothesized significant differences in suicide mortality and transport accidents between three partitions within timezones based on longitude of the county seat (WME: Western-vs-Middle-vs-Eastern), with higher mortality in Western partitions.

Suicide deaths among medical students, residents and physicians in India spanning a decade (2010-2019): An exploratory study using on line news portals and Google database.

Despite having one of the world's largest medical education consortium, India lacks a comprehensive and nationally representative data on suicide deaths among medical students and physicians unlike the one found in most of the developed nations of the world. We aimed to explore the different characteristics of suicide deaths among medical students, residents and physicians in India over a decade (2010-2019). Content analysis of all suicide death reports among medical students, residents and physicians available from online news portals and other publicly available sites was done. Search was done retrospectively using pertinent search words individually or in combination with language restricted to Hindi and English and timed from January 2010 to December 2019. Reports on completed suicide by allopathic medical students, residents and physicians from India were included. Socio-demographic and suicidological variables were analysed using R software. A total of 358 suicide deaths among medical students (125), residents (105) and physicians (128) were reported between 2010 and 2019. Around 7 out of 10 suicides happened before the age of 30 and had mean age 29.9 (±12.2) years. Female residents and physicians were younger than their male counterparts at the time of suicide. Overall maximum suicide deaths were concentrated in South India except the state of Kerala. The specialty of anesthesiology (22.4%) followed by obstetrics-gynaecology (16.0%) had the highest suicide deaths. Violent suicide methods were more commonly used by all, with hanging being the most common mean of suicide. Academic stress among medical students (45.2%) and residents (23.1%), and marital discord among physicians (26.7%) were the most noticeable reasons for suicide. Mental health problems were the next most common reason in medical students (24%) and physicians (20%) while harassment (20.5%) was in residents. Twenty six percent had exhibited suicide warning signs and only 13% had ever sought psychiatric help before ending their lives. A total of nine reports of suicide pact were found with the average deaths per pact being 2.4 and predominantly driven by financial reasons. Academic stress among medical students and residents, and marital discord in physicians emerged as the key reasons for suicide. However, this preventable domain should be further explored through focused research. This is the first of its kind study from India which attempted to explore this vital yet neglected public health issue using the most feasible and practical method of online news content-based analysis.

Completed suicide in bipolar ii patients after their first hospitalization

IntroductionBipolar disorder, especially Bipolar II subtype, is a mental disorder that has one of the greatest risk of completed suicide (CS).ObjectivesDetermine the rate and the risk factors of CS in a cohort of Bipolar II patients followed after their first hospitalizationMethodsWe choose all Bipolar II patients (DSM-IV) who were hospitalized for first time in our Psychiatric unit between 1996 and 2016. We reviewed the charts of first hospitalization and recorded multiple baseline variables. In the follow-up we updated the database recording all patients who CS. We compared the different baseline variables between Bipolar II patients who CS and the restResultsOf a total of 59 bipolar II patients 6 (10 %) CS in the mean of 13 years of follow up (rate 120 times higher than General Population). The average age at CS was 45.3 years (range between 33 and 57 years old) so there was a 2 years gap on average between the first psychiatric hospitalization and suicide. CS was characterized by a violent act (5 out of 6 cases, 83 %). When we compared BP II patients who CS with the rest, only history of previous violent suicide attempt was detected as a risk factor significantly associated (P&lt;0.04) with CS.ConclusionsBipolar II patients CS early after their first hospitalization and at very high rate (120 times than GP) almost always by violent method. History of previous violent suicide attempt is predictor of completed suicideDisclosureNo significant relationships.

Reduction of Violent Mortality in Order to Ensure National Security and Achieve Sustainable Development Goals in Ukraine

The aim of the article was to analyze violent mortality in Ukraine for some causes (level and structure), track its changes in the dynamics of 1991-2020 and reflect activities to reduce its level in the tasks to achieve the Sustainable Development Goals: Ukraine to highlight the importance of the problem for national security of the country. Scientific novelty. The importance of combating violence as an urgent task for public administration at the national, regional and local levels, aimed at ensuring public and personal safety and reducing the loss of human life as a result of violent deaths, is substantiated. The importance of the problem for Ukraine was illustrated through the representation of tasks related to the prevention of deaths from violence in the national strategy for achieving the Sustainable Development Goals. The analysis of violent mortality in the dynamics since Ukraine's independence according to the official data of the State Statistics Service of Ukraine of the WHO European Regional Database (European mortality database) revealed such features as significant differentiation by sex and higher than in the EU-15 probability of death over 65 years. Ukraine also differs from the excessively high level of losses classified as harm with uncertain intent. Despite the positive dynamics (decreasing of mortality rates due to suicides, homicides and intentional injuries) since 1991, the predominance of indicators compared to the EU-15 has increased. The hypothesis of probable changes under the influence of the Covid-19 pandemic is substantiated. Conclusion. Achieving the Sustainable Development Goals in the process of reducing violence and related threats to life, health and well-being of citizens will be facilitated by the consistent adoption and implementation by Ukraine of measures at the international, national and local levels aimed at political, social and economic determinants. Key words: violent mortality, suicide and self-inflicted injury, homicide and assault, Sustainable Development Goals, national security management.

Exploring the role of serum lipid profile and neutrophil-to-lymphocyte ratio in violent suicide attempters: a cross sectional study.

Suicidality is one of the most common complications of mental disorders, so that the identification of potential biomarkers may be relevant in clinical practice. To date, the role of serum lipids and neutrophil/lymphocyte ratio (NLR) has been explored albeit with conflicting results. To the best of our knowledge, no study has explored lipid levels concomitantly with NLR in relation to violent suicide attempts. Therefore, we aimed to investigate whether serum lipid levels and NLR might be associated with the violent method of suicide attempts. The study group consisted of 163 inpatients who attempted suicide. Blood samples were collected at the beginning of hospitalization to measure total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein, very-low-density lipoprotein (VLDL), triglycerides, and NLR. Descriptive analyses of the total sample were performed. The included patients were divided into two groups according to violent/nonviolent method. Groups were compared in terms of lipid (MANCOVAs). Plasma levels of total cholesterol (F=5.66; P=.02), LDL (F=4.94; P=.03), VLDL (F=5.66; P=.02), and NLR (F=8.17; P<.01) resulted to be significantly lower in patients that used a violent method compared to patients who attempted suicide with a nonviolent method. Low cholesterol, LDL, and VLDL levels as well as low NLR value were associated with a violent method of suicide attempt in patients with mental disorders. Further studies are needed to confirm these results.

P.418 Are serum lipid profile and neutrophil/lymphocyte ratio associated with violent suicide attempt in patients with mental disorders? A cross-sectional study

P.418 Are serum lipid profile and neutrophil/lymphocyte ratio associated with violent suicide attempt in patients with mental disorders? A cross-sectional study

Suicide: Can the Past Predict the Future?

Barczyk et al.’s article “Predictors of traumatic suicide attempts in youth presenting to hospitals with level I trauma centers” adds to the current literature by examining predictors of traumatic suicide attempts in youth from 2 Texas hospitals (1). This study, while limited in scope and generalizability, does add information on risk factors that may be associated with violent suicide attempts compared with attempts related to either ingestion or overdose.

COVID-19 Pandemia

Religious terror movements have long since been associated with violent Jihad and suicide bombings. As such, associated Jihadist perpetrators operate according to specific Muslim Fatwas (Clerical permissions), in order to carry out suicide attacks against their chosen targets. These perpetrators proclaim their willing to die for a definitive cause, regardless of any danger, as they expect an affluent after life in heaven. As COVID 19 erupted, the world came to a standstill and closure. The new situation affected terror movements globally. While previously Jihadists used to be regarded as fearless towards any death threat, COVID 19 is changing such former thoughts. Radical clerics issued new warnings for these Jihadists, to be aware of infected areas, temporarily making Europe practically a non-target for terror operations. This new significant modus operandum is an important topic for research. For the first time suicide bombers and Jihadists implement self-preservation techniques, while death itself is being considered as a threat rather than an achievement. This study finds that these perpetrators implement rational, calculated tactics, as religion is considered to be a part of this tactic, yet, they are not monolithic. They operate differently from one country to another, while having to review constantly the effectiveness of their operation vis-à-vis the support of the local population.

The role of the 5-HTTLPR polymorphism in acquired capability for suicide.

According to the Interpersonal Psychological Theory of Suicide, capability for suicide comprises two dimensions: fearlessness about death and elevated pain tolerance. The short (S) allelic variant of the serotonin transporter gene-linked polymorphic region (5-HTTLPR) has repeatedly been associated with more violent and lethal suicide methods and lethality of suicide attempts. The current study aimed to investigate whether 5-HTTLPR allelic variants are associated with fearlessness about death and pain tolerance/persistence and whether it moderates the relationship between childhood maltreatment and acquired capability for suicide. A cohort of 208 inpatients hospitalized due to a recent suicide attempt or severe suicidal ideation was genotyped for the 5-HTTLPR and assessed for childhood maltreatment. Subjective pain tolerance and fearlessness about death as well as objective pain persistence was assessed using a pressure algometer. Fearlessness about death, pain tolerance, and pain persistence did not differ between 5-HTTLPR genotypes. However, there was a significant correlation between self-reported childhood maltreatment and fearlessness about death that emerged exclusively in homozygous S-allele carriers. Results suggest that there are no "high-risk"-alleles that generally increase capability for suicide. However, in terms of future suicide-related behaviors exposure to childhood maltreatment events could exert a particularly negative influence on homozygous S-allele carriers by increasing their fearlessness about death.

Sex differences in the transcription of glutamate transporters in major depression and suicide.

BackgroundAccumulating evidence indicates that the glutamate system contributes to the pathophysiology of major depressive disorder (MDD) and suicide. We previously reported higher mRNA expression of glutamate receptors in the dorsolateral prefrontal cortex (DLPFC) of females with MDD. MethodsIn the current study, we measured the expression of mRNAs encoding glutamate transporters in the DLPFC of MDD subjects who died by suicide (MDD-S, n = 51), MDD non-suicide subjects (MDD-NS, n = 28), and individuals who did not have a history of neurological illness (CTRL, n = 32). ResultsFemales but not males with MDD showed higher expression of EAATs and VGLUTs relative to CTRLs. VGLUT expression was significantly higher in the female MDD-S group, relative to the other groups. EAAT expression was lower in the male violent suicides. LimitationsThis study has limitations common to most human studies, including medication history and demographic differences between the diagnostic groups. We mitigated the effects of confounders by including them as covariates in our analyses. ConclusionsWe report sex differences in the expression of glutamate transporter genes in the DLPFC in MDD. Increased neuronal glutamate transporter expression may increase synaptic glutamate, leading to neuronal and glial loss in the DLPFC in MDD. These deficits may lower DLPFC activity, impair problem solving and impair executive function in depression, perhaps increasing vulnerability to suicidal behavior. These data add to accumulating support for the hypothesis that glutamatergic transmission is dysregulated in MDD and suicide. Glutamate transporters may be novel targets for the development of rapidly acting antidepressant therapies.

Legal and Ethical Challenges in the Psychiatric Treatment of College Students.

This article will examine issues of autonomy, privacy, decision-making, and voluntariness of the psychiatric treatment of college students. There is little consensus on balancing the individual student's rights with the university's duties. Conflicts between federal legislation, case law, and ethical recommendations will be explored. Landmark legal cases assert that universities have a specific duty to protect their students from both violent peers and suicide. College students are vulnerable to a range of psychiatric symptoms but have low rates of adherence to psychiatric treatment. Many institutions require an urgent psychiatric evaluation when there is evidence that a student is at imminent risk of danger, and some may require psychiatric treatment as a condition of returning to either classes or dormitories. Legally, patients are entitled to privacy and autonomous medical decision-making at 18years of age. Pragmatically, dependence on parents and university for basic resources limits both the privacy and the voluntariness of their treatment.

Risk behaviors of high school students among parental separation families in urban society

The study was conducted to explore the risk behaviors of high school students among parental separation families. The quantitative social survey was conducted in 2016 and 1333 Hanoi high school students were randomly selected and to be invited to do the survey. The result showed that there was 13% of all respondents were living in divorce or separated families. Noticeably, students from these families got a higher risk of different risk behaviors such as violent behaviors, suicide intention, and suicide attempts, tobacco smoking and shisha smoking, drug-using and the risk of having different unsafe traffic behaviors. For example, the proportion of high school students from divorce or separated families involved in tobacco or shisha smoking, drug-using, or involved in violent behaviors were about 1.5 times higher than these proportion among students living with both parents' families. In terms of suicide intention and suicide attempt, about 24.4% students was living in separation families said that they ever had suicide intention and 8.8% of them reported that they ever had a suicide attempt, while these proportion among students living in both parents families were remarkable lower: 17.3% and 4.2% respectively. The implication of the study suggested some solutions for managing and supporting high school students among parental separated families which would be an increasing issue in urban society in Vietnam on the process of dynamic urbanization and industrialization.

Impact of comorbid obsessive-compulsive disorder on suicidality in patients with bipolar disorder

This study evaluated the impact of comorbid OCD on suicide attempt risk and suicide methods in 990 patients with main diagnosis of BD. Two hundred and one patients (20.3%) had lifetime comorbid OCD. No significant differences were found comparing rates of lifetime suicide attempts between patients with or without comorbid OCD (30.3% vs 24.6%). In the subgroup of patients with concomitant OCD more subjects performed suicide attempts with violent methods (48.3% vs 28.7%). Therefore, our results suggest a correlation between comorbid OCD and violent suicide attempts. This finding is worthy of interest and deserves to be explored by further studies.

Characteristics of Suicides and Toxicology in a Cohort of Individuals With Opioid Use Disorder

Suicide in patients with opioid use disorder (OUD) is a complex issue. In addition to accidental intoxications, a higher prevalence of fatal suicides in patients with OUD can be found compared to the general population. In this study, suicides with a diagnosis of OUD documented in the project “Suicides, A National Survey” were extracted from our data bank. Individuals with a diagnosis of OUD in their medical history were compared to other suicides. The analyses included clinical and demographic factors as well as an investigation of suicide methods and toxicology of psychotropic drugs. For the statistical analyses, we applied chi-square tests and calculated odds ratios. Out of 6,495 suicide cases in Switzerland between 2000 and 2010, 215 individuals with a medical history of OUD could be identified. Persons in OUD cases were significantly younger than in other suicide cases (p < .001) and had more frequently a positive history for suicide attempts (p = .02). In addition, persons in OUD cases were more often female (p = .076). Intentional self-poisoning with medication was applied more often in individuals with OUD compared to other suicide methods (p < .001). When self-poisoning with drugs was compared to violent suicide methods, a combination of benzodiazepines with antidepressants was predominantly found. Our study yielded significant characteristics and risk factors for suicides in individuals with OUD. The predominant method of suicide in individuals with OUD was intended self-poisoning by medication. This knowledge is of clinical importance for the monitoring of at-risk individuals with OUD as well as for suicide prevention in this patient group.

Dexamethasone Suppression Test May Predict More Severe/Violent Suicidal Behavior.

IntroductionSeveral studies demonstrated that the hypothalamic-pituitary-adrenal (HPA) axis is dysregulated in suicide attempters. Prospective studies found that people with an abnormal response at the dexamethasone suppression test (DST) are more likely to commit suicide. However, whether DST may predict suicide attempts remains less clear. A possible strategy to address this question is to consider the suicide attempt lethality.Objectives(1) To compare the pre- and post-DST cortisol levels in serious/violent suicide attempters and in non-serious/non-violent suicide attempters, and (2) to investigate whether cortisol level can predict new suicide attempts or their lethality.MethodsThe study included 70 recent suicide attempters (25 with a serious or violent attempt) who were followed for two years. Three saliva samples for cortisol measurement were obtained at 8a.m., 3p.m., and 9p.m. before the DST (pre-DST). Then, at 11 p.m., 1 mg of dexamethasone was given orally. The following day (post-DST), three saliva samples were collected at the same hours as before. The post-DST–pre-DST salivary cortisol Δ index was calculated for each collection time. The Risk-Rescue Ratio Scale (RRRS) and the Suicidal Intent Scale (SIS) were used to characterize the suicide attempt at inclusion and those occurring during the follow-up.ResultsPost-DST cortisol level at 9 p.m. was higher in patients with an initial violent or serious suicide attempt than in non-violent/non-serious attempters (p < .010). Higher post-DST cortisol at 9p.m. was associated with lower RRRS rescue score and higher clinical impression of suicide severity at inclusion. Among the 66 patients who completed the follow-up, 26 attempted suicide again at least once. Higher pre-DST cortisol at 8a.m. predicted new suicide attempts during the follow-up (OR = 2.15 [1.11, 4.15]), and higher cortisol Δ index at 9p.m. was associated with higher suicide intent during the follow-up.ConclusionsOur results suggest that HPA axis hyper-reactivity monitored with the DST is a marker of violent/serious suicide attempt with lower rescue possibility. Furthermore, higher changes between pre-DST and post-DST cortisol levels may predict higher suicide intent. These findings might help to characterize the biological features of nearest suicide phenotypes.

Postmortem serotonin level in cerebrospinal fluid as a marker of the manner of death

Background/Aim. Serotonin [5-hydroxytriptanine (5-HT)], as a neurotransmitter in the central nervous system, is included in the regulation of autonomic and cognitive functions, sensory processing, motor activity, emotions, mood, and almost every kind of behavior. In forensic investigations of death, 5-HT has been studied in different body fluids, regarding the cause of death, particularly in suicides and drug abuse or as a marker of an acute stress response. The aim of this study was to establish 5-HT levels in cerebrospinal fluid (CSF) as a marker of its central activity during fatal event in deaths different in manner, particularly in cases where the victims were aware of the stressful event. Methods. Study sample consisted of 81 postmortem CSF obtained during autopsy. Concentrations of the 5-HT were established regarding natural versus violent (accidents, homicides and suicides) deaths. After preparation, samples were analyzed through the liquid chromatography-tandem mass spectrometry method. Results. Violent deaths had significantly higher 5-HT levels (U = 519.000; p &lt; 0.05). Differences were found in mean values among different causes of death (higher in blunt injury, stabbing and intoxication, while lower in cardiac deaths and hypothermia) but without statistical significance. 5-HT levels significantly differed among age groups (?2 = 13.354; p = 0.001), with the tendency to decrease with age. No differences in 5-HT levels were observed regarding gender, length of agony period, and awareness of impending lethal outcome. The values tended to increase with postmortem interval albeit without significant differences. Conclusion. Serotonin could be a useful postmortem biochemical marker to distinguish natural and violent death, regardless of individual variability in concentrations.

The rate, trends and lethality of common violent suicide attempt methods in Iran, a systematic review and meta-analysis

The rate, trends and lethality of common violent suicide attempt methods in Iran, a systematic review and meta-analysis