Andrew Page

Prevalence of nonsuicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression

Published prevalence estimates of nonsuicidal self-injury (NSSI) among nonclinical samples are highly heterogeneous, raising concerns about their reliability and hindering attempts to explore the alleged increase in NSSI over time. Accordingly, the objectives of this study were to investigate the influence of methodological factors on heterogeneity in NSSI prevalence estimates, explore changes over time, and estimate overall international NSSI prevalence. Results showed that methodological factors contributed over half (51.6%) of the heterogeneity in prevalence estimates, and, after adjusting for these factors, NSSI prevalence did not increase over time. Overall, pooled NSSI prevalence was 17.2% among adolescents, 13.4% among young adults, and 5.5% among adults. Clearly, development of standardized methodology in NSSI research is crucial if accurate estimates are desired.

Attributable risk of psychiatric and socio-economic factors for suicide from individual-level, population-based studies: A systematic review

The overall importance of a risk factor for suicide in a population is determined not only by the relative risk (RR) of suicide but also the prevalence of the risk factor in the population, which can be combined with the RR to calculate the population attributable risk (PAR). This study compares risk factors from two well studied domains of suicide research - socio-economic deprivation (relatively low RR, but high population prevalence) and mental disorders (relatively high RR risk, but low population prevalence). RR and PAR associated with suicide was estimated for high prevalence ICD-10/DSM-IV psychiatric disorders and measures of socio-economic status (SES) from individual-level, population-based studies. A systematic review and meta-analysis was conducted of population-based case-control and cohort studies of suicide where relative risk estimates for males and females could be extracted. RR for any mental disorder was 7.5 (6.2-9.0) for males and 11.7 (9.7-14.1) for females, compared to RR for the lowest SES groups of 2.1 (1.5-2.8) for males and 1.5 (1.2-1.9) for females. PAR in males for low educational achievement (41%, range 19-47%) and low occupational status (33%, range 21-42%) was of a similar magnitude to affective disorders (26%, range 7-45%) and substance use disorders (9%, range 5-24%). Similarly in females the PAR for low educational achievement (20%, range 19-22%) was of a similar magnitude to affective disorders (32%, range 19-67%), substance use disorder (25%, range 5-32%) and anxiety disorder (12%, range 6-22%). The findings of the present study suggest that prevention strategies which focus on lower socio-economic strata (more distal risk factors) have the potential to have similar population-level effects as strategies which target more proximal psychiatric risk factors in the prevention and control of suicide.

Suicide in Australian farming, 1988–1997

Objectives: To identify and describe suicide data for occupational classifications relating to farm managers and agricultural labourers for Australia for the period 1988 to 1997, and to relate resultant suicide rates to farmers’ terms of trade. Method: Descriptive and linear regression analysis of aggregated mortality data. Results: In the period 1988 to 1997, 921 suicides were identified. The majority of these suicides were farm managers (67.4%). Farm manager suicides occurred predominantly in older age groups (55 + years). In comparison agricultural labourer suicides were younger, with the majority of suicides occurring in the 15–39 years age group. The most common methods for both groups were firearms (particularly hunting rifles and shot guns), hanging and motor vehicle exhaust gas. These methods accounted for approximately 81% of all male farm suicides. Firearms accounted for 51% of male farm suicide, in comparison to 23% for the wider Australian male population for the same period. Estimated age standardized rates per 100 000 for male farm managers for the 10-year period ranged from 24.8 to 51.4. For male agricultural labourers these rates ranged from 23.5 to 41.9. Analyses also revealed a negative correlation (r = −0.75, p < 0.01) between farm manager suicide rates and farmers’ terms of trade. Conclusion: Male farm manager and agricultural labourer suicide rates are higher than male national rates and rates in the wider rural population, particularly in the later years of the period investigated. Firearms prefigure as the most common method of suicide, despite decreases in this method in the wider rural population. Establishing more accurate denominator data for the farming community is a priority, as is preventative action that accounts for unique aspects of farm life.

The Burden Attributable to Mental and Substance Use Disorders as Risk Factors for Suicide: Findings from the Global Burden of Disease Study 2010

Background The Global Burden of Disease Study 2010 (GBD 2010) identified mental and substance use disorders as the 5th leading contributor of burden in 2010, measured by disability adjusted life years (DALYs). This estimate was incomplete as it excluded burden resulting from the increased risk of suicide captured elsewhere in GBD 2010s mutually exclusive list of diseases and injuries. Here, we estimate suicide DALYs attributable to mental and substance use disorders. Methods Relative-risk estimates of suicide due to mental and substance use disorders and the global prevalence of each disorder were used to estimate population attributable fractions. These were adjusted for global differences in the proportion of suicide due to mental and substance use disorders compared to other causes then multiplied by suicide DALYs reported in GBD 2010 to estimate attributable DALYs (with 95% uncertainty). Results Mental and substance use disorders were responsible for 22.5 million (14.8–29.8 million) of the 36.2 million (26.5–44.3 million) DALYs allocated to suicide in 2010. Depression was responsible for the largest proportion of suicide DALYs (46.1% (28.0%–60.8%)) and anorexia nervosa the lowest (0.2% (0.02%–0.5%)). DALYs occurred throughout the lifespan, with the largest proportion found in Eastern Europe and Asia, and males aged 20–30 years. The inclusion of attributable suicide DALYs would have increased the overall burden of mental and substance use disorders (assigned to them in GBD 2010 as a direct cause) from 7.4% (6.2%–8.6%) to 8.3% (7.1%–9.6%) of global DALYs, and would have changed the global ranking from 5th to 3rd leading cause of burden. Conclusions Capturing the suicide burden attributable to mental and substance use disorders allows for more accurate estimates of burden. More consideration needs to be given to interventions targeted to populations with, or at risk for, mental and substance use disorders as an effective strategy for suicide prevention.

Long-Term Unemployment and Suicide: A Systematic Review and Meta-Analysis

Purpose There have been a number of reviews on the association+ between unemployment and suicide, but none have investigated how this relationship is influenced by duration of unemployment. Method A systematic review and meta-analysis was conducted of those studies that assessed duration of unemployment as a risk factor for suicide. Studies considered as eligible for inclusion were population-based cohort or case-control designs; population-based ecological designs, or hospital based clinical cohort or case-control designs published in the year 1980 or later. Results The review identified 16 eligible studies, out of a possible 10,358 articles resulting from a search of four databases: PubMed, Web of Knowledge, Scopus and Proquest. While all 16 studies measured unemployment duration in different ways, a common finding was that longer duration of unemployment was related to greater risk of suicide and suicide attempt. A random effects meta-analysis on a subsample of six cohort studies indicated that the pooled relative risk of suicide in relation to average follow-up time after unemployment was 1.70 (95% CI 1.22 to 2.18). However, results also suggested a possible habituation effect to unemployment over time, with the greatest risk of suicide occurring within five years of unemployment compared to the employed population (RR = 2.50, 95% CI 1.83 to 3.17). Relative risk appeared to decline in studies of those unemployed between 12 and 16 years compared to those currently employed (RR = 1.21, 95% CI 1.10 to 1.33). Conclusion Findings suggest that long-term unemployment is associated with greater incidence of suicide. Results of the meta-analysis suggest that risk is greatest in the first five years, and persists at a lower but elevated level up to 16 years after unemployment. These findings are limited by the paucity of data on this topic.

Child Maltreatment, Subsequent Non-Suicidal Self-Injury and the Mediating Roles of Dissociation, Alexithymia and Self-Blame.

OBJECTIVE Although child maltreatment is associated with later non-suicidal self-injury (NSSI), the mechanism through which it might lead to NSSI is not well understood. The current retrospective case-control study examined associations between child maltreatment and later NSSI, and investigated the mediating roles of dissociation, alexithymia, and self-blame. METHODS Participants were 11,423 Australian adults (response rate 38.5%), randomly selected from the Australian Electronic White Pages, aged between 18 and 100 (M=52.11, SD=16.89), 62.2% female. Data were collected via telephone interviewing. Main outcome measures were reported history of child maltreatment (sexual abuse, physical abuse, neglect) and reported 12-month NSSI. Dissociation, alexithymia, and self-blame were examined as potential mediating variables in the relationship between child maltreatment and later NSSI. All analyses were conducted using logistic regression and adjusted for age and psychiatric diagnosis. RESULTS Results differed by gender. Compared to no child maltreatment, physical abuse (OR 2.75, 95% CI 1.68-4.51) and neglect (OR 2.56, 95% CI 1.65-3.99) independently increased the odds of NSSI among females. Physical abuse (OR 2.69, 95% CI 1.44-5.03) increased the odds of NSSI among males. Sexual abuse did not independently increase the odds of NSSI for males or females. For females, self-blame had the greatest effect on the child maltreatment-NSSI relationship (OR decreased by 14.6%, p<.000), although dissociation and alexithymia also partially mediated the relationship. For males, dissociation had the greatest effect (OR decreased by 12.9%, p=.003) with self-blame also having a relatively strong effect. CONCLUSIONS The results indicate that child maltreatment, and in particular, physical abuse, is strongly associated with the development of subsequent NSSI and may be partially mediated by dissociation, alexithymia, and self-blame for females and dissociation and self-blame for males. Altering attributional style (through cognitive therapy or emotion focussed therapy) and improving the capacity to regulate emotions (through dialectical behaviour therapy) may contribute to reduction or cessation of NSSI.

The Prevalence of Sexually Transmitted Infections in Papua New Guinea: A Systematic Review and Meta-Analysis

Background The potential for an expanded HIV epidemic in Papua New Guinea (PNG) demands an effective, evidence-based and locally-appropriate national response. As sexually transmitted infections (STIs) may be important co-factors in HIV transmission nationally, it is timely to conduct a systematic review of STI prevalences to inform national policy on sexual health and HIV/STI prevention. Methodology/Principal Findings We undertook a systematic review and meta-analysis of HIV and STI prevalences in PNG, reported in peer-reviewed and non-peer-reviewed publications for the period 1950–2010. Prevalence estimates were stratified by study site (community or clinic-based), geographic area and socio-demographic characteristics. The search strategy identified 105 reports, of which 25 studies (10 community-based; 10 clinic-based; and 5 among self-identified female sex workers) reported STI prevalences and were included in the systematic review. High prevalences of chlamydia, gonorrhoea, syphilis and trichomonas were reported in all settings, particularly among female sex workers, where pooled estimates of 26.1%, 33.6%, 33.1% and 39.3% respectively were observed. Pooled HIV prevalence in community-based studies was 1.8% (95% CI:1.2–2.4) in men; 2.6% (95% CI:1.7–3.5) in women; and 11.8% (95% CI:5.8–17.7) among female sex workers. Conclusions/Significance The epidemiology of STIs and HIV in PNG shows considerable heterogeneity by geographical setting and sexual risk group. Prevalences from community-based studies in PNG were higher than in many other countries in the Asia-Pacific. A renewed focus on national STI/HIV surveillance priorities and systems for routine and periodic data collection will be essential to building effective culturally-relevant behavioural and biomedical STI/HIV prevention programs in PNG.

Cause and effect in studies on unemployment, mental health and suicide: a meta-analytic and conceptual review

BACKGROUND There are ongoing questions about whether unemployment has causal effects on suicide as this relationship may be confounded by past experiences of mental illness. The present review quantified the effects of adjustment for mental health on the relationship between unemployment and suicide. Findings were used to develop and interpret likely causal models of unemployment, mental health and suicide. METHOD A random-effects meta-analysis was conducted on five population-based cohort studies where temporal relationships could be clearly ascertained. RESULTS Results of the meta-analysis showed that unemployment was associated with a significantly higher relative risk (RR) of suicide before adjustment for prior mental health [RR 1.58, 95% confidence interval (CI) 1.33-1.83]. After controlling for mental health, the RR of suicide following unemployment was reduced by approximately 37% (RR 1.15, 95% CI 1.00-1.30). Greater exposure to unemployment was associated with higher RR of suicide, and the pooled RR was higher for males than for females. CONCLUSIONS Plausible interpretations of likely pathways between unemployment and suicide are complex and difficult to validate given the poor delineation of associations over time and analytic rationale for confounder adjustment evident in the revised literature. Future research would be strengthened by explicit articulation of temporal relationships and causal assumptions. This would be complemented by longitudinal study designs suitable to assess potential confounders, mediators and effect modifiers influencing the relationship between unemployment and suicide.

Predictors of continuation and cessation of nonsuicidal self-injury

PURPOSE This paper reports the first prospective study of risk factors for continuation of nonsuicidal self-injury (NSSI) during adolescence. METHODS We examined whether NSSI became more severe among those continuing to self-injure 1 year later, as well as characteristics and predictors of continuation, relative to cessation, drawn from a sample of 1,973 community-based adolescents from five states in Australia. Multiple sociodemographic and psychosocial factors were assessed in a series of sequential logistic regressions. RESULTS Of those reporting NSSI at follow-up (12% total sample), 4.1% (95% CI: 3.3%-5.0%; n = 80) continued from baseline and an additional 4.1% had stopped this behavior by follow-up (95% CI: 3.3%-5.1%, n = 81; 3.8% new cases). Frequency, potential lethality and number of methods of NSSI increased among adolescents continuing to self-injure. These individuals also had overall higher frequency and more serious wounds compared with those who had stopped self-injuring, possibly providing parameters to differentiate these groups. Continuation of NSSI was associated with higher frequency (OR = 1.06; 95% CI = .99-1.13, p = .08), lower cognitive reappraisal (OR = .86; 95% CI = .78-.95, p = .004) and higher emotional suppression (OR = 1.10; 95% CI = .98-1.22, p = .09) relative to cessation at T1. CONCLUSIONS These findings may assist to better identify young people more likely to continue self-injuring and also highlight potentially modifiable factors to inform early intervention initiatives.

Suicide and political regime in New South Wales and Australia during the 20th century

Study objective: Australia has had a two party parliamentary political system for most of the period since its Federation in 1901, dominated either by a social democratic (Labor) or a conservative ideological perspective. This paper investigates whether such political differences at Federal and State levels have influenced suicide rates in the state of New South Wales (NSW) for the period 1901–1998. Design: Federal government type, NSW State government type, and combinations of both Federal and NSW State government type were examined. Poisson regression models were stratified by sex and controlled for the effects of age, annual change in gross domestic product, sedative availability, drought, and both world wars. Results: When both Federal and NSW State governments were conservative the relative risk of suicide for NSW men was 1.17 (p<0.001) and for women 1.40 (p<0.001) compared with both governments being Labor (1.00). A statistically significant linear trend (p<0.001) in suicide risk was evident across the continuum of Federal/State government combinations, from both Labor (lowest), to mixed (intermediate), to both conservative (highest). Conclusion: Significantly higher suicide risk was associated with conservative government tenures compared with social democratic incumbents. Results are discussed in terms of the differences underpinning conservative and social democratic government programme ideology, and their relevance to Durkheim’s theories of suicide, social regulation, and integration.