David Titelman

Suicide mortality trends in the Nordic countries 1980–2009

Abstract Background and aim: The Nordic countries provide a suitable setting for comparing trends in suicide mortality. The aim of this report is to compare suicide trends by age, gender, region and methods in Denmark, Finland, Iceland, Norway and Sweden 1980–2009. Methods: Suicide statistics 1980–2009 were analyzed for men and women aged 15 years and above and the age group 15–24 years. Regional suicide rates in 2009 were presented in maps. Results: The suicide rates across the Nordic countries declined from 25–50 per 100,000 in 1980 to 20–36 in 2009 for men and from 9–26 in 1980 to 8–11 in 2009 for women. The rates in Finland were consistently higher than those of the other countries. A significant increase of suicides in young women in Finland and Norway and a lack of a decline among young women in Sweden were noted. The male– female ratio of suicide converged to approximately 3:1 across the region during the study period. Rural areas in Finland, Norway and Sweden saw the highest suicide rates, whereas the rates in the capital regions of Denmark, Norway and Sweden were lower than the respective national rates. Conclusions: We hold that the overall decline of suicide rates in the Nordic countries reflects the socio-economic development and stability of the region, including the well-functioning healthcare. The increasing rates in Finland and Norway and the unchanged rate in Sweden of suicide in young women are an alarming trend break that calls for continued monitoring.

Assessment and treatment of asylum seekers after a suicide attempt: a comparative study of people registered at mental health services in a Swedish location

BackgroundEven though asylum seekers are considered vulnerable to mental ill-health, knowledge of their suicidal behaviour is limited. The aim of this study was to improve our understanding of factors that influence the clinical assessment of asylum seekers who have attempted suicide compared to the assessment of non-asylum seekers.MethodsThe study focused on 88 asylum seekers registered for suicide attempts in mental health services 2005–2009, who were matched for age and gender and compared with 88 suicide attempters with Swedish personal identity numbers. The medical records were analysed with a quantitative protocol, focusing on social risk and protective factors, health history, current clinical picture as well as the assessment procedure, diagnostics, patterns of treatment and follow-up in this clinical group. Data was analysed using the chi-square test, Fisher’s exact probability test, and the Mann–Whitney U test.ResultsAs in earlier studies, asylum seekers were more traumatized, had different social risk factors and received different diagnoses than the controls. Asylum seekers were referred to less specialized follow-up after treatment, in spite of their health history and of previous and current clinical pictures indicating a similar or - in the case of the female asylum seekers - more serious mental health condition. Female asylum seekers also received more intense and prolonged in-patient treatment than female controls.Asylum seekers appeared to have social networks more often than the control group. However, there was less documentation of the social context, previous suicidal behaviour, and on suicide in the family and close environment of the asylum-seeking men. Information on suicidal intent was lacking in a majority of both groups.The time relation of the suicide attempt and the asylum process suggested the importance of the asylum decision, as well as the possible role of earlier mental health problems and premigration stress, for the suicidal behaviour.ConclusionsThe groups had different sets of risk factors and clinical pictures. There was a lack of early and thorough exploration of suicide intent for both groups, and of contextual and subjective factors for the asylum seekers. Differences in follow-up indicate unequal access to care.

Depression, Anxiety, and Psychological Defense in Attempted Suicide: A Pilot Study using PORT

Depressive affect, anxiety, and psychological defenses were studied in the presented research with PORT, a projective test that exploits subliminal perception of object-relation images. Protocols of 20 hospitalized suicide attempters were compared to those of 20 matched controls, 34 previously studied nonsuicidal depressed patients, 18 patients with panic attack, and 32 patients with borderline and psychotic disorders. The suicide attempters were anxious; their defenses resembled those seen in borderline pathology; depressive reactions were limited in symbolic content; reality testing was poor. The closeness between depression and anxiety in suicidality is further discussed throughout this article. A constellation of signs using the PORT test was hypothesized to be a marker for suicidality. The test is deemed useful for future research on suicide.

Skepticism towards the Swedish vision zero for suicide: interviews with 12 psychiatrists

BackgroundThe main causes of suicide and how suicide could and should be prevented are ongoing controversies in the scientific literature as well as in public media. In the bill on public health from 2008 (Prop 2007/08:110), the Swedish Parliament adopted an overarching “Vision Zero for Suicide” (VZ) and nine strategies for suicide prevention. However, how the VZ should be interpreted in healthcare is unclear. The VZ has been criticized both from a philosophical perspective and against the background of clinical experience and alleged empirical claims regarding the consequences of regulating suicide prevention. This study is part of a larger research project in medical ethics with the overarching aim to explore whether the VZ is ethically justifiable. The aim is to enrich the normative discussion by investigating empirically how the VZ is perceived in healthcare.MethodsInterviews based on a semi-structured interview guide were performed with 12 Swedish psychiatrists. The interviews were analysed with descriptive qualitative content analysis aiming for identifying perceptions of the Vision Zero for Suicide as well as arguments for and against it.ResultsThough most of the participants mentioned at least some potential benefit of the Vision Zero for Suicide, the overall impression was a predominant skepticism. Some participants focused on why they consider the VZ to be unachievable, while others focused more on its potential consequences and normative implications.ConclusionsThe VZ was perceived to be impossible to realize, nonconstructive or potentially counterproductive, and undesirable because of potential conflicts with other values and interests of patients as well as the general public. There were also important notions of the VZ having negative consequences for the working conditions of psychiatrists in Sweden, in increasing their work-related anxiety and thwarting the patient-physician relationship.

Suicide-bereaved siblings' perception of health services

The authors investigated suicide-bereaved siblings’ reported reasons for seeking or not seeking professional support, their reported satisfaction when receiving it, and their recommendations to health services when meeting suicide-bereaved siblings. Using qualitative content analysis of 18 interviews with suicide-bereaved siblings, the authors found that the perception of health services as being helpful was influenced by both the participants’ and by the deceased siblings’ experiences with health services. They conclude that the bereaved siblings and the deceased siblings unmet needs may generate negative attitudes toward health services, which reduces the likelihood of seeking professional help as well as medication acceptance in some cases.

A psychoanalytic understanding of antipsychotic drug treatment: an attempt at applied psychoanalysis

A study on the subjective experience of neuroleptic treatment is used as an example of research that employs psychoanalytic theory and methodology outside the clinical situation. Psychoanalytic tenets such as psychosexuality and the unconscious are highlighted, and the systematic study of internal reality is discussed with reference to the study on neuroleptics, the results of which are presented in extenso. Metapsychology is considered as a means for systematization, and self-reflexive countertransference analysis is seen as a means for fostering trustworthiness and reliability. The validity criteria discussed are clinical relevance, coherence, and originality (as distinct from merely confirming received theory). Value conflicts between academic and psychoanalytic scientific cultures are described with reference to the data of the specimen study. The concluding discussion includes a brief comparison of the time-limited interview method with long-term, clinical psychoanalytic inquiries. “Flechsigs Brain ...

Know before whom you stand: Mikael Enckell’s Companions of the Unknown [Okändhetens följeslagare]

ABSTRACT Mikael Enckell’s book is discussed as a combined self-analytic tour de force and psychoanalytic supplement to Jewish philosophy represented by Frans Rosenzweig and others. The author discusses Enckell’s views on the roots of psychoanalysis in Jewish thought, anti-Semitism, historiography, the importance of human dialogue, revelation and psychic integration, atheism, and the nature of recovery in psychoanalysis. Enckell’s views of a triad of human activities open to conflict and ambiguity – Judaism, poetry, and psychoanalysis – are supplemented by a short discussion on the role of annihilation anxiety in these areas.

Facing the other within: Mikael Enckell's Perspectives from the other side

Beginning to read Mikael Enckell’s Perspectives from the other side (2012), I was taken aback by the resistance that it seemed to offer. It was only on reading it again that I realized that this volume is not merely a new collection of essays on known themes: the closeness between psychoanalysis and Jewish thought; the challenge of knowing the Other and the obligation to face this challenge in psychoanalysis and in life in general; the riddle of anti-Semitism; the rôle of the mother and the father in the psyche. The book, more movingly than I first understood, bears testimony to the fact that Enckell’s attachment to Judaism is not a mere intellectual interest or a passing infatuation, and not merely another admirable defense of one of our cultural wellsprings, but a life-long, almost mystical love relation and his fate to the end. This book is part of an ongoing self-analysis in which Enckell uses his imagined reader as a listener whose presence he, the seasoned analyst, requires no less than does any serious analyzand. Enckell lets us know that he at one point imagined that he didn’t have to write this book, since, in his previous book,On the art of loving the Scripture [Om konsten att älska skriften] (2009), he had provided what he considered the missing link to closing his oeuvre (that notion, too, is a challenge) by writing about the women of literature who had played an important rôle in his life. His earlier work had focused on men: his fatherRabbe Enckell, a distinguished writer and poet, and other father figures and male intellectual heroes, often found among Jewish writers, film makers, philosophers, and others, including secret and even “symbolic Jews”. A prominent representative of the last-mentioned category to whom Enckell returns in Perspectives is the Finnish modernist writer Gunnar Björling. He is awarded this honor for his courage and moral autonomy as well as for his sympathy for the Jews and his position of someone who struggles to think clearly and refuses to be victimized under the onslaught of demonization or of being pressured to conform by a dominating majority – in the cultural debate in Finland after World War 2, the political left. Let me inject here that the historian and philosopher Yirmiyahu Yovel, from whose work (Yovel, 2009) I have borrowed the title of this discussion, sees a prototype of the now considered position in the predicament of the Jews of Spain and Portugal, including those who were coerced to convert to Christianity but in some cases remained secret, crypto-Jews in the 14th, 15th and 16th centuries. The near-complete destruction of the more than 1000-year long Jewish presence on the Iberian peninsula that eventually took place is a trauma that is strangely suppressed from the consciousness of European historians as well as people in general. The obliteration of this experience from collective memory may have something to do with its reflecting a European norm: the expulsion of the Spanish Jews was a larger-scale repetition of expulsions of Jews from England and France during the Middle Ages; it was repeated again in the pogroms of tsarist and communist Russia and Eastern Europe in the 19th and 20th centuries; and then again – in a format that seems near-impossible to come to terms with for our own generations and which therefore, as Enckell repeatedly emphasizes, continues to beset us – in the Holocaust. Further, as Enckell compellingly castigates, increasingly morbid ideas about Jews are part of the political and populist discourse of the Arab and Muslim world of today, frequently with the uncanny support from an ahistorical, left-leaning and supposedly egalitarian sector of the public opinion in the democratic West. Enckell doesn’t write much about the Jews of Spain, except stating in passing and somewhat enigmatically – and more than once – that Spanish culture is suicidal. However, he does mention that the the first Jewish books he read belonged to his paternal grandmother, herself the grand-daughter of a Jewish trader from Stockholm who barely managed to establish himself and not be expelled from Helsinki. Among these books, which he read as a teenager 1940–1943, were Landet mellan öster och väster [The country between East and West] and Österlandets själ [The soul of Eastern lands] by the renowned Chief Rabbi of Stockholm 1914–1948, Marcus Ehrenpreis. Both books were published 1926–1927. The first depicts the history of the the Marranos [crypto-Jews] of Spain and Portugal. Enckell recalls how he, as a displaced lonely son