Diego De Leo

Suicide attempts, plans, and ideation in culturally diverse sites: the WHO SUPRE-MISS community survey

BACKGROUND The objectives were to assess thoughts about suicide, plans to commit suicide and suicide attempts in the community, to investigate the use of health services following a suicide attempt, and to describe basic socio-cultural indices of the community. METHOD The community survey was one component of the larger WHO multisite intervention study on suicidal behaviours (SUPRE-MISS). In each site, it aimed at randomly selecting and interviewing at least 500 subjects of the general population living in the catchment area of the emergency department where the intervention component of the study was conducted. Communities of eight SUPRE-MISS sites (in Brazil, China, Estonia, India, Iran, South Africa, Sri Lanka, and Viet Nam) participated plus two additional sites from Australia and Sweden conducting similar surveys. RESULTS Suicide attempts (0.4-4.2%), plans (1.1-15.6%), and ideation (2.6-25.4%) varied by a factor of 10-14 across sites, but remained mostly within the ranges of previously published data. Depending on the site, the ratios between attempts, plans, and thoughts of suicide differed substantially. Medical attention following a suicide attempt varied between 22% and 88% of the attempts. CONCLUSIONS The idea of the suicidal process as a continuous and smooth evolution from thoughts to plans and attempts of suicide needs to be further investigated as it seems to be dependent on the cultural setting. There are indications, that the burden of undetected attempted suicide is high in different cultures; an improved response from the health sector on how to identify and support these individuals is needed.

Psychiatric diagnoses and suicide: revisiting the evidence.

BACKGROUND The key role of prevention and treatment of mental disorders in the prevention of suicide is widely acknowledged. Which specific disorders need to be targeted remains to be conclusively demonstrated. AIMS To re-examine the presence of psychiatric diagnosis in cases of completed suicide from a global perspective. METHOD A review of studies reporting diagnoses of mental disorders in cases of completed suicide with or without history of admission to mental hospitals. RESULTS Most cases were from Europe and North America (82.2%). The majority (98%) of these had a diagnosis of at least one mental disorder. Among all diagnoses, mood disorders accounted for 30.2%, followed by substance-use related disorders (17.6%), schizophrenia (14.1%), and personality disorders (13.0%). CONCLUSIONS The mental health paradigm in suicide prevention covers just a part of the problem. Antisuicide strategies focusing exclusively on the identification and treatment of depression need to be reconsidered. In addition to this, other mental disorders should be targeted, in particular alcohol-use disorders and schizophrenia. More emphasis should also be placed on psychosocial and environmental interventions diminishing and counteracting stress.

Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries

OBJECTIVE To determine whether brief intervention and contact is effective in reducing subsequent suicide mortality among suicide attempters in low and middle-income countries. METHODS Suicide attempters (n = 1867) identified by medical staff in the emergency units of eight collaborating hospitals in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, China) participated, from January 2002 to October 2005, in a randomized controlled trial to receive either treatment as usual, or treatment as usual plus brief intervention and contact (BIC), which included patient education and follow-up. Overall, 91% completed the study. The primary study outcome measurement was death from suicide at 18-month follow-up. FINDINGS Significantly fewer deaths from suicide occurred in the BIC than in the treatment-as-usual group (0.2% versus 2.2%, respectively; chi2 = 13.83, P < 0.001). CONCLUSION This low-cost brief intervention may be an important part of suicide prevention programmes for underresourced low- and middle-income countries.

The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013

Background The Global Burden of Diseases (GBD), Injuries, and Risk Factors study used the disability-adjusted life year (DALY) to quantify the burden of diseases, injuries, and risk factors. This paper provides an overview of injury estimates from the 2013 update of GBD, with detailed information on incidence, mortality, DALYs and rates of change from 1990 to 2013 for 26 causes of injury, globally, by region and by country. Methods Injury mortality was estimated using the extensive GBD mortality database, corrections for ill-defined cause of death and the cause of death ensemble modelling tool. Morbidity estimation was based on inpatient and outpatient data sets, 26 cause-of-injury and 47 nature-of-injury categories, and seven follow-up studies with patient-reported long-term outcome measures. Results In 2013, 973 million (uncertainty interval (UI) 942 to 993) people sustained injuries that warranted some type of healthcare and 4.8 million (UI 4.5 to 5.1) people died from injuries. Between 1990 and 2013 the global age-standardised injury DALY rate decreased by 31% (UI 26% to 35%). The rate of decline in DALY rates was significant for 22 cause-of-injury categories, including all the major injuries. Conclusions Injuries continue to be an important cause of morbidity and mortality in the developed and developing world. The decline in rates for almost all injuries is so prominent that it warrants a general statement that the world is becoming a safer place to live in. However, the patterns vary widely by cause, age, sex, region and time and there are still large improvements that need to be made.

Definitions of Suicidal Behaviour:Lessons learned from the WHO/EURO Multicentre Study.

Based on the experience matured during the 15 years of the WHO/EURO Multicentre Study on Suicidal Behavior, this paper provides an excursus on main elements that characterize components for definitional needs. It describes the rationale for choosing the initial set of definitions within the study and the subsequent problems and developments. As a result, unifying terminologies are proposed.

A Systematic Review of Elderly Suicide Prevention Programs

BACKGROUND Suicide rates are highest among the elderly, yet research on suicide prevention in old age remains a much-neglected area. AIMS We carried out a systematic review to examine the results of interventions aimed at suicidal elderly persons and to identify successful strategies and areas needing further exploration. METHODS Searches through various electronic databases yielded 19 studies with an empirical evaluation of a suicide prevention or intervention program designed especially for adults aged 60 years and older. RESULTS Most studies were centered on the reduction of risk factors (depression screening and treatment, and decreasing isolation), but when gender was considered, programs were mostly efficient for women. The empirical evaluations of programs attending to the needs of high-risk older adults seemed positive; most studies showed a reduction in the level of suicidal ideation of patients or in the suicide rate of the participating communities. However, not all studies used measures of suicidality to evaluate the outcome of the intervention, and rarely did they aim at improving protective factors. CONCLUSIONS Innovative strategies should improve resilience and positive aging, engage family and community gatekeepers, use telecommunications to reach vulnerable older adult, and evaluate the effects of means restriction and physicians education on elderly suicide.

Why people engage in parasuicide: a-cross-cultural study of Intentions.

Information obtained at interview from 1,646 parasuicide patients in 14 regions in 13 European countries participating in the WHO/EURO Multicentre Study on Suicidal Behaviour was used to study self-reported intentions involved in parasuicide. Comparisons were made across cultures, genders, and age groups. Although some statistically significant differences were found, the effect sizes were very small. The main finding from this study is thus that parasuicide patients in different countries tend to indicate that similar types of intentions are involved in their acts of parasuicide, and that the intentions do not vary greatly with gender or age. The hypothesis that rates of suicide and parasuicide vary between regions with the frequency with which suicidal intention is indicated by the patients was also tested, but was supported only for women and in relation to national suicide rates. The findings from this study are likely to be generalizable to other settings and have implications for clinical practice.

Relation between attempted suicide and suicide rates among young people in Europe.

STUDY OBJECTIVE: To determine if there are associations between rates of suicide and attempted suicide in 15-24 year olds in different countries in Europe. DESIGN: Attempted suicide rates were based on data collected in centres in Europe between 1989 and 1992 as part of the WHO/EURO Multicentre Study of Parasuicide. Comparison was made with both national suicide rates and local suicide rates for the areas in which the attempted suicide monitoring centres are based. SETTING: 15 centres in 13 European countries. PATIENTS: Young people aged 15-24 years who had taken overdoses or deliberately injured themselves and been identified in health care facilities. MAIN RESULTS: There were positive correlations (Spearman rank order) between rates of attempted suicide and suicide rates in both sexes. The correlations only reached statistical significance for male subjects: regional suicide rates, r = 0.65, p < 0.02; national suicide rates, r = 0.55, p < 0.02. CONCLUSIONS: Rates of attempted suicide and suicide in the young covary. The recent increase in attempted suicide rates in young male subjects in several European countries could herald a further increase in suicide rates.

A systematic review of social factors and suicidal behavior in older adulthood

Suicide in later life is a global public health problem. The aim of this review was to conduct a systematic analysis of studies with comparison groups that examined the associations between social factors and suicidal behavior (including ideation, non-fatal suicidal behavior, or deaths) among individuals aged 65 and older. Our search identified only 16 articles (across 14 independent samples) that met inclusion criteria. The limited number of studies points to the need for further research. Included studies were conducted in Canada (n = 2), Germany (n = 1), Hong Kong (n = 1), Japan (n = 1), Singapore (n = 1), Sweden (n = 2), Taiwan (n = 1), the U.K. (n = 2), and the U.S. (n = 3). The majority of the social factors examined in this review can be conceptualized as indices of positive social connectedness—the degree of positive involvement with family, friends, and social groups. Findings indicated that at least in industrialized countries, limited social connectedness is associated with suicidal ideation, non-fatal suicidal behavior, and suicide in later life. Primary prevention programs designed to enhance social connections as well as a sense of community could potentially decrease suicide risk, especially among men.

Repetition of attempted suicide among teenagers in Europe: frequency, timing and risk factors

Background. Adolescents in many countries show high rates of suicide attempts and repetitions of attempts as a common feature. Attempted suicide is the best predictor of future suicide. Repetition of attempts further increases the risk of suicide. The present study sought to identify patterns and risk factors for repetition of attempts in older teenagers. Methods. Data were collected by uniform procedures in a longitudinal follow-up study in seven European centres participating in the WHO/EURO Multicentre Study on Suicidal Behaviour. Information on attempted suicide in the 15–19-year age group during the period 1989–1995 was analysed. Results. A total of 1,720 attempts by 1,264 individuals over a mean follow-up period of 204 weeks (SD 108.9) were recorded. When life-table analysis was performed, 24 % of the individuals who had previously attempted suicide made another attempt within one year after the index attempt, compared with 6.8 % of the “first-evers”, with no major gender difference. Cox regression analysis revealed that previous attempted suicide (OR 3.3, 95 % CI 2.4–4.4) and use of “hard” methods (OR 1.5, 95 % CI 1.1–2.1) were both significantly associated with repetition of attempted suicide. Stepwise Cox regression analysis showed that a history of previous attempted suicide was the most important independent predictor of repetition (OR 3.2, 95 % CI 2.4–4.4). Conclusion. For young suicide attempters, follow-up and adequate aftercare are very important if repetition and risk of suicide are to be reduced. This applies particularly to those who have already made more than one attempt.