Erik Christiansen

Risk of repetition of suicide attempt, suicide or all deaths after an episode of attempted suicide: a register-based survival analysis

Objective: This study was undertaken in order to estimate the incidence of repetition of suicide attempt, suicide and all deaths, and to analyse the influence of psychiatric illness and socio-demographic factors on these. Method: The study is a Danish register-based survival analysis that retrieved personal data on socio-economic, psychiatric and mortality conditions from various registers. Hazards were estimated using Cox regression with a time-dependence covariate. Suicide-attempters (2.614) and non-attempters (39.210)were analysed being matched by gender, age and place of residence. Results: The average follow-up period for suicide-attempters was 3.88 years, during which 271 (10.37%) of them died. By comparison, death occurred four times more often among suicide-attempters than among non-attempters. Suicide was far more common among attempters (61, 2.33%) than among non-attempters (16, 0.04%). A proportion of the attempters (31.33%) repeated their attempt within the follow-up period. The most reliable predictors for suicide and death were repetition, suicide attempt method and treatment for mental illness. The most reliable predictors for repetition were age, gender and mental illness. Discussion: Individuals with a history of suicide attempts form a well-defined high-risk group for suicide, and are in need of treatment immediately after the episode. Somatic and psychiatric staff must be informed about the risk factors for subsequent suicidal behaviour after an episode of attempted suicide. Furthermore, departments that are in contact with suicidal individuals need action plans to ensure that all such individuals are discharged to proper treatment immediately after the suicide attempt.

Quality of life in eating disorders: A meta-analysis

Eating disorders (EDs) comprise a variety of symptoms and have a profound impact on everyday life. They are associated with high morbidity and mortality. The objective of this study was to analyse published data on health-related quality of life (HRQoL) in EDs so as to compare the results to general population norm data and to investigate potential differences between ED diagnostic groups. A systematic review of the current literature was conducted using a keyword-based search in PubMed and PsychInfo. The search covered anorexia nervosa (AN), bulimia nervosa (BN), eating disorders not otherwise specified (EDNOS) and binge eating disorder (BED) and used the Medical Outcomes Study Short Form-36 Health Survey (SF-36) as a measure of HRQoL. Of the 102 citations identified, 85 abstracts were reviewed and seven studies were included in the meta-analysis. AN patients were included in five studies (n=227), BN in four studies (n=216), EDNOS in two studies (n=166) and BED in four studies (n=148). We tested for between-study variation and significant differences between the diagnostic groups. The results confirmed a significantly lower level of HRQoL in all EDs compared to a population mean. It was not possible to establish any differences between the diagnostic groups.

Risk for attempted suicide in children and youths after contact with somatic hospitals: a Danish register based nested case–control study

Background A range of studies have found an association between some somatic diseases and increased risk of suicide and attempted suicide. These studies are mostly analyses of adult populations and illnesses related to adulthood. Objectives To study the risk of attempted suicide in children and youths with a somatic diagnosis, and to assess a possible association from a somatic perspective. Methods From a cohort of 403 431 individuals (born 1983–89), 3465 children and youths who had attempted suicide were identified. Each case was matched with 20 population controls. 72 765 children and youths constituted the case–control population. All data were obtained from national population registers and analysed in a nested case–control design. Results Contact of children and youths with a somatic hospital is correlated with increased risk of attempted suicide; the risk peaks in the time immediately after contact. Risk factors were treatment for injury caused by violence, epilepsy, asthma and malformation for males; and spontaneous and medical abortions, treatment for injury caused by violence, epilepsy, asthma, insulin dependent diabetes mellitus and malformation for females. Not all the mentioned diagnoses were significant in the adjusted model. Conclusions Based on the results of the study a strategy to minimise the risk of attempted suicide among children and youths must be implemented. The strategy should mainly focus on children at high risk—that is, children from families with low socioeconomic status, and children with a psychiatric history, a history of previous suicide attempts and with an unstable somatic disease subsequently causing many admissions.

Exercise addiction: A study of eating disorder symptoms, quality of life, personality traits and attachment styles

Exercise addiction is characterized by excessive exercise patterns with potential negative consequences such as overuse injuries. The aim of this study was to compare eating disorder symptoms, quality of life, personality traits and attachments styles in exercisers with and without indications of exercise addiction. A case-control study with 121 exercisers was conducted. The exercisers were categorized into an addiction group (n=41) or a control group (n=80) on the basis of their responses to the Exercise Addiction Inventory. The participants completed the Eating Disorder Inventory 2, the Short-Form 36, the NEO Personality Inventory Revised and the Adult Attachment Scale. The addiction group scored higher on eating disorder symptoms, especially on perfectionism but not as high as eating disorder populations. The characteristic personality traits in the addiction group were high levels of excitement-seeking and achievement striving whereas scores on straightforwardness and compliance were lower than in the exercise control group. The addiction group reported more bodily pain and injuries. This study supports the hypothesis that exercise addiction is separate to an eating disorder, but shares some of the concerns of body and performance. It is driven by a striving for high goals and excitement which results in pain and injuries from overuse.

Incidence and risk factors for suicide attempts in a general population of young people: A Danish register-based study

Objective: To estimate the Danish epidemiological long-term incidence rates for suicide attempts in the general population of children and adolescents, and to analyze the impact from single and multiple risk factors on the risk of suicide attempts. Method: We used longitudinal register data from a total cohort of all individuals born between 1983 and 1989 and living in Denmark to calculate incidence rates. From the cohort, we identified all who have attempted suicide, and matched 50 controls to each case. A nested case–control design was used to estimate the impact from risk factors on the risk for index suicide attempts. We established a link to the biological parents and identified risk factors for two generations. Risk factors were analyzed in a conditional logistic regression model. Results: We identified 3718 suicide attempters and 185,900 controls (189,618 individuals, aged 10–21 years). We found increasing incidence rates during the period 1994–2005, and higher incidence rates for girls and the oldest adolescents. Mental illness was the strongest independent risk factor (IRR = 4.77, CI = (4.35–5.23), p < 0.0001), but parental mental illness (psychopharmacological drugs: IRR = 1.27, CI = (1.18–1.37), p < 0.0001) and socio-demographic factors (parents not living together: IRR = 1.38, CI = (1.28–1.48), p < 0.0001) were also significant independent risk factors. Exposure to multiple risk factors increased the risk significantly. Conclusions: Suicide attempt is a multi-factorial problem, and a problem on the increase in the period studied. Individuals exposed to multiple risk factors are at the highest risk for suicide attempts, and when spotted or in contact with authorities they should be given proper care and treatment to prevent suicide attempts and death.

Exercise addiction in team sport and individual sport: Prevalences and validation of the exercise addiction inventory

Exercise addiction is characterized by increasing exercise amounts which take priority over other areas of life. It is mostly observed in individual sports, such as running and weight-lifting, whereas addiction in team sport has not previously been investigated. The aim of this study was to estimate the prevalence of exercise addiction in a team sport (football) compared to an individual sport (fitness) and to test the psychometric properties of the Exercise Addiction Inventory in these populations. The Exercise Addiction Inventory was completed by 274 men in the age group of 16–39 years (98 football players and 176 fitness exercisers). The prevalence of exercise addiction was statistically equal in the two groups (7.1% in football and 9.7% in fitness). The Cronbachs alpha showed good internal reliability in both groups and factor analysis found one underlying factor interpreted as exercise addiction. Less of the variance was explained in the football sample with low loading on item 2: conflicts (0.2). We compared the structure of the scale between the two groups by using structural equation models and we found that exercise addiction can explain the six Exercise Addiction Inventory (EAI) variables. Thus, the EAI is recommended for identification of addiction in both populations but in football players the item of conflicts could be replaced. Motivation for exercise in the football group seemed to be enjoyment and competition, while the fitness group exercised for health and weight reasons. Different motivation for exercise might explain the psychometric differences of the scale, but further studies are warranted.

Suicide attempts in chronic pain patients. A register-based study

Abstract Background There are several studies about the relationship between depression and chronic non-malignant pain. These studies have shown that up to 50% of chronic pain patients are suffering from depression. It is, therefore, reasonable to expect that pain patients would also have an increased risk of suicidal behaviour. This problem is not well studied. Since 1990 the Centre for Suicide Research, Odense, Denmark has registered all suicide attempts in patients residing in the Region of Funen, Denmark. The Pain Clinic, Odense University Hospital receives patients with chronic pain from the entire Region of Southern Denmark. Purpose The purpose of the study has been: To investigate, whether patients treated in the Pain Clinic during the period from 1 January 2004 to 31 December 2009 had an increased risk of suicide attempts compared with the background population. Materials and methods The Register for Suicide Attempts (RSA) is a product of the WHO research programme WHO/EURO Multicentre Study on Para suicide. The RSA is a longitudinal person-based register. It contains information about people who have been in contact with the health care system in the County of Funen as a result of a suicide attempt. The Pain Clinic, Odense University Hospital receives patients with non-malignant chronic pain from the Region of Southern Denmark with 1,194,659 inhabitants. Data about age, sex, and time of treatment for patients treated in the Pain Clinic during the period were registered. Time and method of the suicide attempts were registered in the RSA. By registry linkages between the patient registers it was possible to calculate any excess risk of suicide attempts in chronic pain patients in the study period. We used a cohort design and calculated incidence rates (IR) and incidence rate ratios (IRRs) for suicide attempts, based on data from RSA. Poisson Regression analyses were used for calculation of IR and IRR for suicide attempts. Results In the study period from 1 January 2004 to 31 December 2009 1871 patients residing in the Region of Funen in Denmark were referred to The Pain Clinic. In the patient group 258 suicide attempts in 110 persons were registered. In all 6% of the patient group had attempted suicide. An increased risk of suicide attempts was found in the pain population as the incidence rate ratio (IRR) was 3.76 95% CI (3.22; 4.40). No statistical significant differences between men and women were found. Conclusion In a chronic non-malignant pain population, referred to a pain clinic, the risk of suicide attempts was increased. Implications It is important to be aware of risk factors for suicidal behaviour, i.e. pain history, depression, anxiety, abuse problems, and social problems when caring for patients with chronic pain. More knowledge and training of the staff caring for chronic pain patients are needed to decrease the risk of suicidal behaviour.

Validation of the exercise addiction inventory in a Danish sport context

Exercise addiction is characterized by excessive exercise behavior with potential negative consequences. The symptoms consist of salience, mood modification, tolerance, withdrawal symptoms, conflicts, and relapse. The purpose of this study was to test the psychometric properties of the exercise addiction inventory (EAI) and to estimate the prevalence of exercise addiction in a Danish normal weight sport population. A sample of 780 habitual fitness and football exercisers were contacted and 590 completed the EAI and an in‐house questionnaire containing questions about variables related to exercise addiction: (a) exercise frequency; (b) continuance despite injuries; and (c) personal perception of addiction. The results demonstrated an overall prevalence of exercise addiction of 5.8%. There was no significant difference between fitness and football prevalences. The internal reliability of EAI was acceptable with a Cronbachs α of 0.66. The criterion validity was tested toward the three variables related to exercise addiction. The dependent group had significantly higher scores on the three variables than the non‐dependent group. Exercise addiction seems to exist in both fitness and football. The EAI is a useful screening tool and might be applicable in future screening and prevention of exercise addiction. However, further investigation about the population is needed to understand the phenomenon and to identify the risk group.

A nested case–control study of the risk of suicide attempts after discharge from psychiatric care: The role of co-morbid substance use disorder

The literature suggests that the risk of suicide is high within the first weeks after discharge from psychiatric care, but practically no studies have estimated the risk of suicide attempt after discharge from psychiatric care. The aim of this study was to examine the risk level for suicide attempt after discharge from psychiatric care, and to control for effects from psychiatric diagnoses, number and length of previous admission. An analysis of the role of co-morbid substance use disorder in suicide attempts risk was completed. The study is a Danish register-based nested case–control study; 3037 cases were identified from Register for Suicide Attempts, and 60,295 individuals, matched by gender and age, were identified for comparison. Retrospective personal data on psychiatric care was obtained from the Danish Psychiatric Central Register. Risk of suicide attempts was estimated by the use of conditional logistic regression. We found a significant high peak in risk of suicide attempts in the first weeks after discharge from psychiatric care. The risk was lowered as time passed by. Suicide attempt risk was not equally distributed across various psychiatric diagnoses, and co-morbidity of substance abuse with mental illness raised risk in an additive way. We found only small gender differences in risk. In order to lower the risk of suicide attempts, we need to improve after-care when discharging from psychiatric care. A differentiation between the possibilities of after-care for different mental illnesses is needed.

Risk factors and study designs used in research of youths' suicide behaviour-An epidemiological discussion with focus on level of evidence

Abstract Introduction: Many different epidemiology study designs have been used to analyse risk factors for suicide behaviour. The purpose of this study was to obtain an insight into the current study design used in research on youths’ risk factors for suicide behaviour and to rank the studies according to level of evidence (LoE). Methods: We searched PubMed and psycINFO in order to identify relevant individual studies. Results: We included 36 studies of children and youth on suicidal behaviour and ideation—many rank low on LoE. For suicide, cohort design was often used, and mental illness (depression, substance abuse and severity of mental illness) was the most common risk factor. Cohort studies are ranked 2b, which is high according to LoE. For suicide attempts, survey was often used, and psychopathology, substance abuse and being exposed to suicidal behaviour were the most common risk factors. For suicidal ideation, survey was the only design used, and substance abuse and psychopathology the most common risk factors. Surveys are ranked 4, which are low according to LoE. Many risk factors were broad and unspecific, and standard definitions of outcome and exposure were rarely used. Conclusion: A good study of risk factors for suicidal behaviour would need a high LoE, as a high-powered longitudinal epidemiological study (cohort or case–control) of very specific risk factors. The factors would have high prevention potential, compared with more broad and unspecific risk factors, to which many people are exposed. We would recommend a cohort design (in high-risk populations) or a case–control design to identify risk factors, using clinical and/or register data instead of self-reported information, reporting adjusted estimates and using standard definition of suicidal outcome and risk factors.