Jaana Suokas

Mental disorders and comorbidity in attempted suicide

The present study examined the prevalence and comorbidity of mental disorders according to DSM‐III‐R among male and female suicide attempters. A systematic sample of 114 patients from consecutive cases of attempted suicide referred to a general hospital in Helsinki between 1 January and 31 July 1990 was interviewed. In 98% of the cases at least one Axis I diagnosis was made. Depressive syndromes were more common among females (85%) than males (64%), and alcohol dependence was more common among males (64%) than females (21%). A high proportion of suicide attempters (82%) suffered from comorbid mental disorders. Comorbidity appears to play an important role in parasuicide.

Polypharmacy With Antipsychotics, Antidepressants, or Benzodiazepines and Mortality in Schizophrenia

CONTEXT Polypharmacy is widely used in the treatment of schizophrenia, although it is believed to have major adverse effects on the well-being of patients. OBJECTIVE To investigate if the use of benzodiazepines, antidepressants, or multiple concomitant antipsychotics is associated with increased mortality among patients with schizophrenia. DESIGN Registry-based case linkage study. SETTING Academic research. PATIENTS We linked national databases of mortality and medication prescriptions among a complete nationwide cohort of 2588 patients hospitalized in Finland for the first time with a diagnosis of schizophrenia between January 1, 2000, and December 31, 2007. MAIN OUTCOME MEASURES Hazard ratios (HRs) were computed for all-cause mortality during the use of antipsychotics, antidepressants, or benzodiazepines in outpatient care, adjusting for the effects of sociodemographic and clinical variables, geographic location, and current and past pharmacological treatments. RESULTS Compared with antipsychotic monotherapy, concomitant use of 2 or more antipsychotics was not associated with increased mortality (HR, 0.86; 95% CI, 0.51-1.44). Similarly, antidepressant use was not associated with a higher risk for mortality (HR, 0.57; 95% CI, 0.28-1.16) and was associated with markedly decreased suicide deaths (HR, 0.15; 95% CI, 0.03-0.77). However, benzodiazepine use was associated with a substantial increase in mortality (HR, 1.91; 95% CI, 1.13-3.22), and this was attributable to suicidal deaths (HR, 3.83; 95% CI, 1.45-10.12) and to nonsuicidal deaths (HR, 1.60; 95% CI, 0.86-2.97). In total, 826 of 904 patients (91.4%) who used benzodiazepines had purchased prescriptions that contained more than 28 defined daily doses, violating treatment guidelines. CONCLUSIONS Benzodiazepine use was associated with a marked increase in mortality among patients with schizophrenia, whereas the use of an antidepressant or several concomitant antipsychotics was not. Antidepressant use was associated with decreased suicide deaths. The literature indicates that long-term use of benzodiazepines among patients with schizophrenia is more prevalent in other countries (eg, the United States) compared with Finland, which suggests that benzodiazepine use may contribute to mortality among this patient population worldwide.

Outcome of attempted suicide and psychiatric consultation: risk factors and suicide mortality during a five-year follow-up.

A total of 1018 self‐poisoned patients were treated during the year 1983 in the emergency room of Helsinki University Central Hospital. By the end of a 5‐year follow‐up period, 3.2% of these had committed suicide, making annual suicide mortality 589 per 100,000. During the first year after the index attempt, suicide mortality was 1768 per 100,000, a 50‐fold risk compared with that of the total population in Helsinki. Risk factors were being male of advancing age, having mental disorders, previous suicide attempts, a nonimpulsive index suicide attempt, moderate to very serious lethality and severe intention to die during the index suicide attempt. When the lethality was assessed as being very serious or intention to die as certain, 21% later committed suicide. The relative risk for those left without psychiatric consultation was 0.6 when the lethality was mild and 1.6 when it was severe. Results indirectly indicate that psychiatric consultation seemed to have a positive effect on the outcome of these attempted suicides.

Suicide attempts in which alcohol is involved: a special group in general hospital emergency rooms

Sixty‐two percent of 1018 parasuicide patients treated in the emergency room of Helsinki University Central Hospital in 1983 for 1207 suicide attempts had recently consumed alcohol in addition to medical drugs: 46% were women and 54% men. High body alcohol levels were associated with young age and male gender. Alcohol consumption shortly before, or at the time of, parasuicidal acts was more common among young or lonely men with previous suicide attempts. Their suicide risk was assessed as less severe and they were less often referred to a psychiatrist compared with those who had not consumed alcohol. They were also more often left without arranged after‐care. By the end of a 5.5‐year follow‐up period, 3.3% of these alcohol consumers had committed suicide, an annual suicide mortality of 598/100,000. In the year following the initial attempt, suicide mortality was 1809/100,000, a 51‐fold risk compared to that of the total population in Helsinki. Sixty‐seven percent of alcohol consumers during the initial suicide attempt also took it before actually committing suicide, and 30% of these revealed clear evidence of chronic alcohol consumption. Those who initially consumed alcohol were identifiable as a risk group for suicide, and thus improvement in their recognition and treatment in the emergency rooms of general hospitals is recommended.

Work stress has negative effects on the attitudes of emergency personnel towards patients who attempt suicide

ABSTRACT– Many previous studies indicate that the attitudes of the staff towards patients who attempt suicide are often negative. Nevertheless, the attitudes of the staff working in different areas of an emergency department have not been studied. The purpose of this study was to explain the attitudes of emergency personnel (n= 184) towards patients who attempt suicide in the different stages of treatment in a general hospital by comparing the attitudes of the staff in the emergency room (n= 64), emergency ward (n= 47) and intensive care unit (n= 73). There were clear differences in attitudes of staff in the various units. The attitudes were most negative among emergency room staff, where all attempters are first treated. The intensive care staff, who treat the most serious cases, shared the most positive attitudes. It seems that specialized treatment of suicide attempters makes it possible to treat these patients in a more professional way in a general hospital.

Prevalence and diagnosis of schizophrenia based on register, case record and interview data in an isolated Finnish birth cohort born 1940–1969

IntroductionSchizophrenia occurs worldwide but the prevalence varies markedly. In Finland, schizophrenia is most prevalent in the northeastern region. Our aims were to reassess the register-, case record- and interview-based lifetime prevalence in a genetically homogeneous birth cohort from an isolate population with earlier reported high prevalence of schizophrenia and a chromosome linkage to chromosome 1q.MethodsWe identified all patients with a diagnosis of schizophrenia [International Classification of Diseases (ICD)-8, ICD-9 or ICD-10 codes], born 1940–1969 in the isolate (n=282) and alive (n=237) in 1998 using the Hospital Discharge, Disability Pension and Free Medicine Registers. The corresponding birth cohort of 14,817 persons and 12,368 alive in 1998 was identified from the National Population Register. We validated 69% of the register diagnosis by making DSM-IV consensus diagnoses, and interviewed 131 (55%) of the 237 patients with SCID-I and SCID-II.ResultsThe register-based lifetime prevalence was 1.5% for schizophrenia and 1.9% for schizophrenia spectrum psychotic disorders: in birth cohorts born 1945 to 1959, the latter prevalence was especially high (2.4%). Of those with a register diagnosis of schizophrenia spectrum psychotic disorder, 69% or 63% also received a record-based consensus diagnosis or SCID interview diagnosis of schizophrenia, and the prevalence was 0.9–1.3 and 0.7–1.2%, respectively, when we reassessed most of the register-based cases. The cumulative incidence of schizophrenia spectrum psychotic disorders in the total birth cohort was 1.9%.ConclusionIn this isolate, the register, DSM-IV consensus and SCID interview-based lifetime prevalence of schizophrenia was internationally high. For genetic research work, the register diagnosis should be reassessed using either structured interview or the best estimate consensus diagnosis.

Mortality in eating disorders: A follow-up study of adult eating disorder patients treated in tertiary care, 1995-2010

Elevated mortality risk in anorexia nervosa has been established, but less is known about the outcomes of bulimia nervosa and binge eating disorder. In this follow-up study we determined mortality in adults (N=2450, 95% women) admitted to the eating disorder clinic of the Helsinki University Central Hospital in the period 1995-2010. Most of the patients (80.7%) were outpatients. For each patient four controls were selected and matched for age, sex and place of residence. The matching was taken into account by modelling end-point events using Coxs proportional hazard model. The hazard ratio (HR) for all-cause mortality was 6.51 (95% CI 3.46-12.26) in broad anorexia nervosa (AN), 2.97 (95% CI 1.90-4.65) in broad bulimia nervosa (BN), and 1.77 (95% CI 0.60-5.27) in binge eating disorder (BED). Mortality risk in broad AN was highest during the first years after admission but declined thereafter, while in broad BN the mortality risk started to rise two years after the first admission. The HR for suicide was elevated both in broad AN (HR 5.07; 95% CI 1.37-18.84) and in broad BN (HR 6.07; 95% CI 2.47-14.89). Results show that eating disorders are associated with increased mortality risk even when specialised treatment is available.

Epidemiology of suicide attempts among persons with psychotic disorder in the general population

OBJECTIVE To establish the epidemiology of suicide attempts in persons with psychotic disorder identified from the general population and to investigate the associations of suicidal behavior with other clinical characteristics and with physical violence against other people. METHOD A random sample of 9922 Finnish persons aged 18 years or over was screened for psychotic disorder using multiple sources of information. All screen positives and random sample of screen negatives were invited to an SCID interview. Diagnostic assessment, lifetime history of suicide attempts and violence against others were based on all available systematically evaluated information from the questionnaire, interview and/or case records. RESULTS Of persons with a lifetime history of any primary or substance-induced psychotic disorder (n = 264), 34.5% (women: 34.1%, men: 34.9%) had a history of at least one suicide attempt. There were no suicide attempts among persons with delusional disorder, while the rate of suicide attempts was higher among persons with substance-induced psychotic disorders (48.8%) than in persons with other psychotic disorders 41.8%) (χ(2) = 4.4, d.f. = 1, P = 0.036). Suicide attempts were associated with younger age, comorbid substance use disorders, depressive symptoms, and physical violence against other people. CONCLUSION Suicide attempts are common in all psychotic disorders except for delusional disorder. They are particularly common in substance-induced psychotic disorder and in persons with comorbid substance use disorders. They are associated with severe depressive symptoms but not with the severity of psychotic symptoms. Suicidal behavior correlates with physical violence against other people.

Reproductive health outcomes in eating disorders.

OBJECTIVE Eating disorders are common psychiatric disorders in women at childbearing age. Previous research suggests that eating disorders are associated with fertility problems, unplanned pregnancies, and increased risk of induced abortions and miscarriages. The purpose of this study was to assess how eating disorders are related to reproductive health outcomes in a representative patient population. METHOD Female patients (N = 2,257) treated at the eating disorder clinic of Helsinki University Central Hospital during 1995-2010 were compared with matched controls identified from the Central Population Register (N = 9,028). Patients had been diagnosed (ICD-10) with anorexia nervosa (AN), atypical AN, bulimia nervosa (BN), atypical BN, or binge eating disorder (BED, according to DSM-IV research criteria). Register-based data on number of children, pregnancies, childbirths, induced abortions, miscarriages, and infertility treatments were used to measure reproductive health outcomes. RESULTS Patients were more likely to be childless than controls [odds ratio (OR) 1.86; 95% confidence interval (CI) 1.62-2.13, p < .001]. Pregnancy and childbirth rates were lower among patients than among controls. BN was associated with increased risk of induced abortion compared to controls (OR 1.85; 95% CI 1.43-2.38, p < .001), whereas BED was associated with elevated risk of miscarriage (OR 3.18; 95% CI 1.52-6.66, p = .002). DISCUSSION Reproductive health outcomes are compromised in women with a history of eating disorders across all eating disorder types. Our findings emphasize the importance of reproductive health counseling and monitoring among women with eating disorders.

Pregnancy, obstetric, and perinatal health outcomes in eating disorders

OBJECTIVE The purpose of this study was to assess pregnancy, obstetric, and perinatal health outcomes and complications in women with lifetime eating disorders. STUDY DESIGN Female patients (n = 2257) who were treated at the Eating Disorder Clinic of Helsinki University Central Hospital from 1995-2010 were compared with unexposed women from the population (n = 9028). Register-based information on pregnancy, obstetric, and perinatal health outcomes and complications were acquired for all singleton births during the follow-up period among women with broad anorexia nervosa (AN; n = 302 births), broad bulimia nervosa (BN; n = 724), binge eating disorder (BED; n = 52), and unexposed women (n = 6319). RESULTS Women with AN and BN gave birth to babies with lower birthweight compared with unexposed women, but the opposite was observed in women with BED. Maternal AN was related to anemia, slow fetal growth, premature contractions, short duration of the first stage of labor, very premature birth, small for gestational age, low birthweight, and perinatal death. Increased odds of premature contractions, resuscitation of the neonate, and very low Apgar score at 1 minute were observed in mothers with BN. BED was associated positively with maternal hypertension, long duration of the first and second stage of labor, and birth of large-for-gestational-age infants. CONCLUSION Eating disorders appear to be associated with several adverse perinatal outcomes, particularly in offspring. We recommend close monitoring of pregnant women with either a past or current eating disorder. Attention should be paid to children who are born to these mothers.