Kim Juul Larsen

Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching

BACKGROUND Although deliberate self-harm is a strong predictor of suicide, evidence for effective interventions is missing. The aim of this study was to examine whether psychosocial therapy after self-harm was linked to lower risks of repeated self-harm, suicide, and general mortality. METHODS In this matched cohort study all people who, after deliberate self-harm, received a psychosocial therapy intervention at suicide prevention clinics in Denmark during 1992-2010 were compared with people who did not receive the psychosocial therapy intervention after deliberate self-harm. We applied propensity score matching with a 1:3 ratio and 31 matching factors, and calculated odds ratios for 1, 5, 10, and 20 years of follow-up. The primary endpoints were repeated self-harm, death by suicide, and death by any cause. FINDINGS 5678 recipients of psychosocial therapy (followed up for 42·828 person-years) were matched with 17,034 individuals with no psychosocial therapy in a 1:8 ratio. During 20 year follow-up, 937 (16·5%) recipients of psychosocial therapy repeated the act of self-harm, and 391 (6·9%) died, 93 (16%) by suicide. The psychosocial therapy intervention was linked to lower risks of self-harm than was no psychosocial therapy (odds ratio [OR] 0·73, 95% CI 0·65-0·82) and death by any cause (0·62, 0·47-0·82) within a year. Long-term effects were identified for repeated self-harm (0·84, 0·77-0·91; absolute risk reduction [ARR] 2·6%, 1·5-3·7; numbers needed to treat [NNT] 39, 95% CI 27-69), deaths by suicide (OR 0·75, 0·60-0·94; ARR 0·5%, 0·1-0·9; NNT 188, 108-725), and death by any cause (OR 0·69, 0·62-0·78; ARR 2·7%, 2·0-3·5; NNT 37, 29-52), implying that 145 self-harm episodes and 153 deaths, including 30 deaths by suicide, were prevented. INTERPRETATION Our findings show a lower risk of repeated deliberate self-harm and general mortality in recipients of psychosocial therapy after short-term and long-term follow-up, and a protective effect for suicide after long-term follow-up, which favour the use of psychosocial therapy interventions after deliberate self-harm. FUNDING Danish Health Insurance Foundation; the Research Council of Psychiatry, Region of Southern Denmark; the Research Council of Psychiatry, Capital Region of Denmark; and the Strategic Research Grant from Health Sciences, Capital Region of Denmark.

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.

Young people's risk of suicide attempts after contact with a psychiatric department - a nested case-control design using Danish register data.

BACKGROUND There seems to be an increased risk of children and adolescents committing or attempting suicide after contact with a psychiatric department. Children and adolescents living in families with low socio-economic status (SES) might have an especially increased suicide attempt risk. METHODS A complete extraction of Danish register data for every individual born in the period 1983-1989 was made. Of these 403,431 individuals, 3,465 had attempted suicide. In order to control for confounder effects from gender, age and calendar-time, a nested case-control study was designed. A total population of 72,765 individuals was used to analyze the risk of suicide attempts after contact with a psychiatric department. The case-control data were analyzed using conditional logistic regression. RESULTS This study shows that a child/adolescents risk of suicide attempt peaks immediately after discharge from last contact with a psychiatric department. The risk of suicide attempt is highest for children and adolescents suffering from personality disorders, depression and substance use disorders. Children and adolescents with previous contact with a psychiatric department and parental income in the lowest third have a significantly higher risk of suicide attempt. Suicide attempters were more likely to have been given several different diagnoses and several different psychopharmacological drugs prior to their attempted suicide. CONCLUSIONS The findings in this study highlight the need for psychopathology assessment in every case of attempted suicide. This study also shows that well-known risk factors such as contact with a psychiatric department do not affect all individuals in the same way. Individuals from families with low SES had the highest risk. This suggests that the presence of factors influencing both vulnerability and resiliency, e.g., family level of SES, needs to be included in the assessment.

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.

Differences between youth with a single suicide attempt and repeaters regarding their and their parents history of psychiatric illness

The objective of this study was to determine predictors of repeated suicide attempts in young people, focusing on psychiatric illness. A longitudinal population-based register study of all adolescents born in Denmark between 1984 and 2006 was conducted. Greater numbers of hospitalizations, psychiatric diagnoses, and psychopharmacological medications prescribed to youth before and after the index attempt were risk factors for repeated suicide attempts. Parental diagnoses and drug prescriptions following a childs first suicide attempt moderated the risk of repeated attempts. Psychiatric illness is a strong predictor of repeated suicide attempts in young people, and those with co-morbid diagnoses are at increased risk of repeated suicide attempts. Treatment of psychiatric illness in the parents after their childs first suicide attempt is a potential protective factor.

Youth, suicide attempts and low level of education: A Danish historical register-based cohort study of the outcome of suicide attempt

Background: In Denmark, it is a political goal that 95% of all young people should complete an upper secondary education. For some young people, this goal can be difficult to achieve. An association has been established between suicidal behaviour and school performance. Aim: We hypothesise that young people who have attempted suicide have a lower chance of finishing secondary education. Methods: We used Danish historical population registers to perform a longitudinal cohort design and extended Cox regression modelling to estimate crude and adjusted estimates of the effect of suicide attempt on secondary education. We used the birth cohorts 1983–1989, and all subjects were followed from birth until the end of 2011 (n = 355,725). Results: For suicide attempters, the likelihood of completing secondary education was one-third of non-attempters (crude hazard ratio = 0.38). A part of the impact can be explained by confounding factors. Individuals with a suicide attempt at age 16–20 years or with multiple suicide attempts were most likely not to complete secondary education. Compared to mentally ill non-attempters, suicide attempters with mental illness were more likely not to finish secondary education. Conclusion: A suicide attempt is not necessarily causal for not finishing secondary education, but it is a marker, and it predicts an increased likelihood of not finishing secondary education. We need to identify individuals at risk for suicide attempts and subsequently provide the necessary support. Completing secondary education is important, as it provides better chances of employment, higher wages and more opportunities for individuals in the future.

Predictive Validity of the Columbia-Suicide Severity Rating Scale for Short-Term Suicidal Behavior: A Danish Study of Adolescents at a High Risk of Suicide

Using the Columbia-Suicide Severity Rating Scale (C-SSRS), we examined the predictive and incremental predictive validity of past-month suicidal behavior and ideation for short-term suicidal behavior among adolescents at high risk of suicide. The study was conducted in 2014 on a sample of 85 adolescents (90.6% females) who participated at follow-up (85.9%) out of the 99 (49.7%) baseline respondents. All adolescents were recruited from a specialized suicide-prevention clinic in Denmark. Through multivariate logistic regression analyses, we examined whether baseline suicidal behavior predicted subsequent suicidal behavior (actual attempts and suicidal behavior of any type, including preparatory acts, aborted, interrupted and actual attempts; mean follow-up of 80.8 days, SD = 52.4). Furthermore, we examined whether suicidal ideation severity and intensity incrementally predicted suicidal behavior at follow-up over and above suicidal behavior at baseline. Actual suicide attempts at baseline strongly predicted suicide attempts at follow-up. Baseline suicidal ideation severity and intensity did not significantly predict future actual attempts over and above baseline attempts. The suicidal ideation intensity items deterrents and duration were significant predictors of subsequent actual attempts after adjustment for baseline suicide attempts and suicidal behavior of any type, respectively. Suicidal ideation severity and intensity, and the intensity items frequency, duration and deterrents, all significantly predicted any type of suicidal behavior at follow-up, also after adjusting for baseline suicidal behavior. The present study points to an incremental predictive validity of the C-SSRS suicidal ideation scales for short-term suicidal behavior of any type among high-risk adolescents.

Psychosocial therapy and causes of death after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching

BACKGROUND Psychosocial therapy after deliberate self-harm might be associated with reduced risk of specific causes of death. METHOD In this matched cohort study, we included patients, who after an episode of deliberate self-harm received psychosocial therapy at a Suicide Prevention Clinic in Denmark between 1992 and 2010. We used propensity score matching in a 1:3 ratio to select a comparison group from 59 046 individuals who received standard care. National Danish registers supplied data on specific causes of death over a 20-year follow-up period. RESULTS At the end of follow-up, 391 (6.9%) of 5678 patients in the psychosocial therapy group had died, compared with 1736 (10.2%) of 17 034 patients in the matched comparison group. Lower odds ratios of dying by mental or behavioural disorders [0.54, 95% confidence interval (CI) 0.37-0.79], alcohol-related causes (0.63, 95% CI 0.50-0.80) and other diseases and medical conditions (0.61, 95% CI 0.49-0.77) were noted in the psychosocial therapy group. Also, we found a reduced risk of dying by suicide as well as other external causes, however, not by neoplasms and circulatory system diseases. Numbers needed to treat were 212.9 (95% CI 139.5-448.4) for mental or behavioural disorders as a cause of death, 111.1 (95% CI 79.2-210.5) for alcohol-related causes and 96.8 (95% CI 69.1-161.8) for other diseases and medical conditions. CONCLUSIONS Our findings indicate that psychosocial therapy after deliberate self-harm might reduce long-term risk of death from select medical conditions and external causes. These promising results should be tested in a randomized design.

Suicide Risk Assessment in Adolescents - C-SSRS, K10, and READ

Background: Assessment and screening are often the first step in planning interventions to help adolescents at risk of suicide. Causes of suicidal thoughts and behavior are multifaceted and it is important for clinical work that assessment reflects this complexity. Aims: To investigate whether a general psychological Resilience Scale for Adolescents (READ) is associated with a validated suicide rating scale (C-SSRS). Method: An observational study of self-reported suicidality (C-SSRS), psychological distress (K10), and resiliency (READ) in three adolescent samples: suicide clinic (N = 147); general psychiatric clinic (N = 85); and a nonclinical sample (N = 92). Results: Resiliency scores were significantly higher (p < .05) in the nonclinical compared with the clinic samples on all READ scales. READ scores were similar in the two clinic samples apart from the family cohesion subscale, which was significantly lower in the suicide clinic sample. READ was predictive of levels of suicidality within all samples independently of general psychological distress (K10). Limitations: The study did not examine other early childhood factors that may contribute to individual resiliency or suicidality. Conclusion: READ provides a reliable and valid assessment of individual resilience for both clinical and nonclinical settings. Evaluation of protective resources is a useful adjunct to the assessment and treatment of suicidal behavior.