Peter Nordström

Survival analysis of suicide risk after attempted suicide

Survival analysis of suicide risk by sex and age after attempted suicide was studied in a cohort of 1573 suicide attempters referred to the psychiatric emergency room at the Karolinska Hospital from 1981 to 1988. The time course of suicide risk and the overall prognosis after attempted suicide and, in particular, the possible usefulness of sex and age as risk factors for the prediction of suicide risk after attempted suicide was analyzed. Nearly two thirds of the sample were women and most of the suicide attempters were young (in their twenties and thirties), and the median age was 35 years. The overall mortality after a 5‐year mean observation period after attempted suicide was 11%, and the suicide mortality was 6 %. The suicide risk after attempted suicide among men (8.3%) was nearly twice the female suicide risk (4.3%). Age as a possible suicide risk factor was analyzed for each sex separately by median split subgrouping. It was concluded that both older and younger male suicide attempters are at high risk of suicide (7% and 10% respectively), and older women are at higher risk than younger (6%, vs 2%). The suicide risk is particularly high during the first year after the suicide attempt. The high suicide risk group of young adult male suicide attempters is one of the main feasible targets of psychiatric intervention research programs on suicidal behavior. Suicide among young men is a major cause of years of life lost.

Attempted suicide predicts suicide risk in mood disorders

Suicide risk was studied in a sample of 346 mood disorder inpatients, 92 of whom were admitted after a current suicide attempt. The overall suicide mortality after a mean observation period of 6 years was 8%. The potential of attempted suicide to predict suicide risk in hospitalized patients with mood disorders was studied by survival analysis after subgrouping on the basis of whether a current suicide attempt had occurred or not. The suicide risk the first year after attempting suicide was 12% (11/92), compared with 2% (4/254) in the mood disorder subgroup with no current suicide attempt. The long‐range suicide risk after a current suicide attempt in depression was 15% (14/92) as compared with 5% (13/254) among those without a current suicide attempt. It is concluded that a current suicide attempt in mood disorder inpatients predicts suicide risk particularly within the first year and should be taken very seriously.

Temperamental vulnerability in attempted suicide

The aim of this study was to explore and describe features of suicidal temperament and to describe the psychological domains of vulnerability in attempted suicide. Thirty‐two suicide attempters were compared with 32 sex‐ and age‐matched convalescent surgical controls on self‐report personality inventories; the Eysenck Personality Questionnaire, the Chapman Scales, the Beck Hopelessnes Scale and the Karolinska Scales of Personality. Suicide attempters showed higher scale scores on neuroticism, psychoticism, interpersonal aversiveness, perceptual aberration, nonconformity, hopelessness, somatic anxiety, muscular tension, indirect aggression, suspicion and lower socialization. The features of suicidal temperament include hopelessness and anhedonia, anxiety, hostility and undirected anger expression, psychosis proneness, antisocial traits and interpersonal difficulties. These temperamental features might render the suicidal individual particularly vulnerable to suicidal behavior.

Low CSF oxytocin reflects high intent in suicide attempters

Data from animal studies suggest that oxytocin is an important modulating neuropeptide in regulation of social interaction. One human study has reported a negative correlation between CSF oxytocin levels, life history of aggression and suicidal behaviour. We hypothesized that CSF oxytocin levels would be related to suicidal behaviour, suicide intent, lifetime interpersonal violence and suicide risk. 28 medication free suicide attempters and 19 healthy volunteers participated in this cross sectional and longitudinal study. CSF and plasma morning basal levels of oxytocin were assessed with specific radio-immunoassays. The Beck Suicide Intent Scale (SIS), the Freeman scale and the Karolinska Interpersonal Violence Scale (KIVS) were used to assess suicide intent and lifetime violent behaviour. All patients were followed up for cause of death. The mean follow-up was 21 years. Suicide attempters had lower CSF oxytocin levels compared to healthy volunteers p=0.077. In suicide attempters CSF oxytocin showed a significant negative correlation with the planning subscale of SIS. CSF oxytocin showed a significant negative correlation with suicide intent, the planning subscale of SIS and Freeman interruption probability in male suicide attempters. Correlations between plasma oxytocin levels and the planning subscale of SIS and Freeman interruption probability were significant in male suicide attempters. Lifetime violent behaviour showed a trend to negative correlation with CSF oxytocin. In the regression analysis suicide intent remained a significant predictor of CSF oxytocin corrected for age and gender whereas lifetime violent behaviour showed a trend to be a predictor of CSF oxytocin. Oxytocin levels did not differ significantly in suicide victims compared to survivors. CSF oxytocin may be an important modulator of suicide intent and interpersonal violence in suicide attempters.

HPA axis hyperactivity and attempted suicide in young adult mood disorder inpatients.

BACKGROUND Hyperactivity of the Hypothalamic-Pituitary-Adrenal (HPA) axis is a consistent finding in Major Depressive Disorder (MDD) and most prospective studies of HPA-axis function have found that non-suppressors in the dexamethasone suppression test (DST) are more likely to commit suicide during follow-up. The results of studies on HPA-axis function and attempted suicide are less consistent. Suicide attempts are more common among young people than the elderly, whereas suicide is more common among the elderly. The impact of age related changes in HPA-axis system activity in relation to suicidal behaviour across the lifecycle may be of importance. METHODS The aim of the present study was to investigate the DST results in 36 young adult (30 years or younger) inpatients with mood disorder, with (n=18) and without suicide attempt at the index episode. RESULTS The DST non-suppressor rate was 25% among young mood disorder inpatients. DST non-suppression was associated with suicide attempt and post-dexamethasone serum cortisol at 11:00 p.m. was significantly higher in suicide attempters compared to non-attempters. The DST non-suppressor rate was 39% in young adult suicide attempters compared with 11% in non-attempters. CONCLUSIONS The results add to previous evidence in support of the role of HPA axis hyperactivity and suicidal behaviour. The present findings motivate to include HPA axis measures in the assessment of depression in young adults.

DST non-suppression predicts suicide after attempted suicide

Most prospective studies of HPA axis have found that non-suppressors in the dexamethasone suppression test (DST) are more likely to commit suicide during the follow-up. Attempted suicide is a strong clinical predictor of suicide. The aim of this study was to assess the predictive value of DST for suicide in a group of depressed inpatients with and without an index suicide attempt. Historical cohort of 382 psychiatric inpatients with mood disorder admitted to the department of Psychiatry at the Karolinska University Hospital between 1980 and 2000 were submitted to the DST and followed up for causes of death. During the follow-up (mean 18 years), 36 suicides (9.4%) occurred, 20 of these were non-suppressors and 16 were suppressors. There was no statistically significant difference in suicide risk between the suppressors and non-suppressors for the sample as a whole. An index suicide attempt predicted suicide. In suicide attempters with mood disorder, the non-suppressor status was significantly associated with suicide indicating that HPA axis hyperactivity is a risk factor for suicide in this group. The dexamethasone suppression test may be a useful predictor within this population.

CSF 5-HIAA, suicide intent and hopelessness in the prediction of early suicide in male high-risk suicide attempters

Objective:  To study the predictive value of the Beck Suicide Intent Scale (SIS), the Beck Hopelessness Scale (BHS) and of 5‐hydroxyindoleacetic acid (5‐HIAA) in the cerebrospinal fluid for future early suicide in a group of high‐risk male suicide attempters.

HPA axis hyperactivity and cardiovascular mortality in mood disorder inpatients

Depression is associated with an increased risk of cardiovascular disease (CVD), coronary heart disease (CHD) and cardiac death. Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis function is frequent in major depression and hypercortisolemia may be a mediating factor in these relationships. The aim of this study was to assess HPA axis function measured with the dexamethasone suppression test (DST) in relation to CVD and CHD mortality in a cohort of 382 inpatients with mood disorder admitted to the department of Psychiatry at the Karolinska University Hospital between 1980 and 2000. Death certificates ascertained that 75 patients had died of cardiovascular disease and 30 patients of CHD during the mean follow-up of 18 years. DST non-suppression and higher baseline serum cortisol predicted CVD death. In male inpatients with mood disorder, the DST non-suppressor status was significantly associated with CVD death but not with CHD death. In depressed female inpatients the DST non-suppression was not associated with cardiovascular mortality. Baseline serum cortisol and post-dexamethasone serum cortisol levels at 4:00 p.m. showed a trend to be higher in female CVD/CHD victims. Effect of aging on HPA axis functioning was shown in male CHD deaths. HPA axis dysregulation may be a mediating factor between depression and increased risk of cardiovascular death in male mood disorder inpatients indicating that HPA-axis hyperactivity is a long term risk factor for cardiovascular mortality.

Consultations for research in suicidology

Science means research. Current research in suicidology, however, needs development. Therefore, a task force was established by the International Academy for Suicide Research (IASR) to make recommendations for future study of suicide. These consultations are offered only as current thoughts to assist, not only in research, but also to aid in preventing suicide.

Definite and undetermined forensic diagnoses of suicide among immigrants in Sweden

A total of 707 cases of violent death (suicide, undetermined mode or accident) occurring in 1990 were investigated at the Department of Forensic Medicine in Stockholm. The catchment area of the Department includes about 1.9 million people. Fourteen percent of the population in the area are immigrants. The largest single immigrant group was the 91,015 Finnish‐born inhabitants, who represented 33% of the overall immigrant population. Thirty percent of all undetermined deaths and 20% of the suicides were among people born outside Sweden. A significant overrepresentation of the largest immigrant group (Finnish‐born) was found in both the definite and undetermined suicide categories. There was also an overall overrepresentation of immigrants among the undetermined cases and a trend towards overrepresentation among definite suicides. Also, there was a significant overall overrepresentation of immigrants in the total cases of undetermined and definite suicide. Some psychosocial factors found predominant among the immigrant sample were social isolation, low social class and poor social network. The findings in this study indicates that immigrant status should be considered as a risk factor for suicide in Sweden. Previous reports on the high suicide rates among immigrants in Australia, Canada, Great Britain and the United States suggest that the overrepresentation of immigrants found in our study could represent a worldwide epidemiological trend related to voluntary and forced migration. Possible hypotheses that could explain this phenomenon are discussed.