Tanja Neuner

Predicting inpatient suicides and suicide attempts by using clinical routine data

OBJECTIVE The study aimed at exploring prevalence and risk factors of inpatient suicides and attempted suicides in a psychiatric hospital. METHOD Based on the German psychiatric basic documentation system, 20,543 patients with 40,451 episodes of inpatient care (1995-2004) in a psychiatric state hospital were included. Besides univariate analyses, multivariate logistic regression analyses and classification and regression tree analyses were performed. RESULTS Forty-one inpatient suicides were recorded. Risk of inpatient suicide is increased for patients with resistance to psychopharmacological treatment, previous suicide attempt, severe side effects and supportive psychotherapy before admission. Two hundred fourteen inpatient suicide attempts occurred during the 10-year period. Risk factors of inpatient suicide attempt are assault, personality disorder, previous suicide attempt, psychopharmacological treatment resistance, suicidal thoughts at admission, schizophrenia, depression, female sex and length of stay. CONCLUSION The identified risk factors underline the need for a cautious investigation of previous suicide attempts as well as for giving special attention to patients who have problems with psychopharmacotherapy during hospitalization.

Revisiting the Association of Aggression and Suicidal Behavior in Schizophrenic Inpatients

Our study investigated the association of aggression and suicidal behavior in schizophrenic inpatients. Eight thousand nine hundred one admissions for schizophrenia (1998-2007) to a psychiatric university hospital were included. Schizophrenic suicides (n = 7)/suicide attempters (n = 40) were compared to suicides (n = 30)/suicide attempters (n = 186) with other diagnoses and to schizophrenic non-attempters regarding aggression. Logistic regression analysis was performed to explore risk factors for attempted suicide. Schizophrenic suicides/suicide attempters did not differ from other suicides/suicide attempters or from schizophrenic non-attempters with regard to aggression. Risk of inpatient suicide attempt was increased for patients with attempted suicide at admission, high school graduation, and disorganized subtype. Aggression could not be found to be a predictor of attempted suicide. Aggression seems to have a minor role for suicidal behavior in schizophrenia.

Completed Suicides in 47 Psychiatric Hospitals in Germany - Results from the AGATE-Study

INTRODUCTION There is an ongoing debate about a possibly enhanced risk of suicidal behaviour in some psychiatric patients due to psychopharmacotherapy. Our retrospective study aimed at analyzing the psychopharmacotherapy of 133 inpatient suicides and 133 controls by a matched pair design. METHODS We analyzed all suicides (n = 133) reported in the AGATE study from 1991 to 2008. Besides evaluation of sociodemographic variables and suicide methods, we compared psychopharmacotherapy of suicides with schizophrenia (n = 59) and affective disorders (n = 59) to that of a matched control group. RESULTS Most suicides (n = 102, 76.7%) were judged not to be related to psychopharmacotherapy. In general, more psychopharmacological drugs were prescribed for suicides than for controls. Schizophrenic suicides received more low potency FGAs than their controls. More suicides with affective disorders than controls were treated with NASSAs, SNRIs, and high or low potency FGAs. In contrast to their controls, none of the suicides with affective disorders received lithium. NASSAs, SNRIs, and high or low potency FGAs predicted suicide in regression analysis for inpatients with affective disorders. DISCUSSION Differences in psychopharmacotherapy might mainly result from a recognized risk of suicide or a more severe degree of illness. However, the underrepresentation of lithium in the suicide groups is noticeable.

Suicidal Behaviour of Elderly Psychiatric Inpatients - Prevalence and Risk Factors

OBJECTIVE The study aimed at evaluating prevalence and risk factors of suicidal behaviour of elderly psychiatric inpatients based on the German psychiatric basic documentation system (DGPPN-BADO). METHODS A total of 5,356 elderly psychiatric inpatients (> 65 years) with 7,658 episodes of inpatient care in a psychiatric university hospital between 1996 and 2006 was included in the study. Besides descriptive analyses, univariate analyses and binary logistic regression analyses were performed. RESULTS Four inpatient suicides and 14 attempted suicides of twelve inpatients were recorded during the 11-year period. Three of the 4 inpatient suicides and 6 of the 12 inpatients attempting suicide during hospital stay had a diagnosis of depression. Furthermore, 280 suicides before admission were attempted by 262 patients. Regression analysis revealed life time suicide attempt, ICD-10 diagnosis F43, period of onset of present episode less than one week and ICD-10 diagnosis F32 / F33 as significant predictors of attempted suicide before admission. Suicidal thoughts without concomitant suicide attempt before admission were recorded for 389 admissions of 346 patients. According to regression analysis, risk of suicidal thoughts before admission is increased for patients with life time suicide attempt, ICD-10 diagnosis F43, ICD-10 diagnosis F32 / F33, ICD-10 diagnosis F30 / F31, greater number of hospital admissions, short cumulative length of stay and non-chronic course of disease. CONCLUSIONS Examination of risk faktors of suicidal behaviour within the framework of hospital admissions should not be restricted exclusively to period of hospital stay. Relevant risk factors can be found even before hospital stay and could be a cue for suicide prevention already in the forefront of admission.

Risk Profiles for Suicide of Schizophrenic and Depressive Inpatients - A Psychological Autopsy Study

OBJECTIVE This psychological autopsy study investigates suicide risk factors of schizophrenic and depressive inpatients. METHODS 67 potential risk factors of inpatient suicide were identified by means of literature research and caregiver interviews of schizophrenic and depressive suicidents (1995-2004). The medical records of the suicidents (n = 20) were analysed in respect to the identified risk factors and compared to their respective control group of non-suicidents (n = 20) which was matched by diagnosis, gender, age, year / month of admission and ward. Univariate and multivariate statistical analyses were performed. RESULTS In comparison to their respective control group schizophrenic (n = 11) and depressive suicidents (n = 9) differed clearly by their risk profile. Suffering from side effects of medication was found to be a predictor of suicide for schizophrenic inpatients. CONCLUSIONS Psychological autopsy studies are indispensable for the construction of diagnosis-specific risk profiles. Reduction of side effects of medication seems to play a larger role in suicide prevention for schizophrenic inpatients than previously assumed.

Time patterns of inpatient suicides

Abstract Objective. Time patterns of suicides have been investigated in many population-based studies, but there are no studies exploring time patterns of suicides during psychiatric inpatient stay up to now. Methods. All inpatient suicides (1998–2007) of a psychiatric university hospital were identified by the German psychiatric basic documentation system (DGPPNBADO). Descriptive and univariate analyses were performed to analyse time patterns of inpatient suicides. Results. No significant differences could be found for the occurrence of the 37 inpatient suicides due to season (χ2=1.595, P=0.696), month (χ2=4.838, P=0.958) or weekday (χ2=5.189, P=0.550) of suicide. Furthermore, we could not find an unequal distribution of suicides due to month of birth (χ2=12.622, P=0.337). 78.4% of inpatient suicides occurred within 50 days after admission. Fourteen inpatients committed suicide around public holidays, two around their birthday. Conclusions. Apart from a notably enhanced risk of suicide in the period after admission, we could not find any time patterns to be of high relevance to inpatient suicides. There may be more relevant risk factors than cyclic or temporal variations.

Media running amok after school shooting in Winnenden, Germany!

According to the The Sun , ‘a TEEN shooter went on a bloody rampage at a German high school today killing 15 people before shooting himself during a gunfight with cops’. ‘Police said the classrooms were “running with blood”.’ ‘Smiling happily for the camera, these are three of the girls shot dead by a crazed gunman at a German school.’ ‘I was shot 3 times … Chantal slumped dead by the door.’ ‘Click here to see the latest pictures from the scene!’1 In the morning of 11 March, a 17-year-old teenager went on a shooting spree at his former secondary school in Winnenden near Stuttgart, southwest Germany. The amok2 resulted in 15 deaths, followed by the suicide of the perpetrator, who had graduated from this school 1 year before. Beneath the speculation that—given the wrong circumstances—any of us is capable of running amok,3 from a psychiatric point of view, it seems that the dynamics of school shooting are similar to the mechanics that govern …

Acute psychiatric inpatient care: a cross-cultural comparison between two hospitals in Germany and Japan.

Background: Intercultural differences influence acute inpatient psychiatric care systems. Aims: To evaluate characteristics of acute inpatient care in a German and a Japanese hospital. Method: Based on a sample of 465 admissions to the Psychiatric State Hospital Regensburg (BKR) and 91 admissions to the Hirakawa Hospital (HH) over a six-month period in 2008, data from the psychiatric basic documentation system (BADO) were analysed with regard to socio-demographic characteristics, treatment processes and outcome indicators. Results: Schizophrenia and related psychosis was the most common diagnosis in both hospitals. Cases at the BKR were admitted more quickly after onset of the present episode. Global Assessment of Psychosocial Functioning (GAF) ratings at admission were lower at the HH. Most admissions to both hospitals received psychopharmacological treatment, but more at the HH received psychotherapy. Length of stay was significantly longer at the HH (75 days) than at the BKR (28 days). Admissions to the HH were more improved with regard to GAF and clinical global impression (CGI). Conclusions: Acute admissions in Germany provide intensive care with short hospitalization as crisis intervention. For acute admissions in Japan, comprehensive care for severe mental illness precedes emergency admissions and achieves greater improvement with longer hospitalization.

Assisted suicide on TV—the public ‘License to Kill’?

n 10 December, a British satellite television channel telecast the documentary ‘Right to Die’, which shows the assisted suicide of 59-year old US citizen Craig Ewert at the Dignitas clinic in Switzerland. Amyotrophic lateral sclerosis patient Ewert’s last 4 days were covered, finally showing him drinking a lethal dose of barbiturates before turning off his lung ventilator with a mouth-operated switch. Beneath being relevant to the ‘Right to Die’ debate and the question of legalization of doctor-assisted dying, 1 another aspect has to be considered urgently. In terms of suicide prevention, an increase of imitative suicides due to the ‘Werther effect’, i.e. the increase of suicide rates after detailed reports about suicide in the media, cannot be excluded. The Werther effect had been proved for the first time after a twice broadcast (1981, 1982) of the six-episode serial ‘Death of a student’ in Germany. 2 The number of railway suicides had increased over extended periods up to 175%, most clearly observable in groups age and sex congruent. 2 An Austrian research group showed that after an increase of subway suicides in Vienna between 1984 and 1987, a decrease of 75% could be achieved by a working group of the Austrian Association for Suicide Prevention who had developed media guidelines and initiated discussion with the media over suicide coverage, culminating in an agreement to refrain from reporting suicides. 3 Based on such studies, it has to be assumed that even for assisted suicides within the framework of euthanasia a Werther effect could be induced. Especially, the extremely detailed report of a seemingly peaceful suicide in the context of a TV documentation may tempt terminally ill people to choose suicide as both an adequate and acceptable way to solve their problem. Evidence for this comes from a Swiss study: after the media had reported extensively about the assisted double suicide of a prominent couple, a considerable rise of suicides—especially among women older than 65 years—occurred for a period of 2 years after the event. 4 Here, the almost enthusiastic kind of reporting might have led to the Werther effect. The German Association of Suicide Prevention recommend in their media guidelines for reporting on suicides to avoid inadvertently romanticizing or idealizing the suicide or labelling the act as a heroic one (e.g. ‘He didn’t want to be a burden for someone’). Also classifying the suicide as comprehensible, inevitable or even positive may encourage others. As well, the detailed description of the suicide method has to be avoided therefore. But with broadcasting ‘suicide documentations’— in this case the assisted suicide of Craig Ewert—the suicide method is apparent to the highest extend. Furthermore, it has to be considered that >90% of suicides are based on mental disorders. 5 According to the German Alliance against Depression, 40–70% of all suicidents suffer from depressive disorders. Assuredly patients who are terminally ill are a special case and their wish to die cannot be labelled with ‘mental disorder’ just by implication. Current studies, however, demonstrate an association of the wish to die or desire to receive euthanasia and psychiatric illness, especially depression, for the latter group, too. Hopelessness and depression were the most relevant predictors of desire for hastened death in a sample of advanced AIDS patients. 6 Similarly, diagnosis of major depression is associated with desire for euthanasia or physician-assisted suicide in palliative cancer patients. 7 Even for patients with amyotrophic lateral sclerosis, willingness to contemplate assisted suicide goes along with elevated levels of depressive symptoms and hopelessness. 8 These results highlight that also in terminally ill subjects the mental status has to be scrutinized thoroughly, otherwise protection of patients whose choices are influenced by depression might fail. Unfortunately, as results from Oregon show, an adequate screening for depression or psychiatric evaluation cannot be guaranteed and current practice may fail to protect these patients. 9,10

[Assisted suicide in prime time: the "right to die"].

1I love you, sweetheart, so much.“ ± mit diesen Worten verabschiedete sich der 59−jährige US− Bürger Craig Ewert in der am 10. Dezember bei Sky Real Lives in Großbritannien ausgestrahlten Fernsehdokumentation 1Recht zu Sterben“ von seiner Frau. Die Dokumentation zeigt den beglei− teten Suizid des an amyotropher Lateralsklerose erkrankten pensionierten Universitätsprofessors in einer Klinik der Schweizer Sterbehilfeorgani− sation 1Dignitas“. Zu guter Letzt nimmt Ewert zur besten Sendezeit um 21 Uhr einen Becher mit Barbituraten zu sich und betätigt mit dem Mund eine Zeitschaltuhr, die 45 Minuten später sein Beatmungsgerät abschaltet.