Clinical characteristics of the subjects at entry
Of a total of 3450 admissions to TMMH during the 20-month study period, 292 cases (280 patients) with SB were identified. 176 patients fulfilled criteria (1)-(6) for participation in this study. The numbers of patients excluded from the studied sample according to the criteria items were 18, 24, 8, 9, 33 and 12 in the order of criteria (1)-(6). In 59 cases, the patient or the family guardian did not give consent for study participation (criterion (7)), 2 did not complete the entry assessment, and 9 did not respond to any request for follow-up contact. As a result, 106 patients (60% of the patients eligible for inclusion) participated in at least one of the follow-up assessments. Averages (SDs) of the hospital stay of index admission and duration of the period between admission and end of entry assessment for the subjects were 42.3 (26.3) days and 20.6 (13.6) days, respectively. The admission type of 81 subjects (76%) was involuntary.
A comparison of the 106 subjects included in this study with the remaining 70 eligible but not participating patients, with respect to demographic data, treatment history, diagnoses based on International Classification of Diseases 10th version (ICD-10) in the record of TMMH and the 5 most frequent SB methods, revealed a significant difference in the percentage of psychotic disorders (ICD-10 code: F2) (33% vs. 49%, Chi square=4.28, df=1, p=0.039). This finding suggests that the subjects in this study had a lower rate of psychotic disorders.
The 106 participants in this study were composed of 48 males and 58 females. The mean age (SD) was 36.6 (11.6) years at the entry assessment. Marital states were never married 59 (55%), living with a partner 28 (26%) and widowed, separated or divorced 20 (19%). Education levels were less than high school graduate 27 (26%), high school graduate 47 (44%) and college graduate or higher 32 (30%). 37 subjects (35%) were living alone. Employment conditions were fulltime worker 16 (15%), part-time worker 21 (20%) and unemployed 52 (49%). 91 subjects (85%) had been continuing psychiatric outpatient treatment before index admission. 64 (60%) had a history of psychiatric hospitalization. Overall, high percentages of unemployment, living alone and continuous use of psychiatric services characterized the sample.
SB methods exhibited by the subjects immediately prior to index admission were self-cutting 40 (38%), overdosing 37 (35%), self-strangulation 13 (12%), attempting traffic death 11 (10%) and jumping from a height 10 (9%). Other SB methods numbered only less than 4 (4%). 25, 50 and 75 percentiles (range) of the total number of SBs in lifetime history of the subjects were 4, 7 and 21.25 (1–141), respectively.
present DSM-IV axis I disorders and axis II PDs of the subjects. Mood disorders, anxiety disorders and borderline PD were presented by more than half of the subjects. 91 (86%) of the subjects were diagnosed with at least one PD.
DSM-IV Axis I disorders of the subjects at entry (N=106)
DSM-IV personality disorders (PDs) of the subjects at entry (N=106)
Averages (SDs) of SIS, BDI and BHS scores were 11.5 (5.9), 31.5 (11.9), and 13.6 (5.9), respectively. The results indicated that the subjects exhibited a severe level of SI, depressive symptoms and hopelessness prior to index admission, which were comparable to those of suicidal patients in medical or emergency settings
]. Particularly, 93 (88%) of the subjects reported the presence of SI component (SIS Item 13). From 13 subjects who denied SI in the entry assessment, SI that accompanied SB immediately prior to index admission was heard by family members or others around them. Therefore, the SBs could be understood as suicidal attempts.
A history of any maltreatment before the age of 18 years was reported by 66 (62%) of the subjects. Those who had experienced sexual, physical and verbal maltreatment, and neglect were 16 (15%), 40 (38%), 57 (54%) and 20 (19%), respectively.
Post-hospitalization course and incidence of SB and suicide
Data of the whole 2-year clinical course variables and complete data of all the variables were obtained from 96 subjects (including deceased ones) and 65 subjects, respectively. In a total of 341 follow-up contacts, interviews, correspondences through mail and telephone, and hearing from family informants were 233 (69%), 83 (24%), 8 (2%) and 16 (5%), respectively. Readmission to a psychiatric hospital was seen in 65 (61%) subjects within the 2-year period. In 289 (85%) of 339 assessment contacts, regular outpatient treatment attendance (more than once a month) was recorded.
In a total of 526 SBs recorded during the follow-up, SB methods were self-cutting 161 (31%), overdosing 157 (30%), self-strangulation 119 (23%), attempting traffic death 15 (3%) and jumping from a height 31 (6%). Levels of SI that accompanied SB were “certainly present” 258 (49%), “unclear” 190 (36%) and “absent” 78 (15%). 278 SBs (53%) necessitated medical treatment for the physical damage.
6 deaths by suicide were identified during the follow-up. A very high suicide rate per year of 3.1% (95% confidence interval (CI) 1.4 - 6.5%) was calculated from within 196 person-years of observation. Methods of suicide were hanging (1 person), jumping from a height (1 person), traffic death (1 person), overdosing (1 person) and an unknown method (2 persons). The suicide victims were 3 males and 3 females: 3 females in their twenties or thirties with mood and anxiety disorders and cluster B PDs, 2 of whom also had substance-related disorder, 1 male in his thirties with schizophrenia, anxiety disorder and cluster B PD, and 2 males in their sixties with schizophrenia. Additionally, 1 male in his sixties died from physical disease.
displays the cumulative incidence rate of SB as a whole, SB with SI and suicide during the follow-up period for the total cohort. Incidence rates of SB, SB with SI and suicide within 1 year were 53% (95% CI 43 - 62%), 27% (95% CI 18 - 35%) and 2.8% (95% CI 1.0 - 8.0%), and those within 2 years were 67% (95% CI 58 - 75%), 38% (95% CI 29 - 47%) and 5.7% (95% CI 2.6 - 11.8%), respectively. The median for days between the start of follow-up and the recurrence of SB as a whole was 334 days (95% CI: 252–416).
Cumulative risk of suicidal behavior (SB) (thin line) suicide attempt (SB with suicidal intent (SI)) (dashed line) and suicide (thick line).
presents the serial changes in averages of the numbers of SB as a whole and SB with SI, and the scores of SF-8 PCS, SF-8 MCS and BHS 4-item version recorded in follow-up assessments. Repeated measures ANOVAs of the serial scores found a significant linear component in SF-8 MCS scores and BHS 4-item version scores in addition to their significant time effects. The findings indicated an improvement in distressing mental symptoms and hopelessness during the follow-up period. In contrast, statistical tests for examining SF-8 PCS score and the numbers of SBs and SBs with SI did not yield significant results.
Suicidal behavior recurrence and measures of physical and mental conditions in the follow-up assessments
Association of subsequent BSs with clinical variables
presents the results of univariate Cox proportional hazards regression analyses examining the recurrence of SB as a whole and SB with SI, with demographic and clinical variables as a covariate. SB as a whole was associated with age and unemployment at entry, number of lifetime SBs, and maltreatment before the age of 18 years, anxiety disorders and cluster B PD. SB with SI was associated with age at entry, and scores of BDI and BHS. However, none of 5 SB methods, marital status, education and living alone on index admission was associated with SB during the follow-up.
Univariate Cox proportional hazards regression analyses of suicidal behavior (SB) recurrence during the 2-year follow-up period
presents the results of stepwise Cox proportional hazards regression analyses of SB as a whole and SB with SI. The analyses using diagnostic variables as possible covariates indicated that anxiety disorders and cluster B PD had a significant association with SB as a whole. Regarding SB with SI, no significant association with psychiatric disorders were found. Analyses using all the variables with a significant association demonstrated that SBs as a whole was associated with age at entry, maltreatment before the age of 18 years and number of lifetime SB, and that SB with SI was associated with age at entry and hopelessness prior to index admission. Overall, SB as a whole and SB with SI indicated a rather different pattern of associations: SB as a whole was associated with life historical and life-situational variables, and SB with SI, mainly with depressive symptoms prior to index admission.
Stepwise Cox proportional hazards regression analyses of suicidal behavior recurrence during the 2-year follow-up period
In the Cox proportional hazards regression analyses of SB as a whole and SB with SI within the 3 months subsequent to a follow-up assessment, the variables that indicated a significant association in the previous multivariate analyses of SBs using all the variables with a significant association, were included to control their effects on short-term prediction. During 3 months following the 1st, 2nd and 3rd assessments, subjects who exhibited SB as a whole and SB with SI were 17 (25%) and 10 (11%), 16 (20%) and 7 (9%), and 21 (21%) and 6 (8%), respectively. SB as a whole during the subsequent 3 months was associated with SF-8 PCS score in the 1st and 3rd assessments (Exp (B) 0.884, 95% CI 0.828 - 0.944, p<0.001, and Exp (E) 0.957, 95% CI 0.917 - 0.999, p=0.046, respectively). SB with SI during the subsequent 3 months was associated with SF-8 PCS score in the 1st assessment (Exp (B) 0.865, 95% CI 0.795 - 0.942, p=0.001). No significant association was found between any SB and other variables of follow-up assessments. The results indicated, despite some inconsistency, that SF-8 PCS score could have predictive value for SB as a whole and SB with SI during the subsequent 3-month period.