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1.  Mental health, substance use, and intimate partner problems among pregnant and postpartum suicide victims in the National Violent Death Reporting System 
General Hospital Psychiatry  2011;34(2):139-145.
Suicide during pregnancy and the postpartum is a tragic event for the victim and profoundly impacts the baby, the family, and the community. Prior efforts to study risks for pregnancy-associated suicide have been hampered by the lack of data sources which capture pregnancy and delivery status of victims. Introduction of the United States National Violent Death Reporting System (NVDRS) offers new insights into violent deaths by linking multiple data sources and allowing better examination of psychosocial risk factors.
The analysis used data from 17 states reporting to the NVDRS from 2003–2007 to evaluate suicide patterns among pregnant, postpartum, and non-pregnant or postpartum women. Demographic factors, mental health status, substance use, precipitating circumstances, intimate partner problems, and suicide methods were compared among groups.
The 2083 female suicide victims of reproductive age demonstrated high prevalence of existing mental health diagnosis and current depressed mood with depressed mood significantly higher among postpartum women. Substance use and presence of other precipitating factors were high and similar among groups. Intimate partner problems were higher among pregnant and postpartum victims. Postpartum women were more likely die via asphyxia as cause of death compared to poisoning or firearms
These findings describe important mental health, substance use, and intimate partner problems seen with pregnancy-associated suicide. The study highlights mental health risk factors which could potentially be targeted for intervention in this vulnerable population.
PMCID: PMC3275697  PMID: 22055329
Pregnancy; postpartum; suicide; mental health; intimate partner violence
2.  The impact of work environment on mood disorders and suicide: Evidence and implications 
The purpose of this paper is to review the evidence estimating an impact of occupational factors on mood disorders and suicide, and the efficacy of interventions. This review is based on literature searches using Medline and Psych INFO from 1966 to 2007 (keywords: work stress, job insecurity, job strain, shift work, violence, occupational health, mood disorders, depression, and suicide). To establish the relationship between occupational variables and mood disorders, we focused on clinically significant disorders rather than depressive symptoms. During the last decade, prospective epidemiological studies have suggested a predictive association between the work environment and mood disorders. Recently, increasing numbers of clinical trials have shown favorable effect size of intervention and suggested preferable return-on-investment results. However, low awareness and social stigma still decrease workers access to treatment. Mental health professionals in conjunction with employers have to devise a creative system to make the quality care being offered more accessible to employees. In addition, further outcome data is needed to evaluate the benefit of managing mood disorders in the workplace, and to foster awareness of positive implications for employees, employers, their families, and the society at large. In addition, the work environment, with its chemical (e.g. chemosensory factors, pollutants), physical (e.g. lighting, noise, temperature, outdoor views and activities), biological (e.g., chronobiological factors, allergens, infectious agents), psychological (e.g. demand-control, effort-reward balance), social (e.g. cohesiveness, support), and organizational (e.g. leadership styles) component should meet minimal standards, and may improve with striving towards the optimum.
PMCID: PMC2559945  PMID: 18836547
depression; work stress; occupational health; suicide
3.  Social Work Research on African Americans and Suicidal Behavior: A Systematic 25-year Review 
Health & social work  2008;33(4):249-257.
Suicide among African Americans is a neglected topic. Social workers practice in both clinical and nonclinical settings, and as the largest occupational group of mental health professionals, they have a unique opportunity to reach this underserved group. However, little is known about social work’s empirical knowledge base for recognition and treatment of suicidal behavior among African Americans. The authors performed a systematic critical review of published articles by social workers on African American suicide and suicidal behavior, to ascertain the state of social worker’s contribution to and knowledge of suicide risk factors and effective treatments. They conducted Web-based (for example, Social Work Abstracts, PsycINFO, PubMed, JSTOR) and manual searches of suicide research conducted by social work investigators and published in peer-reviewed journals from 1980 to 2005. References cited in the articles were used to identify candidate articles. According to the search results, social workers contributed only 11 empirical research articles focusing on African American suicide or nonfatal suicidal behavior. Risk factors for suicide are reviewed, and the implications for clinical social work practice and research are addressed.
PMCID: PMC2718709  PMID: 19070272
African Americans; clinical knowledge; ethnic minority populations; suicide
4.  Practical Suicide-Risk Management for the Busy Primary Care Physician 
Mayo Clinic Proceedings  2011;86(8):792-800.
Suicide is a public health problem and a leading cause of death. The number of people thinking seriously about suicide, making plans, and attempting suicide is surprisingly high. In total, primary care clinicians write more prescriptions for antidepressants than mental health clinicians and see patients more often in the month before their death by suicide. Treatment of depression by primary care physicians is improving, but opportunities remain in addressing suicide-related treatment variables. Collaborative care models for treating depression have the potential both to improve depression outcomes and decrease suicide risk. Alcohol use disorders and anxiety symptoms are important comorbid conditions to identify and treat. Management of suicide risk includes understanding the difference between risk factors and warning signs, developing a suicide risk assessment, and practically managing suicidal crises.
PMCID: PMC3146379  PMID: 21709131
5.  Suicidality, depression, and alcohol use among adolescents: A review of empirical findings 
Suicide is a serious health problem as it is currently the third leading cause of death for teenagers between the ages of 15 and 24 years. Depression, which is also a serious problem for adolescents, is the most significant biological and psychological risk factor for teen suicide. Alcohol use remains extremely widespread among today’s teenagers and is related to both suicidality and depression. Suicidality refers to the occurrence of suicidal thoughts or suicidal behavior. The consensus in empirical research is that mental disorders and substance abuse are the most important risk factors in both attempted and completed adolescent suicide. Therefore, it is incumbent upon researchers to identify the factors that can lead to their prevention among today’s youth. This review compiles the existing literature on suicidality, depression, and alcohol use among adolescents spanning over the past 15 years. Both Problem Behavior Theory and Stress-coping Theory can explain the relationships among suicidality, depression and alcohol use. The prevention of suicidality is critical, especially during the early school years, when it is associated with depression and alcohol use. Suicidality, depression and alcohol use are three phenomenon that noticeably increase in adolescence marking this time period as an ideal opportunity for prevention efforts to commence. Future empirical work is needed that will further assess the impact of adolescent depression and alcohol use on suicidality. In sum, this review of empirical research highlights critical results and limitations, as well as indicates a need for continued efforts in preventing suicidality, depression, and alcohol use among adolescents.
PMCID: PMC3134404  PMID: 17458321
Adolescent; depression; suicidality; substance abuse; review; USA
6.  The impact of fathers' physical and psychosocial work conditions on attempted and completed suicide among their children 
BMC Public Health  2006;6:77.
Adverse employment experiences, particularly exposure to unemployment and the threat of unemployment, have been strongly associated with several adverse mental and physical health outcomes including suicide. However, virtually no research has been conducted on the trans-generational impact of parental working conditions on attempted or completed suicide among their children.
We conducted a nested case control study based on a cohort, gathered in the western Canadian province of British Columbia, of male sawmill workers and a second cohort of their children. Physical and psychosocial work conditions to which fathers were exposed during the first 16 years of their children's lives, measured using the demand/control model, were linked to hospital suicide records (attempted and completed) among their children.
Two hundred and fifty children in the cohort attempted or committed suicide between 1985 and 2001. Multivariate models, with partial control for father's mental health outcomes prior to their child's suicide demonstrate, 1) a strong association between low duration of father's employment at a study sawmill and attempted suicide for their male children, 2) elevated odds for attempted suicide among female children of fathers' employed in a sawmill job with low control and, 3) a strong association between fathers in jobs with low psychological demand and completed suicides among male children.
Exposure of fathers to adverse psychosocial work conditions during the first 16 years of their children's life was associated with greater odds for attempted and completed suicide among their children.
PMCID: PMC1435887  PMID: 16566815
7.  Paternal psychosocial work conditions and mental health outcomes: A case-control study 
BMC Public Health  2008;8:104.
The role of social and family environments in the development of mental health problems among children and youth has been widely investigated. However, the degree to which parental working conditions may impact on developmental psychopathology has not been thoroughly studied.
We conducted a case-control study of several mental health outcomes of 19,833 children of sawmill workers and their association with parental work stress, parental socio-demographic characteristics, and paternal mental health.
Multivariate analysis conducted with four distinct age groups (children, adolescents, young adults, and adults) revealed that anxiety based and depressive disorders were associated with paternal work stress in all age groups and that work stress was more strongly associated with alcohol and drug related disorders in adulthood than it was in adolescence and young adulthood.
This study provides support to the tenet that being exposed to paternal work stress during childhood can have long lasting effects on the mental health of individuals.
PMCID: PMC2358891  PMID: 18377651
8.  Racial Differences in the Characteristics of Firearm Suicide Decedents in the United States 
Focusing on the reported growing use of firearms to complete suicide among African Americans, this article analyzes the 1993 National Mortality Followback Survey to examine the association of firearm suicide with race, education, geographic region, access to a firearm, depressive symptoms, and mental health service utilization on decedents aged 15 years and older. After controlling for demographic, socioeconomic, and clinical variables, the analysis indicates that African American men were twice as likely as White men to use a firearm to complete suicide. The findings suggest the importance for clinicians to screen for the presence of firearms in depressed African Americans and to reduce their access to firearms. In addition, clinicians, social workers, and public health professionals should consider racial differences in correlates of firearm suicide when designing prevention and intervention initiatives.
PMCID: PMC2754159  PMID: 17352593
black suicide; firearms; risk factors; mortality
9.  Increased mRNA expression of cytochrome oxidase in dorsal raphe nucleus of depressive suicide victims 
Suicidal behavior is a problem with important social repercussions. Some groups of the population show a higher risk of suicide; for example, depression, alcoholism, psychosis or drug abuse frequently precedes suicidal behavior. However, the relationship between metabolic alterations in the brain and premorbid clinical symptoms of suicide remains uncertain. The serotonergic and noradrenergic systems have frequently been, implicated in suicidal behavior and the amount of serotonin in the brain and CSF of suicide victims has been found to be low compared with normal subjects. However, there are contradictory results regarding the role of noradrenergic neurons in the mediation of suicide attempts, possibly reflecting the heterogeneity of conditions that lead to a common outcome. In the present work we focus on the subgroup of suicide victims that share a common diagnosis of major depression. Based on post-mortem studies analyzing mRNA expression by in situ hybridization, serotonergic neurons from the dorsal raphe nucleus (DRN) from depressive suicide victims are seen to over-express cytochrome oxidase mRNA. However, no corresponding changes were found in the expression of tyrosine hydroxylase (TH) mRNA in the noradrenergic neurons of the Locus Coeruleus (LC). These results suggest that, despite of the low levels of serotonin described in suicide victims, the activity of DRN neurons could increase in the suicidally depressed, probably due to the over activation of serotonin re-uptake. No alteration was found in noradrenergic neurons, suggesting that they play no crucial role in the suicidal behavior of depressive patients.
PMCID: PMC2518385  PMID: 18728743
depression; suicidal behavior; dorsal raphe nucleus; noradrenergic neurons
10.  Suicide ideation, plans, and attempts among general practice patients with chronic health conditions in Puerto Rico 
Little is known about suicidal ideation among general practice patients in Puerto Rico. In this study we examined the rates, severity, and correlates of suicidal ideation, plans, and attempts among general practice patients with chronic illnesses. This is important in targeting appropriate interventions and management approaches to minimize and prevent suicide.
We screened patients with chronic physical conditions at general practices. Suicidal ideation was assessed with the suicidality module of the Mini International Neuropsychiatric Interview. Major depression was assessed with the Patient Health Questionnaire depression module. The relationship between sociodemographic factors, depression and suicidal ideation was examined with multiple logistic regression analysis. Among the subgroup that acknowledged suicidal ideation, we used multinomial logistic regression analysis to estimate simultaneously the multivariate associations of depression and sociodemographic factors with suicidality risk levels.
Of the 2068 patients screened, 15.4% acknowledged recent suicidal ideation. Among this group, 8.6% reported passive ideation, 3.7% active ideation without a plan, and 3.1% active ideation with a plan or attempt. According to multivariate logistic regression, suicidal ideation was higher among patients with moderately severe depression and severe depression than for those with milder symptoms. Patients aged 64 years or younger were over one and a half times more likely to acknowledge suicidal ideation than those aged 65 years and older. Compared with patients having a college degree, those with lower education had a twofold higher risk of suicidal ideation. Multinomial logistic regression analysis indicated that severe depression was associated with a higher likelihood of having a suicide plan or attempt.
The findings of this study suggest that public health strategies focusing on the systematic identification of patients with increased depression severity and the implementation of evidence-based depression treatments are relevant for minimizing and preventing suicidal behavior among general practice patients with chronic health conditions.
PMCID: PMC3068880  PMID: 21475631
suicidal ideation; chronic illnesses; depression; Puerto Rican
11.  Suicide index reduction in Slovenia: the impact of primary care provision 
Background Education of primary care providers about diagnosis and treatment of depression and anxiety is an evidence-based suicide prevention measure.
Aim To analyse suicide index, mental health epidemiological data and primary care provision in Slovenian regions and to identify examples of good suicide prevention practices in different Slovenian regions.
Methods Analysis of existent epidemiological data on mental health in Slovenia.
Results Anxiety and depression are the most common complaints in a representative sample of the Slovene population. The number of suicides in Slovenia had been dropping in the period from 2002 to 2006 and was again slowly rising in 2008. The number of visits to family physicians' practices because of mental health problems is low in comparison to other European countries, which might be attributed also to the high workload of family physicians. Suicide prevention programmes follow the example of the Suicide Prevention Project in the central-east region of Slovenia. This programme is based on education of primary care providers and the general public about recognition and treatment of depression in line with international guidelines.
Conclusions The differentiation of causes for suicide reduction needs further research, as well as urgent improvement in the accessibility of primary care teams in Slovenia.
PMCID: PMC3134213  PMID: 22479292
family physicians; Slovenia; suicide prevention
12.  Predictors of Wellness and American Indians 
Wellness is an important American Indian (AI) concept, understood as being in balance with one’s body, mind, and environment. Wellness predictors are reported in this paper within the context of health. A cross-sectional randomized household survey of 457 AI adults at 13 rural health care sites in California was conducted. Measures included wellness perceptions, barriers, health status/health conditions, spirituality, cultural connectivity, high-risk behaviors and abuse history. Statistical analysis obtained the best predictive model for wellness. Predictors of wellness were general health status perception, participation in AI cultural practices and suicide ideation. Significant differences in wellness status were observed depending on experience of adverse events in childhood and adulthood (neglect, physical abuse, and sexual abuse). Cultural connectivity (speaking tribal language, participating in AI practices, and feeling connected to community) was also associated with perceptions of wellness. Recommendations are for culturally-appropriate education and interventions emphasizing community and cultural connectivity for improving wellness status.
PMCID: PMC3287368  PMID: 21841279
Wellness; cultural connectivity; American Indians; risk factors; barriers
13.  Suicidal expressions among young people in Nicaragua and Cambodia: a cross-cultural study 
BMC Psychiatry  2012;12:28.
Whereas prevalence of suicidal expressions among young people is fairly similar in different countries, less is known about associated risk factors. This study compares young people in Nicaragua and Cambodia to examine if the pattern of association between mental health problems and suicidal expressions differs.
368 and 316 secondary school students, from each country respectively, participated. Self-reported suicidal expressions, exposure to suicidal behavior in significant others and mental health problems among the students were measured using Attitude Towards Suicide (ATTS) and the Youth Self-Report (YSR) questionnaires.
Prevalence of serious suicidal expressions (plans and attempts) during recent year, did not differ between countries. Cambodian young people scored significantly higher on all eight YSR-syndromes, except for withdrawn/depressed. In Nicaragua, all YSR-syndromes were significantly associated with serious suicidal expressions in both genders compared to Cambodia where only one syndrome showed an association in each gender; Withdrawn/depressed among girls and Somatic complaints among boys. Associations between being exposed to suicide among significant others and serious suicidal expressions also differed between Cambodia and Nicaragua.
While the magnitude of serious suicidal expressions is similar between these structurally similar but culturally different countries, determinants behave differently. Qualitative studies are warranted to further explore cultural specific determinants for suicidal expressions among young people.
PMCID: PMC3359217  PMID: 22463077
Suicidal expressions; Adolescents; Young People Cross-cultural comparison; Nicaragua and Cambodia
14.  Designing an intervention to prevent suicide: PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial)  
Suicide is a major public health problem with greatest risk in the very old. This paper describes an approach to reducing the risk of suicide by intervening on depression in elderly primary care patients. Depression is an appropriate target for an intervention as it is highly prevalent in primary care, is a strong risk factor for suicide, and is more often than not inadequately treated. PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) is a National institute of Mental Health (NIMH)-funded collaborative study that is testing this approach to suicide risk prevention in 18 primary care practices in the United States. PROSPECT'S intervention of “guideline management” introduces a health specialist into the primary care setting to help physicians provide “on-time, on-target” treatment and long-term management of late-life depression following structured clinical guidelines. The effectiveness of the intervention in reducing suicidal risk and depression is evaluated by following a representative sample of older patients identified using a 2-stage design.
PMCID: PMC3181574  PMID: 22033641
depression; suicide; intervention; elderly; primary care
15.  The epidemiology of firearm suicide in the United States 
Little attention has been given to the role of firearms in suicide. In 1998, firearms were the leading method of committing suicide for both men and women, responsible for three times the number of suicides compared to the next leading method. Understanding the epidemiology of firearm suicide will increase awareness of firearm suicide as a major public health problem.
Rates of firearm suicide have changed little over the past two decades and have consistently exceeded rates of firearm homicide. the firearm suicide rate among men is approximately six times that of women. While firearm suicide rates are highest among the elderly, the majority (66%) of firearm suicides are among persons under 55 years of age. Firearm suicide rates among women of all ages have dropped modestly, while rates among elderly men have risen considerably. Whites have roughly twice the rate of firearm suicide as do blacks and other race/ethnicity groups. Individual-level empirical studies have consistently indicated that keeping firearms in the home is associated with an increased risk of suicide.
For suicide prevention to be effective, the availability and use of firearms in suicides must be addressed.
PMCID: PMC3456384  PMID: 11937614
Firearms; Guns; Suicide
16.  Identification of Suicide Risk Among Rural Youth: Implications for the Use of HEADSS 
Nurse practitioners have the power to detect suicide risk and prevent suicide, a problem plaguing rural areas of the United States. Suicide risk assessment can be completed using the HEADSS (Home, Education, Activities, Drug use and abuse, Sexual behavior, and Suicidality and depression) interview instrument. The purpose of this study was to determine if HEADSS is appropriate for guiding suicide risk assessment of rural adolescents.
High school students in Southwestern Pennsylvania completed qualitative questions from the Child Behavior Checklist and Coping Response Inventory as part of the Intervention to Promote Mental Health in Rural Youth. Qualitative content analysis was performed.
Prominent themes identified by participants included academic performance, relationships, dislikes about school, friends, death, mental health, and the future. Several minor themes concerned safety. Most known risk factors for suicide were concerns of participants.
The expansion of HEADSS to include death and safety should be considered. The modified version—HEADDSSS— can be used to guide suicide risk assessment of youth in rural Pennsylvania, ensuring both thoroughness of assessment and safety.
PMCID: PMC2863017  PMID: 20417887
17.  The relationship between suicidal ideation and symptoms of depression in Japanese workers: a cross-sectional study 
BMJ Open  2013;3(11):e003643.
The prevalence of suicidal ideation and predictors for suicidal ideation among Japanese workers is unknown, although a previous study reported a 30% prevalence rate of suicidal ideation in a psychosomatic clinical setting. Hence, we evaluated the prevalence of suicidal ideation and its relationship with depressive symptoms among Japanese workers.
For this purpose, a cross-sectional design was used. Major depressive disorder (MDD) and suicidal ideation in 1266 workers (1100 men and 166 women, aged 20–69 years) were assessed through clinical interviews conducted in accordance with the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.
A total of 34 and 70 participants were diagnosed with suicidal ideation and MDD, respectively. Suicidal ideation was especially prevalent in 40-year-olds to 49-year-olds. Six of the eight symptoms of MDD (depressive mood, loss of interest, weight loss, psychomotor agitation, worthlessness and concentration loss) were related to suicidal ideation. Depressive mood had the strongest relationship with suicidal ideation, followed by worthlessness and concentration loss. Worthlessness had the highest area under the curve in predicting suicidal ideation, followed by concentration loss and depressive mood.
We conclude that MDD symptoms—particularly depressive mood, worthlessness and concentration loss—are potential predictors of suicidal ideation in Japanese workers.
PMCID: PMC3845061  PMID: 24293204
18.  Details on suicide among U.S. physicians: Data from the National Violent Death Reporting System 
General hospital psychiatry  2012;35(1):45-49.
Physician suicide is an important public health problem as the rate of suicide is higher among physicians than the general population. Unfortunately, few studies have evaluated information about mental health comorbidities and psychosocial stressors which may contribute to physician suicide. We sought to evaluate these factors among physicians versus non-physician suicide victims.
We used data from the United States National Violent Death Reporting System to evaluate demographics, mental health variables, recent stressors, and suicide methods among physician versus non-physician suicide victims in 17 states.
The dataset included 31,636 suicide victims of whom 203 were identified as physicians. Multivariable logistic regression found that having a known mental health disorder or a job problem which contributed to the suicide significantly predicted being a physician. Physicians were significantly more likely than non-physicians to have antipsychotics, benzodiazepines, and barbiturates present on toxicology testing but not antidepressants or antipsychotics.
Mental illness is an important comorbidity for physicians who complete a suicide but postmortem toxicology data shows low rates of medication treatment. Inadequate treatment and increased problems related to job stress may be potentially-modifiable risk factors to reduce suicidal death among physicians.
PMCID: PMC3549025  PMID: 23123101
suicide; physicians; health professionals; mental health; depression
19.  A Comparative Study of Attitude of Mental Health Versus Nonmental Professionals toward Suicide 
Suicide is a major public health problem. Suicide can be prevented by understanding the disorder. Attitude plays a significant role in doing so.
To assess the attitudes of mental health professionals and non-mental health professionals towards an act of suicide and to compare the two groups regarding their attitudes.
Materials and Methods:
A semistructured questionnaire having yes/no type questions was administered to 30 mental health and 30 nonmental health professionals. A blind analysis of the data was done.
Statistical Analysis:
Comparative analysis using mean and standard deviation and analysis of variance was performed to rate significance in differences of responses to questions that rate attitudes.
The results show a significant positive attitude of mental health professionals toward dealing with the patients who attempted suicide.
Considering the magnitude of the problem, simple training and education of nonmental health professionals can change their attitude toward patients who attempt suicide, which in turn leads to an optimal management.
The study shows that the mental health professionals are much more positive in their approach towards a patient of parasuicide.
PMCID: PMC3361847  PMID: 22661811
Attitude; training; mental health professionals; nonmental health professionals; suicide
20.  Adolescent care 
Canadian Family Physician  2006;52(11):1440.
To investigate how often family physicians see adolescents with mental health problems and how they manage these problems.
Mailed survey completed anonymously.
Province of Quebec.
All 358 French-speaking family physicians who practise primarily in local community health centres (CLSCs), including physicians working in CLSC youth clinics, and 749 French-speaking practitioners randomly selected from private practice.
Frequency with which physicians saw adolescents with mental health problems, such as depression, suicidal thoughts, behavioural disorders, substance abuse, attempted suicide, or suicide, during the last year or since they started practice.
Response rate was 70%. Most physicians reported having seen adolescents with mental health problems during the last year. About 10% of practitioners not working in youth clinics reported seeing adolescents with these disorders at least weekly. Anxiety was the most frequently seen problem. A greater proportion of physicians working in youth clinics reported often seeing adolescents for all the mental health problems examined in this study. Between 8% and 33% of general practitioners not working in youth clinics said they had not seen any adolescents with depression, behavioural disorders, or substance abuse. More than 80% of physicians had seen adolescents who had attempted suicide, and close to 30% had had adolescent patients who committed suicide.
Family physicians play a role in adolescent mental health care. The prevalence of mental health problems seems higher among adolescents who attend youth clinics. Given the high prevalence of these problems during adolescence, we suggest on the basis of our results that screening for these disorders in primary care could be improved.
PMCID: PMC1783702  PMID: 17279202
21.  Imagery about suicide in depression—“Flash-forwards”? 
Suicide is a significant world health problem, with more deaths by suicide globally than by war. We need to better understand the cognitive processes underlying suicidal thinking for improved treatment development. Cognitive psychology indicates that mental imagery can be causal in determining future behavior, yet the occurrence of suicide-related imagery has not previously been investigated. Interviews with 15 depressed and formerly suicidal patients in remission found that all patients reported experiencing detailed mental imagery in addition to verbal thoughts when at their most despairing, for example images of making a future suicide attempt. A clinical measure of the severity of suicidal ideation was associated with both preoccupation with suicide-related imagery and perceived imagery realness. Echoing flashbacks in posttraumatic stress disorder, the current images appeared like “flash-forwards” to suicide. These results provide the first data to our knowledge on the existence of mental imagery in suicidality, opening a promising new avenue for research.
PMCID: PMC2808471  PMID: 18037390
Mental imagery; Suicide; Intrusive memory; Flashback; Depression; Transdiagnostic; Intrusive image; Image rescripting
22.  Quality of life, depression, anxiety and suicidal ideation among men who inject drugs in Delhi, India 
BMC Psychiatry  2013;13:151.
Mental disorders such as depression, anxiety and suicide represent an important public health problem in India. Elsewhere in the world a high prevalence of symptoms of common mental disorders have been found among people who inject drugs (PWID). Research in India has largely overlooked symptoms of common mental disorders among this high risk group. This paper reports on the results of a survey examining quality of life, depression, anxiety and suicidal ideation among adult males who inject drugs living in Delhi.
Participants (n = 420) were recruited from needle and syringe programs using time location sampling and were interviewed using an interviewer-administered questionnaire. Self-report symptom scales were used to measure the severity of symptoms of depression (PHQ-9) and anxiety (GAD-2) within the preceding 2 weeks. We assessed the presence of suicidal thoughts and attempts within the past 12 months.
The mean length of injecting career was 20.9 years indicating a sample of chronic injecting drug users, of whom only one-third (38%) were born in Delhi. The level of illiteracy was very high (62%), and just 2% had completed class 12. Scavenging / rag picking was the main form of income for 48%, and many were homeless (69%). One-third (33%) had been beaten up at least twice during the preceding 6 months, and many either never (45%) or rarely (27%) attended family events. We found a high prevalence of depressive (84%, cut-off ≥10) and anxiety (71%, cut-off score of ≥3) symptoms. Fifty-three percent thought about killing themselves in the past 12 months, and 36% had attempted to kill themselves.
Our findings revealed a socially excluded population of PWID in Delhi who have minimal education and are often homeless, leaving them vulnerable to physical violence, poverty, poor health, imprisonment and disconnection from family. The high prevalence of psychological distress found in this study has implications for programmes seeking to engage, treat and rehabilitate PWID in India.
PMCID: PMC3680014  PMID: 23711075
23.  Sexual Minority-Related Victimization as a Mediator of Mental Health Disparities in Sexual Minority Youth: A Longitudinal Analysis 
Journal of youth and adolescence  2013;42(3):394-402.
Sexual minority youth (youth who are attracted to the same sex or endorse a gay/lesbian/bisexual identity) report significantly higher rates of depression and suicidality than heterosexual youth. The minority stress hypothesis contends that the stigma and discrimination experienced by sexual minority youth create a hostile social environment that can lead to chronic stress and mental health problems. The present study used longitudinal mediation models to directly test sexual minority-specific victimization as a potential explanatory mechanism of the mental health disparities of sexual minority youth. One hundred ninety seven adolescents (14–19 years old; 70% female; 29% sexual minority) completed measures of sexual minority-specific victimization, depressive symptoms, and suicidality at two time points six months apart. Compared to heterosexual youth, sexual minority youth reported higher levels of sexual minority-specific victimization, depressive symptoms, and suicidality. Sexual minority-specific victimization significantly mediated the effect of sexual minority status on depressive symptoms and suicidality. The results support the minority stress hypothesis that targeted harassment and victimization are partly responsible for the higher levels of depressive symptoms and suicidality found in sexual minority youth. This research lends support to public policy initiatives that reduce bullying and hate crimes because reducing victimization can have a significant impact on the health and well-being of sexual minority youth.
PMCID: PMC3570607  PMID: 23292751
sexual minority youth; victimization; depression; suicidality; minority stress
24.  Judeo-Christian concepts related to psychiatry 
Indian Journal of Psychiatry  2013;55(Suppl 2):S201-S204.
The behavioral manifestations of psychotic disorders that are attributed to evil spirits in the Judeo-Christian scriptures as demonstrated by Jesus Christ have been narrated. The descriptions of false beliefs and the perceptual experiences that are consistent with the psychiatric terminologies “delusions and hallucinations” are briefly discussed. Attempt has been made to analyze the patterns of suicidal behaviors, guilt feelings, and, expressions of depressive symptoms in the Jewish culture. Of interest is the mass suicide by the Jews in the 1st century AD at the Fort Masada, perhaps the first of its kind recorded in the history. Noteworthy are alcohol and related mental health problems prevalent in the Jewish culture. While highlighting the descriptions of dreams and their revelations recorded in the Bible, it is suggested that such concepts about dreams might have influenced Sigmund Freud's classical works on dreams. The biblical messages and teachings that could be applied for psychotherapy and behavior modification strategies have been outlined. The mental concepts of Jewish culture and their relevance to Indian culture have also been discussed from a cross-cultural perspective.
PMCID: PMC3705683  PMID: 23858255
Alcohol; culture; depression; delusions; dreams; evil spirits; guilt; hallucinations; psychotherapy; suicide
25.  Attitudes towards those bereaved by a suicide: a population-based, cross-sectional study in rural Japan 
BMC Public Health  2008;8:334.
Family or friends bereaved by suicide are at risk of experiencing complications because of attitudes regarding suicide. It is important that individuals close to those grieving after a death by suicide demonstrate adequate knowledge and compassionate attitudes. To this end, we examined the factors that contribute to attitudes toward persons bereaved by the suicide of a family member or friend, and perceptions of suicide prevention and the promotion of mental health.
A total of 5154 residents of a rural town in northern Japan aged 30–69 years completed a cross-sectional questionnaire. The questionnaire gathered data about demographic variables, depressive symptoms, and issues related to suicide including personal experience of an acquaintance's suicide, attitudes towards those bereaved by suicide, and perceptions regarding suicide prevention. Factors related to these attitudes and perceptions were analysed using logistic regression models.
Overall, 67.5% of respondents demonstrated appropriate attitudes towards those bereaved by suicide; 30.4% of responses were undetermined, and 2.1% were inappropriate. Undetermined attitudes were associated with male gender (adjusted OR 1.42, 95%CI = 1.26–1.61), younger age (2.64, 2.12–3.29), lower education level (1.32, 1.07–1.62), greater severity of depression (3.81, 2.80–5.20), and lack of personal experience of an acquaintance's suicide (1.39, 1.22–1.57). Inappropriate attitudes were associated with male gender (adjusted OR 1.98, 95%CI = 1.33–2.94), lower education level (2.55 1.34–4.83), and greater severity of depression (6.93, 3.52–13.67). Overall, 16.0% demonstrated passive thoughts regarding suicide prevention and the promotion of mental health in the community, and were associated with male gender (1.22, 1.04–1.42), younger age (2.72, 2.03–3.65), lower education level (1.32, 1.02–1.71), and greater severity of depression (4.94, 3.58–6.82).
Factors that contributed to undetermined attitudes included male gender, younger age, lower education level, greater severity of depression, and lack of personal experience of an acquaintance's suicide. Passive thoughts regarding suicide prevention and the promotion of mental health were associated with male gender, younger age, lower education level, and greater severity of depression.
PMCID: PMC2577115  PMID: 18816411

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