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1.  Self-harm: 1. Suicide. 
Although suicide rates have remained relatively stable, the risk of suicide has increased among 25- to 35-year-old men. Attempts to understand suicide fall into three major frameworks: sociologic theories, psychologic theories and the relation of suicide to psychiatric illness. The risk of suicide can be assessed by means of a relatively simple clinical interview. Since most suicide victims consult their family doctors within the month before their death, physicians are in a unique position to prevent suicide. Routine assessment of the risk of suicide among patients who appear depressed or are undergoing an emotional crisis can lead to accurate diagnosis and effective intervention. Similarly, the appropriate use of psychotropic medication can lead to effective treatment while minimizing the risk of a lethal overdose.
PMCID: PMC1874937  PMID: 6861043
2.  Towards A Suicide Free Society: Identify Suicide Prevention As Public Health Policy* 
Mens Sana Monographs  2004;2(1):21-33.
Suicide is amongst the top ten causes of death for all age groups in most countries of the world. It is the second most important cause of death in the younger age group (15-19 yrs.) , second only to vehicular accidents.Attempted suicides are ten times the successful suicide figures, and 1-2% attempted suicides become successful suicides every year. Male sex, widowhood, single or divorced marital status, addiction to alcohol ordrugs, concomitant chronic physical or mental illness, past suicidal attempt, adverse life events, staying in lodging homes or staying alone,or in areas with a changing population, all these conditions predispose people to suicides. The key factor probably is social isolation. An important WHO Study established that out of a total of 6003 suicides,98% had a psychiatric disorder. Hence mental health professionals havean important role to play in the prevention and management of suicide.Moreover, social disintegration also increases suicides, as was witnessed in the Baltic States following collapse of the Soviet Union. Hence, reducing social isolation, preventing social disintegration and treating mental disorders is the three pronged attack that must be the crux of any public health programme to reduce/prevent suicide. This requires an integrated effort on the part of mental health professionals (including crisis intervention and medication/psychotherapy), governmental measures to tackle poverty and unemployment, and social attempts toreorient value systems and prevent sudden disintegration of norms and mores. Suicide prevention and control is thus a movement which involves the state, professionals, NGOs, volunteers and an enlightened public.Further, the Global Burden of Diseases Study has projected a rise of more than 50% in mental disorders by the year 2020 (from 9.7% in 1990to 15% in 2020). And one third of this rise will be due to Major Depression. One of the prominent causes of preventable mortality issuicidal attempts made by patients of Major Depression. Therefore facilities to tackle this condition need to be set up globally on a warfooting by governments, NGOs and health care delivery systems, if morbidity and mortality of the world population has to be seriously controlled . The need, first of all, is to identify suicide prevention as public health policy, just as we think in terms of Malaria or Polio eradication, or have achieved smallpox eradication.
PMCID: PMC3400318  PMID: 22815599
Suicide Prevention; Social Isolation; Social Disintegration; Depression; DALY (Disability Adjusted Life Years); Global Burden of Diseases; Psychiatric treatment in suicide
3.  The characteristics of serious suicide attempters in Japanese adolescents- comparison study between adolescents and adults 
BMC Psychiatry  2012;12:191.
Suicide is the leading cause of death among Japanese adolescents, and they may commit suicide differently from adults. However, there are few studies in medical-based data concerning adolescent patients seriously attempting suicide. We aimed to explore the characteristics of serious suicide attempts in Japanese adolescents, comparing them with those in adults.
We investigated adolescents who seriously attempted suicide and were treated at the Critical Care Medical Center (CCMC) of Nippon Medical School Hospital between 2000 and 2010, and we compared them with adult suicide attempters treated during 2009. We retrospectively studied medical records and collected clinical data and socio-demographic factors, including age, sex, psychiatric symptoms or diagnosis, methods of suicide attempt, motives for suicide attempt, previous deliberate self-harm, previous psychiatric history, parent loss experience, and previous psychiatric history in the family.
Adolescent attempters were 15 males and 44 females, 13 to 18 years old (mean 16.39). Adult attempters were 37 males and 65 females, 19 to 79 years old (mean 39.45). In comparison to adult attempters, adolescent attempters were more frequently diagnosed with Borderline Personality Disorder (BPD), had more school problems and parent loss experience, but they had less financial problems. Gender differences between adolescents and adults were examined, and male adolescent attempters were found to be more frequently diagnosed with schizophrenia and had less financial problems than their adult counterparts, while female adolescent attempters were more frequently diagnosed with BPD, had more school problems and parent loss, but they had less previous psychiatric history than their adult counterparts.
Our findings indicated that adolescent attempters were more frequently diagnosed with BPD and had more school problems and parent loss experience but had less financial problems. Additionally, in male adolescent attempters, identifying patients with schizophrenia seemed important, as it was their most frequent psychiatric diagnosis. For female adolescents, adequately assessing family function and interpersonal conflicts seemed important, as they were more often diagnosed with BPD and had more school and family problems.
PMCID: PMC3539954  PMID: 23137108
Suicide attempts; Adolescents; Age differences; Critical care medicine
Indian Journal of Psychiatry  1999;41(4):280-288.
Suicide is an important mode of death. There are many psychiatrically ill patients in therapy running different degree of suicide risk. The risk of death by suicide is with almost all psychiatric illnesses, but it is found more with depressive disease, schizophrenia and personality disorder. Many studies have reported higher incidences of suicide attempts and suicide among alcoholics, which is often precipitated by family crises. Drug problems, low threshold for tolerance of day to day frustration, unemployement and poor parenting are major causes for youth suicide.
There is biological evidence of suicidal behaviour. Fall in the level of serotonin and 5-HIAA in the CSF and in hind brain is found in subjects dying from suicide. Researchers have found decreased melatonin level in depression and suicide attempters. Long term therapy with antidepressants (Tricyclics), mood stabilizers (lithium and valproate) and new SSRIs prevent relapses and lessen suicide. It was concluded that general hospital doctors are in position of reducing suicide rates. Education of physician in detection of depression and suicide prevention will result in decline in number of suicides. The important measures include limiting the ability of methods of self-harm, antidepressants, paracetamol and insecticides.
PMCID: PMC2963831  PMID: 21430799
Suicide; depression; suicide prevention; suicide rate
5.  Prevention of: self harm in British South Asian women: study protocol of an exploratory RCT of culturally adapted manual assisted Problem Solving Training (C- MAP) 
Trials  2011;12:159.
Suicide is a major public health problem worldwide. In the UK suicide is the second most common cause of death in people aged 15-24 years. Self harm is one of the commonest reasons for medical admission in the UK. In the year following a suicide attempt the risk of a repeat attempt or death by suicide may be up to 100 times greater than in people who have never attempted suicide.
Research evidence shows increased risk of suicide and attempted suicide among British South Asian women. There are concerns about the current service provision and its appropriateness for this community due to the low numbers that get involved with the services. Both problem solving and interpersonal forms of psychotherapy are beneficial in the treatment of patients who self harm and could potentially be helpful in this ethnic group.
The paper describes the trial protocol of adapting and evaluating a culturally appropriate psychological treatment for the adult British South Asian women who self harm.
We plan to test a culturally adapted Problem Solving Therapy (C- MAP) in British South Asian women who self harm. Eight sessions of problem solving each lasting approximately 50 minutes will be delivered over 3 months. The intervention will be assessed using a prospective rater blind randomized controlled design comparing with treatment as usual (TAU). Outcome assessments will be carried out at 3 and 6 months. A sub group of the participants will be invited for qualitative interviews.
This study will test the feasibility and acceptability of the C- MAP in British South Asian women. We will be informed on whether a culturally adapted brief psychological intervention compared with treatment as usual for self-harm results in decreased hopelessness and suicidal ideation. This will also enable us to collect necessary information on recruitment, effect size, the optimal delivery method and acceptability of the intervention in preparation for a definitive RCT using repetition of self harm and cost effectiveness as primary outcome measures.
Trial Registration
Current Controlled Trials 08/H1013/6
PMCID: PMC3132723  PMID: 21693027
6.  Self-perceived Difficulties With Suicidal Patients in A Sample of Italian General Practitioners 
Suicidal behaviours are relatively common among primary care patients, but suicide ideation seems to be poorly detected by GPs. The purpose of the present study is to investigate the frequency of issues related to suicidal behaviour in GPs’ setting and to inquire the level of difficulties perceived by physicians when dealing with suicidal patients.
A survey on 88 GPs in Rovigo (Italy) has been conducted through the use of a self-administered questionnaire inquiring about suicidal behaviour in patients, personal history and outside professional lives.
Four out of 5 doctors have encountered at least a case of suicide in their professional career, and 3 out of 4 recorded at least a case of suicide attempt in a working year. The frequency of personal history of suicidal ideation/behaviour was 2.3%. One third of GPs have come into contact with suicides or suicide attempts outside the professional setting. Sixty one per cent of doctors admitted difficulties in exploring suicidal ideation, but tended to ascribe it to a reluctant attitude of patients.
The study underscores GPs’ need of being helped in the difficult task of recognising suicidal patients.
General practitioner; Suicide ideation; Suicide; Suicide attempt
PMCID: PMC3279475  PMID: 22393342
7.  Non-Fatal Suicidal Behaviors in Adolescents 
Indian Journal of Psychiatry  2004;46(4):310-318.
In the USA, suicide ranked as the third leading cause of death for adolescents in 1999. Non-fatal suicidal behaviours are suicidal thought, specific suicidal plan and suicide attempt. Prospective studies have emphasized the high subsequent suicide rates in clinically presenting suicide attempters. This study was planned to critically review the existing international literature on this area, and compare, if possible, with the Indian data. Both electronic and manual search for published and unpublished works was done for the review of this area. Both international and Indian studies on prevalence, risk factors, management, and prevention of non-fatal suicidal behaviours in adolescents were collected, analysed and reviewed. The study concludes that professionals, like general practitioners, paediatricians, school teachers, school counselors, need to be trained in identifying non-fatal suicidal behaviours in adolescents, and know when to refer them to a mental health professional or mental health service for thorough assessment and effective management. Timely and efficient management of non-fatal suicidal behaviors can prevent future suicidal attempts and completed suicide in most of this highly vulnerable population. Indian studies are very few and without robust study design. Systematic studies in India on this important topic are required.
PMCID: PMC2950949  PMID: 21206789
suicide; suicidal ideation; suicide attempt; adolescents
8.  Prevalence, correlates and treatment of lifetime suicidal behavior among adolescents: Results from the National Comorbidity Survey Replication – Adolescent Supplement (NCS-A) 
JAMA psychiatry  2013;70(3):10.1001/2013.jamapsychiatry.55.
Although suicide is the third leading cause of death among US adolescents, little is known about the prevalence, correlates, or treatment of its immediate precursors, adolescent suicidal behaviors (i.e., suicide ideation, plans, and attempts).
To estimate lifetime prevalence of suicidal behaviors among US adolescents and associations of retrospectively-reported temporally primary DSM-IV disorders with the subsequent onset of suicidal behaviors.
Dual-frame national sample of adolescents from the National Comorbidity Survey-Replication Adolescent Supplement (NCS-A).
Face-to-face household interviews with adolescents and questionnaires with parents.
6,483 adolescents (ages 13–18 years) and parents.
Main outcome measures
Lifetime suicide ideation, plans, and attempts.
The estimated lifetime prevalence of suicide ideation, plans, and attempts among NCS-A respondents is 12.1%, 4.0% and 4.1%. The vast majority of adolescents with these behaviors meet lifetime criteria for at least one DSM-IV mental disorder assessed in the survey. Most temporally primary (based on retrospective age-of-onset reports) fear/anger, distress, disruptive behavior, and substance disorders significantly predict elevated odds of subsequent suicidal behaviors in bivariate models. The most consistently significant associations of these disorders are with suicide ideation, although a number of disorders also predict plans and both planned and unplanned attempts among ideators. Most suicidal adolescents (>80%) receive some form of mental health treatment. In most cases (>55%) treatment starts prior to onset of suicidal behaviors but fails to prevent these behaviors from occurring.
Suicidal behaviors are commonly occurring among US adolescents, with rates that approach those of adults. The vast majority of youth with suicidal behaviors have pre-existing mental disorders. The disorders most powerfully predicting ideation, though, are different from those most powerfully predicting conditional transitions from ideation to plans and attempts. These differences suggest that distinct prediction and prevention strategies are needed for ideation, plans among ideators, planned attempts, and unplanned attempts.
PMCID: PMC3886236  PMID: 23303463
9.  Deliberate Self-harm: A Search for Distinct Group of Suicide 
Some persons attempt suicide with a strong intention to die and some are not. Presently, no distinctive grouping has been done on the basis of the suicidal intention, though there is a significant variation in the psycho-socio-demographic profile, suicidal ideation, and intent within the persons making suicidal attempt. The aim of our study was to find the psycho-socio-demographic profile, suicide intent in survivors of suicide attempt, categorizing them by suicide intent, and finally to define the deliberate self-harm (DSH) group.
Materials and Methods:
It was a cross-sectional study. Two hundred patients who survived suicide attempt were evaluated by a psychiatrist. The data were recorded for sociodemographic variables, psychiatric disorder, suicide intent, and lethality of suicide attempt. Grouping was done by using suicide intent as the determining dimension. The DSH group was defined by psycho-socio-demographic characteristics of the patient.
The mean age of the DSH group was 26.72 years, mostly females (50.5%), semiskilled workers (43.43%) and housewives (32.32%), from nuclear family (60.6%) with no psychiatric disorder (35.35%). Most of them attempted a nonlethal suicide attempt (87.87%) by organophosphorus poisoning (87.87%).
The DSH group is a distinct group among suicide attempters, having different psycho-socio-demographic characteristics.
PMCID: PMC3271497  PMID: 22345847
Deliberate self-harm; lethality; suicide; suicide intent
10.  Clinical characteristics in schizophrenia patients with or without suicide attempts and non-suicidal self-harm - a cross-sectional study 
BMC Psychiatry  2013;13:255.
To investigate whether schizophrenia patients with both suicide attempts and non-suicidal self-harm have earlier age of onset of psychotic and depressive symptoms and higher levels of clinical symptoms compared to patients with only suicide attempts or without suicide attempt.
Using a cross-sectional design, 251 patients (18–61 years old, 58% men) with schizophrenia treated at hospitals in Oslo and Innlandet Hospital Trust, Norway, were assessed with a comprehensive clinical research protocol and divided into three groups based on their history of suicide attempts and non-suicidal self-harm.
Suicide attempts were present in 88 patients (35%); 52 had suicide attempts only (29%) and 36 had both suicide attempts and non-suicidal self-harm (14%). When compared with nonattempters and those with suicide attempts without non-suicidal self-harm, patients with both suicide attempts and non-suicidal self-harm were more frequently women, younger at the onset of psychotic symptoms, had longer duration of untreated psychosis, and had higher levels of current impulsivity/aggression and depression. Patients with both suicide attempts and non-suicidal self-harm were more likely to repeat suicide attempts than patients with suicide attempts only.
Patients with both suicide attempts and non-suicidal self-harm had different illness history and clinical characteristics compared to patients with only suicide attempts or patients without suicidal behavior. Our study suggests that patients with both suicide attempts and non-suicidal self-harm represent a distinct subgroup among patients with schizophrenia and suicidal behavior with their early onset of psychotic symptoms, high rate of repeated suicidal behavior and significant treatment delay.
PMCID: PMC3852098  PMID: 24106884
Suicide attempt; Non-suicidal self-harm; Self-harm; Schizophrenia; Schizoaffective; Risk factor; Depression
11.  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
12.  Feasibility of Screening Patients With Nonpsychiatric Complaints for Suicide Risk in a Pediatric Emergency Department 
Pediatric Emergency Care  2010;26(11):787-792.
Screening children for suicide risk when they present to the emergency department (ED) with nonpsychiatric complaints could lead to better identification and treatment of high-risk youth. Before suicide screening protocols can be implemented for nonpsychiatric patients in pediatric EDs, it is essential to determine whether such efforts are feasible.
As part of an instrument validation study, ED patients (10–21 years old) with both psychiatric and nonpsychiatric presenting complaints were recruited to take part in suicide screening. Clinically significant suicidal thoughts, as measured by the Suicidal Ideation Questionnaire, and suicidal behaviors were assessed, as well as patient opinions about suicide screening. Recruitment rates for the study as well as impact on length of stay were assessed.
Of the 266 patients and parents approached for the study, 159 (60%) agreed to participate. For patients entering the ED for nonpsychiatric reasons (n = 106), 5.7% (n = 6) reported previous suicidal behavior, and 5.7% (n = 6) reported clinically significant suicidal ideation. There were no significant differences for mean length of stay in the ED for nonpsychiatric patients with positive triggers and those who screened negative (means, 382 [SD, 198] and 393 [SD, 166] minutes, respectively; P = 0.80). Ninety-six percent of participants agreed that suicide screening should occur in the ED.
Suicide screening of nonpsychiatric patients in the ED is feasible in terms of acceptability to parents, prevalence of suicidal thoughts and behaviors, practicality to ED flow, and patient opinion. Future endeavors should address brief screening tools validated on nonpsychiatric populations.
PMCID: PMC3298546  PMID: 20944511
suicide; screening; nonpsychiatric patients; feasibility
13.  Suicide among children and adolescents in Canada: trends and sex differences, 1980–2008 
Suicide is the second leading cause of death for young Canadians (10–19 years of age) — a disturbing trend that has shown little improvement in recent years. Our objective was to examine suicide trends among Canadian children and adolescents.
We conducted a retrospective analysis of standardized suicide rates using Statistics Canada mortality data for the period spanning from 1980 to 2008. We analyzed the data by sex and by suicide method over time for two age groups: 10–14 year olds (children) and 15–19 year olds (adolescents). We quantified annual trends by calculating the average annual percent change (AAPC).
We found an average annual decrease of 1.0% (95% confidence interval [CI] −1.5 to −0.4) in the suicide rate for children and adolescents, but stratification by age and sex showed significant variation. We saw an increase in suicide by suffocation among female children (AAPC = 8.1%, 95% CI 6.0 to 10.4) and adolescents (AAPC = 8.0%, 95% CI 6.2 to 9.8). In addition, we noted a decrease in suicides involving poisoning and firearms during the study period.
Our results show that suicide rates in Canada are increasing among female children and adolescents and decreasing among male children and adolescents. Limiting access to lethal means has some potential to mitigate risk. However, suffocation, which has become the predominant method for committing suicide for these age groups, is not amenable to this type of primary prevention.
PMCID: PMC3381767  PMID: 22470172
14.  Suicide and Suicidal Behavior 
Epidemiologic reviews  2008;30(1):133-154.
Suicidal behavior is a leading cause of injury and death worldwide. Information about the epidemiology of such behavior is important for policy-making and prevention. The authors reviewed government data on suicide and suicidal behavior and conducted a systematic review of studies on the epidemiology of suicide published from 1997 to 2007. The authors' aims were to examine the prevalence of, trends in, and risk and protective factors for suicidal behavior in the United States and cross-nationally. The data revealed significant cross-national variability in the prevalence of suicidal behavior but consistency in age of onset, transition probabilities, and key risk factors. Suicide is more prevalent among men, whereas nonfatal suicidal behaviors are more prevalent among women and persons who are young, are unmarried, or have a psychiatric disorder. Despite an increase in the treatment of suicidal persons over the past decade, incidence rates of suicidal behavior have remained largely unchanged. Most epidemiologic research on suicidal behavior has focused on patterns and correlates of prevalence. The next generation of studies must examine synergistic effects among modifiable risk and protective factors. New studies must incorporate recent advances in survey methods and clinical assessment. Results should be used in ongoing efforts to decrease the significant loss of life caused by suicidal behavior.
PMCID: PMC2576496  PMID: 18653727
psychiatry; public health; risk factors; self-injurious behavior; suicide; suicide, attempted
15.  Influence of stressors and possible pathways of onset of seventh graders’ suicidal ideation in urban and rural areas in Taiwan 
BMC Public Health  2013;13:1233.
Suicide is the second leading cause of death among young people in Taiwan. However, few studies have investigated children’s suicidal ideation, and longitudinal studies are particularly rare. The purposes of this study were: (1) to describe the proportion of students with suicidal ideation in one month and incidence of suicidal ideation in the 7th graders (the first year of junior high school) living in urban and rural areas; (2) to realize the influence of perceived stressors on the onset of 7th graders’ suicidal ideation; and (3) to explore possible pathways through which trigger factors and perceived stressors lead to suicidal ideation.
A total of 1,589 students were followed from grade 4 to grade 7. Logistic regression was then used to investigate the influence of perceived stressors on the onset of suicidal ideation in grade 7. Structural equation modeling was used to analyze possible pathways through which trigger factors led to increased pressure from certain stressors which in turn resulted in suicidal ideation.
The proportion of students with suicidal ideation in one month was 2 to 3 times higher in both areas compared to that in elementary school. However, the incidence in the rural area showed a large increase from 10.2% and 9.5% in grades 5 and 6 to 15.5% in grade 7. Urban–rural difference was observed. Important stressors and pathways of suicidal ideation differ between urban and rural areas.
This study showed that the influential stressors in urban and rural areas might be different. Thus, interventions focused on coping skills for regional specific stressors and trigger factors could be beneficial in the transition time.
PMCID: PMC3883481  PMID: 24369819
Taiwan; Suicidal ideation; Adolescent; Stressor; Urban; Rural
16.  Suicide or accident? A psychological autopsy study of suicide in youths under the age of 16 compared to deaths labeled as accidents 
In the present paper, we describe suicide in youths under 16 years of age and compare their risk factors for suicide to those of older adolescents as described in the literature. Furthermore, we evaluate the possible mislabeling of suicides as accidents, and vice versa.
We used the data from a nationwide psychological autopsy of youths 15 years and younger who had committed suicide or died in accidents in Norway from 1993 to 2004 (n = 84). We additionally constructed a suicide index to distinguish between the two causes of death.
The young suicide victims presented, with little gender difference, fewer obvious risk factors and less suicide intent than commonly described for older adolescents. The suicide index distinguished quite well between suicides and accidents, with few cases indicating a possible mislabeling, although some suicide cases could have been labeled as uncertain.
In line with previous research, suicides in 11-15-year-olds have many similarities to suicides in older adolescents in terms of external circumstances, but they present less apparent warning signs. In our total sample of 84 deaths, there were few indications of incorrect labeling.
PMCID: PMC3526543  PMID: 22971572
Children; Adolescent; Suicide; Accident; Suicide intent; Labeling
17.  Level of suicidal intent predicts overall mortality and suicide after attempted suicide: a 12-year follow-up study 
BMC Psychiatry  2004;4:11.
The aim of this study was to comprehensively examine clinical risk factors, including suicide intent and hopelessness, for suicide and risk of death from all causes after attempted suicide over a 12-year follow-up period.
A systematic sample of 224 patients from consecutive cases of attempted suicide referred to health care in four Finnish cities between 1 January and 31 July 1990 was interviewed.
After 12 years of follow-up 22% of these patients had died, 8% by committing suicide. The only statistically significant risk factor for eventual suicide was high scores on Beck's Suicidal Intention Scale. Male gender, older age, physical illness or disability and high scores on Beck's Suicidal Intention Scale predicted death overall.
Following attempted suicide, high intention to kill oneself is a significant risk factor for both death from all causes and suicide.
PMCID: PMC415554  PMID: 15099401
attempted suicide; suicide; outcome; follow-up studies; risk factors; suicide intent; hopelessness
18.  Cross-National Analysis of the Associations among Mental Disorders and Suicidal Behavior: Findings from the WHO World Mental Health Surveys 
PLoS Medicine  2009;6(8):e1000123.
Using data from over 100,000 individuals in 21 countries participating in the WHO World Mental Health Surveys, Matthew Nock and colleagues investigate which mental health disorders increase the odds of experiencing suicidal thoughts and actual suicide attempts, and how these relationships differ across developed and developing countries.
Suicide is a leading cause of death worldwide. Mental disorders are among the strongest predictors of suicide; however, little is known about which disorders are uniquely predictive of suicidal behavior, the extent to which disorders predict suicide attempts beyond their association with suicidal thoughts, and whether these associations are similar across developed and developing countries. This study was designed to test each of these questions with a focus on nonfatal suicide attempts.
Methods and Findings
Data on the lifetime presence and age-of-onset of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders and nonfatal suicidal behaviors were collected via structured face-to-face interviews with 108,664 respondents from 21 countries participating in the WHO World Mental Health Surveys. The results show that each lifetime disorder examined significantly predicts the subsequent first onset of suicide attempt (odds ratios [ORs] = 2.9–8.9). After controlling for comorbidity, these associations decreased substantially (ORs = 1.5–5.6) but remained significant in most cases. Overall, mental disorders were equally predictive in developed and developing countries, with a key difference being that the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and post-traumatic stress disorders were most predictive. Disaggregation of the associations between mental disorders and nonfatal suicide attempts showed that these associations are largely due to disorders predicting the onset of suicidal thoughts rather than predicting progression from thoughts to attempts. In the few instances where mental disorders predicted the transition from suicidal thoughts to attempts, the significant disorders are characterized by anxiety and poor impulse-control. The limitations of this study include the use of retrospective self-reports of lifetime occurrence and age-of-onset of mental disorders and suicidal behaviors, as well as the narrow focus on mental disorders as predictors of nonfatal suicidal behaviors, each of which must be addressed in future studies.
This study found that a wide range of mental disorders increased the odds of experiencing suicide ideation. However, after controlling for psychiatric comorbidity, only disorders characterized by anxiety and poor impulse-control predict which people with suicide ideation act on such thoughts. These findings provide a more fine-grained understanding of the associations between mental disorders and subsequent suicidal behavior than previously available and indicate that mental disorders predict suicidal behaviors similarly in both developed and developing countries. Future research is needed to delineate the mechanisms through which people come to think about suicide and subsequently progress from ideation to attempts.
Please see later in the article for Editors' Summary
Editors' Summary
Suicide is a leading cause of death worldwide. Every 40 seconds, someone somewhere commits suicide. Over a year, this adds up to about 1 million self-inflicted deaths. In the USA, for example, where suicide is the 11th leading cause of death, more than 30,000 people commit suicide every year. The figures for nonfatal suicidal behavior (suicidal thoughts or ideation, suicide planning, and suicide attempts) are even more shocking. Globally, suicide attempts, for example, are estimated to be 20 times as frequent as completed suicides. Risk factors for nonfatal suicidal behaviors and for suicide include depression and other mental disorders, alcohol or drug abuse, stressful life events, a family history of suicide, and having a friend or relative commit suicide. Importantly, nonfatal suicidal behaviors are powerful predictors of subsequent suicide deaths so individuals who talk about killing themselves must always be taken seriously and given as much help as possible by friends, relatives, and mental-health professionals.
Why Was This Study Done?
Experts believe that it might be possible to find ways to decrease suicide rates by answering three questions. First, which individual mental disorders are predictive of nonfatal suicidal behaviors? Although previous studies have reported that virtually all mental disorders are associated with an increased risk of suicidal behaviors, people often have two or more mental disorders (“comorbidity”), so many of these associations may reflect the effects of only a few disorders. Second, do some mental disorders predict suicidal ideation whereas others predict who will act on these thoughts? Finally, are the associations between mental disorders and suicidal behavior similar in developed countries (where most studies have been done) and in developing countries? By answering these questions, it should be possible to improve the screening, clinical risk assessment, and treatment of suicide around the world. Thus, in this study, the researchers undertake a cross-national analysis of the associations among mental disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV]) and nonfatal suicidal behaviors.
What Did the Researchers Do and Find?
The researchers collected and analyzed data on the lifetime presence and age-of-onset of mental disorders and of nonfatal suicidal behaviors in structured interviews with nearly 110,000 participants from 21 countries (part of the World Health Organization's World Mental Health Survey Initiative). The lifetime presence of each of the 16 disorders considered (mood disorders such as depression; anxiety disorders such as post-traumatic stress disorder [PTSD]; impulse-control disorders such as attention deficit/hyperactivity disorder; and substance misuse) predicted first suicide attempts in both developed and developing countries. However, the increased risk of a suicide attempt associated with each disorder varied. So, for example, in developed countries, after controlling for comorbid mental disorders, major depression increased the risk of a suicide attempt 3-fold but drug abuse/dependency increased the risk only 2-fold. Similarly, although the strongest predictors of suicide attempts in developed countries were mood disorders, in developing countries the strongest predictors were impulse-control disorders, substance misuse disorders, and PTSD. Other analyses indicate that mental disorders were generally more predictive of the onset of suicidal thoughts than of suicide plans and attempts, but that anxiety and poor impulse-control disorders were the strongest predictors of suicide attempts in both developed and developing countries.
What Do These Findings Mean?
Although this study has several limitations—for example, it relies on retrospective self-reports by study participants—its findings nevertheless provide a more detailed understanding of the associations between mental disorders and subsequent suicidal behaviors than previously available. In particular, its findings reveal that a wide range of individual mental disorders increase the chances of an individual thinking about suicide in both developed and developing countries and provide new information about the mental disorders that predict which people with suicidal ideas will act on such thoughts. However, the findings also show that only half of people who have seriously considered killing themselves have a mental disorder. Thus although future suicide prevention efforts should include a focus on screening and treating mental disorders, ways must also be found to identify the many people without mental disorders who are at risk of suicidal behaviors.
Additional Information
Please access these Web sites via the online version of this summary at
The US National Institute of Mental Health provides information about suicide in the US: statistics and prevention
The UK National Health Service provides information about suicide, including statistics about suicide in the UK and links to other resources
The World Health Organization provides global statistics about suicide and information on suicide prevention
MedlinePlus provides links to further information and advice about suicide and about mental health (in English and Spanish)
Further details about the World Mental Health Survey Initiative and about DSM-IV are available
PMCID: PMC2717212  PMID: 19668361
19.  Suicide: An Indian perspective 
Indian Journal of Psychiatry  2012;54(4):304-319.
Suicide is the third leading cause of death among young adults worldwide. There is a growing recognition that prevention strategies need to be tailored to the region-specific demographics of a country and to be implemented in a culturally-sensitive manner. This review explores the historical, epidemiological and demographic factors of suicide in India and examines the strategies aimed at the prevention of suicide. There has been an increase in the rates of suicide in India over the years, although trends of both increases and decline in suicide rates have been present. Distinct from global demographic risk factors, In India, marital status is not necessarily protective and the female: male ratio in the rate of suicide is higher. The motives and modes of suicide are also distinct from western countries. Preventive strategies implemented at a community level and identifying vulnerable individuals maybe more effective than global strategies.
PMCID: PMC3554961  PMID: 23372232
Suicide; India; epidemiology; prevention
20.  Cross-National Prevalence and Risk Factors for Suicidal Ideation, Plans, and Attempts 
Suicide is a leading cause of death world-wide; however, the prevalence and risk factors for the immediate precursors to suicide: suicidal ideation, plans and attempts, are not well-known, especially in developing countries.
To report on the prevalence and risk factors for suicidal behaviors across 17 countries.
84,850 adults were interviewed regarding suicidal behaviors and socio-demographic and psychiatric risk factors.
The cross-national lifetime prevalence (standard error) of suicidal ideation, plans, and attempts is 9.2% (0.1), 3.1% (0.1), and 2.7% (0.1). Across all countries, 60% of transitions from ideation to plan and attempt occur within the first year after ideation onset. Consistent cross-national risk factors included being: female, younger, less educated, unmarried, and having a mental disorder. Interestingly, the strongest diagnostic risk factors were mood disorders in developed countries but impulse-control disorders in developing countries.
Despite cross-national variability in prevalence, there is strong consistency in the characteristics of and risk factors for suicidal behaviors. These findings have significant implications for the prediction and prevention of suicidal behaviors.
PMCID: PMC2259024  PMID: 18245022
21.  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
22.  Epidemiology of Youth Suicide and Suicidal Behavior 
Current opinion in pediatrics  2009;21(5):613-619.
Purpose of Review
Suicide is the third leading cause of death among young people in the U.S. and represents a significant public health problem worldwide. This review focuses on recent developments in our understanding of the epidemiology and risk factors for adolescent suicide and suicidal behavior.
Recent Findings
The suicide rate among children and adolescents in the U.S. has increased dramatically in recent years and has been accompanied by substantial changes in the leading methods of youth suicide, especially among young girls. Much work is currently underway to elucidate the relationships between psychopathology, substance use, child abuse, bullying, internet use, and youth suicidal behavior. Recent evidence also suggests sex-specific and moderating roles of gender in influencing risk for suicide and suicidal behavior.
Empirical research into the causal mechanisms underlying youth suicide and suicidal behavior is needed to inform early identification and prevention efforts.
PMCID: PMC2885157  PMID: 19644372
suicide; adolescents; youth; risk factors; epidemiology; attempted suicide
23.  Prevalence and predictors of persistent suicide ideation, plans, and attempts during college 
Journal of affective disorders  2010;127(1-3):287-294.
Suicide is the second-leading cause of death among college students in the US and is preventable. Approximately 1,100 college students die by suicide each year. This study examined the prevalence and predictors of one-time and persistent suicide ideation, plans, and attempts reported during college.
Data were gathered prospectively over four years. Face-to-face interviews were conducted with 1,253 first-year college students at one large mid-Atlantic university. Risk factors were measured in Year 1.
An estimated 12%wt of individuals experienced suicide ideation at some point during college, and of those individuals, 25% had more than one episode of ideation (persistent ideation; 2.6%wt of the overall sample). Ten individuals had a plan or attempt during college (0.9%wt of the sample). Risk factors for persistent suicide ideation included low social support, childhood or adolescent exposure to domestic violence, maternal depression, and high self-reported depressive symptoms. Persistent ideators differed from one-time ideators only by higher levels of depression (p=.027). Persistent ideators were no more likely than one-time ideators to have made a suicide plan or attempt during college (8% vs. 9%, respectively).
Although the sample size is large, only a small percentage of participants had persistent ideation, suicide plans or attempts during college.
These results have implications for programs aimed at identifying college students at risk for suicide. The accurate identification of college students at-risk for suicide is an important step toward suicide prevention.
PMCID: PMC2924459  PMID: 20471691
College students; Depression; Family psychopathology; Social support; Suicidal behavior; Suicide ideation
24.  The development of a guideline and its impact on the media reporting of suicide 
Indian Journal of Psychiatry  2011;53(3):224-228.
A causal association between media reporting of suicides and the subsequent actual suicides has been observed. There are no studies from India regarding media reporting of suicide. This study examines whether educating media professionals about responsible reporting of suicides can change the quality of reporting.
To study the impact of a guideline on the reporting style of suicides by journalists.
Settings and Design:
Newspaper reports in the local language examined by psychiatrists.
Materials and Methods:
The Department of Psychiatry of a Teaching Hospital conducted a workshop for journalists, with the collaboration of media and mental health professionals and came out with a guideline about responsible reporting of suicide. Using this, a proforma was designed for assessing newspaper reports of suicides. All the suicide reports in the leading newspapers in Kerala were analyzed for one year prior to the workshop, the immediate next year, the second year, and six years later, using the 15 item proforma and whether each report was concordant or discordant to each item in the proforma was noted.
The total concordant responses were 43.7% in the year prior to the workshop, 45.2% during the first year following the workshop, 46.2% in the next year, and 45.7% after six years. When the trend of each item was examined, the concordance rates were increasing in each item, except two. There was no statistical significance.
A workshop for journalists could bring about positive changes in the media reporting of suicides. The changes persisted over the years, although they did not reach statistical significance.
PMCID: PMC3221178  PMID: 22135440
Media reporting; suicide; guideline
25.  Evaluating the SOS suicide prevention program: a replication and extension 
BMC Public Health  2007;7:161.
Suicide is a leading cause of death for children and youth in the United States. Although school based programs have been the principal vehicle for youth suicide prevention efforts for over two decades, few have been systematically evaluated. This study examined the effectiveness of the Signs of Suicide (SOS) prevention program in reducing suicidal behavior.
4133 students in 9 high schools in Columbus, Georgia, western Massachusetts, and Hartford, Connecticut were randomly assigned to intervention and control groups during the 2001–02 and 2002–03 school years. Self-administered questionnaires were completed by students in both groups approximately 3 months after program implementation.
Significantly lower rates of suicide attempts and greater knowledge and more adaptive attitudes about depression and suicide were observed among students in the intervention group. Students' race/ethnicity, grade, and gender did not alter the impact of the intervention on any of the outcomes assessed in this analysis.
This study has confirmed preliminary analysis of Year 1 data with a larger and more racially and socio-economically diverse sample. SOS continues to be the only universal school-based suicide prevention program to demonstrate significant effects of self-reported suicide attempts in a study utilizing a randomized experimental design. Moreover, the beneficial effects of SOS were observed among high school-aged youth from diverse racial/ethnic backgrounds, highlighting the program's utility as a universal prevention program.
Trial registration NCT000387855.
PMCID: PMC1941734  PMID: 17640366

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