Suicides in Mood Disorders in Psychiatric Settings in Nordic National Register–Based Studies

Isometsä, Erkki

doi:10.3389/fpsyt.2020.00721

Cited by 18 publications

(27 citation statements)

References 47 publications

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“…Research into the effect of suicide prevention strategies is generally faced with several methodological challenges. Given the rarity of suicide, studies powered to detect risk factors must be large 9,46 , and intervention studies even larger in order to assess potential effects of these on number of completed suicides. In an ideal world, experimental research methods would be used for research for detecting suicide prevention strategies, fulfilling all requirements of falsifiability and generalization.…”

Section: Methodological Challenges In Suicide Researchmentioning

confidence: 99%

“…Studies of suicide deaths are needed for confirming generalizability of findings between the populations as provided e.g. in large national register studies 9 .…”

Section: Methodological Challenges In Suicide Researchmentioning

confidence: 99%

“…Depression as part of a uni-or bipolar disorder is according to WHO a leading cause of disability worldwide and is a major contributor to the overall global burden of disease 6 . About half of all suicides have been found to suffer from affective disorders [7][8][9] .…”

Section: List Of Tablesmentioning

confidence: 99%

Section: Depression and Suicide Risk Related To Inpatient Treatmentmentioning

confidence: 99%

“…Patients with depression are the largest diagnostic group associated with suicide both during and after inpatient stays 9,56,57,59,70,71 . Suicide risk in recently discharged patients also increases with the severity of their depressive episode 9,32,58,68,72 . A review of Nordic national register based studies, found 2%-8% of psychiatric inpatients with unipolar depression to have died by suicide after discharge, and 4-8% of bipolar patients having died by suicide in long term 9 .…”

Section: Depression and Suicide Risk Related To Inpatient Treatmentmentioning

confidence: 99%

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Psychotic depression and suicide risk: a mixed methods study

Fredriksen¹

2022

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Background: The reasons behind suicide are multifactorial, complex, and poorly understood. Despite decades of research, suicide rates remain elevated both during hospitalization as well as shortly after discharge. Clinically relevant knowledge and tools for suicide risk assessments to guide decision-making processes in acute settings are needed. Objectives: The thesis objective was to examine and improve understanding of the complex relationship between psychotic depression and suicide behaviour. We also examined risk factors of clinical relevance in hospital settings, both during treatment, and after discharge. Methods: This research project used a sequential exploratory strategy, commencing with a qualitative part (paper 1-2), followed by a quantitative part (paper 3-4). In paper 1 and 2, we conducted qualitative interviews with nine patients diagnosed with psychotic depression as part of uni- or bipolar disorder. Papers 3 and 4 used data from the naturalistic prospective cohort study Suicidality in Psychiatric Emergency Admissions. In paper 3, we included all patients with depression (N= 1846) in a representative sample to identify risk factors for suicide using a cox regression analysis. Paper 4 investigated a mixed diagnostic sample of 7000 acutely admitted inpatients to identify imminent- and short-term risk factors for suicide. The findings from all four papers were combined into a secondary analysis, where we thematically synthesized the perspectives of patients’ experiences with the main findings from the prospective cohort study based on clinical assessment. Results thematic summarized: Our main finding was that psychotic symptoms in depression are associated with increased suicide risk, both short- and long-term (Paper 3). A possible mechanism to explain this association is the combination of intense emotional suffering and cognitive impairment which may motivate impulsive behaviour in psychotic depression (Papers 1 and 2). Depressed mood including overvalued ideas and delusions of self-blame and guilt predicted suicide the first following week after admission (Paper 4). The association of intense affective states with both imminent and long-term suicide risk factors was supported by patient experiences of sleeplessness and intense anxiety as warning signs for suicidal behaviour (Paper 1 and 2). In further support of this, depression severity assessed by the Health of the Nation Scale item 7 predicted suicide the first following week after admission (Paper 4). We found higher short-term suicide rates in patients diagnosed with psychotic depression as compared to those without psychotic symptoms at all follow-up points (Paper 3). A diagnosis of psychotic depression and depression severity assessed by MADRS depression scale as independent predictors of suicide provided knowledge on the long-term perspective (median 5.5 years follow-up). Also of clinical importance is our finding that self-report of suicidal ideation is not a good measure of imminent, short- or long-term suicide risk. Our qualitative findings indicate that shame, psychotically motivated paranoid ideation and impulsivity motivated underreporting of both suicidal ideation and psychotic symptoms in themselves. This may partly explain why, despite reporting less suicidal ideation/planning on admission, the suicide rate was higher for patients with psychotic symptoms on admission than for those without such symptoms (Paper 3). Although reported suicidal ideation was less relevant for clinical risk assessment, paper 3 and 4 identified male gender and recent suicide attempt as significant risk factors for completed suicide. The last main finding was that patients found both security measures and a treatment approach focusing on modifying psychotic experiences, intense anxiety and sleeplessness was helpful during hospitalization. Taking the time to talk to establish good patient relations is essential for optimal treatment conditions. Conclusions: The periods of acute inpatient treatment and immediately post- discharge are associated with the highest suicide risk. High symptom load as well as a diagnosis of psychotic depression, especially the presence of overvalued ideas and delusions of self-blame and guilt, appear to indicate especially high suicide risk regardless of time horizon. Identifying delusions and other psychotic symptoms is thus of the utmost importance. Psychosis- and depression-focused interventions and treatment approaches aiming specifically to reduce both psychotic and affective symptom load may act as a suicide prevention strategy for psychotic depressed patients. We found self-report of suicidal ideation of limited relevance when assessing suicide risk. Such assessments should thus always be combined with thorough clinical assessment by trained staff. This is especially true when assessing patients with psychotic depression, but especially given the frequent underreporting of psychotic symptoms, it remains important with any patient admitted for a depressive episode. Structured depression rating scales for clinician use may meaningfully contribute to suicide risk assessments. When assessing acute admission patients, we recommend paying particularly close attention to males, and patients with prior and recent suicide attempts.

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Section: Methodological Challenges In Suicide Researchmentioning

confidence: 99%

“…Studies of suicide deaths are needed for confirming generalizability of findings between the populations as provided e.g. in large national register studies 9 .…”

Section: Methodological Challenges In Suicide Researchmentioning

confidence: 99%

Section: List Of Tablesmentioning

confidence: 99%

Section: Depression and Suicide Risk Related To Inpatient Treatmentmentioning

confidence: 99%

Section: Depression and Suicide Risk Related To Inpatient Treatmentmentioning

confidence: 99%

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Psychotic depression and suicide risk: a mixed methods study

Fredriksen¹

2022

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Variations in Suicide Risk and Risk Factors After Hospitalization for Depression in Finland, 1996-2017

Aaltonen,

Sund,

Hakulinen

et al. 2024

JAMA Psychiatry

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ImportanceAlthough incidence of suicide in depression varies remarkably temporally, risk factors have been modeled as constant and remain uncharted in the short term. How effectively factors measured at one point in time predict risk at different time points is unknown.ObjectiveTo examine the absolute risk and risk factors for suicide in hospitalized patients with depression starting from the first days after discharge up to 2 years and to evaluate whether the size of relative risk by factor displays temporal patterns over consecutive phases of follow-up.Design, Setting, and ParticipantsThis population-based study using Finnish registers (hospital discharge, population, and cause of death registers) included all hospitalizations for depression as the principal diagnosis in Finland from 1996 to 2017, with a maximum follow-up of 2 years. Data were analyzed from January 2022 to November 2023.Main Outcomes and MeasuresIncidence rate (IR), IR ratios, hazard functions, and hazard ratios for suicide by consecutive time periods (0 to 3 days, 4 to 7 days, 7 to 30 days, 31 to 90 days, 91 to 365 days, and 1 to 2 years) since discharge.ResultsThis study included 193 197 hospitalizations among 91 161 individuals, of whom 51 197 (56.2%) were female, and the mean (SD) age was 44.0 (17.3) years. Altogether, patients were followed up to 226 615 person-years. A total of 1219 men and 757 women died of suicide. Incidence of suicide was extremely high during the first days after discharge (IR of 6062 [95% CI, 4963-7404] per 100 000 on days 0 to 3; IR of 3884 [95% CI, 3119-4835] per 100 000 on days 4 to 7) and declined thereafter. Several factors were associated with risk of suicide over the first days after discharge. Current suicide attempt by hanging or firearms increased the risk of suicide most on days 0 to 3 (IR ratio, 18.9; 95% CI, 3.1-59.8) and on days 0 to 7 (IR ratio, 10.1; 95% CI, 1.7-31.5). Temporal patterns of the size of the relative risk diverged over time, being constant, declining, or increasing. Clinical factors had the strongest association immediately. Relative risk remained constant among men and even increased among those with alcohol or substance use disorder.Conclusions and RelevanceIn this study, patients hospitalized for depression had extremely high risk of suicide during the first days after discharge. Thereafter, incidence declined steeply but remained high. Within the periods of the highest risk of suicide, several factors increased overall risk manyfold. Risk factors’ observed potencies varied over time and had characteristic temporal patterns.

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Suicide Risk Among Psychiatric Patients

Isometsä

2022

Suicide Risk Assessment and Prevention

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Suicides in Mood Disorders in Psychiatric Settings in Nordic National Register–Based Studies

Cited by 18 publications

References 47 publications

Psychotic depression and suicide risk: a mixed methods study

Psychotic depression and suicide risk: a mixed methods study

Variations in Suicide Risk and Risk Factors After Hospitalization for Depression in Finland, 1996-2017

Suicide Risk Among Psychiatric Patients

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