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The National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institutet, S-171 77, Stockholm, Sweden
Department of Clinical and Theoretical Mental Health and Department of Psychiatry and Psychotherapy, Semmelweis University, Faculty of Medicine, Budapest, Hungary
c
Ludwig Maximilians University, Munich, Germany
d
Department of Health Sciences, University of Molise, Campobasso, Italy
e
Geha Mental Health Centre, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
f
Division of Molecular Imaging and Neuropathology, Psychiatry Department, Columbia University, New York, USA
b
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 11 April 2011
Received in revised form 7 June 2011
Accepted 13 June 2011
Available online 1 December 2011
Suicide is a major public health problem in the WHO European Region accounting for over 150,000
deaths per year.
Suicidal crisis: Acute intervention should start immediately in order to keep the patient alive.
Diagnosis: An underlying psychiatric disorder is present in up to 90% of people who completed suicide.
Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to
achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment
for the underlying disorder are essential.
Treatment: Existing evidence supports the efcacy of pharmacological treatment and cognitive
behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are
promising, but the supporting evidence is currently insufcient. Studies show that antidepressant
treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal
behaviour in depressed patients treated with antidepressants exists during the rst 1014 days of
treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and
hypnotics in the case of anxiety and insomnia is recommended. Treatment with antidepressants of children
and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium
has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar
and bipolar depression. Treatment with clozapine is effective in reducing suicidal behaviour in patients
with schizophrenia. Other atypical antipsychotics are promising but more evidence is required.
Treatment team: Multidisciplinary treatment teams including psychiatrist and other professionals such
as psychologist, social worker, and occupational therapist are always preferable, as integration of
pharmacological, psychological and social rehabilitation is recommended especially for patients with
chronic suicidality.
Family: The suicidal person independently of age should always be motivated to involve family in the
treatment.
Social support: Psychosocial treatment and support is recommended, as the majority of suicidal patients
have problems with relationships, work, school and lack functioning social networks.
Safety: A secure home, public and hospital environment, without access to suicidal means is a necessary
strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the
patient from hospital should be carefully evaluated against the involved risks.
Training of personnel: Training of general practitioners (GPs) is effective in the prevention of suicide. It
improves treatment of depression and anxiety, quality of the provided care and attitudes towards
suicide. Continuous training including discussions about ethical and legal issues is necessary for
psychiatrists and other mental health professionals.
2011 Elsevier Masson SAS. All rights reserved.
Keywords:
Suicide
Depression
Psychiatric diagnosis
Prevention
Identication
Treatment
130
1. Epidemiology of suicide
1.1. Suicide in the world
According to the World Health Organization (WHO), approximately 1 million people die by suicide in the world every year and
it is estimated that 1.5 million will die from suicide in 2020. The
global suicide rate is 14 suicides per 100,000 inhabitants: 18
suicides per 100,000 for males and 11 suicides per 100,000 for
females. The global suicide rate among those aged 75 years is
approximately three times higher than the rate among youth 25
years [160]. There is a clear predominance of male over female
suicides. The age group in which most suicides occur is 3544
years for both genders. Suicide is the third cause of death among
adolescents in the world; however, suicide is very rare before
puberty [17,77].
1.2. Suicide and attempted suicide in the WHO European Region
Information from the WHO on mortality due to suicide for the
WHO European is presented in Table 1. It is estimated that there
are 1040 attempted suicides for each completed suicide [15]. This
ratio is higher among adolescents and decreases with age. The
prevalence of lifetime suicide attempts in the general population is
around 2.7 to 5.9% [98,110,156].
According to the latest WHO statistics [160], approximately
150,000 people in the WHO European Region completed suicide
and 1,500,000 attempt suicide. The highest suicide rates for both
males and females are found in Lithuania, Russian Federation,
Belarus, Finland, Hungary and Latvia. However, in the last 23
decades several countries in Europe showed a marked decline in
their suicide mortality, particularly in the countries with high
suicide rates (e.g., Denmark, Estonia, Germany, Hungary, Sweden),
while few others, primarily those with relatively low suicide rates,
showed a slightly increasing tendency [115]. Suicide usually has no
single cause; however, up to 90% of individuals who complete
suicide meet the criteria for a psychiatric disorder, such as mood
disorder, substance use disorder, psychosis or personality disorders [10,28,52,83,114,140]. Comorbidity of depression with
personality and anxiety disorders is very common [28,52,137].
Attempted suicide is the most important predictor of a completed
suicide [143]. Prevention of attempted suicide and suicide through
adequate diagnostic procedures and treatment of those disorders
is, therefore, a high priority in the psychiatric praxis.
Approximately 1,000,000 people die by suicide in the world
every year. Suicide rates are higher amongst men than
females. The age group in which most suicides occur is 35
44 years for both genders. It is estimated that there are 1040
attempted suicides for each completed suicide [15]. This ratio is
higher among adolescents and decreases with age. Up to 90%
of individuals who complete suicide meet the criteria for a
psychiatric disorder. Comorbidity with psychiatric disorders is
high.
2. Denition
A meritorious attempt to revise the nomenclature for the study
of suicide was performed by Silverman [130,131]. Suicide attempt
is dened as a self-inicted, potentially injurious behaviour with a
nonfatal outcome for which there is evidence (either explicit or
implicit) of intent to die. The term parasuicide originated in Europe
and covers both suicide attempts and other self-destructive
behaviour. Deliberate self-harm (DSH) is dened as an intentional
Table 1
Suicide rates (number of suicides per 100,000 inhabitants) in the European region,
according to the latest WHO mortality data, and year for which latest data are
available.
Country
Males
Females
Total
Year
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Macedonia
Malta
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
6.31
4.51
26.1
1.8
46.56
26.37
20.3
17.70
25.57
3.43
20.20
16.04
29.07
28.96
22.79
3.30
15.46
4.78
37.15
16.42
14.43
7.88
8.43
44.92
15.99
32.60
55.93
19.71
10.48
5.35
11.17
14.00
23.04
15.64
30.78
18.37
50.55
7.28
22.17
21.80
28.75
10.48
16.29
21.85
2.4
36.51
9.71
8.87
3.45
1.00
8.20
0.5
7.61
9.14
3.3
4.29
6.18
0.96
4.16
5.69
6.23
8.27
7.52
0.97
4.68
0.99
8.59
7.45
4.18
1.68
2.29
9.25
4.02
6.16
9.10
7.37
3.94
1.03
4.91
6.09
3.74
4.08
5.38
3.55
8.13
0.00
7.97
3.15
6.64
3.11
6.59
9.11
3.4
5.66
2.66
2.37
4.84
2.53
12.69
0.70
25.26
17.46
12.91
10.48
14.99
2.13
11.79
10.59
16.49
18.45
14.68
2.05
9.80
2.85
21.53
12.10
9.29
4.65
5.19
25.69
9.76
17.84
30.72
13.07
7.07
3.13
8.02
10.02
12.94
9.36
17.24
10.63
27.40
3.62
14.62
11.93
17.19
6.61
11.36
15.12
2.9
19.54
6.12
5.53
2004
2006
2008
2007
2007
2004
2007
2006
2008
2007
2008
2006
2008
2008
2007
2001
2006
2008
2008
2008
2008
2007
2007
2008
2006
2007
2008
2006
2003
2008
2008
2007
2007
2003
2008
2008
2006
2000
2008
2005
2008
2005
2007
2007
2005
2006
2007
2005
but nonetheless have neither considered taking their own lives nor
committed suicidal acts. The propensity to suicide has interested
many researchers and various models have been devised to explain
the aetiology of suicidality. In the stress-vulnerability model
[89,149,152] (Fig. 1), genetic make-up as well as acquired
susceptibility contributes to a persons predisposition or vulnerability. Early traumatic life experiences, chronic illness (especially in
the central nervous system [CNS]), chronic alcohol and substance
abuse, and also environmental factors such as social position,
culture, diet, etc. all play a part in the development of vulnerability.
Vulnerability for suicidal behaviour is held to be the crucial
determinant of whether or not it is manifested under the impact of
external stressors. The vulnerability towards suicidal behaviour, in
certain individuals, involves both environmental and genetic
factors, as well as interactions in-between (GxE) [73,153,154].
Suicidal behaviours cluster into families, and twin and adoption
studies show that the genetic set-up can explain up to 50% of the
variance in suicidal behaviour [23]. Suicidal behaviour belongs to
the category of complex diseases, and thus involves different sets
of interacting gene clusters, active at different time points during
the life span, often depending on the presence of adverse
environmental exposures, and this results in a probabilistic rather
than deterministic genetic diathesis, which can catalyse (rather
than cause) the emergence of suicidal behaviour later in life
[153,154]. The observed pleiotrophy of certain genes, e.g. the
serotonin transporter (SLC6A4) and monoamine oxidase (MAO)
genes, which play a role in both the developmental stages in youth
as well as in adult activity of the same circuits, in parallel with
novel hypotheses concerning modelling plasticity, in addition to
vulnerability, may help to resolve certain paradoxes observed in
relation to the outcomes of treatment with Selective Serotonin
Reuptake Inhibitors (SSRIs) and sometimes contradictory GxE
observations [154]. Gene-environment approach gave new hope
for possible associations especially with the short allele (S) of the
serotonin transporter promoter polymorphism (5HTTLPR). Caspi
et al. [27] have demonstrated that individuals carrying at least one
copy of the S allele who experienced stressful life events had an
increase in depressive symptoms between ages 21 and 26.
Furthermore, life events occurring after age 21 predicted depression and suicide ideation or attempt at age 26 among carriers of S
allele who did not have a prior history of depression. A recent
meta-analysis in which 54 published studies were included and
analysis were stratied by the type of stressor studied, showed a
strong evidence for an association between the S allele and
131
Fig. 1. The suicidal process and its evolution on the basis of the individual vulnerability.
From D. Wasserman, C. Wasserman. Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective [155].
132
133
134
135
Suicide risk should be specifically evaluated with clinical interviews assessing psychological and social functioning of the
patient. Specific psychometric scales can be useful in the
determination of suicidal risk.
The most promising predictors of suicidality are low concentrations of the serotonin metabolite 5-hydroxyindoleacetic acid (5HIAA) in the spinal uid [88] in combination with hypothalamic
pituitaryadrenal (HPA) axis dysfunction measured by dexamethasone non-suppression (DST). However, those measurements can only
be performed at specialized clinics and are mainly used in the
research setting. Therefore, psychiatric, psychological and social
assessment, in combination with psychometric scales, is currently
used in ordinary psychiatric practice for the evaluation of suicidal
risk.
8.1. Evaluation
One of the very rst difcult decisions that the clinician has to
make is whether to admit the patient to a psychiatric ward or
perform the treatment in outpatient care. While this decision is
straightforward in severe cases or when physical injury is present,
it can be much more difcult in the majority of cases in which the
advantages and disadvantages of hospitalization are blurred. Even
if in the recent past, admission to a psychiatric unit was almost a
clinical reex, today everything is additionally complicated by the
need to carefully administer the available economical resources.
Moreover, there is today an increased awareness about negative
effects of hospitalization, which needs to be taken into account.
Hospitalization certainly has its advantages: rst of all, it
usually provides increased security for the patient. If appropriate
safety measures are followed, the psychiatric ward allows for
continuous care and observation of the patient over a longer period
of time, gives the opportunity to acquire all necessary information,
allows utilizing a multi-disciplinary treatment team, and provides
a framework for the necessary treatment. On the other hand, it is
impossible to achieve complete security in the psychiatric ward. It
has been reported that 14% of all deaths by suicide are committed
by psychiatric inpatients [64]. The gures from the systematic
investigations of suicide during psychiatric treatment in Sweden
show that up to 20% of all suicides were committed by inpatients
[129].
Major disadvantage of hospitalization, besides a higher
treatment cost, is that, especially if forces, it can endanger a
previously established therapeutic alliance in an on-going
treatment. Moreover, loss of freedom may deepen regression. A
crucial decision about hospitalization depends on the presence of a
social network surrounding the patient and the accessibility of
qualied outpatient treatment. Even in mild cases, sending a
136
137
138
10. Conclusion
Suicide and attempted suicide can be prevented by adequate
treatment. As many suicide victims, especially older die by their
139
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