[MadRiverTurtle]

By Todd Neale, Staff Writer, MedPage Today
Published: November 19, 2008
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.

STOCKHOLM, Nov. 19 -- Following an unsuccessful suicide attempt, patients with psychopathologies are more likely to succeed on a second try than those without such disorders, a long-term cohort study showed.

Patients with unipolar depression, bipolar disorder, and schizophrenia, specifically, who had tried suicide unsuccessfully had the highest risk of completing suicide after up to 31 years of follow-up, Dag Tidemalm, a doctoral student at the Karolinska Institute here, and colleagues reported online in BMJ.

The risk was highest within one year of hospitalization for a previous attempt. For patients with bipolar and unipolar disorder, 63.8% of suicides in men and 42.3% in women occurred in this time frame.

For schizophrenia patients, 56.2% of suicides in men and 53.9% in women occurred during the first year following an attempt.

"The present results suggest that attempted suicide in those with schizophrenia or bipolar and unipolar disorder is particularly worrying and underlines the need for more focused care during at least the first two years after a suicide attempt," the researchers said.

Although it is well known that the risk of suicide is significantly increased in those who have previously attempted to take their lives, the influence of coexistent psychiatric disorders remains uncertain, they said.

So the investigators took a cohort of 39,685 patients ages 10 and older (53% female; mean age 38.4 for men and 37.0 for women) who were hospitalized for a suicide attempt in Sweden from 1973 through 1982 and followed them until 2003.

Most (68%) were not diagnosed with a psychiatric disorder at hospital discharge.

The rest were diagnosed with one of the following disorders: bipolar and unipolar disorder (1,043), other depressive disorder (5,082), schizophrenia (713), anxiety disorder (1,328), adjustment disorder or posttraumatic stress disorder (764), alcohol abuse or dependence (2,702), drug abuse or dependence (385), or personality disorder (664).

In all diagnostic categories, a high percentage of the suicides during follow-up (13.5% to 63.8% in men and 14.3% to 53.9% in women) occurred during the first year.

The proportion of suicides occurring in the first year was high in the group free from psychiatric disorders as well (45.1% for men and 39.6% in women), although the completed suicide rate was low (5.1% in men and 2.8% in women).

Over the entire follow-up period, patients with bipolar and unipolar disorder (HR for men 3.5, 95% CI 3.0 to 4.2; HR for women 2.5, 95% CI 2.1 to 3.0) and schizophrenia (HR for men 4.1, 95% CI 3.5 to 4.8; HR for women 3.5, 95% CI 2.8 to 4.4) had the highest risk of successfully committing suicide.

Among patients with schizophrenia, 4.6% of the suicides in men and 2.8% in women were attributed to the disorder.

For those with unipolar and bipolar disorder, the corresponding percentages were 4% and 4.1%, respectively.

Risks were also increased for patients with other depressive disorders, anxiety disorder, alcohol misuse (in women only), drug misuse, and personality disorder, but not for patients with adjustment disorder or posttraumatic stress disorder and men who misused alcohol.

The rate of successful suicide in patients with other depressive disorders was not as high as for unipolar, bipolar disorder or schizophrenia, but the number of patients was high because the diagnosis was common.

The researchers called for enhanced aftercare for at least two years following a suicide attempt for these high-risk patients.

Agreeing were Udo Reulbach, M.D., of the National Suicide Research Foundation in Cork, Ireland, and Stefan Bleich, M.D., of the Medical School of Hanover in Germany, who said that "making the prevention of suicide a health service and public health priority is justified on medical, ethical, and cost-effectiveness grounds."

In an accompanying editorial, they recommended "systematic referral to professional services before and after discharge" for patients who attempt to kill or harm themselves.

For patients at highest risk, "aftercare should also include education of their immediate family and friends," they said.

The study authors acknowledged several limitations of the study, including the inclusion of patients who required inpatient care following a suicide attempt only, the lack of information on the contribution of physical illness and multiple psychiatric comorbidity, a possible underestimation of patients with adjustment disorder or posttraumatic stress disorder, and potential misclassification of patients who may have been diagnosed with a psychiatric disorder outside of the week following a suicide attempt.

In addition, they said, the results of the study may not be generalizable to a broader definition of bipolar disorder.

The study was funded by the Stockholm County Council, the Karolinska Institute, and the Swedish Prison and Probation Service. One of Mr. Tidemalm's co-authors is funded by the Swedish Research Council.

Neither the study authors nor the editorialists reported any conflicts of interest.


Primary source: BMJ
Source reference:
Tidemalm D, et al "Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long-term follow-up" BMJ 2008; DOI: 10.1136/bmj.a2205.

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[konj]

damn its soo real. all my comrades in the struggle with mental illness. i hope noone commits suicide. i pray to god that no one has to die b/c of mental illness.
i will do my best to help those in need. god bless you!