Suicidal behaviour : An epidemiological study of suicide and attempted suicide in relation to mental health services

Psychiatric disorders and a history of suicide attempts are the best known risk factors for suicide. Thus, major changes in mental health services and interventions aimed at patients who have attempted suicide might affect the risk of subsequent suicide attempts and suicide. The overall aim of the present thesis was to evaluate the impact of health services on suicidal behaviour, and thereby gain new knowledge relevant for preventing suicidal behaviour. The thesis consists of three papers. Paper I was designed as a prospective cohort study. We investigated whether individuals admitted to inpatient psychiatric care after a suicide attempt had shorter length of stays in the period 1996-2006 than individuals admitted in the former period 1984-1995. We also considered whether length of stays and time period in which the patients received treatment were related to the risk of subsequent suicide attempts and/or suicide. Individuals hospitalised in the period 1996-2006 had significantly shorter stays than individuals hospitalised in the former period (log rank P 0.05). Considering that shortened length of stays might increase the likelihood of incomplete recovery, and thereby increased risk of subsequent suicidal behaviour, our interpretation of the results were that shortened length of stays was compensated by improved mental health services, in particular through the major extension of outpatient services. Paper II was designed as an ecological study. We examined whether increased resources in specialist mental health services in the period 1990-2006 were inversely associated with female and male suicide mortality in five Norwegian health regions. None of the variables that measured mental health service resources (number of man-labour years by all personnel, number of discharges, number of outpatient consultations, number of inpatient days and number of hospital beds) were associated with female or male suicide mortality (adjusted P > 0.05). Paper III was designed as a prospective cohort study. The aim was to explore whether a chain of care intervention aimed at individuals who have attempted suicide was effective in preventing subsequent suicide attempts and suicide. In general, a chain of care intervention means the establishment of an integrated health care system which aims to improve quality of care. We compared the risk of subsequent suicidal behaviour among patients who received a community based chain of care intervention in addition ’to treatment as usual’ with patients who only received ’treatment as usual’. We observed no significant differences between the two groups in the risk of a repeated suicide attempt; not within six months (adjusted OR = 1.08; 95% CI = 0.66-1.74), 12 months (adjusted OR = 0.86; 95% CI = 0.57-1.30) or five years of follow-up (adjusted RR = 0.90; 95 % CI = 0.67-1.22). Nor did we observe significant differences in the risk of committing suicide (adjusted RR = 0.85; 95% CI = 0.46-1.57). Intervention was not assigned to patients for whom the standard aftercare was already deemed sufficient. Thus, we interpreted the results to indicate that this intervention was at least able to render, in terms of outcomes, patients judged to be needier and those judged to be less needy, as indistinguishable

Changes in mental health services and suicide mortality in Norway: an ecological study

<p>Abstract</p> <p>Background</p> <p>Mental disorders are strongly associated with excess suicide risk, and successful treatment might prevent suicide. Since 1990, and particularly after 1998, there has been a substantial increase in mental health service resources in Norway. This study aimed to investigate whether these changes have had an impact on suicide mortality.</p> <p>Methods</p> <p>We used Poisson regression analyses to assess the effect of changes in five mental health services variables on suicide mortality in five Norwegian health regions during the period 1990-2006. These variables included: number of man-labour years by all personnel, number of discharges, number of outpatient consultations, number of inpatient days, and number of hospital beds. Adjustments were made for sales of alcohol, sales of antidepressants, education, and unemployment.</p> <p>Results</p> <p>In the period 1990-2006, we observed a total of 9480 suicides and the total suicide rate declined by 26%. None of the mental health services variables were significantly associated with female or male suicide mortality in the adjusted analyses (p > 0.05). Sales of antidepressants (adjusted Incidence Rate Ratio = 0.98; 95% CI = 0.97-1.00) and sales of alcohol (adjusted IRR = 1.41; 95% CI = 1.18-1.72) were significantly associated with female suicide mortality; education (adjusted IRR = 0.86; 95% CI = 0.79-0.94) and unemployment (adjusted IRR = 0.91; 95% CI = 0.85-0.97) were significantly associated with male suicide mortality.</p> <p>Conclusions</p> <p>The adjusted analyses in the present study indicate that increased resources in Norwegian mental health services in the period 1990-2006 were statistically unrelated to suicide mortality.</p

Chain of care for patients who have attempted suicide: a follow-up study from Bærum, Norway

<p>Abstract</p> <p>Background</p> <p>Individuals who have attempted suicide are at increased risk of subsequent suicidal behavior. Since 1983, a community-based suicide prevention team has been operating in the municipality of Bærum, Norway. This study aimed to test the effectiveness of the team's interventions in preventing repeated suicide attempts and suicide deaths, as part of a chain of care model for all general hospital treated suicide attempters.</p> <p>Methods</p> <p>Data has been collected consecutively since 1984 and a follow-up was conducted on all individuals admitted to the general hospital after a suicide attempt. The risk of repeated suicide attempt and suicide were comparatively examined in subjects who received assistance from the suicide prevention team in addition to treatment as usual versus those who received treatment as usual only. Logistic regression and Cox regression were used to analyze the data.</p> <p>Results</p> <p>Between January 1984 and December 2007, 1,616 subjects were registered as having attempted suicide; 197 of them (12%) made another attempt within 12 months. Compared to subjects who did not receive assistance from the suicide prevention team, individuals involved in the prevention program did not have a significantly different risk of repeated attempt within 6 months (adjusted <it>OR </it>= 1.08; 95% CI = 0.66-1.74), 12 months (adjusted <it>OR </it>= 0.86; 95% CI = 0.57-1.30), or 5 years (adjusted <it>RR </it>= 0.90; 95% CI = 0.67-1.22) after their first recorded attempt. There was also no difference in risk of suicide (adjusted <it>RR </it>= 0.85; 95% CI = 0.46-1.57). Previous suicide attempts, marital status, and employment status were significantly associated with a repeated suicide attempt within 6 and 12 months (p < 0.05). Alcohol misuse, employment status, and previous suicide attempts were significantly associated with a repeated attempt within 5 years (p < 0.05) while marital status became non-significant (p > 0.05). With each year of age, the risk of suicide increased by 3% (p < 0.05).</p> <p>Conclusions</p> <p>The present study did not find any differences in the risk of fatal and non-fatal suicidal behavior between subjects who received treatment as usual combined with community assistance versus subjects who received only treatment as usual. However, assistance from the community team was mainly offered to attempters who were not receiving sufficient support from treatment as usual and was accepted by 50-60% of those deemed eligible. Thus, obtaining similar outcomes for individuals, all of whom were clinically judged to have different needs, could in itself be considered a desirable result.</p

Psychosocial and organizational risk factors for doctor-certified sick leave: a prospective study of female health and social workers in Norway

BACKGROUND: Doctor-certified sick leave differs substantially across sectors, and among health and social workers, in particular, there is an increased risk. Previous studies have shown that work environmental factors contribute to sick leave. Hence, the identification of specific organizational and psychosocial risk factors for long- term sick leave, taking into account potential confounding related to mechanical risk factors such as lifting and awkward body postures, will be of importance in the work of prevention. METHODS: A randomly drawn population sample of Norwegian residents was interviewed about working conditions in 2009 (n = 12,255; response rate 60.9%). Female health and social care workers (n = 925) were followed in a national registry for subsequent sickness absence during 2010. The outcome of interest was doctor-certified sick leave of 21 days or more (long-term sick leave). Eleven work-related psychosocial and organizational factors were evaluated. RESULTS: In total, 186 persons (20.1%) were classified with subsequent long-term sick leave. After thoroughly adjusting for competing explanatory variables, the most consistent predictors for long-term sick leave were violence and threats of violence (OR = 1.67; 95% CI 1.14–2.45). The estimated population attributable risk for violence and threats of violence was 13%. CONCLUSIONS: The present study among female health and social care workers revealed a substantial relationship between self-reported violence and threats of violence and subsequent long- term sick leave

The contribution from psychological, social, and organizational work factors to risk of disability retirement: a systematic review with meta-analyses

Abstract Background Previous studies indicate that psychological, social, and organizational factors at work contribute to health, motivation, absence from work, and functional ability. The objective of the study was to assess the current state of knowledge of the contribution of psychological, social, and organizational factors to disability retirement by a systematic review and meta-analyses. Methods Data sources: A systematic literature search for studies of retirement due to disability in Medline, Embase, and PsychINFO was performed. Reference lists of relevant articles were hand-searched for additional studies. Data extraction: Internal validity was assessed independently by two referees with a detailed checklist for sources of bias. Conclusions were drawn based on studies with acceptable quality. Data synthesis: We calculated combined effect estimates by means of averaged associations (Risk ratios) across samples, weighting observed associations by the study’s sample size. Thirty-nine studies of accepted quality were found, 37 of which from the Nordic countries. Results There was moderate evidence for the role of low control (supported by weighted average RR = 1.40; 95% CI = 1.21-1.61) and moderate evidence for the combination of high demands and low control (although weighted average was RR = 1.45; 95% CI = 0.96-2.19) as predictors of disability retirement. There were no major systematic differences in findings between the highest rated and the lowest rated studies that passed the criterion for adequate quality. There was limited evidence for downsizing, organizational change, lack of employee development and supplementary training, repetitive work tasks, effort-reward imbalance to increase risk of disability pension. Very limited evidence was found for job demands, evening or night work, and low social support from ones superior. Conclusions Psychological and organizational factors at work contribute to disability retirement with the most robust evidence for the role of work control. We recommend the measurement of specific exposure factors in future studies