Patients with depressive disorders or schizophrenia more likely to re-attempt suicide

Men and women who have tried to kill themselves and are suffering from unipolar disorder (major depression), bipolar disorder (manic depression) or schizophrenia are at a very high risk of committing suicide within a year of their first attempt, concludes a study published today on bmj.com. This is the first time research has identified a link between specific psychiatric disorders and increased suicide risk in such a large study of people who have attempted suicide. The authors call for prevention programmes to target these high risk groups.

It is well known that there is a 30-40 times increased risk of death from suicide in individuals who have previously attempted suicide compared with the general population. But little is known about the impact of coexisting psychiatric disorders on the risk of suicide in this group.

Dag Tidemalm and colleagues from the Karolinska Institutet in Stockholm studied nearly 40 000 individuals (53% women) who were admitted to hospital in Sweden following a suicide attempt during 1973-82. They analysed how many suicides were completed during the 30 year follow-up and if the risk varied with type of psychiatric disorder.

The authors found that schizophrenia and unipolar/bipolar disorder were the strongest predictors of completed suicide throughout the follow-up period. In patients suffering from unipolar/bipolar disorder, 64% of all suicides in men and 42% of suicides in women occurred within the first year of follow-up; the matching figures for schizophrenia were 56% in men and 54% in women.

Death from suicide occurred mostly within the five years after the initial suicide attempt.

People suffering with most other psychiatric disorders had a lower but still significantly increased risk of suicide. Interestingly, individuals suffering from adjustment disorder, post-traumatic stress disorder and alcohol abuse (men only) were not at significantly increased risk of re-attempting suicide compared to suicide attempters without a psychiatric diagnosis at baseline.

The authors call for patients who have unipolar/bipolar disorder or schizophrenia and previous suicidal behaviour to be given more intensive after-care, especially in the first few years after trying to kill themselves.

In an accompanying editorial, Dr Udo Reulbach from the National Suicide Research Foundation in Ireland and Professor Stefan Bleich from the Medical School of Hannover in Germany, explain that suicide is one of the 10 leading causes of death worldwide with predictions of 1.5 million people dying from suicide each year by 2020. Therefore, they say, suicide prevention must be made a health service and public health priority on medical, ethical and cost effectiveness grounds.

In another research paper, Professor David Gunnell from the University of Bristol and colleagues report that non-fatal self-harm may occur in over 10% of adults discharged from psychiatric inpatient care in England and Wales, and that the risk is greatest in the first month. Patients who had previous self-harming behaviour were at the greatest risk. Others at increased risk included women, the young, and those with depression, personality disorders and substance misuse.

These findings suggest the need to develop interventions to reduce the risk of fatal and non-fatal self-harm in the weeks immediately after hospital discharge—these might include improved discharge arrangements and clear crisis plans and lines of communication with specialist staff.

Source: BMJ-British Medical Journal