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Q Which factors are associated with suicidal thoughts and likelihood of recovery?
A sample of people from the second National Psychiatric Morbidity Survey, which randomly selected people living in private households in the UK: initial interviews between March and September 2000; follow up interviews after 18 months.
3561 people (all people with a Clinical Interview Schedule−Revised (CIS–R) score above 5 and a 20% random sample of people with a CIS–R score below 5) in initial interview; 2404 of these people in follow up interview included in analysis.
People were questioned on presence of suicidal thoughts, defined as positive response to “Have you ever thought of taking your life, even if you would not really do it?” They were also questioned on their age, gender, baseline CIS–R score, marital status, size of primary support group, life events, occupational social class, weekly income, housing tenure, employment status, and substance misuse.
Incidence of suicidal thoughts; recovery from suicidal thoughts.
Follow up period:
The annual incidence of suicidal thoughts at baseline was 2.3% (95% CI 1.8% to 2.9%). Annual incidence of suicidal thoughts was associated with: being female; baseline CIS–R score above 5; not being part of the workforce (that is, homemakers, retired people, students); having a small support network (four to eight people); age 16–24 years, and being single, divorced, or separated. Of those with suicidal thoughts at baseline, recovery occurred in 56.8% (95% CI 46.5% to 66.5%) by the follow up interview. Similar risk factors were responsible for reducing recovery from suicidal thoughts. There was no association between incidence of suicidal thoughts or recovery and: life events; occupational social class; weekly income; housing tenure, or substance misuse (see http://www.ebmentalhealth.com/supplemental for table).
Programmes that reduce the risk factors identified in this study may help to reduce suicide rates. However, further studies are needed to inform suicide prevention strategies.
Results may not apply to the general population. The sample population of this study may not be representative of the general population, because it included all people with CIS–R score above 5 and only 20% of people with a CIS–R score below 5. The study performed multiple analyses, which are prone to finding effects by chance. The suggested risk factors, while plausible, should therefore be regarded with caution pending further research.
One of the enduring difficulties in psychiatric practice is in accurately identifying people at risk of committing suicide. The public health policy problem is in devising effective screening and intervention programmes that could reduce suicide rates.
The dilemma lies in the complex relationship between suicidal ideation and completed suicide. There is an inherent asymmetry in that everyone who dies by suicide experiences (if only briefly) suicidal ideation, but the vast majority of people who experience suicidal ideation do not go on to complete this act. The actual incidence of suicidal ideation in the general population is not well known, nor are the risk factors that lead to this condition.
The study by Gunnell et al attempts to quantify the incidence of suicidal ideation in the British population and to define relevant risk factors, as captured by the second National Psychiatric Morbidity Survey. The authors identified people who had experienced suicidal ideation in the year prior to the survey and then resurveyed these people 18 months later. The annual incidence of suicidal ideation in this sample was 2.3% at the baseline assessment, but more than half reported this resolved by the 18 month follow up survey. The factor most closely associated with suicidal ideation was presence of a psychiatric disorder, determined by a screening instrument. This recapitulates other research on suicide attempts and completed suicide, in which the strongest risk factor is presence of a mental illness.1,3
The clinical practice and public health policy ramifications of this investigation are that suicide prevention efforts need to be focused on those at highest risk, which is not defined by current or past year suicidal ideation, but by other risk factors, in particular presence of a mental illness.
For correspondence: David Gunnell, Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK;
Sources of funding: Department of Health and Scottish Executive Health Department