Biomedical subjects
Publications and source records attributed to K Hawton.
Several countries in the Western hemisphere have experienced a marked increase in suicide rates in young males in recent years. This article considers this phenomenon largely from the perspective of the United Kingdom, where rates of suicide in 15-24-year-old males nearly doubled in just over a decade. The possible reasons for this are considered, particularly in the context of relative stability of suicide rates in young females.
STUDY OBJECTIVE: To determine if there are associations between rates of suicide and attempted suicide in 15-24 year olds in different countries in Europe. DESIGN: Attempted suicide rates were based on data collected in centres in Europe between 1989 and 1992 as part of the WHO/EURO Multicentre Study of Parasuicide. Comparison was made with both national suicide rates and local suicide rates for the areas in which the attempted suicide monitoring centres are based. SETTING: 15 centres in 13 European countries. PATIENTS: Young people aged 15-24 years who had taken overdoses or deliberately injured themselves and been identified in health care facilities. MAIN RESULTS: There were positive correlations (Spearman rank order) between rates of attempted suicide and suicide rates in both sexes. The correlations only reached statistical significance for male subjects: regional suicide rates, r = 0.65, p < 0.02; national suicide rates, r = 0.55, p < 0.02. CONCLUSIONS: Rates of attempted suicide and suicide in the young covary. The recent increase in attempted suicide rates in young male subjects in several European countries could herald a further increase in suicide rates.
OBJECTIVES: To investigate potential sources of stress for farmers in England and Wales METHOD: A postal questionnaire was sent to a randomly selected group of 800 members of the National Farmers' Union and 200 members of the Farmers' Union of Wales. RESULTS: 500 questionnaires (51%) were returned completed between October 1995 and March 1996. Farmers had problems with record keeping and paperwork (62%), difficulty understanding forms (56%), and problems arising from the effects of new legislation and regulations (49%). Nearly a quarter (23%) reported financial problems and most worried about money (79%). Very few were socially isolated, with over 90% having at least one confidant. 70% worked > 10 hours a day, and 31% had health problems which interfered with their work, including more than a quarter of those < 50. 16% of the sheep farmers reported symptoms which they attributed to organophosphate poisoning. The farmers most vulnerable to financial and other problems were those with small farms and mixed farming operations. Farmers in Wales also seemed more vulnerable than those in England, but a lower response rate from members of the Farmers' Union of Wales means this difference should be interpreted cautiously. CONCLUSION: The survey confirms findings from several regional studies that many farmers are experiencing considerable stress from various causes. Local and national initiatives to assist farmers, including outreach programmes, should be encouraged. Policy makers should be aware of the potential impact of legislation, particularly on the more vulnerable groups.
BACKGROUND: Farmers in the UK have an elevated risk of suicide. It has been suggested that this may be related to their ease of access to dangerous means for suicidal behaviour. The extent to which farmers use these means and changes in their use may be relevant to suicide prevention. METHOD: Data on 719 deaths in farmers of both genders in England and Wales between 1981 and 1993 in which a verdict of suicide or undetermined cause (open verdict) was recorded were analysed. RESULTS: Of 702 deaths in male farmers, firearms were involved in 40.0%, hanging in 29.6%, carbon monoxide in 16.4%, poisoning in 8.0% (over half of which involved agricultural or horticultural poisons) and other methods in 6.1%. There was a considerable excess of deaths due to firearms compared with the distribution of methods of suicide and open verdict deaths in males in the general population. Hanging was also somewhat more frequent. During the study period there was a reduction in firearm death rates, particularly after 1989 when there was national legislation on firearm ownership, registration and storage. There were also fewer farming suicides after this date. By the end of the study period hanging was more frequent than deaths involving firearms. CONCLUSIONS: Farmers who commit suicide tend to use methods to which they have easy access. Restriction of the ready availability of such methods, particularly in farmers known to be depressed or otherwise at risk, might prevent some suicides.
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There is conflicting evidence regarding the effects of hormone replacement therapy (HRT) with estrogens on psychological and psychiatric symptoms of menopause. Forty women already attending a menopause clinic for continuing HRT by estrogen implants were studied in a randomized, double-blind, placebo-controlled study of estrogen reimplantation versus implantation of a placebo preparation. Assessment included self rating with visual analog scales, standardized psychological and menopause rating scales (Hospital Anxiety and Depression Scale, Self-Concept Questionnaire, Cognitive Failures Questionnaire, Greene Menopause Index), and interview with the Present State Examination. No difference in outcome with regard to either psychological or psychiatric symptoms was found 2 months after entry to the study between the women who received an active implant and those who received a placebo implant, in spite of the former group having a significant rise in estradiol levels. The only effect of HRT on physical symptoms was a nonsignificant reduction in flushes. Psychiatric morbidity of the study population was high with nearly half being "psychiatric cases" according to the Present State Examination at both initial assessment and follow-up. At entry to the study nearly all the women had levels of estradiol in the premenopausal range and four had supraphysiological levels. It appears likely that women were returning requesting a new implant because of symptoms related to nonhormonal factors. Women receiving continuing HRT for menopausal symptoms should be reassessed both for hormonal status and current psychosocial factors when they present with recurrent symptoms, especially those of a psychological or psychiatric nature.
The chronic fatigue syndrome is a disabling chronic condition of uncertain cause. Previous studies have found that patients seen in hospital clinics with the syndrome often strongly believe that their illness is physical in nature and minimize the role of psychological and social factors. There is also evidence that patients cope by avoiding activity. However, almost all of these studies have assessed illness beliefs only by questionnaire. The aim of this study was to explore the nature and origin of illness beliefs in more detail using in-depth interviews and a qualitative analysis of patient responses. Sixty-six consecutive referrals meeting Oxford criteria for chronic fatigue syndrome were recruited. Analysis of responses indicated that, whereas the most commonly described explanation for the illness was a physical one, more than half the patients also believed "stress" had played a role. Patients believed that they could partially control the symptoms by reducing activity but felt helpless to influence the physical disease process and hence the course of the illness. Patients reported that they had arrived at these beliefs about the illness after prolonged reflection on their own experience combined with the reading of media reports, self help books, and patient group literature. The views of health professionals played a relatively small role. There is potentially a considerable opportunity to help patients arrive at a wider and more enabling explanation of their illness when they first present to primary care.
The proportional mortality ratio for suicide is higher in farmers than in the general population. The reasons for this are likely to be complex, but may include easy availability of firearms, stress related to work, financial difficulties, and family problems. A psychological autopsy study of suicide in 84 farmers who died between 1991-1994 is presented and some preliminary findings are discussed.
The aims of this study were to describe the characteristics of alcohol and drug misusers presenting to a general hospital following suicide attempts and to investigate the patterns of clinical care they received before and after the attempts. The Oxford Monitoring System for Attempted Suicide and patient case-notes were used to obtain information on alcohol and drug misusers assessed by the general hospital psychiatric services after deliberate self-harm in 1992. Of 724 patients, 200 (28%) were substance misusers (36% of males, 23% of females). Both alcoholics and drug misusers were more likely than other attempters to be male, have histories of personality disorder and criminal offences and to make repeat attempts, and the drug misusers were more likely to be living alone and unemployed. These are characteristics associated with particularly high risk of suicide. A large proportion of the substance misusers had received specific treatment for their misuse before their attempts and the majority were offered this afterwards. Over a quarter did not accept the care they were offered. The general hospital management of attempted suicide patients must include systematic assessment for evidence of alcohol and drug misuse and maintain close links with substance misuse services. Patients identified as having problems in the use of alcohol without having developed dependence and/or physical symptoms are a group that warrants specific attention. Audits should be conducted in general hospitals to ensure that sufficient attention is being paid to the detection and management of suicide attempters with substance misuse.
OBJECTIVE: To investigate the relationship between the availability of paracetamol and its use for overdose and suicide. DESIGN: Analysis of routinely collected information on time trends for paracetamol suicides, non-fatal overdoses, and sales. SETTING: England and Wales and France. RESULTS: There were strong correlations between trends in paracetamol sales in the UK and trends in non-fatal paracetamol overdose in Oxford between 1976 and 1993 (Spearman's r = 0.86; 95% confidence interval (CI) 0.54, 0.96) and between paracetamol sales and non-fatal overdoses in France between 1974 and 1990 (r = 0.99; 95% CI 0.97, 1.00). Sales figures were also correlated with paracetamol related suicides in both England and Wales, 1983-91 (r = 0.72; 95% CI 0.11, 0.94) and France, 1974-90 (r = 0.79; 95% CI 0.50, 0.92). Similarly strong relationships were observed between trends in non-fatal overdoses and suicide by paracetamol poisoning in England and Wales (r = 0.85; 95% CI 0.61, 0.95) and France (r = 0.79; 95% CI 0.50, 0.92). It is estimated that approximately 32,000 overdoses involving paracetamol occur annually in England and Wales. Fatality rates from paracetamol overdose were four times as high in England and Wales (0.4%, 95% CI 0.38, 0.46) as in France (0.1%, 95% CI 0.06, 0.17). CONCLUSION: Trends towards greater availability of paracetamol are paralleled by increases in its use for both non-fatal overdose and suicide. Paracetamol related morbidity and mortality seem to be less frequent in France where the quantity of paracetamol in a single purchase is limited. Although not conclusive, these data add to a body of evidence which suggests that restrictions in the quantity of paracetamol available as a single purchase in the UK may reduce suicide and liver failure related to paracetamol.
BACKGROUND: A randomised clinical trial was carried out in suicide attempters to assess clinical efficacy of an intensive psychosocial intervention compared with treatment as usual. METHOD: Two hundred and seventy-four suicide attempters presenting for medical treatment were randomly assigned to either intensive psychosocial treatment or 'care as usual'. Intensive psychosocial treatment consisted of brief admission to a special crisis-intervention unit and problem-solving aftercare. 'Care as usual' included any form of treatment the assessing clinicians thought appropriate. Psychological well-being was evaluated by the SCL-90 and the Hopelessness Scale at 3, 6 and 12 months following entry in the study. RESULTS: No differences in outcome were found. The probability of repeat suicide attempts in the 12-month follow-up was 0.17 for patients in the experimental group and 0.15 for the control group. There were no differences in ratings on the SCL-90 and the Hopelessness Scale. Patients in the experimental group attended significantly more out-patient treatment sessions. CONCLUSIONS: General implementation of an intensive in-patient and community intervention programme for suicide attempters does not seem justified.
BACKGROUND: Deliberate self-harm (DSH) has been a major health problem in the UK for nearly three decades. Any changes in rates of DSH or the demographic characteristics of the patient population are likely to have important implications for clinical services and suicide prevention. METHOD: Data collected by the Oxford Monitoring System for Attempted Suicide were used to review trends in DSH between 1985-1995. RESULTS: There was a substantial increase in DSH rates during the 11-year study period, with a 62.1% increase in males and a 42.2% increase in females. The largest rise was in 15-24-year-old males (+ 194.1%). Changes in DSH rates correlated with changes in national suicide rates in both males and females in this age group. Rates of repetition of DSH increase in both genders during the study period. Paracetamol self-poisoning has continued to increase, half of all overdoses in 1995 involving paracetamol, and antidepressant overdoses have become more common. CONCLUSIONS: The increase in DSH, especially in young males, has important implications for general hospital DSH and medical services. It may herald a reversal of recent progress towards achievement of national suicide targets.
BACKGROUND: The Health of the Nation includes a target for reducing population suicide rates. We have examined and quantified various high-risk and population-based strategies for prevention based upon a number of stated assumptions and hypothetical interventions. METHOD: The published literature was used to estimate the population attributable fractions for both high-risk and population-based strategies. The number needed to treat for the high-risk strategies was calculated, assuming an intervention that reduced suicide rates by 25%. RESULTS: Interventions that would reduce rates of suicide by 25% would reduce population rates by about 2.6% for those recently discharged from hospital and by up to 5.8% for those presenting to general hospital with deliberate self-harm. The population attributable fraction for unemployment was 10.9%. CONCLUSIONS: High-risk strategies will have only a modest effect on population suicide rates, even if effective interventions are developed. Evaluating interventions for deliberate self-harm patients seems worthwhile. The UK Government's target for suicide reduction is more likely to be achieved using population-based strategies. Reducing the availability of methods commonly used for committing suicide is the most practicable current policy, although more radical approaches, for example reducing unemployment, may also substantially reduce suicide rates.
This study examines the link between duration of depression before treatment is introduced and the duration of depressive illness after treatment in a population of 59 female psychiatric inpatients. Most women were suffering with severe depression and the majority had had previous depressive illnesses. Calculation of the rank order correlation coefficient demonstrated no significant correlation between the duration of depression before initiation of treatment and the duration after treatment was introduced. This finding is discussed in relation to other relevant studies.
We studied the endocrine and subjective responses that followed acute administration of the 5-HT1A receptor agonist buspirone (0.5 mg/kg orally) in 11 male patients with chronic fatigue syndrome (CFS) and a group of matched healthy controls. Patients with CFS had significantly higher plasma prolactin concentrations and experienced more nausea in response to buspirone than did controls. However, the growth hormone response to buspirone did not distinguish CFS patients from controls. Our data question whether the enhancement of buspirone-induced prolactin release in CFS is a consequence of increased sensitivity of post-synaptic 5-HT1A receptors. It is possible that the increased prolactin response to buspirone in CFS could reflect changes in dopamine function.
OBJECTIVE: To evaluate the acceptability and efficacy of adding cognitive behaviour therapy to the medical care of patients presenting with the chronic fatigue syndrome. DESIGN: Randomised controlled trial with final assessment at 12 months. SETTING: An infectious diseases outpatient clinic. SUBJECTS: 60 consecutively referred patients meeting consensus criteria for the chronic fatigue syndrome. INTERVENTIONS: Medical care comprised assessment, advice, and follow up in general practice. Patients who received cognitive behaviour therapy were offered 16 individual weekly sessions in addition to their medical care. MAIN OUTCOME MEASURES: The proportions of patients (a) who achieved normal daily functioning (Karnofsky score 80 or more) and (b) who achieved a clinically significant improvement in functioning (change in Karnofsky score 10 points or more) by 12 months after randomisation. RESULTS: Only two eligible patients refused to participate. All randomised patients completed treatment. An intention to treat analysis showed that 73% (22/30) of recipients of cognitive behaviour therapy achieved a satisfactory outcome as compared with 27% (8/30) of patients who were given only medical care (difference 47 percentage points; 95% confidence interval 24 to 69). Similar differences were observed in subsidiary outcome measures. The improvement in disability among patients given cognitive behaviour therapy continued after completion of therapy. Illness beliefs and coping behaviour previously associated with a poor outcome changed more with cognitive behaviour therapy than with medical care alone. CONCLUSION: Adding cognitive behaviour therapy to the medical care of patients with the chronic fatigue syndrome is acceptable to patients and leads to a sustained reduction in functional impairment.
Despite the clinical impressions that there are considerable psychological benefits from HRT, there is only clear evidence for amelioration of psychological symptoms (including improvement in cognitive function) in women who have undergone a surgical menopause. Otherwise in the natural menopause it remains unclear which, if any, non-sexual psychological symptoms respond directly to oestrogen except as a secondary response to reduction in physical symptoms. Overall, it has to be said that there is little scientific backing for hormonal treatment of psychological problems on their own around the time of the natural menopause. In most cases psychological treatment or counselling will be more appropriate than HRT. It must be remembered that the prevalence of psychological symptoms in the menopause and gynaecology clinic is high just as it is in all hospital settings. The task is to identify which women: 1. Have a predominance of psychological symptoms and might have psychiatric disorders. They may have presented in the clinic because they also happen to be menopausal, but it may well be that the psychiatric disorder has a quite independent aetiology. They will benefit from specific treatment for that disorder. 2. Have, and complain of, low moods or other non-specific psychological symptoms and have presented in the clinic because they are menopausal. They might benefit from practical, supportive help with current and ongoing stresses and strains. 3. Present appropriate menopausal complaints and only on enquiry reveal their psychological problems. In particular, disorders such as depressive illness, anxiety states and alcohol abuse can present with physical symptoms including ones which mimic vasomotor ones. This group may well be non-responders to HRT. Women requiring particular consideration might be those with other health problems (particularly chronic ones that might carry on in to old age) who are possibly more at risk of developing depression as they pass through the menopause. There is clearer evidence that HRT has beneficial effects on sexual function. When sexual symptoms are presented it is worth clarifying the exact features contributing to the complaint. Is it a problem of sexual interest, of infrequency of sexual activity, of vaginal dryness and dyspareunia, or is it a mixture of these complaints? Reduction of sexual interest and reduced sexual activity with the partner and possibly orgasm may accompany the menopause. Oestrogens have been shown to have some beneficial effect on sexual desire. Where oestrogen alone is ineffective, testosterone is usually beneficial. This treatment effect is particularly clear in surgically menopausal women. Non-menopausal aspects of the sexual relationship must be considered too. These aspects include the quality of the relationship, the sexual performance of the partner (since sexual desire decreases in both sexes with age), and age-related changes in self-image. These issues may need to be addressed at a simple health education level or with specific counselling. Although a woman's motivation or desire might change as a result of HRT, on its own this will not influence the frequency of intercourse or response during intercourse unless the partner variables permit this. The situation is more straightforward when problems of postmenopausal vaginal dryness and dyspareunia are the key issues. Oestrogens have been shown to be highly effective in such circumstances. It is also worth noting that regular and continued sexual activity has been found to protect against vaginal dryness.
The 15 areas under study in the WHO/Euro Multicentre Study on Parasuicide vary considerably with regard to socio-economic factors, culture, life-styles, etc. In this paper, the authors discuss whether the traditional high risk factors for suicidal behavior (such as unemployment, abuse, divorce, etc.) take on different weights depending on local societal and cultural settings. Results from analyzing covariations between various background factors characteristic of the different areas under study and the frequency of attempted suicide showed weak or insignificant correlations, indicating that high-risk factors can only be identified from international pooled data with great care.