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PAPERS: Merete Nordentoft, Thomas Munk Laursen, Esben Agerbo, Ping Qin, Eyd Hansen Høyer, and Preben Bo Mortensen Change in suicide rates for patients with schizophrenia in Denmark, 1981-97: nested case-control study BMJ 2004; 0: bmj.38133.622488.63v1 [Abstract]

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Availability of means to commit suicide

gopal s chinnari, Stephanie Fulton   (29 June 2004)

Good news for mental health - pity psychiatry had nothing to do with it.

Woody Caan   (30 June 2004)

Let's have more !

A.A.W. Amarasinghe, MD,   (1 August 2004)

Is it mainly due to common factors?

Lena K Palaniyappan   (1 August 2004)

Suicide and schizophrenia: role of depression and stigma!

Dr. Naseem A. Qureshi, MD, IMAPA, LMIPS   (3 August 2004)

The role of misdagnosis

Andrew Al-Adwani   (4 August 2004)

Suicide in psychiatric patients

Dermot Walsh   (10 August 2004)

Availability of means to commit suicide 29 June 2004
gopal s chinnari, SHOin psychiatry margaret stanhope center, burton on trent, DE13 0RB, Stephanie Fulton Send response to journal: Re: Availability of means to commit suicide	Dear sir, I cannot completely agree with your conclusions.Especially the availability of means to commit suicide.I think there is definitely increased availability of means to commit suicide.Over the period, we had more access to drugs(over dosage), and other means.Inspite the decreased mortality from suicide could be due to better treatment options and support. Competing interests: None declared
Good news for mental health - pity psychiatry had nothing to do with it. 30 June 2004
Woody Caan, Professor of public health APU, Chelmsford, Essex CM1 1SQ, UK. Send response to journal: Re: Good news for mental health - pity psychiatry had nothing to do with it.	Based on World Health Statistics from the 1990s, the gloomy prediction was that societies with increasing gross national product would report increasing suicides among both men and women (1). On a World scale, Denmark is a very prosperous society, that has now reported substantially reduced suicide rates over a generation (2). What a cause for hope in the UK! Since the same decline took place for the general population, for all ages, for both sexes, as for intensively treated psychiatric "cases", inspite of major changes in the provision and staffing of psychiatric services in the later period of this study (2), it is unlikely that suicide reduction had anything to do with psychiatry. The authors helpfully identify a key risk period and population that has never been effectively addressed: the month after discharge from first inpatient admission for young male patients with schizophrenic psychosis. In the UK (in Lambeth) this was addressed ten years ago (3) in an inter- professional demonstration project called Bridging Therapy funded by the Kings Fund. However, it is not clear that the learning from this and similar innovative but short-term projects has any impact on the wider British system of care. One lesson we could learn from the Danes is that an increasingly diverse society can simultaneously become more tolerant and inclusive. Feelings of shame, failure, rejection and disconnectedness in young men could all predipose to suicide during or after hospital admission. In relation to lethal shame and isolation, could a growing culture of forebearance, hope and integration in Denmark have contributed to their overall reductions in suicide? To reduce social stigma and helplessness around mental health in young men, Britain now has a national opportunity for action to "include" psychiatric patients. The Government has invited suggestions for a Framework for Vocational Rehabilitation for better employment prospects (4). Let's work on it. 1 Moniruzzaman S, Andersson R. Relationship between economic development and suicide mortality: a global cross-sectional analysis in an epidemiological transition perspective. Public Health 2004; 118: 346-348. 2 Nordentoft M, Laursen TM, Agerbo E, Qin P, Høyer EH, Mortensen PB. Change in suicide rates for patients with schizophrenia in Denmark, 1981- 97: nested case-control study BMJ 2004; 0: bmj.38133.622488.63v1-0 3 Rainsford E, Caan W. Experience of supervising discharges. J Clin Nurs 1994;3(3):133-4. 4 Department for Work and Pensions. Developing a Framework for Vocational Rehabilitation. London: DWP, 2004. Competing interests: None declared
Let's have more ! 1 August 2004
A.A.W. Amarasinghe, MD,, Consultant Psychiatrist 102 Bayberry Hills McDonough Ga USA30253 4005 Send response to journal: Re: Let's have more !	The factors that lead to suicide among the persons afflicted with schizophrenia are different from those among the general population. However, the very clear parallel nature of the incidence of suicide in the Danish schizophrenics and their total population begs for further studies in diverse socio-cultural mileu. Competing interests: None declared
Is it mainly due to common factors? 1 August 2004
Lena K Palaniyappan, Clinical Observer Outer North CMHT, Swindon, SN1 4JA Send response to journal: Re: Is it mainly due to common factors?	Dear Editor, The analysis of suicidal rate among Schizophrenia patients by Merete Nordentoft et al(1) is certainly one of the very important piece of work in this subject. Though at the end of the study we are left with no strong reasons for this significant decline, there is much room for educated speculations that can drive further research into this crucial topic. The authors feel that factors that patients share with the general population, such as less access to means to commit suicide and better treatment after attempted suicide may be the main influences. But before concluding so we have to address some concerns: 1. There is a better reduction of suicide rate in female population in both subjects and controls. Based on this we cannot say that same factors operate for both controls and subjects and that is why we have same pattern of change (i.e. female better than male suicide rates). The logic says that causal relations cannot be ascertained by just observing sameness in content and pattern of outcome in two groups under study. 2. If we assume that the same factors operated to reduce suicidal rate in both groups we have to believe that the additional operating factors in subject population such as antipsychotic treatment, antidepressant cover and improvement in Quality of Life (of mentally ill patients in particular) did nothing or insignificant if anything to reduce suicide rate. This is very difficult to accept given the recent studies in this direction (2,3,4). Apart from this issue, as now it is generally well known that the risk of suicide is highest during the first year after first contact with the health care, the pattern of variation in incidence of schizophrenia itself correlated to suicide rates (say in every next 12 – 18 months time) should be looked into in future studies of similar nature. 1.Merete Nordentoft, Thomas Munk Laursen, Esben Agerbo, Ping Qin, Eyd Hansen Hoyer, and Preben Bo Mortensen. Change in suicide rates for patients with schizophrenia in Denmark, 1981-97: nested case-control study BMJ 2004; 329: 261-0. 2.Harkavy-Friedman JM, Nelson EA, Venarde DF, Mann JJ. Suicidal behaviour in schizophrenia and schizoaffective disorder: examining the role of depression. Suicide Life Threat Behav. 2004 spring; 34(1): 66-76. 3.Potkin SG, Alphs L, Hsu C, Krishnan KR, Anand R, Young FK, Meltzer H, Green A; InterSePT Study Group. Predicting suicidal risk in schizophrenic and schizoaffective patients in a prospective two-year trial. Biol Psychiatry. 2003 Aug 15; 54(4): 444-52 4.Ponizovsky AM, Grinshpoon A, Levav I, Ritsner MS. Life satisfaction and suicidal attempts among persons with schizophrenia. Compr Psychiatry. 2003 Nov-Dec; 44(6): 442-7 Competing interests: None declared
Suicide and schizophrenia: role of depression and stigma! 3 August 2004
Dr. Naseem A. Qureshi, MD, IMAPA, LMIPS, Medical Director [A], Director, CME&R Buraidah Mental Health Hospital, Postcode.2292, Saudi Arabia Send response to journal: Re: Suicide and schizophrenia: role of depression and stigma!	Sir: Notably, suicide is more commonly reported among patients with mood disorders as compared to patients with schizophrenia and related spectrum disorders. Unlike suicide, homicide is more common among patients with schizophrenia. Both suicide and homicide are more common among psychiatric population with severe mental illnesses than in general population. Core depressive features-either reactive/psychogenic or endogenous- are known to occur in patients with schizophrenia and these symptoms tremendously enhance the suicidality. The constellation of depressive symptoms usually manifest either during prodromal phase of psychotic breakdown or following resolution of psychotic symptoms, as post-psychotic depression. Episodes of suicide well correlate temporally with these periods of psychosocial devastation and personal disintegration, which are coupled with tremendous stigma. Early recognition of psychotic breakdown, prompt access to psychiatric services, proper treatment of early or late breakthrough depression, overall effective management of schizophrenic psychosis by atypical antipsychotics with better clinical and adverse effect profiles and continuing antistigmatization campaigns worldwide are some of the other determinants of suicide reduction among patients with schizophrenia and related disorders. Finally, suicide is a preventable phenomenon and hence effective preventive programs should be continued in order to further reduce the still high rate of suicide among vulnerable patients with severe psychoses. Reference: Merete Nordentoft, Thomas Munk Laursen, Esben Agerbo, Ping Qin, Eyd Hansen Høyer, and Preben Bo Mortensen. Change in suicide rates for patients with schizophrenia in Denmark, 1981-97: nested case-control study. BMJ 2004; 329: 261-0 Competing interests: None declared
The role of misdagnosis 4 August 2004
Andrew Al-Adwani, Consultant Psychiatrist Department of Mental Health, Scunthopre General Hospital, DN15 7BH Send response to journal: Re: The role of misdagnosis	Sir: Atlhough misdiagnoses of schizophrenia were more widespread in the USA, this is not a problem that Europe was immune from. I have come accross many patients in my practice, as I am sure have my colleagues, who either have clear bipolar disorder or personlity disorder but who have attracted a long term diagnosis of schizophrenia. This issue does not seem to be addressed in this paper and could account, to some extent, for the observed fall in suicide rates possibly coinciding with improved treatment of and for affective disorder. Competing interests: None declared
Suicide in psychiatric patients 10 August 2004
Dermot Walsh, research psychiatrist Health Research Board, Dublin Send response to journal: Re: Suicide in psychiatric patients	Nordentoft et al(1) report the correspondence of changes in suicide rates among those with schizophrenia and the general population in Denmark. Here in Ireland Corcoran and I reported the same confluence and remarked that suicide in psychiatric inpatients over a century from the 1880s moved " in tandem with that in the general population" (2). In recent years with more refined diagnostic classifiactions the changes in suicide numbers were uniform across diagnostic categories, including schizophrenia, and more common off than on site, whether leave was authorised or not. Sadly, unlike in Denmark, our rates in both groups, have increased substantially. Obviously the factors credited with the Danish decline do not operate here and the similarity of change over so long a period and before modern treatments invites speculation as to generic cultural and social influences - wharever they may be! 1 Nordentoft M,Laursen TM,Agerbo E,Qin P, Hoyer EH, Mortensen PB.Change in suicide rates for patients with schizophrenia in Denmark,1981 -97: nested case-control study.BMJ 2004; 329: 261-264 2 Corcoran E, Walsh D. Suicide in psychiatric inpatients in Ireland. Ir J Psych Med 1999; 16(4): 127 - 131. Competing interests: None declared