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The association between somatic disorders and suicidal behaviour has been examined in many studies. Despite large variation in quality and study design, recent studies have improved our knowledge substantially, not only regarding the extent of risk but also factors influencing the risk. Most studies have been conducted in European countries, the US, Australia, Japan, and South Korea. A series of studies have examined suicide risk in relation to somatic disorders of older persons, while others addressed somatic disorders and attempted suicide in children and youth. Physical conditions may play an important role in medical settings, regardless of whether mental disorders are present or not, though especially when mental disorders are present. This chapter presents a review of present knowledge on suicide and suicidal behaviour in selected somatic disorders and pain syndromes, with a focus on studies from different parts of the world.

Background: Workplace bullying may severely affect mental health, but its association with suicidal behaviour is unknown. We analysed whether individuals reporting exposure to workplace bullying had higher risk of suicidal behaviour than those not reporting such exposure. Methods: Using a prospective cohort study design, we linked data from nine Danish questionnaire-based surveys (2004-2014) to national register data until December 31st, 2016. Exposure to workplace bullying was measured by a single item. Suicide attempts were identified in hospital registers and death by suicide in the Cause of Death Register. Among participants with no previous suicide attempts, we estimated Hazard Ratios (HR) and 95% Confidence Intervals (CI), adjusting for sex, age, marital status, socio-economic status, and history of psychiatric morbidity. Outcomes: The sample consisted of 98 330 participants (713 809 person-years); 63·6% women, mean age 44·5 years. Workplace bullying was reported by 10 259 participants (10·4%). During a mean follow-up of 7·3 years, we observed 186 cases of suicidal behaviour, including 145 suicide attempts, 36 deaths by suicide and 5 cases that died by suicide after surviving a suicide attempt. The fully-adjusted HR for the association between workplace bullying and suicidal behaviour was 1·70 (95% CI 1·10–2·61). The HRs for suicide attempts and death by suicide were 1·72 (1·14–2·58) and 2·29 (1·00–5·53), respectively. A multiplicative interaction with sex (2·78, CI 1·59–4·88) indicated that workplace bullying was associated with suicidal behaviour among men. Interpretation: The results suggested an elevated risk of suicidal behaviour among men reporting workplace bullying. Funding Information: Region of Southern Denmark (grant number A1763); Danish Working Environment Research Fund (grant number 20130023294); Danish Working Environment Research Fund (grant number 10-2019-03). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The project has been approved by the Danish Data Protection Agency (Capital Region of Denmark; j.nr.: 2012-58-0004).

Background: The suicide rate in first week after psychiatric discharge is alarmingly high. Although a risk assessment prior to discharge is standard praxis, it can be difficult to take into consideration the obstacles that patient will meet once discharged. A follow-up-visit during the first week after discharge is an opportunity to reevaluate whether a person may be at risk of suicide.Aim: To determine how many patients, of those who were assessed, were evaluated to be at elevated risk of suicide during the first week after psychiatric discharge and secondarily to identify predictors of this and predictors for receiving a follow-up visit during first week after discharge.Methods: All patients discharged between March 1st 2018 to January 17th 2019 were offered a home visit including a systematic risk assessment. Socio-demographics and clinical variables were obtained from medical records and logistic regression analyses were used to identify predictors of a higher suicide risk assessment as well as receiving a follow-up visit.Results: Information from 1905 discharges were included. Of these, 1,052 were seen in follow-up meetings. Risk assessments was conducted in a total of 567 discharge procedures, of which 28 (5%) had an elevated risk of suicide. A history of suicide attempt, suicide risk having been the reason for admission, a first diagnosis of a psychiatric disorder was associated with an elevated risk of suicide after discharge.Conclusion: Follow-up visits could serve as an important tool to identify people whose suicidal risk were overlooked at discharge or exposed to severe stressors after discharge.

Background: Few qualitative studies have focused on clinicians’ perspectives regarding treatment of suicidal people. Despite limited evidence and imperfect risk-assessment tools, the psychosocial therapy at the Danish suicide prevention clinics has been linked to reductions in numbers of repeated self-harm, deaths by suicide, and other causes. This merits an investigation into how clinicians describe their practice. Methods: Using a qualitative design, 10 semi-structured interviews were conducted and analyzed to describe the psychosocial therapy. Results: The practices that the therapists described could be categorized along four dichotomous continuums. These illustrated dilemmas encountered during treatment of suicidal patients: 1) intuitive vs. specific risk assessment, 2) meaningful vs. formal, 3) patient-oriented vs. therapist-oriented and 4) direct vs. indirect approach to suicide prevention. Conclusions: Treatment in the Danish Suicide Prevention Clinics is characterized by methodological flexibility and diversity and with an emphasis on a patient-oriented approach. Furthermore, clinicians balance knowledge available by switching between a direct and an indirect approach according to the perceived suicide risk. If suicide risk was perceived as high, they would administer a direct approach and if low, an indirect approach. Finally, there seems to be differences as to how effective therapeutic methodologies work in the practice of suicide prevention.

Background: The loss of a loved one to suicide can be a devastating experience that can have negative long-term effects on the social life and physical and mental health of the bereaved person. Worldwide, an estimated 237 million older adults have experienced suicide bereavement. As assumed in critical psychology, “the conduct of everyday life” reflects the social self-understanding by which people actively organize their lives based on their personal concerns, negotiation with co-participants in various action contexts, and their life interests. Bereaved people may change their social self-understanding as they adjust to their new roles and relationships in everyday life. The aim of this study was to investigate how older adults bereaved by suicide conducted their everyday life during the first 5 years after the loss of a loved one. Methods: This was a semi-structured qualitative interview study carried out by a research team consisting of co-researchers (older adults aged ≥60 years and bereaved by suicide), health care professionals, and researchers. The team conducted 15 semi-structured interviews with 20 older adults bereaved by suicide. The interviews were audio-recorded and verbatim transcribed. The participants’ mean age was 67.6 (range 61–79) years at the time of the loss. Data were thematically analyzed through a “conduct of everyday life” theoretical perspective. Results: We constructed a central theme “the broken notion of late-life living” in that late-life would no longer be as the participants had imagined. They struggled with their understanding of themselves and other people in social communities when they pursued their concerns adjusting to their broken notions of late-life living. We construed three primary concerns: 1) seeking meaning in the suicide, 2) keeping the memory of the deceased alive, and 3) regaining life despite the loss. Conclusion: The participants’ bereavement process was influenced by their stage in life. They perceived themselves as having reduced possibilities to restore their life project and limited time to re-orient their life. Other age-related factors influenced their possibilities to pursue their concerns in order to adjust to their new life conditions.

The aim of this study was to examine the relation of mental, physical, and social wellbeing measures to death by suicide and self-harm (SH).Using a cohort design, questionnaire data on 266,324 responders aged ≥ 45 years, living in NSW, Australia were linked to hospital and death databases during 2006-2017. Adjusted incidence rate ratios (IRR) were calculated.Overall, 212 suicides and 723 SH episodes were observed. A dose-response relationship with suicidal behaviour was found for Kessler-10 Psychological Distress Scale; IRRs of 4.5 (95% CI 2.4-8.3) for suicide and 8.3 (95% CI 6.5-10.7) for SH were observed for scores of high versus low distress. Elevated rates were also observed for those reporting poor versus good or excellent health (suicide, IRR: 3.8, 95% CI 2.2-6.9; SH, IRR: 4.5 95% CI 3.4-6.1); being dependent versus not dependent on help with daily tasks (suicide, IRR: 2.4 95% CI 1.5-3.7; SH, IRR: 2.6 95% CI 2.0-3.3); being a current smoker (suicide, IRR: 1.8, 95% CI 1.1-2.9; SH, IRR: 2.9 95% CI 2.3-3.5) having versus not having male erectile problems (SH, IRR: 1.9 95% CI 1.4-2.5). Participants with ≥ 5 people versus one person to depend on had reduced suicidal behaviour (suicide, IRR: 0.5 95% CI 0.3-0.7, SH, IRR: 0.5 95% CI 0.4-0.6).An active social network was linked to lower rates of suicide and self-harm. Adverse health, dependence on help, psychological distress were associated with higher rates of suicide and self-harm, while erectile problems were linked to an elevated rate of self-harm.

Suicide is often the outcome of a personal crisis; yet many conditions, both societal and individual, are established predictors of suicide. It remains a major public health problem worldwide, although rates of suicide vary substantially across nations. The highest rates are reported in Russia and East European countries. This chapter summarizes the existing evidence regarding societal and individual risk factors for suicide. At the societal level, risk factors such as economic crisis, social cohesiveness, and media portrayal are mentioned. Individual risk factors include sociodemographic factors, physical and mental disorders, history of suicide attempt, and suicide risk in minority groups. The risk factors associated with the highest risk are mental disorders and history of suicide attempt. Population-attributable risk calculations suggest that preventive efforts should be directed towards the excess risk associated with recent suicide attempt, mental disorders, and common social factors.

BACKGROUND: An increasing number of qualitative research articles have reported on relatives' experiences of providing care for individuals displaying suicidal behaviour. To contribute more fully to theory and practice, these reported experiences must be synthesized.OBJECTIVES: To identify original qualitative studies of relatives' experiences of providing care for individuals with non-fatal suicidal behaviour and to systematically review and synthesize this research using a meta-ethnographic approach.DESIGN: Systematic review and meta-ethnography.DATA SOURCES: Literature searches were undertaken in six bibliographic databases (PubMed, CINAHL, Embase, PsycINFO, Web of Science and Scopus) and limited to peer-reviewed original studies. Eligible studies reported relatives' experiences of providing care for individuals with suicidal behaviour, published in English or a Scandinavian language.REVIEW METHODS: One reviewer screened the titles, abstracts and full texts and then collaborated with another reviewer on excluding ineligible studies. A two-step strategy was used while reviewing publications: 1) appraising study quality, and 2) classifying study findings according to degree of data interpretation. This strategy was used for each study by two independent reviewers who subsequently reached a shared decision on inclusion. Noblit and Hare's methodology for translation and synthesis was followed in developing a novel theoretical interpretation of relatives' experiences. The concept of moral career was adopted in producing this synthesis.RESULTS: Of 7,334 publications screened, 12 studies were eligible for inclusion. The synthesis conveyed relatives' moral career as comprising four stages, each depicting relatives' different perspectives on life and felt identities. First, relatives negotiated conventional ideas about normalcy and positioned themselves as living abnormal family lives in the stage from normal to abnormal. The first career movement could be mediated by social interactions with professionals in the stage feeling helpful or feeling unhelpful. For some relatives, this negotiated perspective of abnormality got stuck in an impasse. They did not interact with their surroundings in ways that would enable them to renegotiate these fixed views, and this stage was named stuck in abnormality. For other relatives, career movement took place as relatives re-positioned themselves as negotiating an alternative perspective of normalcy in the stage from abnormal to normal.CONCLUSIONS: Interactions with other people facing similar difficulties enabled relatives to shift perspectives and alleviated experiences of distress.

Importance: Neurological disorders have been linked to suicide, but the risk across a broad spectrum of neurological disorders remains to be assessed. Objectives: To examine whether people with neurological disorders die by suicide more often than other people and to assess for temporal associations. Design, Setting, and Participants: Nationwide, retrospective cohort study on all persons 15 years or older living in Denmark, from 1980 through 2016 (N = 7300395). Exposures: Medical contact for head injury, stroke, epilepsy, polyneuropathy, diseases of myoneural junction, Parkinson disease, multiple sclerosis, central nervous system infections, meningitis, encephalitis, amyotrophic lateral sclerosis, Huntington disease, dementia, intellectual disability, and other brain diseases from 1977 through 2016 (n = 1248252). Main Outcomes and Measures: Death by suicide during 1980-2016. Adjusted incidence rate ratio (IRRs) were estimated using Poisson regressions, adjusted for sociodemographics, comorbidity, psychiatric diagnoses, and self-harm. Results: Of the more than 7.3 million individuals observed over 161935233 person-years (49.1% males), 35483 died by suicide (median duration of follow-up, 23.6 years; interquartile range, 10.0-37.0 years; mean age, 51.9 years; SD, 17.9 years). Of those, 77.4% were males, and 14.7% (n = 5141) were diagnosed with a neurological disorder, equivalent to a suicide rate of 44.0 per 100000 person-years compared with 20.1 per 100000 person-years among individuals not diagnosed with a neurological disorder. People diagnosed with a neurological disorder had an adjusted IRR of 1.8 (95% CI, 1.7-1.8) compared with those not diagnosed. The excess adjusted IRRs were 4.9 (95% CI, 3.5-6.9) for amyotrophic lateral sclerosis, 4.9 (95% CI, 3.1-7.7) for Huntington disease, 2.2 (95% CI, 1.9-2.6) for multiple sclerosis, 1.7 (95% CI, 1.6-1.7) for head injury, 1.3 (95% CI, 1.2-1.3) for stroke, and 1.7 (95% CI, 1.6-1.8) for epilepsy. The association varied according to time since diagnosis with an adjusted IRR for 1 to 3 months of 3.1 (95% CI, 2.7-3.6) and for 10 or more years, 1.5 (95% CI, 1.4 to 1.6, P

ispartof: The Lancet Psychiatry vol:7 issue:6 pages:468-471 ispartof: location:England status: published

Self-poisoning with non-opioid analgesics presents a growing challenge to health care providers. We aimed to assess the impact of an 18-year age restriction of OTC sales and a pack size restriction of non-opioid analgesics sold OTC in pharmacies on hospital-treated poisonings and poisoning severity measured using biomarkers.We applied a before and after design using interrupted time series analysis. Data on all poisonings recorded as hospital admissions were obtained during 2002-2015 and biochemical parameters from laboratory databases during 2011-2015, both covering the entire Danish population.The age restriction was followed by a 17% level reduction in admissions for non-opioid analgesic poisoning among young people age 10-17 years (RR 0.830; 95% CI 0.697-0.988; p 0.036). After the pack size restriction, an instant level reduction of 18.5% (RR 0.815; 95% CI 0.729-0.912; p 0.001) was observed for the entire population. A 27% decrease in the number of poisonings with alanine transaminase levels (ALT) ≥ 210 U/L was observed (RR 0.734; 95% CI 0.579-0.931; p = 0.011) followed by 40% decrease in biomarkers indicative of liver failure (RR 0.597; 95% CI 0.421-0.847; p = 0.004). We also observed similar reductions for other poisonings such as psychotropics.Although declines in poisonings were observed after implementation of means restrictive measures, a causal link cannot be inferred.Age and pack size restriction were assiociated with a reduction in the numbers of poisonings. This was also observed for pharmaceutical poisonings in general, which might suggest a non-specific or spill-over effect.

The objective of this study was to explore different stakeholder perspectives on the MYPLAN app for suicide prevention safety planning. The study was a comparative analysis of 4 focus groups with Danish MYPLAN stakeholders, young users, adult users, relatives, and clinicians. The focus groups were audio recorded, transcribed, and subjected to a thematic analysis. The analysis contextualized the participants’ experiences of the benefits and limitations of MYPLAN. While participants believed that MYPLAN could potentially interrupt early stages of a suicidal process, clinicians’ involvement in safety planning was considered important. MYPLAN could potentially give users a sense of increased personal control but learning how to effectively safety plan was not perceived to be simple and additional support should be considered for MYPLAN users.

Background and aims Almost 20% of the adult population suffers from chronic pain. Chronic pain may be linked to an elevated mortality; however, results from previous studies are inconsistent. Some studies find similar mortality levels in chronic pain patients and pain-free controls while other studies show elevated mortality levels among chronic pain patients, primarily with respect to cancer, diseases of the circulatory and respiratory systems, and suicide. These conflicting results are potentially due to different population samples and different operational definitions of chronic pain. Further research on overall and cause-specific mortality in patients with severe chronic pain is needed to inform clinical practice. The objective of this register-linkage study was to investigate whether patients with severe chronic pain referred to multidisciplinary pain treatment have higher cause-specific mortality rates than the general population. Methods In this register-linkage cohort study, data from 6,142 chronic pain patients (female: n=3,941, male: n=2,201, mean age: 48.2±14.2; range: 16–97 years) attending an interdisciplinary Pain Center in Odense, Denmark from 2005 to 2014 were linked to the Danish Register of Causes of Death. Age and gender standardized mortality ratios (SMRs) with their 95% confidence intervals (CI) were calculated and compared with those of the general population. Data from the general population was extracted from the Danish Register of Causes of Death, and Causes of death were classified according to national Classification of Disease (ICD-10). Results In all, 276 deaths (women: n=152, men: n=124) were observed among the chronic pain patients, and a six-fold higher overall mortality rate was found [SMR: 6.2 (95% CI: 5.5–7.0)] compared with the general population. Elevated cause-specific mortality rates were noted for chronic patients with respect to cancer and neoplasms [4.7 (95% CI: 3.7–5.9)], diseases of the circulatory system [5.7 (95% CI: 4.3–7.3)], diseases of the respiratory system [8.7 (95% CI: 6.2–11.9)], and suicide [7.3 (95% CI: 2.7–15.9)]. Conclusions The overall mortality rate of patients with severe chronic pain in this study was six-fold higher than the rate of the general population in this region. This was reflected in select specific causes of death (cancer and neoplasms, diseases of the circulatory system, diseases of the respiratory system, and suicide). The results are in agreement with previous studies and emphasize the need to understand which factors causally affect this increased mortality allowing for targeted interventions in similar chronic pain populations. Implications Potential reasons for the excess mortality should be adequately addressed by future studies in order to better target this in the management of these patients. The chronic pain population included in this study may have several comorbidities contributing to the increased mortality. To better address these aspects, complete medical profiles are needed in future studies. In addition, implementation of management strategies towards potential risk factors such as poor diet, low levels of physical activity, smoking, and high BMI as well as sleep deprivation and morphine use previously shown associated with having pain may reduce the excess mortality ratio.

Objectives: Prevalence rates of death by euthanasia (EUT) and physician-assisted suicide (PAS) have increased among older adults, and public debates on these practices are still taking place. In this context, it seemed important to conduct a systematic review of the predictors (demographic, physical health, psychological, social, quality of life, religious, or existential) associated with attitudes toward, wishes and requests for, as well as death by EUT/PAS among individuals aged 60 years and over.Method: The search for quantitative studies in PsycINFO and MEDLINE databases was conducted three times from February 2016 until April 2018. Articles of probable relevance (n = 327) were assessed for eligibility. Studies that only presented descriptive data (n = 306) were excluded.Results: This review identified 21 studies with predictive analyses, but in only 4 did older adults face actual end-of-life decisions. Most studies (17) investigated attitudes toward EUT/PAS (9 through hypothetical scenarios). Younger age, lower religiosity, higher education, and higher socio-economic status were the most consistent predictors of endorsement of EUT/PAS. Findings were heterogeneous with regard to physical health, psychological, and social factors. Findings were difficult to compare across studies because of the variety of sample characteristics and outcomes measures.Conclusion: Future studies should adopt common and explicit definitions of EUT/PAS, as well as research designs (e.g. mixed longitudinal) that allow for better consideration of personal, social, and cultural factors, and their interplay, on EUT/PAS decisions.

Family studies have shown an aggregation of suicidal behavior in families. Yet, molecular studies are needed to identify loci accounting for genetic heritability. We conducted a genome-wide association study and estimated single nucleotide polymorphisms (SNP) heritability for a suicide attempt. In a case-cohort study, national data on all individuals born in Denmark after 1981 and diagnosed with severe mental disorders prior to 2013 (n = 57,377) and individuals from the general population (n = 30,000) were obtained. After quality control, the sample consisted of 6024 cases with an incidence of suicide attempt and 44,240 controls with no record of a suicide attempt. Suggestive associations between SNPs, rs6880062 (p-value: 5.4 × 10(−8)) and rs6880461 (p-value: 9.5 × 10(−8)), and suicide attempt were identified when adjusting for socio-demographics. Adjusting for mental disorders, three significant associations, all on chromosome 20, were identified: rs4809706 (p-value: 2.8 × 10(−8)), rs4810824 (p-value: 3.5 × 10(−8)), and rs6019297 (p-value: 4.7 × 10(8)). Sub-group analysis of cases with affective disorders revealed SNPs associated with suicide attempts when compared to the general population for gene PDE4B. All SNPs explained 4.6% [CI-95: 2.9–6.3%] of the variation in suicide attempt. Controlling for mental disorders reduced the heritability to 1.9% [CI-95: 0.3–3.5%]. Affective and autism spectrum disorders exhibited a SNP heritability of 5.6% [CI-95: 1.9–9.3%] and 9.6% [CI-95: 1.1–18.1%], respectively. Using the largest sample to date, we identified significant SNP associations with suicide attempts and support for a genetic transmission of suicide attempt, which might not solely be explained by mental disorders.

Introduction Sleep disorders and psychiatric disease are closely related, and psychiatric diseases are associated with elevated suicide risks. Yet, it is not clear if sleep disorders are associated with suicide as previous studies were limited by self-reported measures. The aim of this study was to examine whether people with a hospital-diagnosis of sleep disorders had higher suicide rates than people with no diagnosis. Methods Using a retrospective cohort design, national data on all persons aged 15 years and over who lived in Denmark during 1980–2016 (males: 3,674,563, females: 3,688,164) were obtained. People with sleep disorders were identified in somatic hospital registers. The main outcome was death by suicide as recorded in the Danish Cause of Death register. Incidence Rate Ratios were obtained using Poisson regressions while adjusting for relevant covariates. Results Out of 23,927 male and 11,556 female suicide deaths, 299 and 117 had been diagnosed with a sleep disorder, respectively. Males with sleep disorders had a suicide rate of 47.4 (95% CI, 42.0–52.7) per 100,000 person-years compared to 29.9 (95% CI, 29.5–30.3) among those with no sleep disorders. For females the respective rates were 42.3 (95% CI, 34.7–50.0) versus 13.9 (95% CI, 13.6–14.1). An adjusted IRR of 1.6 (95% CI, 1.4–1.7) and 2.2 (95% CI, 1.8–2.6) was noted among males and females with sleep disorders, respectively, when compared to those with no disorders. Excess rates were noted with respect to insomnia, narcolepsy and, in males, sleep apnea. A difference with respect to age and sex was observed (p Conclusion In this study, individuals with sleep disorders had an increased suicide rate when compared to those with no sleep disorders. Higher suicide rates were found for individuals suffering from narcolepsy, insomnia and sleep apnea. More attention towards risks of suicide among people with sleep disorders might be needed. Support (if any)

BACKGROUND: Prevalence rates of mental disorders in patients with chronic pain vary and may be overestimated when assessed by screening instruments only. Objectives were to estimate the 10-year prevalence of different mental disorders diagnosed by psychiatrists in patients with chronic pain compared with the Danish general population.METHODS: Patients (n = 7197) consulted in the interdisciplinary Pain Clinic South at Odense University Hospital, Denmark, from 2005 to 2015 were included. Data from the Pain Clinic were linked to the Danish National Patient Register-Psychiatry and the Danish Civil Registration System. Age and gender standardized prevalence ratios (SPR) were calculated.RESULTS: In all, 17.8% of patients with chronic pain had been diagnosed with a mental disorder. The most frequent diagnoses were adjustment disorders (subcategory of anxiety disorders) (8.9%), depression (6.1%), personality disorders (3.8%), and substance abuse disorders (3.5%). Women and men with chronic pain had higher rates of anxiety disorders (SPR 3.1; 95% CI 2.9-3.4) and depression (SPR 2.5; 95% CI 2.3-2.8), whereas men had higher rates of substance abuse disorders (SPR 1.6; 95% CI 1.3-1.9) than found for the general population.CONCLUSIONS: Although depression and anxiety were noted more frequently among patients with chronic pain than the general population, prevalence rates were lower than previously reported. The most frequent diagnoses were adjustment disorders.SIGNIFICANCE: Prevalence rates of anxiety and depression diagnosed by psychiatrists in patients with chronic pain were found to be lower than previous findings using screening instruments. Adjustment disorders were the most frequent disorders diagnosed, as this study is the first to investigate.

BACKGROUND: Systematic reviews have consistently shown that individuals with mental disorders have an increased risk of premature mortality. Traditionally, this evidence has been based on relative risks or crude estimates of reduced life expectancy. The aim of this study was to compile a comprehensive analysis of mortality-related health metrics associated with mental disorders, including sex-specific and age-specific mortality rate ratios (MRRs) and life-years lost (LYLs), a measure that takes into account age of onset of the disorder.METHODS: In this population-based cohort study, we included all people younger than 95 years of age who lived in Denmark at some point between Jan 1, 1995, and Dec 31, 2015. Information on mental disorders was obtained from the Danish Psychiatric Central Research Register and the date and cause of death was obtained from the Danish Register of Causes of Death. We classified mental disorders into ten groups and causes of death into 11 groups, which were further categorised into natural causes (deaths from diseases and medical conditions) and external causes (suicide, homicide, and accidents). For each specific mental disorder, we estimated MRRs using Poisson regression models, adjusting for sex, age, and calendar time, and excess LYLs (ie, difference in LYLs between people with a mental disorder and the general population) for all-cause mortality and for each specific cause of death.FINDINGS: 7 369 926 people were included in our analysis. We found that mortality rates were higher for people with a diagnosis of a mental disorder than for the general Danish population (28·70 deaths [95% CI 28·57-28·82] vs 12·95 deaths [12·93-12·98] per 1000 person-years). Additionally, all types of disorders were associated with higher mortality rates, with MRRs ranging from 1·92 (95% CI 1·91-1·94) for mood disorders to 3·91 (3·87-3·94) for substance use disorders. All types of mental disorders were associated with shorter life expectancies, with excess LYLs ranging from 5·42 years (95% CI 5·36-5·48) for organic disorders in females to 14·84 years (14·70-14·99) for substance use disorders in males. When we examined specific causes of death, we found that males with any type of mental disorder lost fewer years due to neoplasm-related deaths compared with the general population, although their cancer mortality rates were higher.INTERPRETATION: Mental disorders are associated with premature mortality. We provide a comprehensive analysis of mortality by different types of disorders, presenting both MRRs and premature mortality based on LYLs, displayed by age, sex, and cause of death. By providing accurate estimates of premature mortality, we reveal previously underappreciated features related to competing risks and specific causes of death.FUNDING: Danish National Research Foundation.

Background People belonging to sexual minority groups have higher levels of suicidality than heterosexuals. However, findings regarding suicide death are sparse. Using unique national data from two countries, we investigated whether individuals entering a same-sex marriage (SSM), a proxy group of sexual minority individuals, had higher suicide rates than those entering opposite-sex marriage (OSM). Methods A cohort study of all males and females who entered an SSM (n=28 649) or OSM (n=3 918 617) in Denmark and Sweden during 1989–2016 was conducted. Incidence rate ratios (IRRs) for suicide were calculated using adjusted Poisson regression models. Results In total, 97 suicides occurred among individuals who had entered an SSM compared with 6074 among those who entered an OSM, corresponding to an adjusted IRR of 2.3 (95% CI 1.9 to 2.8). For people who entered SSM, a 46% decline was noted over time from an IRR of 2.8 (95% CI 1.9 to 4.0) during 1989–2002 to 1.5 (95% CI 1.2 to 1.9) during 2003–2016. The excess suicide mortality was present in all age groups but most pronounced among younger individuals aged 18–34 years of age (IRR 2.7, 95% CI 1.5 to 4.8) and females (IRR 2.7, 95% CI 1.8 to 3.9). Conclusion This large register-based study found higher suicide rates among individuals who entered an SSM, compared with those who entered an OSM. A lower suicide rate was noted for individuals in SSMs in recent years. More research is needed to identify the unique suicide risk and protective factors for sexual minority people.

BACKGROUND: Evidence links infections to mental disorders and suicidal behavior. However, knowledge is sparse regarding less severe infections, anti-infective treatment, and deliberate self-harm. Using nationwide Danish longitudinal registers, we estimated associations between infections treated with anti-infective agents and infections requiring hospitalization with the risk of deliberate self-harm.METHODS: A total of 1.3 million people born between 1977 and 2002 were followed during the period from 1995 to 2013. In total, 15,042 individuals were recorded with deliberate self-harm (92% had been treated with anti-infective agents and 19% had been hospitalized for infections) and 114 died by suicide (64% had been treated with anti-infective agents and 13% had been hospitalized for infections). Hazard rate ratios were obtained while adjusting for age, gender, calendar period, education, hospitalizations with infections, prescribed anti-infective agents during childhood, parental mental disorders, and parental deliberate self-harm.RESULTS: Individuals with infections treated with anti-infective agents had an increased risk of deliberate self-harm with a hazard rate ratio of 1.80 (95% confidence interval = 1.68-1.91). The associations fitted a dose-response relationship (p < .001) and remained significant up to 5 years after last infection. An additive effect was found for individuals with an additional hospitalization for infections with an increased hazard rate ratio of 3.20 (95% confidence interval = 2.96-3.45) for deliberate self-harm.CONCLUSIONS: An increased risk of deliberate self-harm was found among individuals with infections treated with anti-infective agents in temporal and dose-response associations. These results add to the growing literature on a possible link between infections and the pathophysiological mechanisms of suicidal behavior.

Suicide is a major public health problem and there is a paucity of knowledge about the particular needs of people bereaved by suicide late in life. This study protocol describes a co-operative inquiry designed to collaboratively explore the needs for psychosocial support for this group and to use ‘action circles’ to develop and test psychosocial interventions. Further, it explores how the co-operative partnership influences the overall research processes. Data will be subjected to thematic analysis and discourse analysis. The protocol was approved in December 2016 and the study will take place between April 2017 and March 2020.

Background The effect of safety planning for people in suicidal crisis is not yet determined, but using safety plans to mitigate acute psychological crisis is regarded as best practice. Between 2016 and 2017, Australian and Danish stakeholders were involved in revising and updating the Danish MYPLAN mobile phone safety plan and translating the app into a culturally appropriate version for Australia. Objective The objective of this study was to examine the negotiation of stakeholders’ suggestions and contributions to the design, function, and content of the MYPLAN app and to characterize significant developments in the emerging user-involving processes. Methods We utilized a case study design where 4 focus groups and 5 user-involving workshops in Denmark and Australia were subjected to thematic analysis. Results The analyses identified 3 consecutive phases in the extensive development of the app: from phase 1, Suggesting core functions, through phase 2, Refining functions, to phase 3, Negotiating the finish. The user-involving processes continued to prevent closure and challenged researchers and software developers to repeatedly reconsider the app’s basic user interface and functionality. It was a limitation that the analysis did not include potentially determinative backstage dimensions of the decision-making process. Conclusions The extended user involvement prolonged the development process, but it also allowed for an extensive exploration of different user perspectives and needs.

BACKGROUND: Suicide accounts for more than 800,000 annual deaths worldwide. Some of these deaths may be preventable by timely identification of individuals at risk and effective intervention. General practitioners (GPs) may have the potential to play an important role in this process.AIM: The present study aimed to assess the frequency of primary health care utilization in the year preceding suicide.METHODS: Using Danish national registers, we identified all persons who died by suicide in Denmark from 1997 through 2013 and assessed the frequency of their primary care utilization and compared it with that of an age- and sex-matched reference group sampled from the background population.RESULTS: We identified 11,191 persons who died by suicide (males: 8,095, females: 3,096). Compared with the reference group (N = 55,955), a greater proportion attended general practice in the year before index date (83% vs. 76%). In the last month before index date, these figures were 32.0% and 19.4%, respectively, corresponding to a difference of 12.0 95% CI: (11.1; 12.9) percentage points after adjustment for demographic characteristics and physical comorbidity. Suicide cases had a higher GP attendance in every week in the year before suicide, but the difference increased specifically in the last four months.CONCLUSION: More than 30% attended the GP in the month before the suicide. This indicates that general practice could be a possible place to identify suicide cases and offer intervention. However, although this proportion represents a markedly higher GP attendance than seen in the reference group, almost 70% of those who died by suicide did not attend primary care in the month before the suicide. Our study suggests that it is important that the GPs have easy access to effective suicide prevention programs for patients at risk of suicide, and that persons with suicidal thoughts are encouraged to contact their GP.

Importance: There is limited evidence supporting an association of autism spectrum disorder (ASD) with suicidality and the risk factors for suicide attempt and suicide among people with ASD. Existing research highlights the need for national cohort studies. Objectives: To analyze whether people with ASD have higher rates of suicide attempt and suicide compared with people without ASD using national register data, identify potential risk factors for suicide attempt and suicide among those with ASD, and examine associations with comorbid disorders. Design, Setting, and Participants: In this cohort study, nationwide register data from January 1, 1995, to December 31, 2016, were gathered on 6 559 266 individuals in Denmark aged 10 years or older. Statistical analysis was performed from November 20, 2018, to November 21, 2020. Main Outcomes and Measures: Rates of suicide attempt and suicide among persons with ASD were compared with rates among persons without ASD, using Poisson regression models to calculate incidence rate ratios adjusted for sex, age, and time period. Results: Of the total study population of 6 559 266 individuals, 35 020 individuals (25 718 male [73.4%]; mean [SD] age at diagnosis, 13.4 [9.3] years) received a diagnosis of ASD. A total of 64 109 incidents of suicide attempts (587 [0.9%] among individuals with ASD) and 14 197 suicides (53 [0.4%] among individuals with ASD) were recorded. Persons with ASD had a more than 3-fold higher rate of suicide attempt (adjusted incidence rate ratio [aIRR], 3.19; 95% CI, 2.93-3.46) and suicide (aIRR, 3.75; 95% CI, 2.85-4.92) than those without ASD. For individuals with ASD, the aIRR for suicide attempt among female individuals was 4.41-fold (95% CI, 3.74-5.19) higher compared with male individuals; for individuals without ASD, the aIRR for female individuals was 1.41-fold (95% CI, 1.39-1.43) higher compared with male individuals. Higher rates of suicide attempt were noted across all age groups for those with ASD. Persons with a diagnosis of ASD only had an aIRR of 1.33 (95% CI, 0.99-1.78) for suicide attempt, whereas those with other comorbid disorders had an aIRR of 9.27 (95% CI, 8.51-10.10) for suicide attempt compared with those without any psychiatric disorders. A total of 542 of 587 individuals with ASD (92.3%) who attempted suicide had at least 1 other comorbid condition and 48 of 53 individuals with ASD (90.6%) who died by suicide had at least 1 other comorbid condition. Conclusions and Relevance: This nationwide retrospective cohort study found a higher rate of suicide attempt and suicide among persons with ASD. Psychiatric comorbidity was found to be a major risk factor, with more than 90% of those with ASD who attempted or died by suicide having another comorbid condition. Several risk factors are different from the risk factors in the general population, which suggests the need for tailored suicide prevention strategies.

Aim: Few population-based, family studies have examined associations between exposure to one vs. two parent(s) with alcohol use disorder (AUD) and the risk of offspring developing substance use disorder (SUD). Moreover, these studies have focused solely on the development of AUD, and not SUD, in offspring. The purpose of this study was to investigate whether exposure to one vs. two parent(s) with AUD increases the risk of offspring developing SUD. Methods: A population-based, cohort study was conducted in which offspring born in Denmark between 1983 and 1989 were followed through national registries until 2011. Register-based data were obtained from the: Psychiatric Central Research Register, National Patient Registry, Civil Registration System, Fertility Database, and Cause of Death Register. Adjusted hazard ratios were calculated using multivariate Cox-regression models.Findings: A total of 398,881 offspring were included in this study. Of these, 3.9 % had at least one parent with AUD. Parental AUD was significantly associated with the development of SUD in offspring. Having one parent with AUD was linked to a 1.44-fold increased risk (95% CL, 1.29 - 1.61), while having two parents with AUD was linked to a 2.29-fold increased risk (95% CI, 1.64 – 3.20). No significant differences were found in relation to either parental or offspring gender.Conclusions: Exposure to parental AUD is linked to an increased risk of offspring developing SUD. This risk is additive for offspring exposed to double parental AUD. The findings have important implications for clinical assessment and intervention strategies, as well as the management of offspring exposed to parental AUD.

Using the Columbia-Suicide Severity Rating Scale (C-SSRS), we examined the predictive and incremental predictive validity of past-month suicidal behavior and ideation for short-term suicidal behavior among adolescents at high risk of suicide. The study was conducted in 2014 on a sample of 85 adolescents (90.6% females) who participated at follow-up (85.9%) out of the 99 (49.7%) baseline respondents. All adolescents were recruited from a specialized suicide-prevention clinic in Denmark. Through multivariate logistic regression analyses, we examined whether baseline suicidal behavior predicted subsequent suicidal behavior (actual attempts and suicidal behavior of any type, including preparatory acts, aborted, interrupted and actual attempts; mean follow-up of 80.8 days, SD = 52.4). Furthermore, we examined whether suicidal ideation severity and intensity incrementally predicted suicidal behavior at follow-up over and above suicidal behavior at baseline. Actual suicide attempts at baseline strongly predicted suicide attempts at follow-up. Baseline suicidal ideation severity and intensity did not significantly predict future actual attempts over and above baseline attempts. The suicidal ideation intensity items deterrents and duration were significant predictors of subsequent actual attempts after adjustment for baseline suicide attempts and suicidal behavior of any type, respectively. Suicidal ideation severity and intensity, and the intensity items frequency, duration and deterrents, all significantly predicted any type of suicidal behavior at follow-up, also after adjusting for baseline suicidal behavior. The present study points to an incremental predictive validity of the C-SSRS suicidal ideation scales for short-term suicidal behavior of any type among high-risk adolescents.

Abstract. Background: Safety plans have been suggested as an intervention for people at risk of suicide. Given the impulsive character of suicidal ideation, a safety plan in the format of a mobile phone application is likely to be more available and useful than traditional paper versions. Aims: The study describes MYPLAN, a mobile phone application designed to support people at risk of suicide by letting them create a safety plan. Method: MYPLAN was developed in collaboration with clinical psychiatric staff at Danish suicide preventive clinics. The mobile application lets the user create an individualized safety plan by filling in templates with strategies, actions, and direct links to contact persons. Results: MYPLAN was developed in 2013 and is freely available in Denmark and Norway. It is designed for iPhone and android platforms. As of December 2015, the application has been downloaded almost 8,000 times. Users at risk of suicide as well as clinical staff have provided positive feedback on the mobile application. Conclusion: Support via mobile phone applications might be particularly useful for younger age groups at risk of suicide as well as in areas or countries where support options are lacking. Yet, it is important to examine the effectiveness of this type of intervention.

BACKGROUND: People with schizophrenia have an increased risk of premature mortality compared to the general population. We aimed to quantify which types of causes of death contributed to the excess mortality, and to examine whether there has been an increase in the excess mortality among persons with schizophrenia in the period 1995 to 2015.METHOD: We used a cohort design including the entire Danish population. We calculated life years lost of the cohort members compared to a set reference-age at 95 years old. Using a decomposition model we examined differences of cause-specific death among those with schizophrenia and the general population, including calendar trends during the last two decades.RESULTS: In the general population, as well as in persons with schizophrenia, we found improvements in life years lost during the last two decades. Men with schizophrenia lost 13.5 years more than the general population (women; 11.4 years). Compared to the general population, a large improvement in life years lost with respect to suicide and accidents was found in those with schizophrenia, but, this improvement was offset by an increasing number of life years lost in deaths from diseases and medical conditions.CONCLUSION: Our findings highlight the urgent need for focused treatment of general medical conditions in those with schizophrenia. Without such an investment, it is probable that the life years lost among persons with schizophrenia (compared to the general population) will continue to worsen in future decades.

The objective of the present study was to identify empirical studies of older adults (≥60) bereaved by the loss of a significant other to suicide. A systematic literature search in CINAHL, Embase, Medline, PsycINFO, and SCOPUS was conducted. The inclusion criteria were empirical studies investigating people bereaved by suicide at age ≥60 published in English or a Nordic language. Although a total of 12,871 references were identified, after screening, no articles fulfilled the inclusion criteria. The study led to the conclusion that there is a lack of research on older adults bereaved by suicide. With the aim of tailoring evidence-based interventions to this group, future research should investigate whether they have particular experiences, psychosocial responses and needs, and help-seeking strategies.

BACKGROUND The effect of safety planning for people in suicidal crisis is not yet determined, but using safety plans to mitigate acute psychological crisis is regarded as best practice. Between 2016 and 2017, Australian and Danish stakeholders were involved in revising and updating the Danish MYPLAN mobile phone safety plan and translating the app into a culturally appropriate version for Australia. OBJECTIVE The objective of this study was to examine the negotiation of stakeholders’ suggestions and contributions to the design, function, and content of the MYPLAN app and to characterize significant developments in the emerging user-involving processes. METHODS We utilized a case study design where 4 focus groups and 5 user-involving workshops in Denmark and Australia were subjected to thematic analysis. RESULTS The analyses identified 3 consecutive phases in the extensive development of the app: from phase 1, Suggesting core functions, through phase 2, Refining functions, to phase 3, Negotiating the finish. The user-involving processes continued to prevent closure and challenged researchers and software developers to repeatedly reconsider the app’s basic user interface and functionality. It was a limitation that the analysis did not include potentially determinative backstage dimensions of the decision-making process. CONCLUSIONS The extended user involvement prolonged the development process, but it also allowed for an extensive exploration of different user perspectives and needs.

INTRODUCTION: Major advances have been achieved in suicide prevention over the past decades. Effective suicide prevention requires vigilant monitoring of suicide trends. The aim of this study was to assess the change in the Danish suicide rate over time using joinpoint regression analysis and to examine the distribution of suicide methods in the 1980-2015 period.METHODS: Nationwide register data were obtained from the Central Research Register and the Danish Cause of Death Register. Rates were calculated per 100,000 persons by gender and agegroup. Joinpoint regression analysis was used to assess changes over time in the overall suicide rate.RESULTS: The suicide rate declined from 40.4 (95% confidence interval (CI): 38.4-42.3) in 1980 to 11.9 (95% CI: 10.9-12.9) in 2015. A significant reduction ranging between 2 and 6% was observed during 1980-1999 after which the decrease was modest. The rate was higher for men than for women (rate ratio 1.9; 95% CI: 1.7-2.1), and more so by the end of the period (rate ratio = 2.4; 95% CI: 1.9-2.8). The suicide rate was found to increase with increasing age. Hanging, poisoning and shooting were the most frequent methods for men, whereas poisoning followed by hanging and drowning were the most frequent methods for women.CONCLUSIONS: The suicide rate fell sharply between 1980 and 1999 in Denmark, but since then the decrease has been modest, especially since 2007. Further reduction in the suicide rate requires new and effective measures.FUNDING: none.TRIAL REGISTRATION: not relevant.

Due to the risk of hepatotoxicity when excessive amounts of paracetamol are consumed, Poisons Information Centers (PICs) frequently receive paracetamol-related enquiries. This study examined how widely pack size restrictions of paracetamol sold over the counter have been implemented in Europe and also availability of paracetamol through non-pharmacy outlets and their possible associations with frequency of poisoning enquiries. A cross-sectional European multi-centre questionnaire study was performed using a questionnaire to identify the extent and nature of paracetamol pack size restrictions, non-pharmacy outlet sales and the frequency of paracetamol-related enquiries to PICs. In total, 21 European countries participated. All PICs provided telephone hotline services. In 14 (67%) countries, pack size restrictions had been implemented in pharmacies (range: 8–30 g). No significant difference (median difference 0.7%, p-value = 0.36) was found when comparing median frequencies of paracetamol-related enquiries in countries with pack size restriction to countries without restrictions. A significantly lower median frequency of paracetamol-related enquiries was found in countries without non-pharmacy outlet sales compared to those with such sales (median difference 2.2%, p = 0.02). Pack size restrictions on pharmacy sales of paracetamol have been implemented in two-thirds of examined countries. There was no difference in the proportion of paracetamol-related enquiries to PICs among countries with and without pack size restrictions. However, a lower rate of paracetamol-related enquiries was noted in countries where paracetamol was not available in non-pharmacy outlets.

BACKGROUND: Persons with a past episode of self-harm or severe suicidal ideation are at elevated risk of self-harm as well as dying by suicide. It is well established that suicidal ideation fluctuates over time. Previous studies have shown that a personal safety plan can assist in providing support, when a person experiences suicide ideation, and help seeking professional assistance if needed. The aim of the trial is to determine whether a newly developed safety mobile app is more effective in reducing suicide ideation and other symptoms, compared to a safety plan on paper.METHODS/DESIGN: The trial is designed as a two-arm, observer-blinded, parallel-group randomized clinical superiority trial, where participants will either receive: (1) Experimental intervention: the safety plan provided as the app MyPlan, or (2) Treatment as Usual: the safety plan in the original paper format. Based on a power calculation, a total of 546 participants, 273 in each arm will be included. They will be recruited from Danish Suicide Prevention Clinics. Both groups will receive standard psychosocial therapeutic care, up to 8-10 sessions of supportive psychotherapy. Primary outcome will be reduction in suicide ideation after 12 months. Follow-up interviews will be conducted at 3, 6, 9, and 12 months after date of inclusion.DISCUSSION: A safety plan is a mandatory part of the treatment in the Suicide Prevention Clinics in Demark. There are no studies investigating the effectiveness of a safety plan app compared to a safety plan on paper on reducing suicide ideation in patients with suicide ideation and suicidal behavior. The trial will gain new knowledge of whether modern technology can augment the effects of traditional personalized safety planning.TRIAL REGISTRATION: ClinicalTrials.gov, NCT02877316 . Registered on 19 August 2016.

Importance Bereavement after spousal suicide has been linked to mental disorders; however, a comprehensive assessment of the effect of spousal suicide is needed. Objective To determine whether bereavement after spousal suicide was linked to an excessive risk of mental, physical, and social health outcomes when compared with the general population and spouses bereaved by other manners. Design, Setting, and Participants This nationwide, register-based cohort study conducted in Denmark of 6.7 million individuals aged 18 years and older from 1980 to 2014 covered more than 136 million person-years and compared people bereaved by spousal suicide with the general population and people bereaved by other manners of death. Incidence rate ratios were calculated using Poisson regressions while adjusting for sociodemographic characteristics and the presence of mental and physical disorders. Main Outcomes and Measures Mental disorders (any disorder, mood, posttraumatic stress disorder, anxiety, alcohol use disorders, drug use disorders, and self-harm); physical disorders (cancers, diabetes, sleep disorder, cardiovascular diseases, chronic lower respiratory tract diseases, liver cirrhosis, and spinal disc herniation); causes of mortality (all-cause, natural, unintentional, suicide, and homicide); social health outcomes; and health care use. Results The total study population included 3 491 939 men, 4814 of whom were bereaved by spousal suicide, and 3 514 959 women, 10 793 of whom were bereaved by spousal suicide. Spouses bereaved by a partner’s suicide had higher risks of developing mental disorders within 5 years of the loss (men: incidence rate ratio, 1.8; 95% CI, 1.6-2.0; women: incidence rate ratio, 1.7; 95% CI, 1.6-1.8) than the general population. Elevated risks for developing physical disorders, such as cirrhosis and sleep disorders, were also noted as well as the use of more municipal support, sick leave benefits, and disability pension funds than the general population. Compared with spouses bereaved by other manners of death, those bereaved by suicide had higher risks for developing mental disorders (men: incidence rate ratio, 1.7; 95% CI, 1.5-1.9; women: incidence rate ratio, 2.0; 95% CI, 1.9-2.2), suicidal behaviors, mortality, and municipal support. Additionally, a higher level of mental health care use was noted. Conclusions and Relevance Exposure to suicide is stressful and affects the bereaved spouse on a broad range of outcomes. The excess risks of mental, physical, and social health outcomes highlight a need for more support directed toward spouses bereaved by suicide.

Background Suicidal thoughts are common, causing distress for millions of people all over the world. However, people with suicidal thoughts might not access support due to financial restraints, stigma or a lack of available treatment offers. Self-help programs provided online could overcome these barriers, and previous efforts show promising results in terms of reducing suicidal thoughts. This study aims to examine the effectiveness of an online self-help intervention in reducing suicidal thoughts among people at risk of suicide. The Danish Self-help Online against Suicidal thoughts (SOS) trial is a partial replication of a previously conducted Dutch trial. Methods and design A randomized, waiting-list controlled trial with 1:1 allocation ratio will be carried out. A total of 438 people with suicidal thoughts will be recruited from the Danish suicide hotline, The Lifeline’s, website and allocated to the intervention condition (N = 219) or the control condition (N = 219). The intervention condition consists of a 6-week, Internet-based self-help therapy intervention. The format of the intervention is self-help, but the participants can be guided by the trial manager. The control condition consists of a waiting-list assignment for 32 weeks. The primary outcomes are frequency and intensity of suicidal thoughts. Secondary outcome measures include depressive symptoms, hopelessness, worrying, quality of life, costs related to health care utilization and production loss. Number of deliberate self-harm episodes, suicides and deaths will, as well as the participant’s evaluation of the intervention and the experience of negative effects, be investigated. Assessments will be conducted over the intervention website through self-report questionnaires at baseline, 2 weeks, 4 weeks, 6 weeks and 32 weeks (6 months post intervention). Discussion If we find the intervention to be linked to reductions in suicidal thoughts, this will strengthen the evidence that online self-help interventions are relevant tools for people with suicidal thoughts. Trial registration ClinicalTrials.gov, NCT02872610. Registered on 9 August 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1794-x) contains supplementary material, which is available to authorized users.

BACKGROUND: People with mental disorders have higher mortality rates than the general population and more detailed estimates of mortality differences are needed to address this public health issue. We aimed to assess whether differences in cause-specific mortality between people with and without mental disorders have changed between 1995 and 2014 by quantifying life-years lost and assessing differences over time.METHODS: Using a cohort design, we linked nationwide population data from the Danish Civil Registration System to information about hospital contacts from the Psychiatric Central Research Register and deaths from the Danish Cause of Death register. All linked data sources contained longitudinal information covering all individuals aged 15-94 years living in Denmark between 1995 and 2014. We assessed cause-specific mortality differences using rate ratios and average life-years lost.FINDINGS: Between 1995 and 2014, 6 107 234 individuals (3 026 132 men and 3 081 102 women) aged 15-94 years were living in Denmark. The study population was observed over 89 216 177 person-years (men: 43 914 948; women 45 301 229). Cause-specific mortality rates were higher for people with mental disorders than those without (total mortality rate per 1000 person-years in men 27·1 vs 11·4, respectively, and in women 21·2 vs 11·0). When compared with individuals without mental disorders, men and women with mental disorders had 10·20 and 7·34 excess life-years lost, respectively. The largest cause-specific differences between those with and without mental disorders in terms of excess life-years lost were for respiratory diseases (men: 0·9; women: 1·4) and alcohol misuse (men: 2·8; women: 1·2). Between 1995 and 2014, we noted an increase in excess life-years lost for neoplasms (men: 0·7; women: 0·4), heart diseases (men: 1·2; women: 0·3), and respiratory diseases (men: 0·3; women: 0·2), and a decrease for suicide (men: -0·7; women: -0·5) and accidents (men: -0·9; women: -0·5).INTERPRETATION: By applying a novel approach, more precise estimates of life-years lost were obtained. The increase in excess mortality due to medical diseases and disorders among people with mental disorders emphasises the need for future interventions to address these aspects as well as the continued high shares of excess mortality due to alcohol misuse, suicide, and accidents.FUNDING: The Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH).

Suicide is a devastating public health problem, afflicting individuals, families, and societies. Fortunately, continuous striving by the World Health Organization to strengthen suicide prevention efforts is paying off. The annual number of suicide deaths decreased from 1 million to 800,000 worldwide during recent decades. A gloomy exception to this trend is the increasing rate of suicide in the United States ([14.0 per 100,000 in 2017][1]). But Denmark's experience offers some hope that prevention of suicide is possible. Why has its decline in suicide been steeper than in most other countries? Historically, the Danish suicide rate was among the highest in the world. In 1980, it was 38 per 100,000 inhabitants over 15 years of age (Hungary's rate was 52 per 100,000). But the Danish rate then began to decline, reaching 11.4 per 100,000 in 2007, roughly where it still stands today. This is among the lowest in high-income countries. > “The Danish example shows that suicide prevention initiatives save lives.” Denmark's strategy for tackling suicide was multipronged and spanned decades. One of the most effective elements was restricting access to dangerous means of suicide. The government initiated restrictions on the availability of [medication][2] with high case fatalities, such as sedatives (barbiturates) and opioids (dextropropoxyphene), and introduced less-toxic antidepressants (such as selective serotonin reuptake inhibitors). [Removal of carbon monoxide][3] from household gas and the introduction of catalytic converters in car exhaust systems (to reduce the emission of toxic concentrations of carbon monoxide) are likely to have been beneficial. In addition, restrictions on firearm availability and regulations requiring that weapons and ammunition be stored separately and locked up probably aided the decline. Psychiatric wards that were redesigned to [eliminate opportunity][4] are also thought to be a valuable contributing factor. As in other Nordic countries, the Danish tax-based, universal, and free health care system has included mental health since its introduction in 1933. All citizens have access to free psychiatric care, including separate psychiatric emergency rooms, early intervention services for young people with psychosis, and specialized treatment for anxiety and depression. A decline observed in the suicide rate among people with mental illnesses over recent decades might be related to better outpatient treatments, which have seen a 66% increase in capacity since 2000. Denmark also implemented initiatives to reach those who are at immediate high risk. For instance, [Suicide Prevention Clinics][5] have offered counseling, therapy, and practical support to persons with suicidal ideation or behavior nationwide since 2007. This therapy has been linked to long-term reductions in fatal (29%) and nonfatal (18%) suicidal acts. A Psychiatric Emergency Outreach team provides support to people in a severe crisis by having a psychiatrist and an ambulance on call 7 days a week. The Strengthening Outpatient Care After Discharge (SAFE) project recently began offering home visits and family support to patients discharged from a psychiatric hospital. In addition, the Danish nonprofit organization Lifeline is a suicide hotline that offers anonymous counseling by trained volunteers. Can Denmark do even better? Further reductions in suicide could be achieved through targeted interventions for selected risk groups. Denmark has an abundance of unique, complete, and individual-level register data, which cover the entire nation and can be linked together through a personal identifier, thus providing excellent opportunities to pinpoint high-risk groups. These include populations with mental or somatic symptom disorders (including alcohol and substance abuse), as well as people experiencing social adversities and marginalized groups, such as homeless individuals, children in foster care, people living in sheltered housing and nursing homes, and incarcerated individuals. Careful monitoring of vulnerable groups and community awareness initiatives will hopefully reduce the national suicide rate even further. The Danish example shows that suicide prevention initiatives save lives. It seems that universal initiatives that address large groups might have secured the largest gains. The body of evidence on effective efforts is substantial, and policy-makers should start using this knowledge to take charge and reduce suicide numbers. [1]: https://www.cdc.gov/nchs/products/databriefs/db330.htm [2]: https://www.ncbi.nlm.nih.gov/pubmed/18208680 [3]: https://www.ncbi.nlm.nih.gov/pubmed/16635927 [4]: https://www.ncbi.nlm.nih.gov/pubmed/24434107 [5]: https://www.ncbi.nlm.nih.gov/pubmed/26359612

Stressful life events have been associated with high risk of suicidal behavior. The aim of this study was to examine whether persons who died by suicide in Denmark had more frequently been exposed to stressful life events, specifically divorce, death of a close relative, exposure to violence, and imprisonment, when compared to gender and age-matched controls. Data from Danish national registers were obtained for the period of 2000-2010 and a nested case-control design was applied. The association between exposure to stressful life events and suicide was examined using logistic regression analysis. In all, 7,115 suicides were identified during the 11 years of follow-up. For each of these, 20 age- and gender-matched controls were randomly selected (n = 142,300). Cases who died by suicide had an odds ratio of 9.3 (CI-95%: 7.8-11.0) of having been exposed to imprisonment five or more times when compared to controls. People who died by suicide had 1.5-fold (CI-95%: 1.3-1.6) higher risk of having experienced a divorce. Stressful life events, such as divorce and imprisonment, were more frequent in temporal proximity to the date of death among the suicide cases than for end of exposure for controls (p

The validity and reliability of suicide statistics have been questioned and few nationwide studies of deliberate self-harm have been presented.To calculate rates of deliberate self-harm in Denmark in order to investigate trends and assess the reliability of hospital records.A register study based on all individuals recorded with an episode of deliberate self-harm or probable deliberate self-harm in nationwide registers during 1994-2011.A substantial difference in the rates of deliberate self-harm and probable deliberate self-harm was noted for both genders. The average incidence rate of deliberate self-harm for women and men was 130.7 (95% CI = 129.6-131.8) per 100,000 and 86.9 (95% CI = 86.0-87.8) per 100,000, respectively. The rates of deliberate self-harm for women increased from 137.6 (95% CI = 132.9-142.3) per 100,000 in 1994 to 152.7 (95% CI = 147.8-157.5) in 2011. For a subgroup of younger women aged 15-24 years, an almost threefold increase was observed, IRR = 2.5 (95% CI = 2.4-2.7). The most frequently used method was self-poisoning.The rates of deliberate self-harm and probable deliberate self-harm differed significantly. An increased incidence of deliberate self-harm among young Danish women was observed, despite detection bias. An improved registration procedure of suicidal behavior is needed.