Category: Completed research projects

Prevention of suicide and suicide attempts in the Nordic countries: A situation analysis

Every suicide death is one too many. A goal of reducing the number of suicides by 25% in 2025 has been put forward by the Nordic Council Welfare Committee’s 2025 Ambition. This is in line with the United Nation’s World Goals for Sustainable Development of a 33% reduction of the suicide mortality rate in the world by 2030.

To gain an overview and to examine whether the suicide rates of the Nordic are decreasing, the Nordic Counsel of Ministers commissioned Danish Research Institute for Suicide Prevention (DRISP) to conduct a Situation Analysis. This situation analysis provides an overview as well as summarizes existing efforts and main challenges. It aims to provide information of relevance for policymakers, researchers, NGOs, and people who are interested in reducing the burden of suicide in the Nordic countries.

DRISP has prepared the report by in collaboration with a long list of highly established researchers and experts in the Nordic countries. The report has now been published by the Nordic Counsel of Ministers.

Some of the main findings are:

  • In 2022, a total of 3,574 individuals died by suicide in the Nordic countries.
  • The highest suicide rate was found in Greenland.
  • With respect to UN’s goal of a 33% reduction in the suicide mortality rate, there has only been achieved modest over recent years in Nordic countries.
  • Suicide statistics from Faroe Islands, Greenland and Aaland Islands are seemingly not being reported to the WHO Mortality Database.
  • Suicide attempts are seemingly not been monitored in almost all of the Nordic countries.
  • Almost all Nordic countries have a national plan for suicide prevention.
  • Follow-up routines for people who present with suicide attempts in somatic emergency departments are seemingly missing in most countries.

Link to the full report can be found here:

Report from the Nordic Counsel of Ministers

Suicidal thought- and behavior among Danish adolescents

Up to one-third of Danish adolescents have experienced suicidal thoughts. This was shown in a study from DRISP, which has recently been published in European Child and Adolescent Psychiatry.

The study was based on questionnaire data from over 47,000 participants aged 18 years in the Danish National Birth Cohort. The findings revealed that 36% of girls and 28% of boys had experienced suicidal thoughts, and one in four of these had made suicide plans. Additionally, 6% of girls and 3% of boys had attempted suicide before turning 18 years. A significant portion of those—especially the boys—did not go to the hospital after the suicide attempt. In fact, among those 5.7% who reported having had a suicide attempt, only 1.7% had been recorded with a hospital contact. In previous studies, this difference has been compared to ‘the hidden part of the iceberg’, i.e. located below the surface of the sea and, thus, not visible.

Furthermore, suicide attempts were more frequent among adolescents with lower parental income.

“It is highly concerning that in a normal class, 2-3 adolescents would have experiences of serious suicidal behavior. We do not know whether these adolescents receive the help they need, especially those who do not present at the hospital after a suicide attempt,” states Ph.D-student Stine Danielsen who conducted the study. These results empathize the need for increased awareness and efforts toward mental health and suicidal behavior among adolescents. Universal prevention strategies tar¬geting adolescents with suicidality in community-based efforts, such as school interventions, may reach those who do not present in the healthcare system.

The study also provided validation for an algorithm, which identifies adolescents with a hospital-recorded suicide attempt, as a major share of these also had self-reported a suicide attempt. The algorithm was developed to identify suicide attempts in Danish registers may therefore be considered as reliable for identification of suicide attempts among adolescents.

DRISP:

Stine Danielsen, Merete Nordentoft, Annette Erlangsen, Trine Madsen

Link to the study:

https://link.springer.com/article/10.1007/s00787-024-02503-w

Collaborative partners:

•  Katrine Strandberg-Larsen, University of Copenhagen

•  Keith Hawton, University of Oxford

Transgender individuals and suicide attempt and mortality in Denmark

Previous studies have suggested that transgender individuals may constitute a high-risk group in terms of suicide attempts and suicide, but the existing knowledge was primarily based on surveys. Large, population-based studies were lacking.

DRISP conducted an analysis of suicide attempts and mortality among transgender individuals in Denmark. The study aimed to investigate whether transgender individuals in Denmark have higher rates of suicide attempts and mortality compared to non-transgender individuals.

The study was nationwide and based on registry data, and it included over 6.6 million individuals born in Denmark, aged 15 or older, and residing in the country at some point between January 1, 1980, and December 31, 2021. Transgender identity was determined through national hospital records and administrative records of legal gender change. The results showed that transgender individuals had significantly higher rates of suicide attempts, suicides, non-suicidal deaths, and overall mortality compared to non-transgender individuals.

The results indicated that despite decreasing suicide attempt and suicide rates over the 42 years examined, the adjusted rates remained significantly elevated in the recent periods up to and including 2021 for all the categories studied. Transgender individuals had a 3.5 times higher risk of suicide and a 7.7 times higher risk of suicide attempts than the general population.

The study emphasizes the need for attention to the specific challenges faced by transgender individuals and the implementation of measures to reduce suicide attempts and improve their overall health and well-being.

The head of program at the Danish Research Institute for Suicide Prevention (DRISP), Annette Erlangsen, stated: “We knew from foreign studies that transgender individuals have an increased risk of suicidal behavior, so it is good to be able to put precise numbers on the relationship. Transgender individuals who have suicidal thoughts may be less likely to seek help from existing psychiatric services because they do not want it to be documented in their patient records, possibly hindering access to later treatment. Danes see ourselves as pioneers in the LGBT+ field, and we have suicide prevention treatments that work, but we lack solutions to this problem.”

Morten Frisch, a senior physician at Statens Serum Institut and the head of the population study Project SEXUS, adds: “Our new study stands out as the world’s first nationally comprehensive study on the suicidal behavior and mortality of transgender individuals. Hopefully, the clear results of the study will help focus attention on the challenges in life that significantly increase the risk of suicide attempts and death among transgender individuals. It is an unmistakable and concerning sign of distress among Danish transgender individuals when this group has an almost eight times higher prevalence of suicide attempts than other Danes.”

Susanne Branner Jespersen, the secretariat manager at LGBT+ Denmark, states: “These are very alarming figures, which unfortunately we were already too familiar with. The numbers indicate that there is a long way to go before we destigmatize what it means to be transgender and create better conditions for them throughout their lives. We all have a great responsibility for this, and the current public debate about what it means to be transgender does not always promote understanding.”

The study was published in the prestigious journal: JAMA Network.

You can find the study and read more here: https://jamanetwork.com/journals/jama/article-abstract/2806531

The project was conducted in partnership with prof Morten Frisch from the Serum Institute and LGBT+ Denmark.

The project in other media:

https://tinyurl.com/2d9eavjf

https://www.nytimes.com/2023/06/27/health/transgender-suicide-risk-denmark.html

Lithium is the best treatment for people with bipolar disorder in terms of a lower risk of suicide.

A study by Cecilie Fitzgerald and colleagues from DRISP in collaboration with international experts documents that lithium is the best treatment for people with bipolar disorder when it comes to preventing suicidal behavior. Although newer commercial drugs have been developed and marketed, lithium remains superior for this patient group. This is important evidence because people with bipolar disorder have an 18-fold higher risk of suicide when compared to other people in the general population.

The study was published in the renowned scientific journal, British Journal of Psychiatry. It  used complete and nationwide data on all people diagnosed with bipolar disorder in Denmark during 1995-2016 and investigated which type of treatment were most effective at preventing suicidal behavior and psychiatric readmission. The findings revealed that people who were in ongoing treatment with lithium had a 26% lower suicide rate when compared to periods of not being in treatment. People treated with lithium had a 33% lower risk of suicide when compared to people treated with valproate.

In total, 33,337 people with bipolar disorder were included in the analyses, and a 60% lower suicide rate was found among those treated with lithium compared to periods without treatment. In addition, the study found fewer psychiatric readmissions among people treated with lithium compared to people who were not in treatment.

The study can be found here: https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/abs/effectiveness-of-medical-treatment-for-bipolar-disorder-regarding-suicide-selfharm-and-psychiatric-hospital-admission-between-and-withinindividual-study-on-danish-national-data/FFDA12AAC21C6722D5B9F6EF94621349

DRISP: Cecilie Aalling, Merete Nordentoft, Annette Erlangsen

Partners:

  • Prof Keith Hawton, Centre for Suicide Research, University of Oxford
  • Michael Eriksen Benros, Psykiatrisk Center København

WHO and DRISP – an analysis of the Eastern Mediterranean Region

DRISP has contributed to the international work of suicide prevention. As a consultant for WHO, Annette Erlangsen has conducted a situation analysis of suicide and attempted suicide in WHO’s Eastern Mediterranean Region (WHO EMRO) from 2000 to 2020. WHO EMRO consists of the countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, West Bank and Gaza, and Yemen.

The analysis found that:

  1. In more than half of the studied countries, data on suicide was either insufficient or of poor quality, making it challenging to monitor the incidence of suicide.
  2. From 2000 to 2019, there was a 7.6% decrease in the suicide rate in the region, primarily among women.
  3. In more than half of the countries, suicide is still considered a criminal act. This is problematic as it can potentially imply that individuals at risk of suicide might not seek help.

The situational analysis can be found here:
https://www.emro.who.int/images/stories/mnh/documents/situation_analysis_emro.pdf

Erlangsen et al, 2023_ArchivesDownload

Cause-specific life years lost among persons with mental disorders

The aim was to quantify the life years lost with respect to cause of death and differences over time between people with and without mental disorders.
This study noted a difference of 10.2 and 7.3 excess life years lost for males and females with mental disorders, respectively. While the overall excess in life years lost between those with and without mental disorders did not change during 1995-2014 However, the excess suicide mortality among persons with mental disorders declined over this period .

The study is published in Lancet Psychiatry.

DRISP: Annette Erlangsen, Merete Nordentoft

Partners:

  • Per Kragh Andersen, PhD, DMSc, Section of Biostatistics, University of Copenhagen, Denmark
  • Thomas Munk Laursen, PhD, Centre for Integrated Register-based Research (CIRRAU), Aarhus University, Denmark
  • Anita Toender, Centre for Integrated Register-based Research (CIRRAU), Aarhus University, Denmark
  • Vladimir Canudas Romo, PhD, Max-Planck Odense Center on the Biodemography of Aging, Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, Denmark

Heart diseases and suicide

Approximately, 11% of Europeans suffer from cardiovascular diseases. Although somatic disorders are linked to suicidal behavior, updated studies on heart diseases and suicide are needed. This study examines whether individuals diagnosed with cardiovascular diseases have higher suicide rates than individuals without cardiovascular diseases. Danish register data for
the period 1980-2016 was used for the analyses.
Several specific disorders, such as heart failure, cardiomyopathy, and acute myocardial infarction were found to be associated with elevated rates of suicide. Particularly, cardiac arrest with successful resuscitation was linked to a 4-fold higher suicide rate. Additionally, the
first time after diagnosis was associated with higher suicide rates. The results underscore the importance of being attentive towards psychological distress in individuals with heart disease.

Link to study:

https://onlinelibrary.wiley.com/doi/abs/10.1111/joim.13025?af=R

Partners:

  • Benjamin Drejer Petersen, University of Southern Denmark
  • Elsebeth Stenager, University of Southern Denmark

Autism spectrum disorders and suicidal behaviour

About 1% in the general population have autism-related conditions. The onset is often in childhood and may have an impact on the child’s upbringing and socialization. Although autism-related conditions have been linked to suicidal behavior, little is known regarding  which characteristics are associated with suicidal behavior in this subgroup.

In this research project, DRISP, in collaboration with international researchers, sought to identify social and disease-related predictors of suicidal behavior among people with autism.

Danish registry data covering the entire Danish population (6,559,266 persons) in the period 1995-2016 were included in the analyses. The results showed that people with autism-related disorders had a more than 3-fold higher rate of both suicide attempts and suicide than people without these disorders. The excess risk of suicidal behavior among people with autism could be observed across all age groups.

People with autism who also had psychiatric disorders were found to have a significantly increased risk and this group accounted for 90% of those who had suicide attempts or died by suicide. The results suggest that people with autism who also have psychiatric disorders should be a target group for suicide preventive efforts.

The project received funding from the Helse Foundation.

You can read the study here: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774853

Partners:

  • Kairi Kõlves, Australian Institute for Suicide Research and Prevention, Griffith University, Brisbane, Australia
  • Stephen James Wood, University of Melbourne, Melbourne, Australia

Suicide risk associated with psychiatric hospitalization

People with mental illness have an increased risk of suicide. Previous Danish studies have shown that the risk is elevated in the period shortly after admission and especially after discharge from psychiatric hospital. Trine Madsen from DRISP has in an updated analyses investigated whether this is still the case or whether the recent decades of efforts in the field have led to an improved situation for people with mental vulnerability.

Register data for the entire Danish population aged 15 years or older in the period 1995-2016 were included in the analysis.

Men and women who were in inpatient treatment for a psychiatric disorder had a suicide rate of 237 and 322 per 100,000, respectively, compared to men and women who had never been inpatients. In the first week after discharge, the suicide rate was 225 and 425 times higher for men and women, respectively, when compared to those who had never been admitted. About 6% of all suicides amongst males and 13% amongst females occurred during the first week of a psychiatric admission or discharge. The study also showed that the suicide rate amongst admitted patients fell by 2.5% per year until 2009, after which the rate rose by 7.5% per year.

The study’s conclusion was that – despite falling suicide rates – the period around admission and discharge from a psychiatric hospital is still associated with an extremely high risk of death by suicide.



You can find the study here: https://onlinelibrary.wiley.com/doi/full/10.1111/acps.13221




DRISP: Trine Madsen, Merete Nordentoft & Annette Erlangsen

DiaS-project

A randomized study of 108 participants with recent suicide attempt and borderline personality disorder. The participants were offered either standard treatment (CAMS) or a short dialectical behavioral therapy course from the competence center for suicide prevention in Region H Psychiatry

DRISP: Kate Andreasson Aamund; Merete Nordentoft.

The study has been published in Depression & Anxiety:

https://onlinelibrary.wiley.com/doi/abs/10.1002/da.22472

Self-help Online against Suicidal Thoughts

In the project Self-Help Online against Suicidal Thoughts (SOS), it was investigated whether internet-based self-help therapy could help people with suicidal thoughts. The study was led by psychologist Charlotte Mühlmann from DRISP in collaboration with colleagues and conducted as a randomized study.

Together with the Danish telephone helpline for suicide prevention (“Livslinien”), 402 adults with suicide thoughts were recruited during 2016-2018. The average age of the participants was 34 years. One third of the participants had previously had a suicide attempt, while 55% were in therapeutic or psychiatric treatment at the time they joined the study.

Half of the 402 participants were randomized to test the online program, while the other half served as a control group, i.e. did not receive the program. The findings showed that after 6 weeks, there was a significant difference; those who had received the self-help program had experienced a reduction of suicidal thoughts, feelings of hopelessness and worries when compared to the control group.

Among the participants who had access to the program, 63% experienced a clinically significant decrease in their suicidal thoughts; corresponding to 6 points on the Beck Scale for Suicidal Ideation, which was the questionnaire used for measuring suicide risk. The significant difference was also present after seven months. Among those surveyed, 78% of the participants rated the program as useful.

You can find the study here: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774853

The project was supported by the Danish TrygFonden.

DRISP: Charlotte Mühlmann, Trine Madsen, Annette Erlangsen, Merete Nordentoft

Partner:

  • Livslinien

Managing suicidality in research on internet- and mobile-based interventions: current practice and recommendations

Many studies on internet-based therapy exclude participants with suicide thoughts. The aim of two studies is to provide an overview of the current practice in the management of suicidality in RCTs of internet interventions for depression and suicide thoughts. Researchers in the field have been found through a literature review and been asked to answer a questionnaire and be interviewed regarding their practices. Based on this overview, best-practice recommendations regarding how to manage suicidality in research on internet interventions for depression was published in 2020.

For more information read https://www.sciencedirect.com/science/article/abs/pii/S0165032719323353.

DRISP: Charlotte Mühlmann


Partners:

  • Institute of Psychology, University of Freiburg
  • Orygen, the National Centre of Excellence in Youth Mental Health

Lyme disease and risk of suicidal behaviour suicidal adfærd

The Borrelia bacterium, which exists in ticks, can develop into an infectious disease in humans when bitten. This disease is known as lyme disease (or Lyme Borreliosis) Infections have previously been associated with an increased risk of suicidal behavior. Trine Madsen from DRISP has, in collaboration with colleagues, investigated whether Lyme Borreliosis was linked to increased prevalence of psychiatric diseases and suicidal behavior.

Using register data for all persons living in Denmark from 1994 to 2016 (n=6,945,837), patients diagnosed with Lyme Borreliosis were identified based on hospital diagnoses. Their risk of developing psychiatric diseases and suicidal behavior was analyzed.

The results showed that persons who developed Lyme Borreliosis (i.e., an infection after a tick bite) had a 1.3-fold higher rate of psychiatric diseases, as well as a 2-fold higher rate of suicide attempts and a 1.75-fold higher suicide rate when compared to the background population. The highest risk of developing a psychiatric disease was observed within the first 6 months after persons developed Lyme Borreliosis. If the person had had multiple incidents of Lyme Borreliosis, this was associated with an increasing risk of suicide attempts.

In conclusion, the study showed that persons diagnosed with Lyme Borreliosis at Danish hospitals have an increased prevalence of psychiatric diseases, suicide attempts and suicide.

You can find the study here: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2021.20091347




DRISP: Trine Madsen, Merete Nordentoft & Annette Erlangsen

Partners:

  • Michael Eriksen Benros, Research Unit, Mental Health Centre Copenhagen
  • Brian A. Fallon, MD, Center for Neuroinflammatory Disorders and Biobehavioral Medicine and director of the Lyme and Tick-Borne Diseases Research Center at Columbia University, USA

Combat exposure and risk of suicide attempt in previously deployed soldiers

Traumatizing events such as exposure to war can affect mental health. After World War I, the term “shell shock” was used to describe the shock effect that individuals who experienced the war may suffer. Although there is an increased awareness of adverse effects for deployed soldiers, stories of individual events, which seem to question the support that provided to veteran soldiers, often find their way to media reports.

To gain deeper insights into the stress experienced by deployed combat soldiers, DRISP has conducted a research project together with the Danish Veteran Center.

The study included more than 12,000 Danish veterans deployed on an international mission in the years 1997-2016 and who participated in a questionnaire survey after returning home. In the survey, they were asked about the level of combat exposure and experiences of the consequences of war. Figures from national registers administered by Statistics Denmark and the Danish Health Authority showed that a total of 83 veterans had had a suicide attempt after returning home. The findings of the study showed that veterans with a higher level of combat exposure have an 8% higher risk of suicide attempt after returning home compared to veterans with a lower level of combat exposure. The findings also confirmed that the increased risk of suicide attempt applied to veterans who, in addition to combat exposure, had symptoms of PTSD and/or depression. No association was found between having witnessed the consequences of war and suicide attempt.

The results point to the importance of attention towards those who have been exposed to combat and subsequently develop PTSD or depression, as this group were at greater risk of later suicide attempt.

You can find the study here: https://www.psychiatrist.com/jcp/trauma/combat-exposure-risk-suicide-attempt-danish-army-military-personnel/



Partners:

Trajectories of suicidal ideations in different patient populations

In growth mixture modelling analyses we have examined the heterogeneity of trajectories of suicidal ideations. We have examined this in people with different diagnosis such as first episode psychosis, bipolar disorders and depression. Overall all these studies have found that between 10-20% of patients seem to have chronic suicidal ideations even after treatment has started.
The study has been published in Journal of Affective disorders.

DRISP: Trine Madsen

Partners:

  • Andy Nierenberg, Harvard Medical School, Boston, Massachusetts
  • Ad Kerkhof, Vrije Universiteit, Amsterdam, Netherlands
  • Ole Mors, Aarhus University Hospital, Risskov, Psychosis Research Unit, Aarhus, Denmark
  • Ole Köhler-Forsberg, Department of Clinical Medicine, Aarhus University Hospital, Denmark