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

WHO National Suicide prevention strategies

WHO National Suicide Prevention Plans
WHO has released a report on national suicide prevention plans.

The World Health Organization (WHO) has released a status report on national suicide prevention plans. The report emphasizes that national plans are important for setting the topic of suicide prevention on the political agenda. A national strategy with an accompanying prevention plan is essential to implement suicide prevention. Without an overarching plan, efforts are at risk of failing and suicide rates remaining unchanged.

The report aims to be a resource tool to inspire governments and policy-makers to implement a national action plan in the field. Examples of national action plans from different WHO regions are presented.

Link to report: https://www.who.int/mental_health/suicide-prevention/national_strategies_2019/en/

In 2021, WHO released guidelines on how to implement a suicide prevention plan. The guide, which called “Live Life”, provides concrete instructions on how to facilitate suicide prevention. It can be used to design national efforts, but the instructions also apply to smaller geographical or administrative units, such as local communities. The guidelines describes how to organize efforts and provides examples of concrete interventions, which previously have been shown to be effective.

Link to LIVE LIFE: https://www.who.int/publications/i/item/9789240026629

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:

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

iCare: Psychoeducation for parents of children with suicide attempt

Each year, there are approximately 11,000 suicide attempts in Denmark, mainly among young people under the age of 25. Clinicians who provide support to young people after suicide attempt are often consulted by the young person’s parents who are keen to support their child. To provide better information to parents, DRISP has developed a website for this target group and in collaboration with parents with lived experiences. This website is now testing to determine whether parents find it useful. In connection with the project, several qualitative studies have been conducted, which are described here below.

Study 1: Existing evidence regarding the experiences of relatives caring for people with suicide attempts was reviewed. A total of 12 studies on the subject were included and a meta-ethnographic synthesis was conducted. The results showed that relatives of people with suicide attempts often pass through four unique phases, which each represent different perspectives and emotions. It was also found that interaction with other relatives who experienced comparable challenges made it easier for relatives to pass through these phases and helped them to find themselves in new and challenging situations.

The study can be found here:
https://www.sciencedirect.com/science/article/pii/S0020748920302790

Study 2: Interviews were conducted with 21 Danish parents of children with suicidal behavior. The results of the study showed that parents’ perceived that their identity was affected by their children’s suicidal acts. The perceived identity of the parents passed through up to three interrelated phases. Each phase reflected a different perspective of their identity and was developed in social interaction with other people. It was also found that not all parents were able to re-establish their parenting agency.

This study can be found here: https://www.sciencedirect.com/science/article/pii/S002074892030279

DRISP: Jette Louise Skovgaard Larsen, Anette Juel Kynde, Britt Morthorst, Annette Erlangsen


Partners

  • Elene Fleischer, PhD Netværk for selvmordsramte (www.nefos.dk)
  • Niels Buus, Mental Health Nursing, Sydney Nursing School, University of Sydney
  • Jan-Henrik Winsløw, Enhed for Selvmordsforebyggelse, Region Nordjylland
  • Prof Keith Hawton, Centre for Suicide Research, University of Oxford

App for people with self-harm – MYPLAN Zero Self-Harm

Some people intentionally harm themselves to relieve mental pain. It may be difficult to stop this behavior once it has been initiated. There are, unfortunately, few treatment options for people with self-harm. One recommended approach is to develop strategies in the form of a safety plan, which can be activated if the urge for self-harm arises.

The Zero Self-Harm app was developed as an extension of the MYPLAN app. People with lived experiences, in the form of current and past self-harm, were included in the development process through focus group interviews. The app helps the user to identify warning signs and to develop strategies to cope with future crises.

Zero Self-Harm is currently being tested in a research project, which consists of: 1) a randomized study to investigate whether the Zero Self-Harm app may reduce self-harming behavior, and 2) a qualitative evaluation of barriers and facilitators for using the app. The RCT is expected to be initiated in the autumn of 2020 and to be completed in 2023.

The project is supported by the TRYG Foundation.

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Drisp: Lene Qvist Larsen, Annette Erlangsen, Jette Louise Skovgaard Larsen; Kate Andreasson Aamund, Merete Nordentoft, Eybjørg A Heygum Egilsdóttir; Evelyn Guerrero

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

Suicide risk according to highest level of psychiatric service received

Different patient groups are seen across psychiatric sectors and it is relevant to know which groups are at imminent risk of suicide. In this project, the risk of suicide is examined according to the highest level of psychiatric service received. The level will be graded according to severity as well as by type of contact, such as psychiatric admission, psychiatric ER visit, psychiatric outpatient, psychiatric medicine.

DRISP: Trine Madsen, Merete Nordentoft, Annette Erlangsen

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:

Suicide rates in Nordic prisons 1999-2016

International research has shown an increased suicide rate among people in prison.  However, studies have yet to address age structural differences. In this longitudinal the suicide rates among male prisoners is compared to the general population in three Nordic countries, Denmark, Iceland, and Norway,  while adjusting for age differences.

Findings from the study shows that men in prison have a 7-fold higher suicide rate compared to the background population in Denmark, Iceland, and Norway and when accounting for age differences. For females, a rate 18-fold higher suicide rate was found among those in prison when compared to the general population. Over the 17-year study period, the suicide rate of people in prison decreased from 129 per 100,000 in 1999 to 70 per 100,000 in 2016. This decline was steeper that the decline observed for the suicide rate in the general population in the Nordic countries.

Link to study

https://www.tandfonline.com/doi/abs/10.1080/13811118.2020.1746943


DRISP: Britt Morthorst, Charlotte Mühlmann, Trine Madsen, Merete Nordentoft
og Annette Erlangsen

Partners

  • Lars Mehlum, Professor, National Centre for Suicide Research and Prevention, Institute of Clinical Medicine Oslo, Norway
  • Aiguröur Pàlsson, MD, Unit of Forensic Psychiatry, Iceland
  • Högni Óskarsson, md, Humus inc., Iceland Yngve Hammerlin, MD, Correctional Service of Norway Staff Academy, Norway

Relative affected by suicidal behaviour in Denmark

International research has demonstrate that a substantially share of the population have experienced to lose a next of kin to suicide. This study examines how many Danes have been affected by a suicide attempt. The aim of this on-going study is the assess how large a share of the Danish population have been affected by suicidal behaviour. The project has received support from the Partnership for Suicide Prevention, Danish Health Authority.

DRISP: Trine Madsen, Anne Ranning, Annette Erlangsen


Partners

  • Karine Hvidkjaer, medicinstuderende ved Københavns Universitet
  • Elene Fleischer, PhD Netværk for selvmordsramte (www.nefos.dk)
  • Jens Peter Eckardt,chefanalytiker, Bedre Psykiatri

Bereaved by suicide: psychological mechanism

Losing a loved one to suicide can be a traumatic and stressful experience, and studies show that bereaved by suicide themselves have an increased risk of stress-related illnesses and suicidal behavior. To determine the burden related to being bereaved, Annette Erlangsen at DRISP is involved in an international research project with researchers from University College London.

The study examined register data on 32,248 individuals living in Denmark who died by suicide in Denmark between 1980 and 2016, as well as identifying their relatives in the form of parents, children, siblings, and partners.

Having lost a loved one to suicide was associated with a 2.8 times higher risk of suicide compared to people who had not lost a loved one. The study also showed that 0.69% of all suicides in Denmark could be prevented if all factors that increase the risk of suicide among relatives of people who have died by suicide could be addressed. This corresponds to 60% of suicides among bereaved by suicide.

Bereaved by suicide have an increased risk of developing suicidal behavior themselves, and, although these suicides only account for a relatively small proportion of the total number of suicides, it is important to provide support to this group.

The project has received funding from the American Foundation for Suicide Prevention. You can find the study here: https://onlinelibrary.wiley.com/doi/10.1111/acps.13493



DRISP: Annette Erlangsen

Partner:

  • Dr Alexandra Pitman, Senior Clinical Lecturer, UCL Division of Psychiatry (projektansvarlig)
  • Dr Gemma Lewis, Research Associate in Psychiatric Epidemiology, UCL Division of Psychiatry
  • Professor Julie Cerel, Professor, College of Social Work, University of Kentucky


Neurological disorders and suicide

Neurological disorders have severe impacts on people’s lives in terms of both disability and dependency and have been linked to suicide. Yet, a comprehensive overview was lacking. This study examined whether people with specific neurological disorders die by suicide more often than other people. The study was based on the register data covering the entire population of Denmark during 1980-2016.

The findings from study, which was published in JAMA, shows that people with neurological disorders have a 75% higher suicide rate than people with no neurological disorders. Still, suicide deaths are rare events. While the suicide rate for the general population was around 20 per 100,000, the rate for people with neurological disorders is around 40 per 100,000 person-years. One out of 150 persons diagnosed with a neurological disorder dies by suicide. For severe neurological diseases, such as Huntington’s, one out of 61 diagnosed went on to die by suicide. This study is the most comprehensive assessment of neurological disorders’ link to suicide conducted to date.

The study shows that people who have been diagnosed with amyotrophic lateral sclerosis (ALS) or Huntington’s disease have a particular high risks, as the suicide rate associated with these disorders is 4-5 times higher than in the general population. People who have been exposed to traumatic brain injury, multiple sclerosis, or epilepsy have a suicide rate, which is double the level of the one found among those with no such disorders.

People with dementia were found to have a 2-3 time higher suicide rate during the first three months after being diagnosed. On the other hand, people who had been diagnosed with dementia more than a year ago were found to have a lower suicide rate than the general population.

– This is the first time we have examined this many different neurological disorders to gain a more detailed understanding of when risk of suicide is pronounced. These insights can help us shape dedicated preventive effort says Dr. Annette Erlangsen, lead author and senior researcher at Danish Research Institute for Suicide Prevention (DRISP). The project has received support from the Psychiatric Research Foundation, Region of Southern Denmark.

Link to study:

https://jamanetwork.com/journals/jama/article-abstract/2760389



DRISP: Annette Erlangsen, Merete Nordentoft

Partners:

  • Egon Stenager, Department of Neurology, Sønderborg, Hospital of Southern Jutland, Denmark
  • Yeates Conwell, Center for the Study and Prevention of Suicide, University of Rochester Medical Center, USA
  • Per Krag Andersen, Section of Biostatistics, University of Copenhagen, Denmark
  • Keith Hawton, Centre for Suicide Research, University of Oxford, United Kingdom
  • Michael Eriksen Benros, Research Unit, Mental Health Centre Copenhagen, Copenhagen, Denmark
  • Elsebeth Stenager, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark

MYPLAN – a self-help tool for management of crisis

People who have had a suicide attempt have a significantly higher risk of repeated suicidal behaviour. MYPLAN was created with the intention of being a self-help tool for management of suicidal crisis. This project consists of 1) a qualitative study of stakeholders on improvements to MYPLAN; 2) a randomized clinical trial to evaluate MYPLAN’s efficacy in reducing suicide intent among persons at risk of suicide, and 3) a person-centered evaluation of the MYPLAN to identify barriers and facilitators to its general implementation. The RCT was initiated in 2019 and is currently ongoing. Following studies have been published :
The project received support from the Danish TRYG Foundation.

Publications

https://trialsjournal.biomedcentral.com
https://www.tandfonline.com


DRISP: Charlotte Mühlmann Kate Andreassen Aamund, Jette Louise S. Larsen, Annette Erlangsen

Partners:

  • Hanne Frandsen, Mental Health Centre Copenhagen, Region H
  • Niels Buus, Mental Health Nursing, Sydney Nursing School, University of Sydney, Australia

Cause-specific life years lost among persons diagnosed with schizophrenia: Is it getting better or worse?

People with schizophrenia have an increased risk of premature mortality compared to the general population. This study aimed to quantify which types of causes of death contributed to the excess mortality. The findings showed that, compared to the general population, a large improvement in life years lost with respect to suicide and accidents was found in those with schizophrenia. However, this improvement was offset by an increasing number of life years lost in deaths from diseases and medical conditions.
The study has been published in Schizophrenia Research
https://www.sciencedirect.com/science/article/pii/S0920996418306339#f0005

DRISP: Annette Erlangsen & Merete Nordentoft

Partners:

  • Thomas Munk Laursen, National Center for Register-based Research, Aarhus Denmark (first author on study)
  • Oleguer Plana-Ripoll, The Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH), Aarhus, Denmark
  • Per Kragh Andersen, Section of Biostatistics, University of Copenhagen
  • John J McGrath, Queensland Brain Institute, University of Queensland
  • Anita Toender, National Center for Register-based Research, Aarhus Denmark
  • Vladimir Canudas-Romo, School of Demography, Australian