Research reportPrevalence and risk factors for first onset of suicidal behaviors in the Netherlands Mental Health Survey and Incidence Study-2
Introduction
In 2009 we reported on incidence and course of suicidal ideation and suicide attempts in the general population, based on the first Netherlands Mental Health Survey and Incidence Study (NEMESIS-1) for which data were collected in 1996–1999 (ten Have et al., 2009). Incidence and course were assessed from the second wave onward over a 3-year period.
The merit of our first report on this subject (ten Have et al., 2009) was that it was one of the few studies worldwide which assessed incidence (Bronisch et al., 2005, Gunnell et al., 2004, Kuo et al., 2001, Kuo et al., 2004) and course (Borges et al., 2008, De Leo et al., 2005, Gunnell et al., 2004) of suicidal behaviours in the general population as well as associated risk factors. However, a lot of questions remained, such as the age of onset of suicidal ideation, the speed of transition from first onset ideation to first onset attempt, and the extent to which suicide attempts are a cry for help without intention to kill oneself. NEMESIS-1 as well as other general population surveys performed in the nineties of the previous century were designed to study mental disorders rather than suicidal behaviours. With the rise of a new generation of psychiatric surveys from the present century onward using the Composite International Diagnostic Interview (CIDI) version 3.0, which included more questions on suicidal behaviours and considered these as a separate problem area and not just a symptom of major depression which was the case in earlier CIDI versions, it became possible to study characteristics and risk factors for first onset suicidal behaviours in more depth.
Two important papers based on these new generation surveys carried out in 17 (Nock et al., 2008a) and 21 (Nock et al., 2009) countries around the world participating in the World Mental Health (WMH) Survey Initiative, showed that the estimated lifetime prevalence of suicidal ideation, plan and attempt in the overall cross-national sample was 9.2% (from 3.1% in China to 15.9% in New Zealand), 3.1% (from 0.7% in Italy to 5.6% in New Zealand) and 2.7% (from 0.5% in Italy to 5.0% in the US), respectively (Nock et al., 2008a). Among suicide ideators, the conditional probability of ever making a suicide attempt was 29.0% (from 17.0% in Japan to 46.4% in Lebanon) (Nock et al., 2008a). Across all countries, about 60% (from 60.5% in Israel to 94.0% in Italy) of transitions from ideation to plan and attempt occurred within the first year after ideation onset. Risk factors for suicidal behaviours included being female, younger, less educated, unmarried, having had childhood adversities (Bruffaerts et al., 2010) and a mental disorder. The strongest diagnostic risk factors were mood disorders in high-income countries and impulse control disorders in low- and middle-income countries (Nock et al., 2008a). Mental disorders were more powerful in predicting the onset of suicidal ideation rather than the transition from ideation to attempt. Disorders characterized by anxiety and poor impulse control (especially bipolar, conduct and substance use disorders) emerged as the strongest predictors of which suicide ideators go on to make a suicide plan or attempt (Nock et al., 2009, Nock et al., 2010). Female gender and being unemployed were also associated with a higher risk of acting on suicidal ideas (Bernal et al., 2007).
In six out of the ten WMH surveys performed in high-income countries some important disorders were not adequately assessed owing to skip logic errors, such as bipolar disorder and substance use disorders (Demyttenaere et al., 2004). These exclusions are unfortunate because research clearly indicates that these disorders are strongly associated with suicidal behaviours. Another limitation is that half of these surveys performed in high-income countries had a response rate below 60% (Nock et al., 2008a) and had rather small samples (less than 3600) which makes it difficult to study low incidence behaviours such as suicidal behaviours using country-specific data.
An issue which has not been studied extensively before is the extent to which mental disorders are still associated with first onset suicidal behaviours after the influence of childhood trauma is taken into account. More insight into this issue could give us some insight into possible mechanisms through which people come to think about suicide.
In this paper data from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a nationally representative survey among the general population aged 18–64 years were used to replicate and expand existing knowledge by studying characteristics and risk factors for suicidal behaviours. Specifically, we report (a) lifetime prevalence rates and mean ages of onset of suicidal ideation, plan and attempt as well as the conditional probabilities and mean ages of onset of ever making a suicide plan or attempt among ideators (b) the contributions of sociodemographic factors, childhood trauma, mental disorders and characteristics of prior suicidal behaviours for the first onset of suicidal behaviours and for the transition from ideation to plan or attempt.
Section snippets
Methods
NEMESIS-2 is a psychiatric epidemiologic survey in the Dutch general population aged 18 to 64 years. It is based on a multistage, stratified random sampling procedure of households, with one respondent randomly selected in each household. This resulted in a total sample of 6646 respondents (response rate 65.1%). This sample was nationally representative, although younger subjects were somewhat underrepresented (De Graaf et al., 2010). In the sample 7.3% was 18–24 years of age. In the population
Prevalence rates of suicidal behaviours
The lifetime prevalence of suicidal ideation, plan and attempt in the total sample was 8.3%, 3.0% and 2.2%, respectively. Women had higher prevalence rates than men, but this difference was only significant for suicide attempt. Among suicide ideators, the conditional probability of ever making a suicide plan or attempt in the total sample was 36.4% and 26.8%, respectively. As shown in Table 1, unplanned attempts were less often prevalent than planned attempts, but still are a third of all
Key findings
The lifetime prevalence of suicidal ideation, plan and attempt in the Netherlands was 8.3%, 3.0% and 2.2%, respectively. Among ideators, the probability of ever making an attempt was 26.8%. 76.5% of transitions from ideation to attempt occurred within the first year after ideation onset. These percentages are within the range of those found in previous population studies using the same instrument (Nock et al., 2008a).
Consistent with data from the WMH Survey Initiative (Bruffaerts et al., 2010,
Role of funding source
Financing the fieldwork of the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2) and this paper.
Conflict of interest
The authors have no conflicts of interest to declare.
All authors have contributed to the manuscript.
Acknowledgements
The Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2) is conducted by the Netherlands Institute of Mental Health and Addiction (Trimbos Institute) in Utrecht. Financial support has been received from the Ministry of Health, Welfare and Sport, with supplement support from the Netherlands Organization for Health Research and Development (ZonMw) and the Genetic Risk and Outcome of Psychosis (GROUP) investigators.
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