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The perimenopause is an individual experience, influenced by life circumstances, cultural context, family history and narrative. The perimenopause can last many years and women, as well as health professionals, can be poorly prepared for this potentially challenging period. Most people know to expect hot flushes, and maybe genitourinary symptoms. However, if the emotional symptoms, such as, reduced ability to cope, irritability and sudden anger, arise first, years before the expected hot flushes, it can be difficult to understand and have a detrimental effect on a woman’s life. We explore widespread physical symptoms of perimenopause and highlight symptoms that are regulated in the brain: hot flushes, body temperature regulation, sleep disturbances, libido. We focus on emotional symptoms, such as mood changes, depression, anxiety, agitation, irritability, a sense of overwhelm and losing the ability to cope, and explore their impact on suicidality. We briefly look at cognitive symptoms and explore the influence of trauma and the differences in experience by ethnicity and cultural influence. Finally, we look at the experience of premature ovarian insufficiency.
Perimenopause is a period of heightened risk of onset and relapse of mental illnesses including depressive disorders, schizophrenia spectrum disorders and bipolar affective disorder, as well as a time of increased risk of psychological symptoms including low mood, cognitive problems and anxiety. Perimenopausal depression can be seen as a distinct diagnostic entity with specific clinical features and treatment pathways. The risk of suicide in the perimenopause is widely reported and we look at the nuances of this association and other possible confounding factors. Perimenopause may be a particularly challenging time for women with pre-existing severe mental illness; women with severe mental illness are at risk of substandard menopause education and care, and there maybe diagnostic overshadowing, with menopausal symptoms not being identified, exacerbation of psychiatric symptoms due to perimenopausal symptoms, and an impact of ovarian hormones on psychopharmacology. We explore the evidence base behind psychological, pharmacological and hormonal treatment strategies (including hormone replacement therapy and selective oestrogen receptor modulators) proposed for treatment of perimenopausal mental illnesses.
Turning from the pulpit to the courtroom, Chapter 4 demonstrates the centrality of frenzy to what would later come to be termed the ‘insanity defence’. The English common law had its own framework for classifying mental illness, one which ran parallel to the medical nosologies explored in Chapter 1. This chapter explores the different categories of ‘madness’ recognizsed by early modern common lawyers – partial versus total, continual versus intermittent – and shows where frenzy fitted within this framework. It then turns to look at how these theories were mobilized in a specific legal context: coroners’ inquests into unexplained drownings. Where suicide was suspected, it argues, a story about frenzy – told right – offered an escape route for suspects and their families. Crucial, here, was the issue of culpability: frantic persons could not be held accountable for what they did while their wits were impaired. Without the capacity for consent, crime was impossible.
A otherwise healthy patient presenting with a subacute acetaminophen overdose must be managed. This chapter highlights the appropriate management of acetaminophen overdose with N-acetylcysteine, based on time and quantity of ingestion.
Globally, suicide is more prevalent in older adults compared with any other age group. Although some research has identified risk and protective factors for suicidal behaviour in older adults, further research is needed to provide an up-to-date overview to inform service delivery.
Aims
This study protocol describes mixed-methods research that will examine and identify factors associated with self-harm and suicide in older adults (aged 60 years and older) living in Ireland.
Method
Four stages will be conducted. First, data from the National Self-Harm Registry of Ireland (NSHRI), will be used to examine recent hospital self-harm presentations of older adults, including during the COVID-19 pandemic. Second, a case-series study will examine the adverse life events and psychosocial factors experienced by older adults before dying by suicide, using data from closed coronial files, through the Irish Probable Suicide Deaths Study (IPSDS). Third, risk of suicide following hospital-presenting self-harm will be examined among older adults via data linkage of the NSHRI and IPSDS. Finally, using semi-structured interviews, the service needs of older adults with suicidal behaviour will be explored from the perspectives of older adults, carers and healthcare practitioners.
Conclusions
A comprehensive understanding of adverse events and psychosocial factors associated with the suicidal behaviour of older adults is needed to inform service provision. This proposed research is aligned with (inter)national priorities, mental health promotion and suicide reduction policies. It aims to address gaps in mental healthcare interventions for older adults at risk of suicide.
In this chapter I give a preliminary argument against suicide, based on the core argument of the book. Suicide is distinguished from permisible acceptance of death as a side effect of some other permissible action.
Pronounced variations in suicide mortality persist across Europe. Understanding long-term temporal patterns through age, period and cohort (APC) effects, alongside suicide means, is essential for tailored prevention. This study aims to determine how suicide mortality rates in Europe have changed across APC dimensions at national and subregional levels.
Methods
Our analysis was restricted to European countries with complete age- and sex-specific suicide mortality data from 1990 to 2019 within the World Health Organization mortality database. The analysis comprised two components. The first component disentangled long-term suicide mortality trends (1990–2019) into APC dimensions using an age-period-cohort model via the National Cancer Institute’s APC Web Tool. The second component involved an assessment of suicide means, restricted to 2010–2019 and to countries with detailed International Classification of Diseases, 10th Revision (ICD-10) cause-of-death data.
Results
In 2019, Europe recorded 47,793 male and 13,111 female suicide deaths. Overall suicide mortality rates declined in most subregions from 1990 to 2019, with the largest reductions among Eastern European men, from 77.81 (95% CI: 77.17–78.45) per 100,000 in the mid-1990s to 22.93 (95% CI: 22.58–23.28) per 100,000 by 2019, although this region retained the highest male suicide burden. Age-specific risk patterns differed markedly: among men, risk peaked in early adulthood and then declined in Eastern Europe, while in Western and Southern Europe, it was lower and more stable but rose after age 60; for women, risk was generally lower, with peaks in early adulthood in Eastern Europe and in midlife elsewhere. Period reflected continued improvement, especially in Eastern Europe where the period risk in 2015–2019 was approximately 60% lower than 2000–2004. Cohort effects similarly showed progressive declines. However, upward trends emerged among younger generations. In Northern Europe, the cohort relative risk for females increased from 0.73 (95% CI: 0.68–0.78) in the 1980 cohort to 0.90 (95% CI: 0.70–1.04) in the 2000 cohort. While the completeness of suicide means analysis varied by subregion, the primary data indicated that hanging was the predominant means for both sexes during 2010–2019.
Conclusions
Despite an overall decline, suicide mortality in Europe exhibits persistent regional and demographic differences. This study reveals emerging risks among younger cohorts, specifically Northern European women and Southern European men, signalling shifting patterns that are not apparent from overall temporal trends alone. This evolving risk profile calls for sustained surveillance and research to investigate the drivers of these population-specific vulnerabilities.
Predicting suicide risk remains a challenge. We examined whether neurocognitive performance on implicit associations toward suicide, motor speed, response inhibition, and executive functioning predicts suicide attempt and behavior in high-risk psychiatric patients.
Method
Our sample (N = 298) consisted of inpatients (n = 161) and outpatients (n = 83) admitted for a suicide attempt (SA; n = 78), for suicidal ideation (SI; n = 76), or were non-suicidal psychiatric controls (PC; n = 90), and healthy controls (HC; n = 54). Participants were followed for 12 months, with follow-up assessments at 3-, 6-, and 12-months. Neurocognitive tasks were administered at baseline. Clinical symptom measures, suicidality, and electronic health record data were collected at each timepoint. ANCOVA was used to compare groups on neurocognitive performance, and logistic and Cox regressions examined whether neurocognitive performance predicted future actual suicide attempt and suicidal behaviors.
Results
Participants had a mean age of 24.34 years (SD = 3.71). A total of 19 participants made an actual suicide attempt during the study. On neurocognitive tasks at baseline, the SA group had stronger implicit associations with death- and suicide-related words compared to the HC (d = 0.88, p < 0.001) and SI (d = 0.63, p = 0.005) groups and poorer executive functioning than the SI (d = 0.44, p = 0.043) group in multivariate models. Stronger implicit associations with death/suicide predicted higher risk of suicide attempts at the univariate (HR = 1.68 p = 000), but not multivariate level (HR = 1.17 p = 000), while slower motor speed predicted actual suicide attempts (HR = 1.81 p = 000) at the multivariate level.
Conclusions
Slower motor speed predicts actual suicide attempt and may help identify psychiatric patients who are at high risk for suicidal behavior.
The COVID-19 pandemic has exerted significant mental health impacts worldwide, with a major concern in the literature being its potential effect on suicide rates. Brazil, one of the countries most severely affected by the pandemic, still lacks clear evidence regarding the consequences of the crisis on self-inflicted deaths. This paper aims to estimate the impact of the COVID-19 pandemic on suicide rates in Brazil.
Methods
We employed an interrupted time series design with seasonal adjustments to estimate changes in suicide rates per 100,000 population. The analysis was based on deaths from all forms of self-inflicted injury, as classified by the International Classification of Diseases. We estimated trends for the total population, stratified by sex and administrative region.
Results
Suicide rates increased significantly before the pandemic (β₁ = 0.00148, p < 0.001). No significant change in trend was observed after the onset of the pandemic at the national level (β₃ = 0.00092, p > 0.05). Among men, both the pre-pandemic trend (β₁ = 0.00236, p < 0.001) and the post-pandemic increase (β₃ = 0.00155, p < 0.05) were significant. For women, the pre-pandemic trend was modest (β₁ = 0.00065, p < 0.001), and the post-pandemic slope was not significant (β₃ = 0.00033, p = 0.10). Regionally, the Central-West (β₃ = 0.00217, p < 0.01) and North (β₃ = 0.00186, p < 0.05) experienced significant post-pandemic increases, while the Southeast (β₃ = 0.00087, p > 0.05) and South (β₃ = −0.00034, p > 0.05) showed no significant changes. Seasonal effects revealed consistent mid-year declines across all groups and regions.
Conclusions
The COVID-19 pandemic did not produce a statistically significant shift in national suicide trends but coincided with the persistence of pre-existing upward patterns in specific demographic and regional contexts. These findings underscore the need for targeted and region-specific suicide prevention strategies.
In The Netherlands, it is unknown whether the number of youth suicide-related emergency department visits has changed over time. Also, insight is needed in the hospital costs for managing these patients, as a first step toward the economic evaluation of suicide prevention measures.
Aims
This study examines (a) changes in emergency department-recorded suicide attempts, suicidal ideation and non-suicidal self-injury in youth, including repeat emergency department visits; and (b) related hospital costs for these patients, from a health insurer perspective.
Method
In this cross-sectional study, data from various sources was combined to identify all youth aged ≤27 years visiting a Dutch inner-city emergency department between 2016 and 2023 for a suicide attempt, suicidal ideation or non-suicidal self-injury. Hospital records were reviewed manually to determine inclusion. Ambiguities were discussed within an expert panel and descriptive analyses, Poisson regression and logistic regression analyses were performed. For a subset of 30 patients, invoiced costs were determined.
Results
The number of suicide attempts increased by approximately 5% annually, peaking in 2022 (n = 172); there were significantly more female patients (71%), and the median age was 21 years. Cases of suicidal ideation showed a similar trend, whereas the number of recorded non-suicidal self-injuries reduced. A total of 28.5% of all patients (n = 281) had one or multiple repeat visits for the above reasons. Median suicide attempt-related costs per case were €930, range €385–€33 473.
Conclusions
Since 2016, an increasing number of youth visited the emergency department of a Dutch hospital after a suicide attempt, but this increase does not seem to continue after 2022. Hospital-invoiced costs differ substantially between patients.
Young migrants encounter heightened challenges as the intersection of their youth and migrant identities magnifies the influence of risk factors for suicide. Social media offers a platform for young migrants to express emotions, seek support and connect with others, often anonymously. However, how they communicate about self-harm and suicide online remains underexplored. This qualitative study involved 17 online interviews with young migrants aged 15–25 years. Transcribed data were coded and thematically explored using Braun and Clarke’s reflexive thematic analysis methodology. Four key themes were identified: (1) Exposed and isolated: The emotional toll of viewing self-harm and suicide-related content on young migrants; (2) Connected but at-risk: The dual role of social media in migrant belonging; (3) Digital belonging across borders: Benefits and strains of staying connected; and (4) Helpful and harmful: The dual nature of support on social media. Social media has a complex impact on young migrants, offering both protective and harmful effects. While exposure to distressing or discriminatory content may exacerbate feelings of isolation and disconnection, social media can also promote belonging, cultural understanding and resilience. It also provides accessible support, though poor-quality advice and stigma may deter help-seeking. These insights can inform culturally responsive mental health interventions.
Although clinically framed as a public health concern, the meanings of suicide are fundamentally shaped by cultural narratives and visual representations.
Aims
To examine the evolution of sculptural representations of suicide from antiquity to the present, and to interpret these works through psychiatric and sociological lenses relevant to contemporary clinical and public health discourse.
Method
A structured search across PubMed, Scopus and Web of Science (up to August 2025) was integrated with museum archives and art-historical catalogues. Selected sculptural works were analysed as interpretive case studies using iconographic, semiotic and contextual approaches. Interpretation focused on affective and relational processes such as psychological pain (psychache), shame, entrapment and social disconnection prioritising cultural formulation over retrospective diagnostic attribution in historical cases.
Results
Sculptural representations frame suicide through shifting moral and social logics: from honour-bound self-death in antiquity and virtue-coded narratives in the early-modern period to interiority and estrangement in modernity. Contemporary public installations shift this focus towards visibility, urban space and prevention. These works externalise private suffering and structural conditions (e.g. isolation, stigma), actively shaping collective imaginaries of self-destruction.
Conclusions
Sculpture provides a unique medium for the translation of individual suffering and the collective meanings of suicide into public form. An interdisciplinary reading of these works supports culturally informed clinical reflection and contributes to ethically attentive public communication and prevention strategies.
The debate on euthanasia for mental suffering in young people in The Netherlands has become highly polarised, with a novel, apparently epidemiological argument taking centre stage: that psychiatric euthanasia is necessary to prevent suicide. This article evaluates that claim. Using data from 353 young applicants (annual suicide risk 2.9%) and optimistic assumptions (80% sensitivity and specificity), the number needed to treat was 10 and the number needed to harm 9. Thus, ten youths would need to undergo assisted dying to prevent one suicide, and nine would die without a preventive purpose having been served. Empirically and ethically, the prevention argument does not appear to hold; real prevention requires other, previously well-debated factors such as relational continuity, trauma-informed care and social inclusion in response to mental suffering.
This case report presents the case of a 25-year-old woman who developed ketamine addiction following a single sub-anaesthetic dose of intranasal ketamine in a pilot study investigating intranasal racemic ketamine for acute suicidality. She had a history of depression, obsessive–compulsive disorder, autism spectrum disorder and anorexia nervosa, and she had sporadically used alcohol and cannabis. Following the intervention, she reported a transient reduction in suicidal ideation but later sought illicit ketamine to recreate its calming effects on intrusive thoughts. Subsequently she also started abusing cocaine and 3-methylmethcathinone (3-MMC). Within weeks she had escalated to daily use, which led to financial distress, housing instability and a suicide attempt when access was cut off. Although she initially ceased use, she later relapsed into ketamine and cocaine addiction. This case highlights the addictive risk of ketamine, even in controlled settings. Given ketamine’s rising use in psychiatric treatment, careful screening, monitoring and awareness of addiction potential are essential. Future research should evaluate patient-specific risk factors and dosing strategies to minimise abuse liability.
C-reactive protein (CRP) has been studied in relation to bipolar disorder (BD) and suicidality independently. Although suicide risk is elevated in youth with BD, little is known about the association of CRP with suicidality in this population.
Methods
211 youth participated, including 23 BD with lifetime suicide attempts (BDSA), 45 BD with lifetime non-suicidal self-injury (NSSI; BDNSSI), 39 BD without lifetime suicide attempt or NSSI (BDNo-SA/NSSI), and 104 healthy controls (HC). Suicide attempts and NSSI were assessed systematically. Fasting blood samples yielded CRP levels. Primary analyses controlled for age, sex, and body mass index percentile.
Results
CRP levels differed across groups (F3,204 = 3.40, p = 0.02, ηp2 = 0.05). In post hoc analyses, CRP levels were significantly higher among BDSA (3.44 ± 6.42 mg/L) vs HC (0.81 ± 0.90 mg/L; p < 0.01) and BDNo-SA/NSSI (1.42 ± 3.31 mg/L; p = 0.01) groups; however, no difference was seen with the BDNSSI group (1.83 ± 2.22 mg/L; p = 0.12). Between-group differences in CRP levels persisted in independent sensitivity analyses controlling for current mood symptoms, lifetime mania score, lifetime smoking, and medications, but not with lifetime depression score.
Conclusions
Suicide attempts among youth with BD are associated with elevated CRP. Given accessibility of CRP testing, the present findings have potential clinical implications. Larger, longitudinal studies with repeated measures are needed to examine time-varying associations between CRP and suicide risk among youth with BD.
Edited by
Liz McDonald, East London NHS Foundation Trust,Roch Cantwell, Perinatal Mental Health Service and West of Scotland Mother & Baby Unit,Ian Jones, Cardiff University
Suicide remains a leading cause of maternal death in the UK and in other high-income countries. While there are clear risks in severe mental disorder, those who die have experienced a range of mental illnesses and often come from more deprived communities. The Confidential Enquiries highlight the distinctive patterns of occurrence and progression in perinatal mental illness and the need for improvements in clinical evaluation of risk, effective risk management and the availability of high-quality perinatal mental healthcare as important factors in helping reduce progression to suicide.
Everyone recognizes that it is, in general, wrong to intentionally kill a human being. But are there exceptions to that rule? In Killing and Christian Ethics, Christopher Tollefsen argues that there are no exceptions: the rule is absolute. The absolute view on killing that he defends has important implications for bioethical issues at the beginning and end of life, such as abortion and euthanasia. It has equally important implications for the morality of capital punishment and the morality of killing in war. Tollefsen argues that a lethal act is morally permissible only when it is an unintended side effect of one's action. In this way, some lethal acts of force, such as personal self-defense, or defense of a polity in a defensive war, may be justified -- but only if they involve no intension of causing death. Even God, Tollefsen argues, neither intends death, nor commands the intentional taking of life.
Interpersonal violence is a known risk factor for suicide, but its impact across racial and ethnic groups, particularly among Black and Indigenous youth, remains underexplored.
Methods
We conducted a nationwide longitudinal study involving 9,788,264 individuals aged 10–29 years who were enrolled in the 100 Million Brazilian Cohort and linked to Notifiable Diseases Information System (SINAN), National Hospital Information System (SIH) and Mortality Information System (SIM) (2011–2018). Exposure was any recorded interpersonal violence; the outcome was suicide (ICD-10 X60–X84). Cox models adjusted for demographic, socioeconomic, household factors, prior psychiatric hospitalization, and self-harm. Analyses were stratified by race.
Findings
During follow-up, 92,287 (0·94%) individuals had a record of interpersonal violence, and 1,657 suicides were identified. Exposure to violence was associated with a higher risk of suicide (HR 2·92; 95% CI 2·06–4·15). Associations were strongest among Indigenous youth (HR 10.61; 95% CI 4.34–25.94), followed by Black youth (HR 3.14; 95% CI 1.92–5.14). No significant association was observed among White youth.
Interpretation
Interpersonal violence is a major risk factor for youth suicide in Brazil, disproportionately affecting Indigenous and Black populations. Addressing systemic racism and structural inequalities is essential for equitable suicide prevention.
Suicidal ideation and trauma exposure are significant health challenges worldwide, and their interaction increases their burden on individuals and communities. However, limited research has been devoted to these conditions in low- and middle-income countries, where the majority of the burden of these disorders exists. Additionally, unique cultural factors that may contribute to differential relationships in these symptoms and disorders make this an important area to explore. This study examines relationships between the number and types of adverse exposures, PTSD symptoms and severity, depression and suicidal ideation in a sample of Cambodian women with experiences of trauma using logistic and linear regressions. Overall, PTSD severity significantly contributes to suicidal ideation, with hyperarousal symptoms playing a particularly influential role in this association. Further, adverse experiences, including physical abuse and parental mental health problems, contributed significantly to increased suicidal ideation. Lastly, depression severity partially mediates the relationship between PTSD severity and suicidal ideation. These results illustrate the significant role of PTSD in the experience of suicidal ideation, particularly within regions like Cambodia with high trauma loads. These findings point to psychological constructs that may be especially important to include in suicidality screening tools and to target within prevention and intervention efforts.