Social Psychiatry and Psychiatric Epidemiology

, Volume 49, Issue 9, pp 1357–1365 | Cite as

Risk of suicide according to level of psychiatric treatment: a nationwide nested case–control study

  • Carsten Rygaard HjorthøjEmail author
  • Trine Madsen
  • Esben Agerbo
  • Merete Nordentoft
Original Paper



Knowledge of the epidemiology of suicide is a necessary prerequisite of suicide prevention. We aimed to conduct a nationwide study investigating suicide risk in relation to level of psychiatric treatment.


Nationwide nested case–control study comparing individuals who died from suicide between 1996 and 2009 to age-, sex-, and year-matched controls. Psychiatric treatment in the previous year was graded as “no treatment,” “medicated,” “outpatient contact,” “psychiatric emergency room contact,” or “admitted to psychiatric hospital.”


There were 2,429 cases and 50,323 controls. Compared with people who had not received any psychiatric treatment in the preceding year, the adjusted rate ratio (95 % confidence interval) for suicide was 5.8 (5.2–6.6) for people receiving only psychiatric medication, 8.2 (6.1–11.0) for people with at most psychiatric outpatient contact, 27.9 (19.5–40.0) for people with at most psychiatric emergency room contacts, and 44.3 (36.1–54.4) for people who had been admitted to a psychiatric hospital. The gradient was steeper for married or cohabiting people, those with higher socioeconomic position, and possibly those without a history of attempted suicide.


Psychiatric admission in the preceding year was highly associated with risk of dying from suicide. Furthermore, even individuals who have been in contact with psychiatric treatment but who have not been admitted are at highly increased risk of suicide.


Suicide Mental health services Population registers Mental disorders 



The study was funded by The Ministry of Social Affairs. The authors have no conflict of interest to report, and the funding organization had no role in design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.

Conflict of interest

All authors declare that we have no conflict of interest.


  1. 1.
  2. 2.
    Mortensen PB, Agerbo E, Erikson T, Qin P, Westergaard-Nielsen N (2000) Psychiatric illness and risk factors for suicide in Denmark. Lancet 355(9197):9–12PubMedCrossRefGoogle Scholar
  3. 3.
    Bostwick JM, Pankratz VS (2000) Affective disorders and suicide risk: a reexamination. Am J Psychiatry 157(12):1925–1932PubMedCrossRefGoogle Scholar
  4. 4.
    Palmer BA, Pankratz VS, Bostwick JM (2005) The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry 62(3):247–253PubMedCrossRefGoogle Scholar
  5. 5.
    Harris EC, Barraclough B (1997) Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatry 170:205–228PubMedCrossRefGoogle Scholar
  6. 6.
    Goldacre M, Seagroatt V, Hawton K (1993) Suicide after discharge from psychiatric inpatient care. Lancet 342(8866):283–286PubMedCrossRefGoogle Scholar
  7. 7.
    Pirkis J, Burgess P (1998) Suicide and recency of health care contacts. A systematic review. Br J Psychiatry 173:462–474PubMedCrossRefGoogle Scholar
  8. 8.
    Qin P, Nordentoft M (2005) Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry 62(4):427–432PubMedCrossRefGoogle Scholar
  9. 9.
    Madsen T, Agerbo E, Mortensen PB, Nordentoft M (2011) Predictors of psychiatric inpatient suicide: a national prospective register-based study. J Clin Psychiatry 73(2):144–151Google Scholar
  10. 10.
    Agerbo E (2007) High income, employment, postgraduate education, and marriage: a suicidal cocktail among psychiatric patients. Arch Gen Psychiatry 64(12):1377–1384PubMedCrossRefGoogle Scholar
  11. 11.
    Hunt IM, Kapur N, Webb R, Robinson J, Burns J, Turnbull P et al (2007) Suicide in current psychiatric in-patients: a case-control study. The National Confidential Inquiry into Suicide and Homicide. Psychol Med 37(6):831–837PubMedCrossRefGoogle Scholar
  12. 12.
    Pedersen CB (2011) The Danish civil registration system. Scand J Public Health 39(7 suppl):22–25PubMedCrossRefGoogle Scholar
  13. 13.
    Helweg-Larsen K (2011) The Danish register of causes of death. Scand J Public Health 39(7 Suppl):26–29PubMedCrossRefGoogle Scholar
  14. 14.
    Borgan O, Goldstein L, Langholz B (1995) Methods for the analysis of sampled cohort data in the Cox proportional hazards model. Ann Stat 23(5):1749–1778CrossRefGoogle Scholar
  15. 15.
    McDowall M (1983) Adjusting proportional mortality ratios for the influence of extraneous causes of death. Stat Med 2(4):467–475PubMedCrossRefGoogle Scholar
  16. 16.
    Roman E, Beral V, Inskip H, McDowall M, Adelstein A (1984) A comparison of standardized and proportional mortality ratios. Stat Med 3(1):7–14PubMedCrossRefGoogle Scholar
  17. 17.
    Mors O, Perto GP, Mortensen PB (2011) The Danish psychiatric central research register. Scand J Public Health 39(7 Suppl):54–57PubMedCrossRefGoogle Scholar
  18. 18.
    Kildemoes HW, Sorensen HT, Hallas J (2011) The Danish national prescription registry. Scand J Public Health 39(7 Suppl):38–41PubMedCrossRefGoogle Scholar
  19. 19.
    Statistics Denmark (2007) Integrated database for labour market research (IDA). Statistics Denmark. Cited 2013 Aug 26.
  20. 20.
    Christiansen E, Larsen KJ, Agerbo E, Bilenberg N, Stenager E (2012) Incidence and risk factors for suicide attempts in a general population of young people: a Danish register-based study. Aust N Z J PsychiatryGoogle Scholar
  21. 21.
    Borgan O, Langholz B (1993) Nonparametric estimation of relative mortality from nested case-control studies. Biometrics 49(2):593–602PubMedCrossRefGoogle Scholar
  22. 22.
    King G, Zeng L (2002) Estimating risk and rate levels, ratios and differences in case-control studies. Stat Med 21(10):1409–1427PubMedCrossRefGoogle Scholar
  23. 23.
    Bjerregaard P, Curtis T (2002) Cultural change and mental health in Greenland: the association of childhood conditions, language, and urbanization with mental health and suicidal thoughts among the Inuit of Greenland. Soc Sci Med 54(1):33–48PubMedCrossRefGoogle Scholar
  24. 24.
    Moustgaard H, Bjerregaard P, Borch-Johnsen K, Jorgensen ME (2005) Diabetes among Inuit migrants in Denmark. Int J Circumpolar Health 64(4):354–364PubMedCrossRefGoogle Scholar
  25. 25.
    Boysen T, Friborg J, Andersen A, Nilsson Poulsen G, Wohlfahrt J, Melbye M (2008) The Inuit cancer pattern—the influence of migration. Int J Cancer 122(11):2568–2572PubMedCrossRefGoogle Scholar
  26. 26.
    Hugo M, Smout M, Bannister J (2002) A comparison in hospitalization rates between a community-based mobile emergency service and a hospital-based emergency service. Aust N Z J Psychiatry 36(4):504–508PubMedCrossRefGoogle Scholar
  27. 27.
    Schnyder U, Klaghofer R, Leuthold A, Buddeberg C (1999) Characteristics of psychiatric emergencies and the choice of intervention strategies. Acta Psychiatr Scand 99(3):179–187PubMedCrossRefGoogle Scholar
  28. 28.
    Baca-Garcia E, Diaz-Sastre C, Resa EG, Blasco H, Conesa DB, Saiz-Ruiz J et al (2004) Variables associated with hospitalization decisions by emergency psychiatrists after a patient’s suicide attempt. Psychiatr Serv 55(7):792–797PubMedCrossRefGoogle Scholar
  29. 29.
    Kapusta ND, Tran US, Rockett IR, De LD, Naylor CP, Niederkrotenthaler T et al (2011) Declining autopsy rates and suicide misclassification: a cross-national analysis of 35 countries. Arch Gen Psychiatry 68(10):1050–1057PubMedCrossRefGoogle Scholar
  30. 30.
    Atkinson MW, Kessel N, Dalgaard JB (1975) The comparability of suicide rates. Br J Psychiatry 127:247–256PubMedCrossRefGoogle Scholar
  31. 31.
    De Leo D, Evans R (2003) International suicide rates: recent trends and implications for Australia. Australian Institute for Suicide Research and Prevention, CanberraGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Carsten Rygaard Hjorthøj
    • 1
    • 2
    Email author
  • Trine Madsen
    • 1
  • Esben Agerbo
    • 2
    • 3
    • 4
  • Merete Nordentoft
    • 1
    • 2
  1. 1.Mental Health Center CopenhagenUniversity of CopenhagenCopenhagenDenmark
  2. 2.The Lundbeck Foundation Initiative for Integrative Psychiatric ResearchiPSYCHCopenhagen and AarhusDenmark
  3. 3.National Centre for Register-based Research, Business and Social SciencesAarhus UniversityAarhusDenmark
  4. 4.CIRRAU - Centre for Integrated Register-based ResearchAarhus UniversityAarhusDenmark

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