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Three Part Question

[In patients at risk of suicide/parasuicide] is [Christmas] a [high risk period]?

Clinical Scenario

You are planning for winter pressures in your emergency department. You wonder if you will need additional psychiatric support over the Christmas period to cope with a perceived increase in the number of suicide attempts. When you bring this up at a senior team meeting a colleague suggests that in fact the number of suicides decreases over the Christmas period. You wonder if this is true.

Search Strategy

MEDLINE(R) In-Process, Other Non-Indexed Citations, MEDLINE 1966-07/2004 using the Ovid interface.
[christmas.mp] AND [suicide.mp. or exp SUICIDE/ or exp SUICIDE, ATTEMPTED/ or exp Suicide, Attempted/ or parasuicide.mp.]

Search Outcome

Altogether 15 papers found of which 6 were relevant to the clinical question. These papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Jessen G et al, 1999, Multicentre WHO study	24388 suicide attempts in patients over 15 years between 1989-1996. Data from 13 European centres. Holidays around Christmas and New Year (20 December to 6 January)	Cohort	Before Christmas	Statistically fewer attempts on the 20th, 21st and 23rd December	Data collection may suffer during public holidays This study only examined suicide attempts rather than deaths that reached health service care
			After Christmas	Statistically more than expected on the 27th (39% increase) and on New Years day.
			General fluctuation	There was a greater degree of fluctuation around all public holidays
Masterton G, 1991, UK	All parasuicide admissions between January 1969 and December 1987 involving people in Edinburgh. Aged >16. 22169 admissions were included	Retrospective database analysis	Parasuicide incidence at Christmas in Women	Approximate 20% drop in rates for the 4 weeks from 4/12 until 1/1. This was followed by an 11% increase in the 1st week of the new year. (comparisons made with average rate over year)	Only one centre Only admitted patients Long time span of study may result in a number of confounding factors (eg need for admission)
			Parasuicide incidence at Christmas in men	No statistical difference over the christmas period.
Cullum SJ et al, 1993, UK	Cases of deliberate self harm presenting to 3 EDs in London. Rates on christmas day were compared with rates on Feb 7th and 15th August	Retrospective database analysis	Total cases on Christmas day over 7 years	12 cases	Although a statistical difference was found (p<0.05) these are still small numbers. There is no account for the effect on incidence on days before and after Christmas as seen in other papers.
			Total cases on Feb 7th	25 cases
			Total cases on Aug 15th	25 cases
Ajdacic-Gross V et al, 2003, Switzerland	Swiss mortality data from 1969-1994. 37158 suicides included in database.	Retrospective database analysis	Suicide rates in December	10% less than average for year	Well performed study
			Dates with lowest rates of suicide	December 23rd, 25th and 30th
Jessen G & Jensen BF, 1999, Denmark	Database of suicides between 1970 and 1994. 32291 suicides included	Retrospective database analysis	Incidence of suicide at Christmas	Decreased in week around Christmas
			Lowest rate of suicide	30% less than expected on Christmas Eve. 20% less than expected on Christmas day.
			Overall rate in December	6% less than expected
Phillips SP & Wills JS, 1987, US	Suicides in the US from 1973-1979. 188,047 suicides included in database	Retrospective database analysis	Rates at Christmas	Fewer (up to 15%) suicides before Christmas (p<0.05).	Interesting paper as shows that reductions in suicides around public holidays show three patterns. Christmas shows a reduction in the days before the 25th and no peak until after the New Year

Comment(s)

Although the papers presented show a mix of suicide and parasuicide statistics it is apparent that there is a general trend for such events to reduce in December and in particular around the days preceding Christmas day. As with all studies in this area there may be difficulties in gauging the true incidence as a result of under reporting. This is unlikely to be a significantly different at Christmas though so overall trends should be valid. The perception of many is that rates go up around Christmas. This has resulted in a greater awareness and access to services at this time. It is an interesting question to ponder whether the reductions seen here are due to an overall reduction in need, or the effectiveness of available help services.

Clinical Bottom Line

Suicide and Para-suicide rates go down around Christmas.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Jessen G, Jensen BF, Arensman E et al Attempted suicide and major public holidays in Europe: findings from the WHO/EURO Multicentre study on parasuicide. Acta Psychiatr Scand 1999;99(6):412-418.
2. Masterton G. Monthly and seasonal variation in parasuicide: A sex difference Br J Psychiatr 1991;158:155-157.
3. Cullum SJ, Catalan J, Berelowitz K, O'Brien S, Millington HT, Preston D. Deliberate self-harm and public holidays: Is there a link? Crisis 1993;14(1):39-42.
4. Ajdacic-Gross V, Wang J, Bopp M, Eich D, Rossler W, Gutzwiller F. Are seasonalities in suicide dependant on suicide methods? A reappraisal. Soc Sci Med 2003;57(7):1173-1181.
5. Jessen G, Jensen BF. Postponed suicide death? Suicide around birthdays and major public holidays Suicide Life Threat Behav 1999;29(3):272-282.
6. Phillips DP, Wills JS. A Drop in suicides around major national holidays. Suicide Life Threat Behav 1987;17(1):1-12.