Lancet 2009; 373: 1372–81 Suicide receives increasing attention worldwide, with many countries developing national strategies for prevention. Centre for Suicide Research, Rates of suicide vary greatly between countries, with the greatest burdens in developing countries. Many more University Department of men than women die by suicide. Although suicide rates in elderly people have fallen in many countries, those in Psychiatry, Warneford Hospital, young people have risen. Rates also vary with ethnic origin, employment status, and occupation. Most people who Oxford, UK (Prof K Hawton DSc); die by suicide have psychiatric disorders, notably mood, substance-related, anxiety, psychotic, and personality and Unit for Suicide Research, University Department of disorders, with comorbidity being common. Previous self-harm is a major risk factor. Suicide is also associated Psychiatry, University with physical characteristics and disorders and smoking. Family history of suicidal behaviour is important, as are Hospital, Gent, Belgium upbringing, exposure to suicidal behaviour by others and in the media, and availability of means. Approaches to suicide prevention include those targeting high-risk groups and population strategies. There are, however, many challenges to large-scale prevention, especially in developing countries. Background and epidemiology
of suicide can be reached on a basis of judgment of
The estimated global burden of suicide is a million intent, as long as there is certainty that the death was
deaths per year,1 and an international policy statement self-inﬂ icted (eg, England and Wales). The decision by WHO in response to the large burden2 has prompted
about the cause of death will be made in private in most
many countries to initiate suicide prevention policies. countries where police or physicians are responsible for Estimated annual mortality is 14·5 deaths per the verdict and in the case of the Procurator Fiscal in 100 000 people, which equates to one death every 40 s.1
Scotland, although in England and Wales coroners’
Self-inﬂ icted death accounts for 1·5% of all deaths and hearings happen in public. is the tenth leading cause of death worldwide.3 Suicide
Diﬀ erent procedures and cultural and social practices
rates vary according to region, sex, age, time, ethnic and values probably have profound eﬀ ects on death origin, and, probably, practices of death registration.
In some countries many deaths (eg, 15% in China4)
(eg, as undetermined death or death due to accident or
are probably unreported, and procedures for recording illness). Some countries (eg, Finland, France, Portugal, deaths as suicide are far from uniform. Countries diﬀ er and Sweden) have very high combined rates of suicide in their death certiﬁ cation procedures for unexpected and undetermined death compared with rates of suicide, deaths and in their requirements for a death to be whereas other countries (eg, Belgium, Denmark, recorded as suicide. Certiﬁ cation of the cause of Germany, and the UK) have moderately high combined unexpected death is made by diﬀ erent bodies, including
rates.5 Detailed independent investigation (verbal
the police (eg, Finland), physicians (eg, China), coroners
autopsy) of unnatural deaths in rural areas of India,
(eg, England and Wales), coroners and medical where suicide is illegal, suggested a nine-fold to ten-fold examiners (eg, USA), or equivalent oﬃ
cials (eg, underestimation of suicide in reported rates.6 Such
Procurator Fiscal in Scotland). The requirements for a ﬁ ndings suggest that oﬃ
death to be recorded as suicide also diﬀ er, with external
burden of suicide1 are substantial underestimates. In
evidence of intent, such as a suicide note being required
many Islamic countries, the view of suicide as a criminal
in some countries (eg, Luxembourg); in others a verdict
oﬀ ence might aﬀ ect registration practices. Epidemio-logical data on suicide in Africa are scarce.
Rates of suicide vary substantially between regions and
Search strategy and selection criteria
countries (ﬁ gure 1). Within Europe, rates are generally higher in northern countries than in southern countries.
We searched the Cochrane Library, Psycinfo, Medline
An eﬀ ect of latitude on suicide rates was found in Japan,
(January, 2003, to July, 2008), and Embase (January, 2003,
suggesting an inﬂ uence of the daily amounts of sunshine
to July, 2008). We used the search term “suicide” in
on suicide.7 However, countries at about the same
combination with the terms “aetiology”, “epidemiology”,
latitude, such as the UK and Hungary, can have
“prevention”, and “psychological autopsy”. Index terms were
substantially diﬀ erent rates of suicide. Suicide is a major
used in preference to free text search terms whenever
concern in former Soviet states.1 More than 30% of
possible; no language restrictions were applied to the
suicides worldwide happen in China, where 3·6% of all
search. We commonly referenced older publications. We also
deaths are by suicide.4 Few countries provide national
searched the reference lists of articles identiﬁ ed in this
suicide rates segregated by residence, and these data
search strategy and selected relevant articles. Reviews and
show no clear pattern; although, in China, suicide rates
book chapters are cited to provide readers with further
are three-times higher in rural than in urban settings.4
reading. Our reference list was modiﬁ ed on the basis of
In developed countries, the male-to-female ratio for
suicide is between two and four to one, and this seems
www.thelancet.comVol 373 April 18, 2009 Figure 1: Suicide rates in selected regions and countries
to be increasing.1 Asian countries typically show much that presence of cultural supports and networks might lower male-to-female ratios, but these might also be be protective.16 However, suicide rates in populations of increasing;8 although in China more women than men immigrants also tend to co-vary with rates in country of die by suicide.4
Suicide rates are highest in elderly people in most
Indigenous populations in several countries have
countries. However, over the past 50 years, rates have high suicide rates compared with the rest of the risen in young people, in particular in men,9 and population, for example Native American people in the decreased in elderly people.10 More recently, suicide USA, Métis and Inuit in Canada, Australian Aborigines, rates in young males have decreased in some developed
and Maori in New Zealand all have high rates of
countries in which they had previously risen.11
suicide.15 Factors that might contribute include
Suicide rates also vary with season, peaking in spring,
marginalisation, disintegration of traditional social
particularly among men, although this association support networks and cultural values, socioeconomic seems to change over time.12 Suicide rates are also high
among people, in particular women, born in spring and
Suicide rates are high in unemployed people;19
although the reasons for this association are complex.
Clear ethnic patterns in suicide rates exist. These In part, high rates are associated with mental illness,
include lower rates of suicide in Hispanic and African which contributes to risks of both unemployment and Americans than in European Americans;14 although the
suicide.20 Among people in employment, some
historically large gap in suicide rates in black people occupational groups are at increased risk of suicide. compared with those in white people in the USA has Medical practitioners have a high risk in most countries, narrowed because of a substantial increase in suicides but female doctors are generally most at risk.21,22 Nurses in young black people.11
also have a high risk.23 In both these professional
Within countries, variations in rates are seen between
groups, access to poisons seems to be an important
diﬀ erent ethnic groups.15 In the UK, for example, young
factor in determining the high rates.23 Among doctors,
Indian women in London have a higher suicide rate anaesthetists are particularly at risk, with anaesthetic than other women, whereas young Afro-Caribbean drugs being used in many suicide deaths.21 Several women have very low rates, and men of Indian and other high-risk occupational groups (eg, dentists, African origin have lower rates than do white men.16
pharmacists, veterinary surgeons, and farmers) also
There are also diﬀ erences in methods of suicide, with have easy access to means for suicide.24women in south Asia commonly using setting ﬁ re to
Suicide rates are high in prisoners in countries that
themselves as a method of suicide.17 Suicide rates within
release data.25 Major risk factors are being conﬁ ned to a
ethnic groups seem to vary inversely according to single prison cell, previous attempted suicide, recent relative population density of each group, suggesting suicidal ideation, and psychiatric disorder or history of
www.thelancet.comVol 373 April 18, 2009 Psychiatric disorders Panel: Risk factors for suicide
The classic method of investigating characteristics of individuals who have died by suicide is through psycho-
logical autopsy, involving interviews with key informants
• Personality characteristics (eg, impulsivity, aggression)
shown that psychiatric disorders are present in about
• Restricted fetal growth and perinatal circumstances
90% of people who kill themselves and contribute
47–74% of population risk of suicide.34 Such studies have
• Neurobiological disturbances (eg, serotonin dysfunction
mostly been done in developed countries. Similar ﬁ ndings
and hypothalamic-pituitary axis hyperactivity)
have come from India.35 In China, however, a much lower
proportion of people who die by suicide seem to have
psychiatric disorders, especially women and girls in rural
areas.36 Aﬀ ective disorder is the most common psychiatric
misuse and schizophrenia. Comorbidity of disorders
The mortality risk for suicide associated with
alcohol problems.26 Rates of attempted suicide in depression is many times the general population risk.37 homosexual and bisexual men and women are high, More than half of all people who die by suicide meet but evidence is lacking for suicide.27
criteria for current depressive disorder;34 although the association seems weaker in Asia. About 4% of depressed
Methods of suicide
individuals die by suicide, but the risk is greatest in
When a person is contemplating suicide, access to males and in those who have needed psychiatric speciﬁ c methods might be the factor that leads to hospitalisation, especially for suicidality.38 Clinical translation of suicidal thoughts into action. The danger
predictors of suicide in people with major depressive
of available methods might determine whether the disorder also include a history of attempted suicide, outcome is fatal or not. In general, men tend to choose
high levels of hopelessness, and high ratings of suicidal
more violent means (eg, hanging or shooting) and tendencies.38 Suicide in major depressive disorder is women less violent methods (eg, self-poisoning).28
most likely to occur during the ﬁ rst episode, and this
Availability of speciﬁ c means for suicide aﬀ ects seems to be related to alcohol misuse and impul-
national patterns in the methods used. In the USA, sive-aggressive personality traits. The eﬀ ect of im-ﬁ rearms are used in most suicides, with risk of their use
aggressive traits is present in child and
being highest where guns are kept in households.29 In adolescent suicide and decreases with age.39rural areas of many developing countries, ingestion of
10–15% of patients with bipolar disorder die by
pesticides is the main method of suicide,30 reﬂ ecting suicide, commonly early in the illness course.40 Risk toxicity, easy availability, and poor storage. As many as factors for suicidal behaviour include previous 30% of global suicide deaths might involve ingestion of self-harm, family history of suicide, early onset and pesticides.30
increasing severity of the disorder, depressive symptoms (including hope lessness), mixed aﬀ ective states, rapid
cycling, comorbid psychiatric disorder, and misuse of
Numerous factors contribute to suicide, which is never alcohol or drugs.41the consequence of one single cause or stressor. These
Recent estimates suggest that lifetime suicide risk in
factors can be categorised as state-dependent or schizophrenia is 4–5%, the risk being highest relatively trait-dependent, or as distal or proximal factors (panel).
early after onset of the disorder.42 Risk is associated less
The relation between risk factors can be described in with the core symptoms of schizophrenia, such as explanatory models of suicide, such as the stress–
delusions and hallucinations, but more with depression
and speciﬁ c aﬀ ective symptoms (eg, agitation, sense of
Acute psychosocial crises and psychiatric disorders worthlessness, and hopelessness). Other factors include
are commonly the proximal stressors leading to suicidal
previous suicide attempts, drug misuse, fear of mental
behaviour, while pessimism or hopelessness and aggres-
disintegration, recent loss, and poor adherence to
sion or impulsivity are components of the diathesis for treatment.43suicidal behaviour. Familial or genetic factors, childhood
Alcohol misuse, particularly dependence, is strongly
experiences, and other factors, including cholesterol associated with suicide risk.44 The severity of the concentrations, inﬂ uence the diathesis.31 The stress–
disorder, aggression, impulsivity, and hopelessness
diathesis model is compatible with recent gene–environ-
seem to predispose to suicide. Key precipitating factors
ment interaction models,32 but prospective studies of its
are depression and stressful life events, particularly
www.thelancet.comVol 373 April 18, 2009
Suicide is a common cause of death in people with
eating disorders, in particular anorexia nervosa.11 The
risk of suicide is increased in adjustment disorder,45 and anxiety disorders and panic disorder are also associated with increased risk.45,46 However, comorbid
mood and substance-misuse disorders are common in anxiety disorders and it is unclear how much these disorders mask anxiety in psychological autopsy studies
or to what extent they are responsible for the increased suicide rate in patients with anxiety disorders.47 The eﬀ ect of anxiety disorders on suicide could therefore be
either underestimated or overestimated. Findings on
post-traumatic stress disorder are inconclusive.48
Attention deﬁ cit hyperactivity disorder seems to Figure 2: A stress–diathesis model of suicide
increase the risk of suicide in males via increasing Adapted from Mann 2003.31severity of comorbidities, in particular conduct disorder and depression.49 Psychopathology, including body injury, systemic lupus erythematosus,61,62 and pain.63 dysmorphic disorder probably explains, at least in part, However, many studies of associations between physical the surprisingly increased risk of suicide after cosmetic
illness and suicide have methodological problems.62
breast augmentation, reported in six epidemiological studies.50 30–40% of people who die by suicide have Other factors personality disorders.51,52 The risk of suicide seems to be
In most studies of risk factors for suicide, a history of
particularly increased in borderline and antisocial self-harm or suicide attempts is the strongest factor, personality dis orders.52,53 However, nearly all individuals
present in at least 40% of cases.34 In prospective studies
with personality disorders who die by suicide have of individuals who present to hospital after non-fatal concurrent depressive symptoms, substance-use self-poisoning or self-injury, 1–6% die by suicide in the disorders, or both.51,52 The concept of personality ﬁ
rst year, although the proportion varies among
disorder might be less relevant in developing countries,
countries.64 The risk is higher in older people, men,65
where suicidal acts often seem to be impulsive.54
people who repeatedly self-harm,66 those whose acts of
About 10% of individuals who die by suicide in most self-harm involved high suicidal intent (ie, apparent
countries have no apparent psychiatric disorder. wish to die),67 people who misuse alcohol, and those not However, psychological autopsy study of such people living with relatives.68 Although there is debate over indicates that most have psychiatric symptoms and whether attempted suicide should be distinguished personality characteristics similar to those in individuals
from non-suicidal self-harm,69 the risk of suicide is
with psych iatric disorder who have died by suicide.55,56
mainly related to whether or not an intentional act of
Thus, in most countries (except China) suicide seems self-poisoning or self-injury has occurred, and less to rarely to occur in the absence of psychiatric disorders or
Suicide is commonly preceded by notable life events,
in particular interpersonal or health-related events.70
Major events aﬀ ecting whole populations, such as
Suicide is associated with poor physical health and earthquakes71 or deaths of famous people,72 can be disabilities. An association between raised body-mass followed by increased suicide rates. By contrast, wars index and increased risk of depression but reduced risk
can be associated with a decline in suicide rates,
of suicide (15% decrease in suicide risk for each 5 kg/m²
possibly because of greater cohesion and shared sense
increase in body-mass index) is intriguing.57 The of purpose in a society, although the eﬀ ect of war might association between low body-mass index and increased
risk of suicide cannot be explained by weight loss
Physical and, in particular, sexual abuse during
caused by mental illness, but low cholesterol childhood is strongly associated with suicide. The eﬀ ects concentrations might play a part.57 Increased risk of of childhood maltreatment and its relation to suicide are suicide is associated with smoking. The relation seems compounded by intergenerational transmission of to be dose related,58 and an underlying biological abuse. Familial transmission of suicidal behaviour is mechanism is possible,59 but depression and alcohol or most likely if the person attempting suicide had been drug disorders might confound the association.60
sexually abused as a child.74 Abuse is, thus, not only a
Suicide is also associated with several physical risk factor for suicidal behaviour for individuals abused
disorders, including cancer (head and neck cancers in as children, but also for their oﬀ spring.11particular), HIV/AIDS, Huntington’s disease, multiple
Risk of suicidal behaviour can be inﬂ uenced by
sclerosis, epilepsy, peptic ulcer, renal disease, spinal-cord
exposure to similar behaviour by other people. People
www.thelancet.comVol 373 April 18, 2009
bereaved by suicide have an increased risk of themselves
environmental stressors.32 Discussion of nature versus
dying by suicide.75 Clusters of suicidal acts can occur in nurture is fuelled by ﬁ ndings of associations between a community, particularly in young people,76 with suicide, young maternal age, and restricted fetal and evidence of speciﬁ c connections (eg, newspaper cuttings,
childhood growth.95–97 Although social factors might
text messages) in some cases. Some multiple deaths by help to explain such associations, environmental suicide involve suicide pacts,77 with a recent development
stressors can include intrauterine determinants of a
being meeting of suicidal individuals through internet diathesis for suicide.98websites before death.78 Some websites might encourage
By contrast with non-fatal self-harm, few studies have
suicide and provide detailed information about methods
in vesti gated personality-related correlates of completed
suicide.99 High levels of lifetime aggression39 are
A substantial body of evidence indicates that certain associated with high risk of suicide, while most, though
types of media reporting and portrayal of suicidal not all, studies suggest impulsivity also aﬀ ects the risk behaviour can inﬂ uence suicide and self-harm in the of suicide.55,100 Hopelessness is a strong predictor of general population.80,81 Newspaper reporting of suicides
can be particularly inﬂ uential if it is sensational, if it includes dramatic headlines and pictures, if it Suicide in young and elderly people reports methods of suicide in detail, and if the subject Suicide rates rise throughout the teenage years, is a celebrity.80,82 Suicide in television dramas can especially in males. Many factors associated with suicide inﬂ uence risk and nature of subsequent suicidal in adults are also present in younger people. Family behaviour.83
transmission of suicide risk is important, especially when suicide occurs on the maternal side.102 Most young
people who die by suicide have psychiatric disorders,
Early studies suggested involvement of neurobiological
dysfunction in attempted and completed suicide.84,85
and disruptive behaviour disorders being most frequent,
Several biological systems might be involved in suicidal
and, as in adults, comorbidity of disorders being
behaviour. Post-mortem studies have shown changes in
common.11 Other important con tributory factors include
central neurotransmission functions in association previous suicide attempts, family disruption and with suicide, particularly with regard to the serotonin discord, loss events, physical and sexual abuse, home-and noradrenalin systems, and in postsynaptic signal lessness, and homosexual and bisexual orientation.11,103 transduction.31 Furthermore, dysfunction of the hypo-
Media inﬂ uences seem important in young people,104
thalamic-pituitary-adrenal axis might predict suicide in and some suicides also seem to happen in clusters.76patients with depression, whether or not they have
In elderly people in developed countries, suicide is
attempted suicide.86,87 Low cholesterol concentrations strongly linked to psychiatric disorder, with depression are associated with an increased risk of suicide,88 but being the main contributor.105 A similar pattern was the greater eﬀ ect on the risk of suicide of cholesterol found in Hong Kong.106 Alcohol misuse might be an lowering by diet than by treatment with statins is important factor in elderly people.105 Cognitive rigidity unexplained.31
and obsessional traits seem to aﬀ ect suicide risk,107,108
Family history of suicide increases the risk at least probably because they undermine elderly people’s
two-fold, particularly in girls and women, independently
ability to cope with challenges of ageing, which often
of family psychiatric history.89 Concordance rates of call for substantial adaptations. Physical illness,109 suicide are higher among monozygotic twins than bereavement, and loss of independence110 are also among dizygotic twins.90 Genetic factors account for important factors. 45% of the variance in suicidal thoughts and behaviours, and candidate genes include those encoding for Prevention tryptophan hydroxylase and the serotonin transporter.90
Several countries have established national suicide
The pheno typic association with suicide is, however, prevention strategies. Some strategies include speciﬁ c unclear; disturbances in the serotoninergic system are targets for reduction in suicides. Although the value of associated with suicide-related characteristics including
these steps has not been proven, they do seem to help
aggression, impulsivity, dysfunctional attitudes about focus attention on the problem of suicide. Prevention of the future, hopelessness,91,92 and impaired decision suicide can best involve strategies thatfocus on making.93 Poor neuropsychological function after individuals in known high-risk groups and strategies exposure to particular stressors94 might explain the aimed at general reduction in population risk of association between disturbed serotoninergic prefrontal
brain function and an increased risk of suicidal behaviour, and thus constitute an endophenotype for Strategies targeting high-risk groups suicidal behaviour. Evidence is accumulating that such Although overall groups at risk can be identiﬁ ed, behaviour results from interaction between genes and prediction of suicide in individuals is diﬃ
www.thelancet.comVol 373 April 18, 2009
individual risk factors account for a small proportion of
patients with schizophrenia or schizoaﬀ ective disorder
cient speciﬁ city, at risk of suicide, patients treated with clozapine had
resulting in high rates of false positives.111
fewer suicide attempts and rescue interventions to
The management of people at risk of suicide is chal-
prevent suicide than did those receiving olanzapine.123
lenging because of the many causes and poor evidence
Because most suicides associated with psychiatric
base. Each person with depression should be screened hospitalisation happen shortly after admission (mostly for suicide risk by speciﬁ cally asking about suicidal through hanging) or after discharge, safer services, thoughts and plans. If suicidal ideation is present or if intensive clinical care, and ongoing care beyond the suicidal intentions are suspected, risk factors for suicide
point of clinical recovery are important to reduce the
(panel) should be assessed. If suicide risk is present, risk of suicide in patients with psychiatric disorders.124further assessment should address the imminence of
The high risk of suicide after self-harm or attempted
suicidal behaviour. Intention to die (explicitly expressed
suicide means that individuals with such behaviours,
or inferred from behaviour), cogent plans, and high especially those with characteristics indicating higher levels of hope lessness might indicate imminent risk. risk, such as repeated self-harm,66,125 should be targeted This risk is likely to be heightened by alcohol misuse in prevention programmes. Speciﬁ c psychological treat-and easy access to methods by which to carry out a ments, especially cognitive behaviour therapy, can suicidal act. In cases of high or imminent suicide risk, reduce repetition of self-harm.126 Voluntary agencies, immediate action is needed, including vigilance and including crisis self-help lines, provide a very substantial supervision of patients, perhaps through hospitalisation,
resource for helping suicidal people, although their
removal of potential methods of suicide, and initiation eﬀ ect on suicide prevention is diﬃ
of vigorous treatment of associated psychiatric disorder. Population strategies
In cases of a mood disorder, treatment options Removal of means used for suicide is important in
include antidepressants, mood stabilisers, and management of individuals, and modiﬁ cation of general psychotherapy. Diagnosis and treatment of depression access to dangerous means can also be eﬀ ective in plays a pivotal part in prevention of suicide. However, suicide prevention at the population level.128 Substitution the relation between antidepressants and risk of of one method with another does happen, but is rare.129 suicidal behaviour is debated,112,113 particularly in young One striking example of the eﬀ ect of availability of a people.114,115 Regulatory agencies have issued warnings common means of suicide was the large reduction in that use of selective serotonin-reuptake inhibitors suicides following the change of the UK gas supply poses a small but sig niﬁ cantly increased risk of suicidal
from toxic coal gas, the most common method used for
ideation or non-fatal suicide attempts for children and suicide during the early 1960s, to non-toxic North Sea adolescents.116 Guidelines therefore recommend that gas.130 More recent examples include reduction in use of antidepressants should be given only to moderate or vehicle exhaust for suicide since catalytic converters severely depressed adolescents and only with have been introduced in cars,131 fewer suicides by psychological therapy.117 The beneﬁ ts of adding cognitive
jumping from bridges and other sites popular for this
behavioural therapy are debated, but might include method of suicide have resulted from the addition of attenuation of the risk of suicidality during medication
safety barriers,132 and, although to a variable extent, the
treatment.118,119 Careful monitoring of symptoms, results of gun-control laws in countries where ﬁ rearms side-eﬀ ects, and suicide risk should be routinely done are often used for suicide.29 The major problem of in all patients, especially when initiating antidepressant
intentional pesticide poisoning in rural areas of many
convulsive therapy is developing countries could be reduced by restriction of
commonly the last resort in the treatment of depression,
access to pesticides through safer storage and stopping
it might have immediate beneﬁ t on expressed suicidal sales of more toxic preparations.54 Hanging, which has intent in patients with depression.120 A recent become more common as a method of suicide in several meta-analysis of randomised trials suggested that the countries, presents particular challenges for prevention risk of death and suicide in people with mood disorders
because of the ready availabilty of the means by which
was reduced by 60% in those taking lithium.121 Possible
mechanisms of anti suicidal action include its eﬀ ects
Up to 40% of individuals who die by suicide have
on mood stabilisation, impulsivity, and aggression, and
visited a family doctor within weeks of death.134 An
a non-speciﬁ c eﬀ ect arising from long-term close initial study of an educational primary care programme monitoring.
to improve detection and management of depression
Excess mortality in schizophrenia is mostly seen in on the Swedish island of Gotland that showed promising
patients who are not taking antipsychotic drugs.122
eﬀ ects on suicide rates135 had methodological problems,
Although studies of the eﬀ ect of treatments on suicidal
but similar results from German and Hungarian studies
behaviour are rare and ﬁ ndings inconsistent, clozapine
have also had positive eﬀ ects on rates of non-fatal
may have an antisuicidal eﬀ ect. In a randomised trial in
www.thelancet.comVol 373 April 18, 2009
School programmes aimed at improving psychological
WHO. World Health Statistics. Geneva: World Health
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Both authors contributed equally to this Seminar.
England and Wales, 1978–2003. Lancet 2005; 366: 1301–02. Conﬂ icts of interest
26 Fazel S, Cartwright J, Nott-Norman A, Hawton K. Suicide in
We declare that we have no conﬂ icts of interest.
prisoners: a systematic review of risk factors. J Clin Psychiatry 2008; 69: 1721–31. Acknowledgments
27 King M, Semlyen J, See Tai S, et al. A systematic review of mental
We thank Lesley Sutton for her help with the references. KH is
disorder, suicide, and deliberate self harm in lesbian, gay and
supported by Oxfordshire and Buckinghamshire Mental Health NHS
bisexual people. BMC Psychiatry 2008; 8: 70.
Foundation Trust and by the National Institute for Health Research.
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The views expressed in this paper are solely those of the authors.
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Effect of joint injections in children with juvenile idiopathic arthritis:evaluation by 3D-gait analysisE Brostro¨m, S Hagelberg and Y Haglund-A Department of Woman and Child Health, Karolinska Institute, Astrid Lindgren Children’s Hospital, Stockholm, Sweden ˚ kerlind Y. Effect of joint injections in children with juvenileidiopathic arthritis: evaluation by 3D-gait analysis. Acta Pædiatr
An extract of black, green, and mulberry teas causes malabsorptionof carbohydrate but not of triacylglycerol in healthy volunteers1–3 Litao Zhong, Julie K Furne, and Michael D Levitt ABSTRACT in green tea are dimerized to form a variety of theaflavins (1); Background: In vitro studies suggest that extracts of black, green, thus, these teas may have different biological activities. and