Hospitalizations for Suicidal Events: Reiteration Risk—The Experience in the Veneto Region, Italy

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This article presents a topic of interest to the general public, but there are some points to revise:

In the methodology section, how many sites in the mentioned region were included?

The inclusion criteria are difficult to follow. Please rewrite this section.

Why were dementia criteria disregarded?

The importance of the cross-cultural perspective and possible differences of mental disorders and suicide attempts should be added (please see relevant recent discussion in doi: 10.1016/S2215-0366(17)30165-7

Suicide in seniors and cross-cultural differences could be also discussed (for a relevant review please read and discuss the section on suicide in: Makri, E., & Giannouli, V. (2022). Cross-cultural cognitive and affective differences in aging: Can culture shape the expression and perception of psychopathology in old age. Encephalos, 59, 34-43.

The title seems to be misleading. Is this an Italian or a Venetian perspective?

Many points in the discussion are not supported by relevant literature. Please provide references (e.g. for the females under 60 exhibiting higher rates of suicide attempts).

Please avoid the term 'subjects' and use individuals instead in all section of the article.

Comments on the Quality of English Language

Moderate English language editing.

Author Response

Dear Reviewer 1,

Thank you for your thorough review. Below are point-by-point responses addressing each comment.

 

This article presents a topic of interest to the general public, but there are some points to revise:

 

Q1: In the methodology section, how many sites in the mentioned region were included?

A1: All inpatient facilities in the Veneto region, both public and private, were considered in the study to include all patients in the region (population of about 5 million). We have better clarified this point in the methods.

 

 

Q2: The inclusion criteria are difficult to follow. Please rewrite this section.

A2: We explained in the limitations the reasons for the criteria used in our study. Unfortunately, our data are limited to those from the hospital discharge records of the Veneto region. It was not possible for us to access the complete medical records. Therefore, our classification is limited to the diagnosis codes recorded in the HDR. In the Veneto region these are still coded using the ICD-9-CM system. We realize that this may be a possible bias and limitation of our results considering the more modern classifications available today, such as the ICD-10-CM or DSM-5 systems.

 

 

Q3: Why were dementia criteria disregarded?

A3: Dementia is coded by ICD 9 CM codes beginning with 290. In our study, it was considered in the group “Psychotic and mood disorders” (ICD-9-CM 290-299). We have made it clearer in the methods.

 

 

Q4: The importance of the cross-cultural perspective and possible differences of mental disorders and suicide attempts should be added (please see relevant recent discussion in doi: 10.1016/S2215-0366(17)30165-7

A4: Thanks for the suggestion, we have improved the discussion section by incorporating evidence from the relevant literature.

 

 

Q5: Suicide in seniors and cross-cultural differences could be also discussed (for a relevant review please read and discuss the section on suicide in: Makri, E., & Giannouli, V. (2022). Cross-cultural cognitive and affective differences in aging: Can culture shape the expression and perception of psychopathology in old age. Encephalos, 59, 34-43.

A5: Thanks for the suggestion, we have improved the discussion section by incorporating evidence from the relevant literature.

 

 

Q6: The title seems to be misleading. Is this an Italian or a Venetian perspective?

A6: Thanks for the suggestion, we have changed the title to Hospitalizations for suicidal events: reiteration risk – the Veneto Region experience, Italy

 

 

Q7: Many points in the discussion are not supported by relevant literature. Please provide references (e.g. for the females under 60 exhibiting higher rates of suicide attempts).

A7: Thanks for the suggestion, we have improved the discussion section by incorporating evidence from the relevant literature.

 

 

Q8: Please avoid the term 'subjects' and use individuals instead in all section of the article.

A8: Thanks for the correction. We replaced the term in all sections of the article.

 

Reviewer 2 Report

Comments and Suggestions for Authors

The paper entitled Hospitalizations for suicidal events: reiteration risk - An Italian regional experience analyzed suicidality in the Veneto region during the period 2012-2021 using Hospital Discharge Records as the primary data. Hospitalization rate trends related to any suicidal event, attempted suicide (AS) and suicidal ideation (SI), were assess, and the selected risk factors associated with recurrent suicidal behaviors were assesed.

 Limitations

-          Sample from one region (Veneto), results not aplicable to whole population of Italy

-          Methodological definition regarding first and repeated suicidal event

-          Methodological case definition and categorization of Mental illness (in Psychotic and mood disorders, Neurotic, behavioural and personality disorders and intellectual disabilities, with further subcategority of Neurotic, behavioural and personality disorders but not of Psychotic and mood disorders) coul you please comment further on the reason for such selection (in methodology) 

E.g. Among personality disorders “borderline personality disorder” was exposed, however mood disorders and substance use disorders were defined in a single group in Psychotic and mood disorders, without further categorization. From this point of view could lead to bias.

 Advantages

-          Manuscript represents a contribution to the yet poorly researched field: comparison between ideated and attempted suicide

-      useful information for the planning and implementation of tailored preventive activities

Title is clear and communicative.

The abstract is appropriate.

The introduction is coherent and adequately lead to the objectives.

The methods are appropriate and with comprehensive description and accuracy of methods. Please just see limitations

Results Table 1. Please see first row-variables  you have 2 times Suicide – probably first of them is suicide ideation

The findings are appropriately discussed.

The discussion is well written and study limitations are reported.

References: cited references relevant to the research. First author cited 2 times, last author cited 1 time.

In my opinion, this is an interesting paper that could provide an useful references for many researchers in the field.

Author Response

Dear Reviewer 2,

Thank you for your thorough review. Below are point-by-point responses addressing each comment.

 

Q1: Limitations

• Sample from one region (Veneto), results not applicable to whole population of Italy

A1.1: We agree, we have reported this aspect in the limitations. We have also provided in the methods a presentation of the Region's main socio-economic indicators (population density, average age, GDP) so that the results presented can be contextualized with the characteristics of the area when compared or generalized to other.

• Methodological definition regarding first and repeated suicidal event
• Methodological case definition and categorization of Mental illness (in Psychotic and mood disorders, Neurotic, behavioural and personality disorders and intellectual disabilities, with further subcategority of Neurotic, behavioural and personality disorders but not of Psychotic and mood disorders) coul you please comment further on the reason for such selection (in methodology) E.g. Among personality disorders “borderline personality disorder” was exposed, however mood disorders and substance use disorders were defined in a single group in Psychotic and mood disorders, without further categorization. From this point of view could lead to bias.

A1.2 and A1.3: We agree with your statements. We better explained in the limitations the reasons for the criteria used in our study. Unfortunately, our data are limited to those from the hospital discharge records of the Veneto region. It was not possible for us to access the complete medical records. Therefore, our classification is limited to the diagnosis codes recorded in the HDR. In the Veneto region these are still coded using the ICD-9-CM system. We realize that this may be a possible bias and limitation of our results considering the more modern classifications available today, such as the ICD-10-CM or DSM-5 systems.

 

 

Q2: Advantages

• Manuscript represents a contribution to the yet poorly researched field: comparison between ideated and attempted suicide
• useful information for the planning and implementation of tailored preventive activities
• Title is clear and communicative.
• The abstract is appropriate.
• The introduction is coherent and adequately lead to the objectives.
• The methods are appropriate and with comprehensive description and accuracy of methods. Please just see limitations

A2: Thanks for your positive comments.

 

 

Q3: Results Table 1. Please see first row-variables you have 2 times Suicide – probably first of them is suicide ideation

A3: Thank you for pointing out the error in the table header. The correction has been made.

 

 

Q4: The findings are appropriately discussed.

The discussion is well written and study limitations are reported.

References: cited references relevant to the research. First author cited 2 times, last author cited 1 time.

In my opinion, this is an interesting paper that could provide an useful references for many researchers in the field.

A4: Thank you for your kind and positive feedback on our work.