Suicidal Behaviour in Mood Disorders—Who,When, and Why?

Objective:

About one-half to two-thirds of all suicides are by people who suffer from mood disorders; preventing suicides among those who suffer from them is thus central for suicide prevention. Understanding factors underlying suicide risk is necessary for rational preventive decisions.

Method:

The literature on risk factors for completed and attempted suicide among subjects with depressive and bipolar disorders (BDs) was reviewed.

Results:

Lifetime risk of completed suicide among psychiatric patients with mood disorders is likely between 5% and 6%, with BDs, and possibly somewhat higher risk than patients with major depressive disorder. Longitudinal and psychological autopsy studies indicate suicidal acts usually take place during major depressive episodes (MDEs) or mixed illness episodes. Incidence of suicide attempts is about 20- to 40-fold, compared with euthymia, during these episodes, and duration of these high-risk states is therefore an important determinant of overall risk. Substance use and cluster B personality disorders also markedly increase risk of suicidal acts during mood episodes. Other major risk factors include hopelessness and presence of impulsive–aggressive traits. Both childhood adversity and recent adverse life events are likely to increase risk of suicide attempts, and suicidal acts are predicted by poor perceived social support. Understanding suicidal thinking and decision making is necessary for advancing treatment and prevention.

Conclusion:

Among subjects with mood disorders, suicidal acts usually occur during MDEs or mixed episodes concurrent with comorbid disorders. Nevertheless, illness factors can only in part explain suicidal behaviour. Illness factors, difficulty controlling impulsive and aggressive responses, plus predisposing early exposures and life situations result in a process of suicidal thinking, planning, and acts.     

Risk factors for suicide in later life.

Suicide rates are higher in later life than in any other age group. The design of effective suicide prevention strategies hinges on the identification of specific, quantifiable risk factors. Methodological challenges include the lack of systematically applied terminology in suicide and risk factor research, the low base rate of suicide, and its complex, multidetermined nature.Although variables in mental, physical, and social domains have been correlated with completed suicide in older adults, controlled studies are necessary to test hypothesized risk factors. Prospective cohort and retrospective case control studies indicate that affective disorder is a powerful independent risk factor for suicide in elders. Other mental illnesses play less of a role. Physical illness and functional impairment increase risk, but their influence appears to be mediated by depression. Social ties and their disruption are significantly and independently associated with risk for suicide in later life, relationships between which may be moderated by a rigid, anxious, and obsessional personality style.Affective illness is a highly potent risk factor for suicide in later life with clear implications for the design of prevention strategies. Additional research is needed to define more precisely the interactions between emotional, physical, and social factors that determine risk for suicide in the older adult.     

Preventing schizophrenia and psychotic behaviour: definitions and methodological issues.

Although schizophrenia onset usually occurs in late adolescence or early adulthood, much research shows that its seeds are planted early in life and that eventual onset occurs at the end of a neurodevelopmental process leading to aberrant brain functioning. This idea, along with the fact that current therapies are far from fully effective, suggests that preventive treatments may be needed to achieve an ideal outcome for schizophrenia patients and those predisposed to the disorder. In this article, we review the methodological challenges that must be overcome before effective preventive interventions can be created. Prevention studies will need to define the target population. This requires the identification of risk factors that will be useful in selecting at-risk people for preventive treatment. We review currently identified risk factors for schizophrenia: genes, psychosocial factors, pregnancy and delivery complications, and viruses. We also review 3 different types of prevention programs: universal, indicated, and selective. For schizophrenia, we distinguish prevention programs that target prodromal cases and those that target the disorder's premorbid precursors. Although those targeting prodromal cases provide a useful framework for early treatment of the disorder, studies of premorbid individuals are needed to design a truly preventive treatment.     

Biological risk factors in late life depression.

A number of biological risk factors have been tentatively identified for unipolar and bipolar disorder in the elderly. The list includes genetic factors as well as medical illness in general and vascular disease in particular. Most of these risk factors have been identified on the basis of cross sectional studies rather than longitudinal studies. There is a need for long term epidemiologic and prevention studies (in the case of modifiable risk factors). The modifiable risk factors include medical illness in general and vascular disease in particular. An example is the use of antidepressants following stroke to prevent the onset of depression. Of particular interest is the role of vascular risk factors and MRI changes suggesting subtle cerebrovascular disease in the development of depression and bipolar disorder in late life. The changes have been established using both clinical samples and in the case of depression in cross sectional epidemiologic samples. The location of these cerebrovascular changes has contributed to our understanding of the regions of the brain implicated in the pathophysiology of depression. Further longitudinal and preventive studies are needed to conclusively demonstrate these as biological risk factors.     

Suicidal behaviour of psychiatric in-patients

OBJECTIVE: The study aimed to examine suicidal behaviour before and during in-patient care in a psychiatric state hospital. METHOD: Based upon a psychiatric basic documentation system prevalence and risk factors of in-patient suicides, suicide attempts and suicidal thoughts were investigated over an 11-year period from 1989 until 1999. RESULTS: A total of 30 in-patient suicides were found among 21 062 patients. According to the multivariate logistic regression analysis the risk of hospital suicide increases for patients with schizophrenia, higher cumulative length of stay, previous suicide attempt, part-time employment and training/retraining. Predictors of suicide attempt during hospitalization are suicide attempt on admission, personality disorder, suicidal thoughts on admission, schizophrenia and affective disorder. CONCLUSION: As Schizophrenics represent the high-risk group of in-patient suicide, suicide prevention should be a major goal in their treatment. More frequent suicide risk assessment is recommended particularly before granting a leave or an outing.     

Suicides in Late Life

Suicide in late life is an enormous public health problem that will likely increase in severity as adults of the baby boom generation age. Data from psychological autopsy studies supplemented with recent studies of suicidal ideation and attempts point to a consistent set of risk factors for the spectrum of suicidal behaviors in late life (suicide ideation, attempts, and deaths). Clinicians should be vigilant for psychiatric illness (especially depression), physical illness, pain, functional impairment, and social disconnectedness. Recent advances in late-life suicide prevention have in common collaborative, multifaceted intervention designs. We suggest that one mechanism shared by all preventive interventions shown to reduce the incidence of late-life suicide is the promotion of connectedness. For the clinician working with older adults, our recommendation is to not only consider risk factors, such as depression, and implement appropriate treatments but to enhance social connectedness as well.     

The clinical nature and formal diagnosis of premenstrual,postpartum, and perimenopausal affective disorders

Various mood and anxiety disorders are more prevalent in reproductive-aged women, and appear to be linked to hormonal and reproductive events. Premenstrual affective disorders consist of premenstrual syndrome, premenstrual dysphoric disorder, and premenstrual exacerbation of mood or anxiety disorders. Postpartum affective disorders can range from postpartum “blues” to postpartum depression with or without psychosis, and also include anxiety disorders, such as panic disorder, generalized anxiety disorder, social phobia, and obsessive-compulsive disorder. In perimenopausal women, the vulnerability to mood and anxiety disorders is increased. All of these disorders share risk factors, and have etiologic features in common, such as exposure to the rise and fall of ovarian sex steroids. The following is a review of these syndromes and their etiology, diagnosis, and treatment.     

Crucial elements in suicide prevention strategies

Ways of conceptualizing suicide prevention are reviewed briefly, and the preventive model: Universal, Selected, and Indicated prevention (USI) is chosen as the structure for the literature review, and the discussion. Universal preventive interventions are directed toward entire population; selective interventions are directed toward individuals who are at greater risk for suicidal behaviour; and indicated preventions are targeted at individuals who have already begun self-destructive behaviour.On the universal prevention level, an overview of the literature is presented with focus on restrictions in firearms and carbon monoxide gas. At the selective prevention level, a review of risk of suicide in homelessness and schizophrenia and risk factors for suicide in schizophrenia is conducted and possible interventions are mentioned together with the evidence for their effect. Suicide rate and preventive measures in affective disorder are also touched upon. At the indicated prevention level, studies of fatal and non-fatal suicide acts after suicide attempt are mentioned. The evidence of preventive measures to reduce repetition rates is presented.Finally, the state of the art is discussed with regard to prevention at the universal, the selected and the indicated level and clinical and research implications are outlined.     

Late‐life homicide‐suicide: a national case series in New Zealand

Homicide‐suicide is a rare event, but it has a significant impact on the family and community of the perpetrator and victim(s). The phenomenon of late‐life homicide‐suicide has not been previously studied in New Zealand, and there is only limited data in the international literature. The aim of this study is to systematically review coroners' records of late‐life homicide‐suicides in New Zealand. After ethics approval was granted, the Coronial Services of New Zealand was approached to provide records of all closed cases with a suicide verdict (age 65+) over a five‐year period (July 2007–December 2012). Of the 225 suicides, 4 cases of homicide‐suicide were identified (an estimated incidence of 0.12 per 100 000 per persons year). All four perpetrators were men; three had been farmers. Their ages ranged from 65 to 82. One case occurred in the context of an underlying psychiatric illness (psychotic depression in bipolar disorder). Firearms were used in three cases. Two cases were categorized as spousal/consortial subtype, one case as filicide‐suicide, and one case as siblicide‐suicide. The prospect of major social upheaval in the form of losing their homes was present in all four cases. The findings of this case series were consistent with the limited existing literature on homicide‐suicide. Age‐related biopsychosocial issues were highlighted in this case series of late‐life homicide‐suicide. Additionally, evaluating firearm licences in high‐risk groups may represent a prevention strategy.     

Psychosocial variables in children and teens of extended families identified through bipolar affective disorder probands

Objectives: This multi‐site study investigated the frequency of risk‐related variables for developing an affective disorder using a within‐pedigree control group. We wished to determine the effect of life events, social relationships, self‐perceived competence, and aspects of home environment for youngsters from extended families with loading for bipolar disorder. Using a within‐family contrast group, we address the following two issues: (1) Do offspring or their parents from families who do and do not have an affected parent report differences (i) in home environment? (ii) in frequency and type of offspring life events? and (iii) in social relations and self‐perception? and (2) Do children or their parents who do or do not have an affective disorder report differently on these areas? Methods: Juvenile offspring (n = 50) and their parents from 14 bipolar pedigrees were assessed. Structured interviews and self‐ or parent‐reported instruments were used to compare offspring with an affected first‐degree relative to those without and to compare offspring with or without an affective disorder. Results: Only one significant psychosocial difference was found between offspring with or without a parent with an affective disorder but several were found between offspring who themselves did or did not have an affective disorder. These differences are in the areas of the need for discipline, social support, and dependent negative life events. Conclusions: The findings identify potential early psychosocial markers for affective disorder in high risk offspring.     

Epidemiological findings of vascular risk factors in Alzheimer's disease: implications for therapeutic and preventive intervention

Alzheimer's disease (AD) is a multifactorial disorder, in which the detrimental effects of vascular risk factors and related disorders (e.g., smoking, obesity, hypertension, diabetes, dyslipidemia and inflammation) have been frequently suggested in numerous observational studies of the general population. In recent years, systematic reviews and meta-analyses of population-based prospective studies have concluded from the life-course perspective, an age-dependent association with the risk of AD for several vascular factors, such as high blood pressure, obesity and high total cholesterol, such that possessing these factors in midlife is associated with an increased risk of late-life AD, whereas having a low level in late life or a decline after middle age in these factors may anticipate clinical onset of AD. The biological plausibility for these vascular factors and related disorders being involved in the pathogenesis and clinical manifestation of AD is also supported by population-based neuroimaging and neuropathological studies. However, randomized placebo-controlled trials that target those major cardiovascular risk factors (e.g., antihypertensive, hormone replacement and anti-inflammatory therapies) have generally failed to prove to be efficacious preventive or therapeutic approaches for AD. The multifactorial nature of AD and the age-dependent relationship between vascular risk factors and the risk of AD should be taken into consideration in the future when designing preventive or therapeutic intervention against the dementing disorder.     

Social competence and positive and negative symptoms: a longitudinal study of children and adolescents at risk for schizophrenia and affective disorder

OBJECTIVE: The authors longitudinally examined social competence and positive and negative symptoms in children at risk for schizophrenia, children at risk for affective disorder, and matched normal subjects. METHOD: The subjects were offspring of parents with schizophrenia or affective disorder and normal comparison subjects matched on age, sex, and socioeconomic status. Ratings of social competence (Premorbid Adjustment Scale), affective flattening and poverty of speech (Scale for the Assessment of Negative Symptoms), and positive formal thought disorder (Scale for the Assessment of Positive Symptoms) were based on videotaped psychiatric interviews conducted in childhood (N = 144), early adolescence (N = 127), and adolescence (N = 106). RESULTS: In childhood, there were no significant group differences. In early adolescence, the subjects at risk for schizophrenia had poorer social competence than those at risk for affective disorder and the normal subjects. In early adolescence, the subjects at risk for schizophrenia also had greater positive thought disorder than those at risk for affective disorder but did not differ significantly from the normal subjects; there were no differences in negative symptoms. In adolescence, the subjects at risk for schizophrenia had poorer social competence and greater positive and negative symptoms than the adolescents at risk for affective disorder and the normal subjects. CONCLUSIONS: During early adolescence and adolescence, poor social competence may be more characteristic of children at risk for schizophrenia than those at risk for affective disorder. Higher levels of positive and negative symptoms may also be specific to subjects at risk for schizophrenia, but only during adolescence.     

Factor analysis of Forced Swimming test, Sucrose Preference test and Open Field test on enriched, social and isolated reared rats

Developmental and social factors are known to play a crucial role in the pathogenesis of affective disorders. Although it has been demonstrated that early life aversive experiences can be a risk factor in the development of human depression, most of the investigation in animals that try to model depression do not include postnatal manipulations. Since housing represents a fundamental ethological factor which modifies behavior and brain development, this study aimed to investigate the impact of different social and structural housing conditions on the development of a depressive-like syndrome in the behavioral despair paradigm and an anxiety-like syndrome in the unconditioned anxiety paradigm. The present study uses several multivariate analyses to study the impact of housing conditions in animal models of depression and anxiety. In this study, social isolation was able to reproduce the effects found in other animals models based on stress, suggesting that only 2 months of social isolation are enough to produce effects that can be useful as behavioral model of depression. Moreover, environmental enrichment showed an antidepressive and anxiolytic like effect in animal models of depression and anxiety. This effect, which has not been reported in earlier studies, suggests that stimulation during the first stages of growth might play a "protective" role on behavior and brain development.     

Lifetime history of traumatic events in a young adult Mexican American sample: Relation to substance dependence,affective disorder,acculturation stress,and PTSD

Mexican Americans comprise one of the most rapidly growing populations in the United States, and within this population, trauma and post-traumatic stress disorder (PTSD) are associated with physical and mental health problems. Therefore, efforts to delineate factors that may uniquely contribute to increased likelihood of trauma, PTSD, and substance use disorders over the lifetime in Mexican Americans are important to address health disparities and to develop treatment and prevention programs. Six hundred fourteen young adults (age 18–30 yrs) of Mexican American heritage, largely second generation, were recruited from the community and assessed with the Semi-Structured Assessment for the Genetics of Alcoholism and an acculturation stress scale. More males (51.2%) reported experiencing traumas than females (41.1%), however, a larger proportion of females received a PTSD diagnosis (15%) than males (8%). Alcohol dependence and affective disorders, but not anxiety disorders, antisocial disorders, nicotine, marijuana, or stimulant dependence, were significantly comorbid with PTSD. Endorsing higher levels of acculturation stress was also significantly associated with both trauma exposure and a diagnosis of PTSD. Logistic regression revealed that female gender, having an affective disorder, alcohol dependence, higher levels of acculturation stress, and lower levels of education were all predictors of PTSD status. Additionally, alcohol dependence generally occurred after the PTSD diagnosis in early adulthood in this high-risk population. These studies suggest that treatment and prevention efforts should particularly focus on young adult second generation Mexican American women with higher levels of acculturation stress, who may be at higher risk for PTSD, affective disorder, and alcohol dependence following trauma exposure.     

Risk of suicide in mood disorders

Suicide is commonly associated with mood disorders. Risk factors for suicide in mood disorders can be organized according to whether their effect is on the threshold or diathesis for suicidal acts or whether they serve mainly as triggers or precipitants of suicidal acts. Predisposition to suicidal behavior or diathesis is a key element that helps to differentiate patients who are at high risk versus those at lower risk. The objective severity of mood disorders does not identify depressed patients at high risk for suicide attempt. There is a lack of agreement over the suicide risk associated with characteristics of depression such as psychotic features, agitation, or anxiety, or mixed mood states as part of bipolar disorder. Risk factors affecting the diathesis for suicidal behavior include family history of suicide, low cerebrospinal fluid 5-hydroxyindolacetic acid, alcohol and/or substance abuse, cluster B personality disorder, high past impulsivity and aggression, chronic physical illness particularly involving the brain, marital isolation, parental loss before age 11, childhood history of physical and sexual abuse, hopelessness, and not living with a child under age 18. Most common precipitants of suicidal acts in mood disorders include interpersonal losses or conflicts, financial trouble, and job problems. Identification of high risk patients and effective treatment are required for suicide prevention to reduce morbidity and mortality in affective disorders.     

Prevention and early intervention in schizophrenia: facts and visions.

There are large-scale preventive programmes to reduce the risk of death and disability caused by several frequent physical diseases. The primary and secondary prevention of schizophrenia, a disorder entailing many years of life in disability, is still being neglected. Prevention is aimed at reducing the incidence, severity or consequences of the disorder. To find ways of preventive intervention in schizophrenia, the aetiological risk factors must be identified, then eliminated or modified. As possible targets pre-, peri- and postnatal complications, urbanicity and early behavioural risk indicators are discussed. As examples of successful early prevention targeted at risk indicators attempts to prevent depression and violence are considered. The most promising approach at present is secondary prevention focused on early illness course. Based on a controlled retrospective assessment of 232 first illness episodes the course of prodromi, impairments and psychotic symptoms prior to the climax of the first episode is shown. Most of the social consequences occur before the first treatment contact, thus making plain the urgent need for preventive action. Tools sufficiently validated are not yet available for early diagnosis and prediction of psychosis onset at the prepsychotic stage. So intervention has to be based on high-risk inclusion criteria, which exclude large proportions of at-risk persons. Appropriate early intervention at the prepsychotic, prodromal and the early psychotic stage as well as relevant ethical considerations are discussed. The frequency of and distress associated with single psychotic symptoms in the general population are potent predictors of a psychosis. The vision of treating this early illness dimension with third-generation, side-effect-free antipsychotics or of preventing its onset by oestrogen-like substances is discussed.     

Identifying target groups for the prevention of anxiety disorders in the general population

Batelaan NM, Smit F, de Graaf R, van Balkom AJLM, Vollebergh WAM, Beekman ATF. Identifying target groups for the prevention of anxiety disorders in the general population. Objective: To avert the public health consequences of anxiety disorders, prevention of their onset and recurrence is necessary. Recent studies have shown that prevention is effective. To maximize the health gain and minimize the effort, preventive strategies should focus on high‐risk groups. Method: Using data from a large prospective national survey, high‐risk groups were selected for i) the prevention of first ever (n = 4437) and ii) either first‐ever or recurrent incident anxiety disorders (n = 4886). Indices used were: exposure rate, odds ratio, population attributable fraction and number needed to be treated. Risk indicators included sociodemographic, psychological and illness‐related factors. Results: Recognition of a few patient characteristics enables efficient identification of high‐risk groups: (subthreshold) panic attacks; an affective disorder; a history of depressed mood; a prior anxiety disorder; chronic somatic illnesses and low mastery. Conclusion: Preventive efforts should be undertaken in the selected high‐risk groups.     

Borderline Personality Disorder Diagnostic Criteria as Risk Factors for Suicidal Behavior Through the Lens of the Interpersonal Theory of Suicide

Borderline personality disorder diagnostic criteria, particularly affective dysregulation and behavioral dysregulation, are avenues through which suicide risk is conferred, though pathways are not well understood. The interpersonal theory of suicide may help elucidate these associations. The current study examined indirect relationships between affective and behavioral dysregulation and suicidal ideation through perceived burdensomeness, thwarted belongingness, and the acquired capability for suicide. 169 outpatients completed measures prior to their intake assessment. Perceived burdensomeness accounted for the relationship between affective dysregulation and suicidal ideation. The acquired capability did not explain the association between behavioral dysregulation and suicide attempt history. Affective and behavioral dysregulation may be key targets in treatment for reducing suicide risk.     

Individual and familial risk factors for bipolar affective disorders in Denmark

BACKGROUND: Few population-based studies have addressed risk factors for bipolar affective disorder. OBJECTIVE: To study the possible association between bipolar affective disorder and history of mental illness in a parent or sibling; urbanicity of birth place; season of birth; sibship characteristics, including birth order; influenza epidemics during pregnancy; and early parental loss. DESIGN: We used a population-based cohort of 2.1 million individuals based on data from the Danish Civil Registration System linked with the Danish Psychiatric Central Register. SETTING: Nationwide population-based sample of all individuals hospitalized or in outpatient clinic contact for the first time with bipolar affective disorder.Patients Overall, 2299 individuals were first diagnosed with bipolar affective disorder during the 31.8 million person-years of follow-up. RESULTS: Risk of bipolar affective disorder was associated with a history of bipolar affective disorder as well as other psychiatric disorders, including schizophrenia and schizoaffective disorder, in parents or siblings. People with a first-degree relative with bipolar affective disorder had a 13.63-fold (95% confidence interval, 11.81-15.71) increased risk of bipolar affective disorder. No other consistent associations were found with the exception of an association between early parental loss, in particular maternal, and bipolar affective disorder. Children who experienced maternal loss before their fifth birthday had a 4.05 (95% confidence interval, 1.68-9.77) increased risk of bipolar affective disorder. CONCLUSIONS: Early parental loss may represent both environmental and genetic risk factors for bipolar affective disorder. Most of the risk factors included in our study that previously have been associated with schizophrenia were not associated with bipolar affective disorder, supporting that the 2 disorders may be at least partially separate etiological entities.