Mental disorders and suicide prevention

Abstract In the research phase of the National Suicide Prevention Project, all suicides ( n = 1397) in Finland between March 1987 and April 1988 were examined retrospectively using the psychological autopsy method. Careful retrospective diagnostic evaluation of the victims according to DSM-III-R criteria was done by weighing and integrating all available information. A series of studies addressing the mental disorders among suicide victims, the treatment received before death and the life events is now reviewed.
Among a random sample of suicide victims from the nationwide suicide population, at least one psychiatric diagnosis was made for 93% of the victims. The most prevalent disorders were depressive syndromes (66%) and alcohol dependence/abuse (43%). The prevalence of major depression was higher among women than among men. Major depression as the principal diagnosis was more common among the elderly suicides. Among adolescent victims, depressive syndromes were also the most prevalent disorders. Adjustment disorders were common (25%) among male adolescent suicides. The majority of suicide victims of all ages suffered from comorbid mental disorders.
Among suicide victims who had had contact with a health carer before death, inadequacy of treatment for mental disorders seems to have been common. Of the major depressive victims only 3% were found to have received adequate psychopharmacological treatment, and only 7% received weekly psychotherapy by a trained therapist.
The analysis of the massive database collected in the research phase of the National Suicide Prevention Project in Finland is still ongoing, and the implications of the findings for suicide prevention will be refined during the research process. The necessity to improve recognition and treatment for comorbid depressive disorders in all age groups seems evident already.     

Differences in suicide behaviour in the elderly: a study in two provinces of Northern Italy

BACKGROUND: to investigate the suicide phenomenon among the elderly (people aged 65 and over) in the Italian provinces of Novara and Verbania, in the time span between January 1990 and December 2000, in order to evaluate if the characteristics of the suicide behaviour correlate to the place of living with particular attention to the psychosocial factors. METHODS: the information was collected from the Republic Procuration of the two provinces. Frequencies and contingency tables were evaluated to compare the data found in the two provinces. Standardised Mortality Ratios (SMRs) with their confidential intervals (95% confidence intervals) were calculated in comparison with the average suicide rates in North West Italy in the same period and in the same age group. RESULTS: One hundred and eighty-four suicides were committed from the elderly, with an average rate of 14.07 per 100 000 inhabitants in Novara and 25.56 in Verbania. The most common methods used to commit suicide were hanging and jumping from height. The factors chiefly related to suicide were mental disease, followed by organic illness. The analysis of SMRs point out that the incidence of suicide in the province of Verbania is higher than in North West Italy while in Novara it is lower. CONCLUSION: the evaluation of the suicide risk in the elderly in a diagnostic and preventive framework must take into consideration the psychosocial factors that vary with the place of living.     

A study of suicides of older people in Sydney

BACKGROUND: Reports based on studies of coroner's files show that suicides in old age are commonly related to depression, but that in a majority of cases disability or ill-health is also a major factor. The aim of this study was to try to understand more clearly the precipitant causes of suicide in an older population. METHOD: An Australian metropolitan coroner's office provided data concerning suicides in 1994-1998 of persons aged over 65 years. RESULTS: Of 210 elderly people who killed themselves, 160 (76%) were clearly depressed, including a majority of the 24% deemed to have understandable reasons for suicide. Physical ill-health or disability was the major factor leading to suicide in 34% and appeared to contribute to suicidal ideation in another 24% of those who died; they had usually not been seen by psychiatrists. CONCLUSION: Because depression is often treatable, even when associated with depressing circumstances, there is potential for further reduction of old age suicide rates by recognising and appropriately responding to symptoms of depression and distress.     

A Population-Based Longitudinal Study of Recent Stressful Life Events as Risk Factors for Suicidal Behavior in Major Depressive Disorder

The purpose of this study is to investigate whether the type and number of stressful life events (SLEs) will be associated with suicidal behavior in a 3-year follow-up period in persons with major depressive disorder (MDD). Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative longitudinal survey of mental health in non-institutionalized adults in the United States. The survey consisted of two waves: Wave 1 (2001-–2002) and Wave 2 (2004–2005), n = 34,653. Twelve past-year SLEs were assessed at baseline. These SLEs were categorized into the following groups based on previous research: Loss or victimization; Relationship, friendship, or interpersonal stress; Financial stress; and Legal problems. Only respondents with MDD at Wave 1 were included (n = 6,004). Several SLEs were strongly associated with suicide attempts, among which, “serious problems with neighbor, friend, or relative” (adjusted odds ratio [AOR] = 2.21; 95% confidence interval [95% CI]: 1.41, 3.45) and “major financial crisis, bankruptcy, or unable to pay bills” (AOR = 2.31; 95% CI: 1.45, 3.66) were the most robust predictors of suicide attempts even after adjusting for sociodemographic variables and any anxiety, substance use, or personality disorder. People with MDD who had been exposed to certain SLEs are at elevated risk for future suicide attempts, even after accounting for the demographic factors and psychiatric comorbidity.     

Differences between adolescent suicide attempters and depressed adolescents.

Most of the characteristics differentiating between adolescent attempters and nonattempters do not have discriminative power in comparing 48 adolescents who recently attempted suicide with 66 depressed adolescents. These characteristics may probably be attributed to an affective disorder that is present in most of the suicide attempters. However, suicide attempters, compared with the depressed group, live in more problematic circumstances (such as family disruption or sexual abuse) and have a cognitive style that promotes a more negative evaluation of events and situations. Their depressive symptoms are distinguished from the depressed group by withdrawal and isolation, besides maintaining a hopeless and negative expectation of the future. Furthermore, there are reasons to accept the idea that suicidal behavior is a serious alternative within their behavioral repertoire. Based on these findings, a psychological interpretation is given concerning the dynamics leading to a suicide attempt. Also, intervention strategies are discussed.     

Age variation in life events and their relationship with common mental disorders in a national survey population

Background Life events (LEs) are recognised to be important risk factors for common mental disorders (CMD). Their prominence may vary across age groups but this issue has received little systematic investigation. Method Data were analysed from the 2000 UK National Survey of Psychiatric Morbidity comprising 8,580 participants aged 16–74 years. A history of recent life events pertaining to health threats, bereavement, interpersonal problems and redundancy was established for the preceding six months. Participants were also asked about earlier lifetime stressors including sexual abuse and expulsion from school. CMD, depression and generalised anxiety disorder were ascertained through the revised Clinical Interview Schedule. Results The strongest associations between LEs and CMD were for recent threats to health, recent interpersonal problems and lifetime stressors. Recent LEs were more strongly associated with depression than anxiety whereas the associations for lifetime stressors were similar in strength. The strength of association between recent LEs and CMD increased steadily up to the 45–54 years age group and then declined. In the 65–74 year age range, CMD was not significantly associated with any recent LE but instead was associated with the following lifetime stressors: bullying, sexual abuse, running away from home, and institutional care in childhood. Conclusions Recent life events were most strongly associated with CMD in mid-rather than early or late adult life. In later life, stronger associations were found with lifetime stressors than recent events.     

Detection of alcohol consumption in suicides

Screening instruments for detection of alcohol consumption, abuse, and dependence for use in psychological autopsy studies with case control design are not validated. Therefore, interrater and test–retest reliability of the Luebeck Alcohol Dependence and Abuse Screening Test (LAST) and the usability of this test for the psychological autopsy method were investigated. Alcohol consumption was evaluated by a semi–structured interview including the Structured Clinical Interview for DSM–IV Axis I (SCID–I) and the LAST in 163 completed suicides (mean age 49.6 ± 19.3 years; 64.4% men) and by personal interview in 396 population–based controls (mean age 51.6 ± 17.0 years; 55.8% men). Of the controls, 35 were additionally assessed by interviewing informants; these results were compared with those generated by personal interview. Comparison of LAST scores by personal and informants interview of controls generated a Spearman correlation coefficient of 0.74 (P < 0.0001). The LAST (7 item–version, cut–off of 2) revealed high sensitivity and specificity for alcohol abuse and dependence, in both controls and suicides. LAST scores were significantly associated with high, frequent, and hazardous alcohol consumption (P < 0.001) in suicides. Our findings provide support for reliability and validity of identifying individuals with alcohol dependence and abuse obtained through the best–estimate method using the LAST. This 7–item questionnaire can be recommended as a useful tool for the psychological autopsy procedure in postmortem research.     

Sexual Abuse and Suicide: Why We May Not Know What We Think We Know

This article reviews the research on the relationship between a reported history of sexual abuse and subsequent suicidal behavior. Based on this review, it is suggested that a conclusion that childhood sexual abuse (CSA) is a significant risk factor for subsequent suicidal ideation, attempts, and completed suicides is premature. Identified limitations of the existing research include the lack of consistency in definitions of CSA and suicidality, issues related to sample selection and causality interpretations, and the absence of theoretical grounding.     

Differences between alcoholic and non alcoholic female psychiatric patients

Sixty-four consecutive DSM-III alcoholic female psychiatric patients (A-group) were compared with 65 non alcoholic women from the same psychiatric units. The A-women more often had nervous sisters. They were younger at the first intercourse, had had more frequent intercourses during the last year, more often had a poor relationship with their children. They had had more heterosexual partners, living-together relationships and divorces, and had more often a dependent adult relationship. The mean age of the first nervous symptoms and of coming to psychiatry was significantly lower in the A-group, and they had more suicidal attempts and criminality. During childhood, adolescence and adult age, they reacted more often to losses with acting out and alcohol abuse. Nervous problems and close contact difficulties seem to have manifested themselves mostly before the alcohol abuse was established.     

Positive and negative life events and personality traits in predicting course of depression and anxiety

Spinhoven P, Elzinga BM, Hovens JGFM, Roelofs K, van Oppen P, Zitman FG, Penninx BWJH. Positive and negative life events and personality traits in predicting course of depression and anxiety. Objective: To examine the prognostic value of personality dimensions and negative and positive life events for diagnostic and symptom course trajectories in depressive and anxiety disorder. Method: A total of 1209 subjects (18–65 years) with depressive and/or anxiety disorder were recruited in primary and specialized mental health care. Personality dimensions at baseline were assessed with the NEO‐FFI and incidence and date of life events retrospectively with a structured interview at 2‐year follow‐up. DSM‐IV‐based diagnostic interviews as well as life chart assessments allowed course assessment at both the diagnostic and symptom trajectory level over 2 years. Results: Life events were significantly related to diagnostic and symptom course trajectories of depression and anxiety also after correcting for sociodemographic and clinical characteristics. Only negative life events prospectively predicted longer time to remission of depressive disorder. Prospective associations of neuroticism and extraversion with prognosis of anxiety and depression were greatly reduced after correcting for baseline severity and duration of index disorder. Personality traits did not moderate the effect of life events on 2‐year course indicators. Conclusions: Negative life events have an independent effect on diagnostic and symptom course trajectories of depression and to a lesser extent anxiety unconfounded by sociodemographic, clinical, and personality characteristics.     

Differences in the determinants of posttraumatic stress disorder and depression after a mass traumatic event

Background: Hurricane Ike struck the Galveston Bay area of Texas on September 13, 2008, leaving substantial destruction and a number of deaths in its wake. We assessed differences in the determinants of posttraumatic stress disorder (PTSD) and depression after this event, including the particular hurricane experiences, including postevent nontraumatic stressors, that were associated with these pathologies. Methods: 658 adults who had been living in Galveston and Chambers counties, TX in the month before Hurricane Ike were interviewed 2–5 months after the hurricane. We collected information on experiences during and after Hurricane Ike, PTSD and depressive symptoms in the month before the interview, and socio‐demographic characteristics. Results: The prevalence of past month hurricane‐related PTSD and depression was 6.1 and 4.9%, respectively. Hurricane experiences, but not socio‐demographic characteristics, were associated with Ike‐related PTSD. By contrast, lower education and household income, and more lifetime stressors were associated with depression, as were hurricane exposures and hurricane‐related stressors. When looking at specific hurricane‐related stressors, loss or damage of sentimental possessions was associated with both PTSD and depression; however, health problems related to Ike were associated only with PTSD, whereas financial loss as a result of the hurricane was associated only with depression. Conclusions: PTSD is indeed a disorder of event exposure, whereas risk of depression is more clearly driven by personal vulnerability and exposure to stressors. The role of nontraumatic stressors in shaping risk of both pathologies suggests that alleviating stressors after disasters has clear potential to mitigate the psychological sequelae of these events. Depression and Anxiety, 2011. © 2011 Wiley‐Liss, Inc.     

Suicide attempts among patients with psychosis in a Chinese rural community

OBJECTIVE: To explore the characteristics of psychotic patients with suicide attempts in a Chinese rural community. METHOD: An epidemiological investigation of psychotic patients with suicide attempts among 123,572 population (over 15 years of age) was conducted in Xinjin County, Chengdu. RESULTS: The rate of suicide attempts was found to be 8.17% among all the psychotic patients (906 cases). Patients with affective psychosis showed a significantly higher rate of suicidal attempts (15.3%) than those with schizophrenia (7.5%) (P < 0.005). Suicide attempts were significantly associated with depression and hopelessness in both schizophrenia and affective psychosis (P < 0.001). Patients with suicide attempts were younger and had an earlier age of onset than those without suicide attempts (P < 0.05). Patients with schizophrenia and affective disorders were the major patients with suicide attempts. CONCLUSION: The rate of suicide attempts in psychotic patients may be largely influenced by the illness itself. Community-based services should be necessary for these patients.     

Retrospective psychiatric assessment of 200 suicides in Budapest

Based on an interview with the closest family member, using the Schedule of Affective Disorders and Schizophrenia--SADS, a retrospective psychiatric assessment and diagnostic classification was carried out on 200 completed suicides. Eighty-one per cent of the victims had a recent psychiatric disorder, in 63% depression. The prevalence of psychiatric illnesses was similar to that of other studies from countries with lower suicide rates.     

Comorbid psychiatric disorders in late life depression.

In late life depression, common comorbid psychiatric disorders are alcohol use, anxiety, and personality disorders. Elderly depressed patients are three to four times more likely to have an alcohol use disorder compared with nondepressed elderly subjects, with a prevalence of 15%-30% in patients with late life major depression. While the presence of a comorbid alcohol use disorder may worsen the prognosis for geriatric depression, limited data suggest that successful treatment of depression combined with reducing alcohol use leads to the best possible outcomes. Most studies show that the overall prevalence of anxiety disorders, particularly panic disorder and obsessive-compulsive disorder, is low in geriatric depression, but generalized anxiety disorder may not be uncommon. It remains unclear if the presence of a comorbid anxiety disorder impacts on the treatment and prognosis of late life major depression. Personality disorders occur in 10%-30% of patients with late life major depression or dysthymic disorder, particularly in patients with early onset depressive illness. Cluster C disorders, including the avoidant, dependent, and obsessive-compulsive subtypes predominate, while Cluster B diagnoses, including borderline, narcissistic, histrionic and antisocial, are rare. Overall, the research database on comorbid psychiatric disorders in major and nonmajor late life depression is relatively sparse. Since comorbid psychiatric disorders affect clinical course and prognosis, and may worsen long-term disability in late life depression, considerably more research in this field is needed.     

A study of attempted suicides in urban versus rural areas, with a follow-up.

The group of subjects consisted of 44 patients (attempters) who were admitted to hospital for treatment because of attempted suicide during a 3-month period in Norther Savo (in Eastern Finland), another 44 patients (non-attempters) admitted to hospital in the same period for other reasons serving as controls. The number of women was the same in both groups, and so was, in consequence, the number of men. The study compared the attempters with the non-attempters and, in addition, the patients coming from urban areas with those coming from rural areas, the ratio of the urban to the rural patients being the same in both groups. The study was based on personal psychiatric interviews with the patients, which took place in each case both immediately following the patient's admission and precisely 3 months afterwards. The results showed that schizophrenia was significantly more frequent in the rural than in the urban attempter group. By contrast, alcoholism and alcohol abuse were more frequent in the urban than in the rural attempter group. Compared with the urban patients, the rural patients tended to be physically more seriously desordered. Poisoning by drugs was a significantly more frequent means of attempted suicide in the urban than in th rural group. The patients in the latter group, again, had resorted oftener to the so-called "active" methods of attempted suicide. Of the attempters, 25% attempted suicide anew during the 3-month follow-up period, the corresponding figure for the non-attempter group being only 6%. During the follow-up period, a greater number of suicidal attempts was made by the patients in the rural group than by those in the urban group, and, as regards the intent to succeed, the attempts of the former were more serious than those of the latter. The so-called "active" methods were used more often by rural than by urban patients also during the follow-up period. All in all, the self-destructive behaviour exhibited during the follow-up period was graver in the rural than in the urban group.     

Differences between Two Questionnaires for Assessment of Typus Melancholicus, Zerssen's F-List and Kasahara's Scale: The Validity and Relationship to DSM-III-R Personality Disorders

Abstract: We examined the validity in various settings of two questionnaires for assessment of Typus melancholicus, F-list and Kasahards scale, and characterological differences between the questionnaires, based on data in 69 : patients with unipolar depression and 386 : normal controla without a history of depression. The questionnaires were performed on both groups. In addition, a diagnosis of DSM-III-R personality disorders was done for the patient group. Our results demonstrated that Kasahara's scale has much more stable validity in various settings for distinction between personalities of the two groups, and that high scorers in Kasahara's scale have more obsessionality and less personality instability than those in F-list. Such differences between the questionnaires suggested that a direct international comparison of premorbid personality of unipolar depressive patients is needed.