Suicidal behaviour during different phases of bipolar disorder

BACKGROUND: There are no previous studies comparing the prevalence and risk factors for suicidal behaviour during different phases of bipolar disorder. METHODS: In the Jorvi Bipolar Study (JoBS), 1630 psychiatric in- and outpatients were screened for bipolar disorders with the Mood Disorder Questionnaire. Using SCID I and II interviews, 191 patients were diagnosed with bipolar disorders (90 bipolar I, 101 bipolar II). Suicidal ideation was measured using the Scale for Suicidal Ideation (SSI). Prevalence and risk factors for ideation and attempts during different phases (depressive, mixed, depressive mixed and hypomanic/manic phases) were investigated. RESULTS: There were marked differences between phases regarding suicide attempts and level of suicidal ideation. Hopelessness predicted suicidal behaviour during the depressive phase, whereas a subjective rating of severity of depression and younger age predicted suicide attempts during mixed phases. LIMITATIONS: The relatively small sample size in some phases. CONCLUSIONS: Suicidal behaviour varied markedly between different phases of BD. Suicide attempts and suicidal ideation were related to phases which are associated with depressive aspects of the illness. Hopelessness and severity of depression were key indicators of risk in all phases.     

Suicidal ideation and suicide attempts among child and adolescent psychiatric inpatients in Finland

BACKGROUND: The aim was to study the prevalence of, and factors associated with, suicidal ideation and suicide attempts among child and adolescent inpatients during hospital treatment. METHODS: The target group included all the child and adolescent psychiatric inpatients (n=504) in Finland on a chosen day. Suicidality was determined by the psychiatrist responsible for the inpatient treatment, using a questionnaire also exploring demographic, diagnostic, and treatment characteristics, as well as traumatic events of the patient. RESULTS: The rate of suicidal ideation was 37.6%, and suicide attempts 10.8%. The factors independently associated with suicidal ideation in multivariate analysis were the following: being affected by open adult sexual behaviour (OR 3.2), having depression (OR 2.5) or conduct disorder (OR 2.4) diagnosis, and manifesting violent acts (OR 2.4). The factors independently associated with suicide attempts were: manifesting violent acts (OR 8.1), having depression diagnosis (OR 5.3), being affected by open adult sexual behaviour (OR 4.9), involuntary treatment (OR 4.7), and being of the female sex (OR 3.7). Suicidal ideation was particularly prevalent among boy patients having conduct disorders, manifesting violent acts, and belonging to the age group under 13 years old. Suicide attempts were particularly prevalent among depressive adolescent girl patients. LIMITATIONS: Suicidality was based solely on the clinician's evaluation. CONCLUSIONS: Suicidal ideation and suicide attempts are common among child and adolescent psychiatric inpatients. Particular attention should be directed to inpatients who manifest violent acts or have depressive disorder.     

Do characteristics of patients with major depressive disorder differ between primary and psychiatric care?

BACKGROUND: Despite the need for rational allocation of resources and cooperation between different treatment settings, clinical differences in patients with major depressive disorder (MDD) between primary and psychiatric care remain obscure. We investigated these differences in representative patient populations from primary care versus secondary level psychiatric care in the city of Vantaa, Finland. METHOD: We compared MDD patients from primary care in the Vantaa Primary Care Depression Study (PC-VDS) (n=79) with psychiatric out-patients (n=223) and in-patients (n=46) in the Vantaa Depression Study (VDS). DSM-IV diagnoses were assigned by the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I in PC-VDS) or Schedules for Clinical Assessment in Neuropsychiatry (SCAN in VDS), and SCID-II interviews. Comparable information was collected on depression severity, Axis I and II co-morbidity, suicidal behaviour, preceding clinical course, and attitudes towards and pathways to treatment. RESULTS: Prevalence of psychotic subtype and severity of depression were highest among in-patients, but otherwise few clinical differences between psychiatric and primary care patients were detected. Suicide attempts, alcohol dependence, and cluster A personality disorder were associated with treatment in psychiatric care, whereas cluster B personality disorder was associated with primary care treatment. Patients' choice of the initial point of contact for current depressive symptoms seemed to be independent of prior clinical history or attitude towards treatment. CONCLUSIONS: Severe, suicidal and psychotic depression cluster in psychiatric in-patient settings, as expected. However, MDD patients in primary care or psychiatric out-patient settings may not differ markedly in their clinical characteristics. This apparent blurring of boundaries between treatment settings calls for enhanced cooperation between settings, and clearer and more structured division of labour.     

Transthyretin in cerebrospinal fluid from suicide attempters

BACKGROUND: Earlier studies have found that transthyretin (TTR) is reduced in cerebrospinal fluid (CSF) from patients with major depressive disorder and that levels correlate negatively with suicidal ideation. The purpose of this study was to examine CSF-TTR in a cohort of suicide attempters with different psychiatric diagnoses and to further assess the relationship between CSF-TTR and suicidal behaviour as well as psychiatric symptoms. METHODS: TTR was measured using enzyme-enhanced Mancini. Diagnostics were performed with the Diagnostic and Statistical Manual of Mental Disorders. Psychiatric symptoms and suicidal behaviour were rated using the Comprehensive Psychopathological Rating Scale (CPRS), the Suicide Assessment Scale and the Suicidal Intent Scale. RESULTS: We found no significant difference in CSF-TTR levels between groups of different psychiatric diagnoses and controls. CSF-TTR correlated negatively to the CPRS item 17, "failing memory". No significant correlations between CSF-TTR and suicidal behaviour or suicide intent were found. LIMITATIONS: Correlation analysis is an indirect method of investigation and does not demonstrate causal relationships. CONCLUSIONS: We conclude that CSF-TTR is unlikely to be relevant for suicidal behaviour and that further studies in non-suicidal psychiatric patients are needed before a role of CSF-TTR in depression can be established.     

Decline in suicidal ideation among patients with MDD is preceded by decline in depression and hopelessness

BACKGROUND: Suicidal ideation is likely to represent a phase preceding suicidal acts among most suicidal patients with major depressive disorder (MDD). Factors predicting reversal of the suicidal process are unknown. Our aim was to test the hypothesis that a decline in suicidal ideation is preceded by a decline in hopelessness among patients with MDD. METHOD: Of the 269 Vantaa Depression Study patients with DSM-IV MDD, 103 patients scored > or = 6 points at baseline on the Scale for Suicidal Ideation (SSI). Seventy of these patients were followed-up weekly either until they scored zero points on the SSI, or up to 26 weeks. RESULTS: The median duration for a decline of suicidal ideation to zero was 2.2 months after baseline. The level of baseline suicidal ideation, depressive symptoms, and the presence of any personality disorder predicted duration of suicidal ideation. A decline in both depression (BDI) and hopelessness (HS) independently predicted a decline in suicidal ideation. LIMITATIONS: Due to study design, we do not know if suicidal ideation relapsed after the first time the patient reached zero score in the SSI. CONCLUSIONS: Among patients with major depressive disorder having suicidal ideation, the decline in suicidal ideation is independently predicted by preceding declines in the levels of both depressive symptoms as well as hopelessness. The findings are consistent with possible causal roles of declines in depression and hopelessness in reversing the suicidal process.     

Depressive disorders in primary care: recurrent, chronic, and co-morbid

BACKGROUND: Preceding longitudinal course and current somatic and psychiatric co-morbidity of depression have been little investigated in primary care. METHOD: Consecutive patients (n = 1111) in primary care in the city of Vantaa, Finland, were screened for depression with the PRIME-MD, and positive cases interviewed by telephone. Cases with current depressive symptoms were diagnosed face-to-face with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P). A cohort of 137 patients with unipolar depressive disorders, comprising all patients with at least two depressive symptoms and clinically significant distress or disability, was recruited. The Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II), medical records, rating scales, and a retrospective life-chart were used to obtain comprehensive cross-sectional and longitudinal information. RESULTS: Current major depressive disorder (MDD) was the most prevalent depressive disorder (66%); it was usually mild to moderate but recurrent. A quarter of cases (23%) had MDD in partial remission or prodromal phase, and only 10% had true minor depression. Axis I co-morbidity was present in 59%, Axis II in 52%, and chronic Axis III disorders in 47%; only 12% had no co-morbidity. One third of patients presented with a psychological complaint, predicted by higher depression severity and younger age. CONCLUSION: From a lifetime perspective, the majority of primary-care patients with depressive disorders suffer from recurrent MDD, although they are currently often in prodromal or residual phase. Psychiatric and somatic co-morbidity are highly prevalent. Treatment of depression in primary care should not rely on an assumption of short-lived, uncomplicated mild disorders.     

Suicidal Behavior,Depression, and Hopelessness in Child Psychiatric Inpatients: A Replication and Extension

Examination of 55 consecutively admitted 6-to 13-year-old psychiatric inpatients indicated that 58% reported suicidal ideation and 40% had attempted suicide. Suicidal ideation was significantly associated with self-reports of hopelessness. Suicide attempts were significantly associated with both hopelessness and a diagnosis of depressive disorder, particularly major depression. Hopelessness and depression were highly correlated, and associations between Suicide attempts, hopelessness, and depression were accounted for partly by a group of hopeless depressed children. Thirty-six percent of suicide attempters had made prior attempts. This group of repeat attempters were older and had the highest rate of depressive disorders (75%). Whereas older (11- to 13-year-old) children tended to contemplate and attempt the same method, younger children tended to think of one method and attempt another, usually less lethal, method.     

Psychiatric and social aspects of suicidal behaviour in prisons

BACKGROUND: Suicidal behaviour and completed suicide are serious problems within British prisons, leading to significant morbidity and mortality, and are the focus of major efforts towards their prevention. AIM: To explore the demographic, social and psychiatric correlates of suicidal behaviour in prisons in England and Wales and their relationship with health service use; and to develop a combined psychosocial model of risk. METHOD: This report analyses the prevalence of suicidal ideation and suicide attempts in the ONS National Prison Survey, and their association with the presence of psychiatric disorders, personality disorder, substance abuse and social risk factors. These data were compared with data from the second national survey of psychiatric morbidity in adults living at home. In both surveys, a two-phase interviewing procedure was used, covering general health, health service use, assessment of psychiatric disorders, life events, social supports, suicidal behaviour, activities of daily living, sociodemographic data, substance abuse and intelligence. RESULTS: Suicidal thoughts and suicide attempts were commoner in prisons than in the general population and these were significantly associated with higher rates of psychosis, neurosis and personality disorder in prisons. In addition, demographic and factors such as being young, single, white, leaving school early and experiencing poor social support and significant social adversity were important risk factors for suicidal thoughts. Crucially, there was no separate category of people at suicidal risk who did not have psychiatric disorders. CONCLUSIONS: The high rates of suicidal behaviour in prisons cannot be addressed without adequate attention to the high rates of psychiatric disorder and vulnerability factors in prisoners.     

Diagnostic outcome of adolescent self-reported suicidal ideation at 8-year follow-up

BACKGROUND: There are few epidemiological data on the outcome of adolescent self-reported suicidal ideation. METHOD: Data from an epidemiological study were used to examine self-reported suicidal ideation in adolescence as a predictor of suicidal ideation and psychiatric diagnoses at 8-year follow-up. RESULTS: Suicidal ideation was reported by 41 (4.5%) of 912 adolescents aged 11-18 and by 19 (2.5%) of 795 young adults aged 19-26. Most parents of adolescents with positive self-report did not report suicidal ideation in their child. Suicidal ideation in adolescents and young adults was associated with other psychiatric problems. Adolescent self-reported suicidal ideation was not a predictor of suicidal ideation or any major psychiatric disorder 8 years later. In males, suicidal ideation in adolescence was associated with specific phobia at follow-up. LIMITATIONS: The sample of adolescents may not be representative of the general population. There were no outcome measures other than DSM-IV diagnoses. Suicidal ideation was assessed by only one item, both at baseline and follow-up. CONCLUSIONS: Adolescents and young adults with self-reported suicidal ideation had high rates of psychiatric problems. Adolescent self-reported suicidal ideation did not predict suicidal ideation or any major psychiatric disorders (i.e. depressive disorders, substance use disorders, or psychotic disorders) at follow-up.     

Correlates of suicidal ideation in dysphoric mania

BACKGROUND: Previous investigations have reported that suicidal ideation and behavior are more prevalent during mixed than pure mania. Uncertainties exist about whether suicidality in mania arises from multiple concurrent depressive symptoms, or rather, as a categorical phenomenon, reflecting dysphoria without necessarily a full major depression. To elucidate the relationship between suicidal ideation and dysphoric mania, we analyzed clinical and demographic features associated with suicidal versus nonsuicidal dysphoric manic inpatients. METHODS: Records were reviewed for 100 DSM-III-R bipolar I manic inpatients at the Payne Whitney Clinic of New York Hospital from 1991-1995. All had > or = 2 concomitant depressive symptoms (other than suicidality). Affective and psychotic symptoms, past suicide attempts, prior illness, and related clinical/demographic variables were assessed by a standardized protocol. RESULTS: Suicidal ideation was significantly more common among dysphoric manics who were caucasian, took antidepressant medications in the week prior to admission, had histories of alcohol abuse/dependence, and made past suicide attempts. Suicidal ideation was evident for nearly half of dysphoric manic patients with < or = 3 depressive symptoms who did not meet DSM criteria for a mixed state. No individual manic or depressive symptoms other than dysphoric mood were more common among suicidal than nonsuicidal patients. LIMITATIONS: Findings from this retrospective study require confirmation using a prospective assessment. Treatments were naturalistic and may have differentially influenced hospital course and illness characteristics. Factors related to suicide attempts (rare in this cohort) or completions (not a focus of this study) may differ from those related only to suicidal ideation. CONCLUSIONS: Caucasian dysphoric manic patients with past suicide attempts and substance abuse may have a significantly elevated risk for suicidality, even when full major depression does not accompany mania. Suicidality is a clinically important consideration in a majority of dysphoric manic patients.     

Assessment of suicidality in a Moroccan metropolitan area

BACKGROUND: The aim of the study was to evaluate the prevalence of suicidal ideations and suicide attempts in a representative sample of the general population of the urban area of Casablanca, Morocco. METHODS: The survey was conducted based on face-to-face household interviews. The Mini International Neuropsychiatric Interview (M.I.N.I.) was used to assess axis I diagnoses according to DSM-IV criteria and the M.I.N.I. suicidality module to rate the severity of active suicidality. RESULTS: The 1-month prevalence of suicidal ideation was 6.3%. Seventeen subjects (2.1%) reported at least one suicide attempt during their lifetime. Some variables were positively associated to suicidal ideation: the non-married status, subjects with a history of psychiatric disorders, and subjects without children. At least one mental disorder was present among 88.2% of subjects with suicidal ideation. Major depressive disorder was the most prevalent one (23.5%). LIMITATIONS: The sample was small and the prevalence was not determined longitudinally. CONCLUSION: Suicidal ideation being relatively frequent in the general population, there is a need to develop programs of prevention of suicide.     

The spectrum of suicidal ideation in Great Britain: comparisons across a 16-74 years age range

BACKGROUND: Previous studies have examined suicidal ideation in older populations and emphasized the strong association with the presence of psychiatric disorder. However, associations with the presence of psychiatric disorder across the age range are unclear. Representative epidemiological estimates are needed. METHOD: In a national survey of psychiatric morbidity in Great Britain, 8580 randomly selected adults were interviewed. Three questions were asked to assess suicidal ideation, and psychiatric disorder was identified using the revised Clinical Interview Schedule (CIS-R). RESULTS: Suicidal ideation was up to three times commoner in younger adults than in those aged 55-74 years but the odds of depression in those with suicidal thoughts was significantly greater in the older age group (p<0.01). Tiredness with life (p<0.01) and thoughts of death (p<0.01) were also more strongly associated with depression in the older age group. Other major associations of suicidal ideation for all ages were: smaller social support group, being divorced or separated, poor self-rated general health, and limitations in activities of daily living (ADL). Being single was an important factor for younger age groups, and widowhood for older people. Life events were also important in younger people, but not in those aged 55-74 years. CONCLUSIONS: Suicidal thoughts and death wishes are comparatively more unusual in older people; however, they are more likely to be associated with clinical depression. In terms of suicide prevention this study emphasizes the importance of improving rates of recognition and treatment of depression in older people.     

Incidence of suicide ideation and attempts in adults: the 13-year follow-up of a community sample in Baltimore, Maryland.

BACKGROUND: Utilizing a prospectively designed community sample, we set out to estimate the rate of newly-incident suicidal ideation and attempts (non-fatal suicide behaviour) in a community sample, to evaluate antecedent sociodemographic characteristics and psychiatric disorders, and to assess use of mental health services in relation to non-fatal suicide behaviour. METHOD: Prospectively-gathered data was utilized from 3481 continuing participants in the 13-year follow-up of the Baltimore sample of the NIMH Epidemiologic Catchment Area survey interviewed in 1981, 1982 and 1993/6. RESULTS: The incidence of suicide attempts was estimated at 148.8 per 100,000 person-years and ideation at 419.9 per 100,000 person-years. Persons in the youngest age group, in the lowest socioeconomic status, and previously married persons were at increased risk for non-fatal suicide behaviour during the follow-up interval. Persons who reported suicidal ideation at baseline were more likely to report having attempted suicide at follow-up (RR = 6.09, 95% CI 2.58-14.36). Psychiatric disorders, especially depression and substance abuse, were associated with new-onset of non-fatal suicidal behaviour. While persons who reported newly-incident suicidal behaviour were more likely to report use of mental health services, few said that suicidal ideation or attempts were the reason for the visits. CONCLUSIONS: Suicidal ideation is a common and important antecedent to suicide attempts and deserves more attention in community and general medical settings.     

住院抑郁症患者自杀相关问题

目的 :探讨住院抑郁症患者自杀相关问题。方法 :调查 2 0 0 0年连续住院抑郁症患者 3 0 9例 ,记录自杀相关问题及相应临床资料。结果 :住院抑郁症患者出现自杀意念、自杀意图、自杀行为的比例相当高。女性病人自杀行为明显多于男性 ,而男性自杀行为的后果较女性更为严重。精神疾病家族史、自杀家族史均与自杀行为关系密切。终身自杀次数与病程、住院次数、总住院时间相关。结论 :住院抑郁症患者存在较多的自杀问题 ,特别对病程长、多次住院、具有精神疾病或自杀家族史者 ,更是自杀预防的重点人群     

Prevalence and comorbidity of affective disorders in persons making suicide attempts in Hungary: importance of the first depressive episodes and of bipolar II diagnoses

BACKGROUND: The purpose of this study was to investigate the prevalence and comorbidity of affective disorders, especially current major depressive episode and bipolar disorder among suicide attempters in Hungary. METHODS: Using a structured interview (Mini International Neuropsychiatric Interview) determining 16 Axis I psychiatric diagnoses defined by the DSM-IV and a semistructured interview collecting background information, the authors examined 100 consecutive suicide attempters, aged 18-65. RESULTS: Eighty-eight percent of the attempters had one or more current diagnoses on Axis I. In 69% it was major depressive episode and 60% of them were suffering their first episode. Thirty-five percent of the patients with current major depressive episode had had hypomanic (n=19) or manic (n=5) episodes in the past. Seventy percent of the individuals received two or more current diagnoses on Axis I. Eighty-six percent of all current Axis I disorders (except major depressive episode) were diagnosed together with a current major depressive episode. The diagnosis of current major depressive episode and the number of current psychiatric disorders was significantly and positively related to the number of suicide attempts, but the diagnosis of past major depressive episode was not. LIMITATIONS: This study included suicide attempters who had presented selfpoisoning, but not individuals with very high risk of fatality. CONCLUSIONS: In suicide attempters there is a very high prevalence of affective disorders, especially major depression, first episode of major depression and bipolar II disorder. This study underlines the importance of early detection and treatment of psychiatric disorders for the prevention of suicidal behavior.     

BDNF promoter methylation and suicidal behavior in depressive patients

Introduction

Suicide is a major health problem, and depression is a major psychiatric cause of suicide. Suicide is influenced by the multifactorial interaction of many risk factors. Therefore, epigenetic research may lead to understandings that are applicable to suicide. This study investigated whether epigenetic changes are associated with suicidal behavior and evaluated the treatment outcome of suicidal ideation in depressive patients.

Methods

In 108 patients with major depression, the promoter methylation of the gene encoding brain-derived neurotrophic factor (BDNF) was measured. Sociodemographic and clinical characteristics including a history of previous depressive episodes, age at onset, duration of illnesses, family history of depression, and number of stressful life events as well as subjective perception of stress and assessment scales for depression (HAMD), anxiety (HAMA), function (SOFAS), disability (WHODAS-12), and quality of life (WHOQOL-BREF) were evaluated at baseline. Suicidal behavior was ascertained using a semistructured clinical interview with questions about severity and intent. Beck Scale for Suicide Ideation (BSS) was administered during 12 weeks of treatment with antidepressants.

Results

A higher BDNF promoter methylation status was significantly associated with a previous suicidal attempt history, suicidal ideation during treatment, and suicidal ideation at last evaluation as well as with higher BSS scores and poor treatment outcomes for suicidal ideation.

Limitations

Methylation status was investigated with limited area of the BDNF gene and sample size was relatively small.

Conclusions

BDNF methylation status could be a proxy marker for previous suicidal attempts and a clinical biomarker for poor treatment outcomes of suicidal ideation in depression.     

Suicidal ideation among patients with acute life-threatening physical illness: patients with stroke, traumatic brain injury, myocardial infarction, and spinal cord injury.

Suicide is one of the leading causes of death in the community. The risk of suicide is greater among patients with physical illnesses than among the general population. This study was undertaken to evaluate the clinical characteristics and correlates of suicidal ideation in patients with acute life-threatening physical illnesses and to assess the duration of suicidal ideation. The study included a consecutive series of patients admitted with stroke, traumatic brain injury, myocardial infarction, or spinal cord injury (n=496). Study participants were administered a semistructured psychiatric interview as well as a series of standardized quantitative scales of mood, cognitive function, physical impairment, social ties, and social functioning. Follow-up evaluations of up to 24 months were also carried out. This study found that 36 (7.3%) patients with acute medical illness had clinically significant suicidal ideation. The suicidal ideation occurred mostly among patients with major depression and sometimes in those with minor depression. About 25% of patients with major depression and acute physical illnesses developed suicidal ideation. After the improvement of depressive disorders, suicidal ideations were ameliorated. These findings suggest that the detection and treatment of depressive disorders is the most important factor in preventing suicide among this patient population.     

Recurrence of suicidal ideation across depressive episodes

BACKGROUND: In recent years it has become clear that depression is a recurrent disorder, with the risk of recurrence in those with two or more episodes being as high as 90%. This has prompted interest in the consistency of individual depressive symptoms across consecutive episodes, an issue that is important for symptoms such as suicidal ideation, where a past history may give important indicators of future behaviour. METHODS: We prospectively examined 69 individuals with a history of Major Depression, over 12 months, 38 of whom experienced a recurrence of major depression during the follow-up period. RESULTS: Spearman's rank order correlations between severity ratings of each symptom of major depression during a previous episode and severity ratings at recurrence showed significant associations for suicidality, guilt or worthlessness and thinking difficulties only. Weighted kappa coefficients indicated relatively low levels of agreement across episodes for most diagnostic symptoms, with suicidality showing the strongest relationship. Using a broad definition of suicidality-- any reporting of thoughts of death or suicide during episode-- a much higher level of agreement (kappa = .64) was found, with 83% of individuals falling into the same category (suicidal/non-suicidal) at both episodes. LIMITATIONS: This study was based on a relatively small sample and examines re-emergence of suicidal ideation in the absence of suicidal behaviour. CONCLUSIONS: This study provides preliminary evidence of cross-episode consistency in the recurrence of suicidal ideation, in line with the differential activation theory of suicidality in depression.     

The close link between suicide attempts and mixed (bipolar) depression: implications for suicide prevention

BACKGROUND: Previous reports have shown a significant relationship between suicide ideation and mixed depression. The aim of this study was to explore the prevalence and clinical characteristics of mixed depression among non-violent suicide attempters. METHODS: Using a structured interview (modified Mini International Neuropsychiatric Interview) and assessing all the symptoms of 16 psychiatric diagnoses, the authors examined 100 consecutive nonviolent suicide attempters (aged 18-65) within 24 h after their attempts. Mixed depression was defined as a major depressive episode (MDE)/dysthymic disorder plus 3 or more co-occurring hypomanic symptoms, according to the definition validated by Akiskal and Benazzi [Akiskal, H.S., Benazzi, F., 2003a. Delineating depressive mixed states: Their therapeutic significance. Clin. Approaches Bipolar Disord. 2, 41-47, Akiskal, H.S., Benazzi, F., 2003b. Family history validation of the bipolar nature of depressive mixed states. J. Affect. Disord. 73, 113-122.]. RESULTS: Current mixed depression was present in 63.0% in the total sample, and in 70.8% among the 89 depressive suicide attempters. Irritability, distractibility and psychomotor agitation were present in more than 90% of the subjects with mixed depression. The rate of mixed depression was significantly higher among bipolar than non-bipolar depressive suicide attempters (90% vs. 62%). Patients with mixed depression had the following concurrent disorders: bipolar disorders 41.0%, panic disorder 30.0%, generalized anxiety disorder 89.0%, alcohol abuse/dependence 56.0%, and substance abuse 27.0%. Mixed depression versus non-mixed depression had the following significant associations (odds ratio=OR): females 2.4, bipolar II disorder 9.3, generalized anxiety disorder 41.3, irritability 101.6 and psychomotor agitation 61.1. LIMITATIONS: The study didn't include suicide attempters with very high risk of fatality. CONCLUSIONS: The important new finding of this study is the very high prevalence of mixed depression among depressed suicide attempters. The rates of mixed depression among bipolar and non-bipolar depressive suicide attempters were much higher than previously reported among nonsuicidal bipolar II and unipolar depressive outpatients, suggesting that suicide attempters come mainly from mixed depressives with predominantly bipolar II base. Irritability and psychomotor agitation were the strongest predictors of suicide attempt. From a public health standpoint, our data highlight the necessity of detecting and treating mixed (bipolar) depression in the prevention of suicidal behaviour.     

Detecting suicidal ideation in older patients: identifying risk factors within the general practice setting

BACKGROUND: GPs are the most frequently accessed health professional among suicidal individuals in the community.AIM: To determine the prevalence of psychological distress and suicidal ideation among patients aged 60 years and older presenting to GPs, and the relationship between these variables in detecting patients who may be contemplating suicide.Design of study: Cross-sectional analysis of older patients presenting to Australian GPs between 2002 and 2003. SETTING: One thousand and sixty-one consecutive patients aged 60 years or over attending one of 54 randomly selected Western Australian GPs. METHOD: Prior to their medical consultation, patients completed a self-report questionnaire, which included questions about current suicidal ideation (Depressive Symptom Inventory Suicidality Subscale [DSI-SS]) and depression (Center for Epidemiological Studies Depression Scale [CES-D]). Patients' chief complaints were obtained from consultation summary sheets completed by their GP. RESULTS: Although only 5.1% of patients presented with psychological complaints, 5.8% acknowledged current suicidal ideation and 23.8% had clinically significant levels of depressive symptomatology. Suicidal ideation was associated with CES-D scores greater than 16 (odds ratio [OR] = 3.7, 95% confidence interval [CI] = 1.5 to 8.9), feelings of depression (OR = 7.7, 95% CI = 3.4 to 17.7), and previous suicide attempt (OR = 7.4, 95% CI = 2.7 to 20.2) in a logistic regression model, but not with poor self-perceived health, use of licit drugs (smoking, alcohol, and hypnotics), or type of presenting complaint at the time of assessment. CONCLUSIONS: Although older general practice patients tend to present for issues related to their physical health, approximately a quarter of this cohort also possess high levels of psychological distress, including current thoughts of suicide. Older patients who show any signs of depression or distress should be asked about psychological symptoms, including suicidal ideation.