Comorbidity patterns in adolescents and young adults with suicide attempts

The role of comorbidity as a risk for suicide attempts is investigated in a random sample of 3021 young adults aged 14–24 years. The M-CIDI, a fully standardized and modified version of the Composite International Diagnostic Interview, was used for the assessment of various DSM-IV lifetime and 12-month diagnoses as well as suicidal ideation and suicide attempts. Of all suicide attempters, 91% had at least one mental disorder, 79% were comorbid or multimorbid respectively and 45% had four or more diagnoses (only 5% in the total sample reached such high levels of comorbidity). Suicide attempters with more than three diagnoses were 18 times more likely (OR = 18.4) to attempt suicide than subjects with no diagnosis. Regarding specific diagnoses, multivariate comorbidity analyses indicated the highest risk for suicide attempt in those suffering from anxiety disorder (OR = 4.3), particularly posttraumatic stress disorder followed by substance disorder (OR = 2.2) and depressive disorder (OR = 2.1). Comorbidity, especially when anxiety disorders are involved, increases the risk for suicide attempts considerably more than any other individual DSM-IV diagnoses. Received: 17 July 1997 / Accepted: 15 December 1997     

Posttraumatic stress disorder comorbid with major depression: factors mediating the association with suicidal behavior

OBJECTIVE: The purpose of the study was to determine if patients with a history of major depressive episode and comorbid posttraumatic stress disorder (PTSD) have a higher risk for suicide attempt and differ in other measures of suicidal behavior, compared to patients with major depressive episode but no PTSD. In addition, to explore how PTSD comorbidity might increase risk for suicidal behavior in major depressive episode, the authors investigated the relationship between PTSD, cluster B personality disorder, childhood sexual or physical abuse, and aggression/impulsivity. METHOD: The subjects were 230 patients with a lifetime history of major depressive episode; 59 also had lifetime comorbid PTSD. The demographic and clinical characteristics of subjects with and without PTSD were compared. Multivariate analysis was used to examine the relationship between suicidal behavior and lifetime history of PTSD, with adjustment for clinical factors known to be associated with suicidal behavior. RESULTS: Patients with a lifetime history of PTSD were significantly more likely to have made a suicide attempt. The groups did not differ with respect to suicidal ideation or intent, number of attempts made, or maximum lethality of attempts. The PTSD group had higher objective depression, impulsivity, and hostility scores; had a higher rate of comorbid cluster B personality disorder; and were more likely to report a childhood history of abuse. However, cluster B personality disorder was the only independent variable related to lifetime suicide attempts in a multiple regression model. CONCLUSIONS: PTSD is frequently comorbid with major depressive episode, and their co-occurrence enhances the risk for suicidal behavior. A higher rate of comorbid cluster B personality disorder appears to be a salient factor contributing to greater risk for suicidal acts in patients with a history of major depressive episode who also have PTSD, compared to those with major depressive episode alone.     

Assessing varying degrees of lethality in depressed adolescent suicide attempters.

OBJECTIVE: Understanding the lethality of suicide attempts and its relation to other psychological variables may improve clinical judgement with regard to suicide risk. METHOD: The lethality of suicidal behaviour was examined in 60 hospitalized adolescent in-patients who had recently attempted suicide. Subjects were divided into non-lethal, low-lethal and high-lethal groups based on the qualities of their suicidal acts. RESULTS: The groups did not differ in terms of hopelessness, depression, substance abuse or self-esteem. Moreover, they did not differ significantly in diagnoses of major depression, adjustment disorder, substance abuse and bipolar disorder. The group of high-lethal attempters was the only group with several individuals diagnosed with a major depressive episode and comorbid attention deficit disorder. The high-lethal group also reported the strongest desire to end their lives. CONCLUSION: Based on lethality of suicide attempts, adolescent suicide attempters can be differentiated in terms of the wish to die as well as some instances of diagnostic comorbidity. However, they may not be differentiated in terms of severity of depression or hopelessness, demographic variables and other aspects of suicidal behaviour.     

Rates and correlates of suicide attempts in first-admission psychotic patients

The relationship of attempted suicide to demographic characteristics, current and lifetime psychiatric diagnoses, clinical history, and current symptoms was assessed in a sample of 184 recently hospitalized psychotic patients. Forty-three patients (23%) had an attempt history, and 28 (15% of sample; 65% of attempters) made an attempt during the episode for which they were hospitalized. Demographic characteristics did not distinguish attempters from nonattempters. Variables significantly associated with having ever attempted suicide were current diagnosis of unipolar major depressive disorder but not bipolar; lifetime major depressive episode; a history characterized by a less acute onset, lower pre-admission psychosocial functioning, and episodes of physical violence; and a symptom picture characterized by greater depression, hopelessness, negative symptoms, hallucinations and less thought disorder. Those with a current attempt had significantly higher rates of lifetime history of major depression and less physical violence than those with past attempts only. The potential importance of the data for predicting future suicidal acts is discussed.     

Association of comorbid posttraumatic stress disorder and major depression with greater risk for suicidal behavior

OBJECTIVE: Posttraumatic stress disorder (PTSD) increases the risk of suicidal behavior; a major depressive episode also increases the risk for suicidal behavior. The authors' goal was to examine the effect of comorbid PTSD and major depressive episode on suicidal behavior. METHOD: Inpatients with a diagnosis of major depressive episode (N=156) were assessed for PTSD, suicidal behavior, and clinical risk factors for suicidal acts. RESULTS: Patients with comorbid major depressive episode and PTSD were more likely to have attempted suicide, and women with both disorders were more likely to have attempted suicide than men with both disorders. Cluster B personality disorder and PTSD were independently related to history of suicide attempts. CONCLUSIONS: The greater rate of suicide attempts among patients with comorbid PTSD and major depressive episode was not due to differences in substance use, childhood abuse, or cluster B personality disorders.     

Posttraumatic stress disorder in hospitalized adolescents: psychiatric comorbidity and clinical correlates

OBJECTIVE: To describe the diagnostic comorbidity and clinical correlates of posttraumatic stress disorder (PTSD) in adolescent psychiatric inpatients. METHOD: Seventy-four adolescent inpatients were given a structured diagnostic interview, the revised version of the Diagnostic Interview for Children and Adolescents, and a battery of standard self-report measures to assess general trauma exposure, posttraumatic stress symptoms, suicidal behavior, dissociation, and depression. RESULTS: Ninety-three percent of subjects reported exposure to at least one traumatic event such as being a witness/victim of community violence, witnessing family violence, or being the victim of physical/sexual abuse. Thirty-two percent of subjects met diagnostic criteria for current PTSD, with sexual abuse cited as the most common traumatic stressor in 69% of PTSD cases. Girls were significantly more likely to develop PTSD than boys, although the total number of types of trauma did not differ by gender. Compared with psychiatric controls, male youngsters with PTSD were significantly more likely to have comorbid diagnoses of eating disorders, other anxiety disorders, and somatization disorder. Furthermore, male and female youngsters with PTSD were significantly more likely to have attempted suicide and report greater depressive and dissociative symptoms. CONCLUSION: In clinical populations of hospitalized adolescents exposed to multiple forms of trauma, PTSD is a common, but highly comorbid disorder. Specific multimodal assessments and treatments targeted to both PTSD and its comorbidity profile are warranted.     

Predictors of serious suicide attempts among patients with panic disorder

Of 74 panic disorder subjects followed up after 7 years, five reported serious suicide attempts and three had completed suicide. Compared with subjects who had not made serious attempts, the serious suicide attempters (including the three suicides) were younger, and fewer of them were married. Also, the serious attempt group had an earlier, more gradual onset of illness. More of the serious attempters had personality disorders and coexisting major depression. At the time of original assessment, the serious attempters had more severe symptoms. These data suggest that among patients with panic disorder, serious suicidal behavior is associated with more severe psychopathology.     

Psychosocial profile of suicide ideators, attempters and completers in India

The study aims to determine the psychological profile of suicide ideators, attempters and completers in a tertiary care teaching hospital. A total of 260 suicidal ideators, 58 attempters and 55 completers were studied. The majority of ideators, attempters and completers were 26-35 years of age, males (except attempters who were predominantly females), married, literate up to high school, employed (ideators) or housewives (attempters and completers). The suicide ideators, attempters and completers who had a past history of attempt were 6.9%, 24.1% and 18.2% respectively. Family history of attempted suicide or completed suicide was also common among patients suffering from depression. In suicidal ideators, mixed anxiety and depressive disorder was the most common psychiatric diagnosis followed by major depression and schizophrenia. Among suicide attempters, adjustment disorder with depression was the most common diagnosis. The most common method of suicide attempt was organophosphorus compound intake whereas in suicide completers, the most common method in use was hanging. The patients with suicidal ideation or attempt need careful evaluation, early intervention and long term follow up.     

A comparison of the medical lethality of suicide attempts in bipolar and major depressive disorders

Objectives:  Among mood disorders, bipolar disorder (BPD) is often noted to involve the highest rates of suicide attempts and possibly of completion. This study sought to determine whether suicide attempters with BPD exhibit suicide attempts with higher lethality than attempters with major depressive disorder (MDD) and to explore differences in clinical features associated with suicidal acts.
Methods:  Mood disordered suicide attempters were interviewed about Axis I and II diagnoses, lifetime history of suicide attempts, suicidal intent, suicidal ideation, the medical lethality of their most severe suicide attempt, severity of depression, hopelessness, lifetime aggression, and impulsivity.
Results:  The maximum lethality of suicidal acts tended to be higher among BPD attempters compared with those with MDD. However, there were no differences in the number of suicide attempts, intent to die or suicidal ideation. Suicide attempters with BPD reported higher levels of aggression and impulsivity but less hopelessness compared with MDD attempters. These differences could not be explained by Cluster B personality disorder comorbidity. Of note, within the BPD group, but not the MDD group, males reported suicidal acts with higher lethality. Multivariate analyses suggested that risk for more lethal suicide attempts is associated with BPD and male sex and that bipolar males appear to be especially vulnerable to these behaviors.
Conclusions:  Males with BPD make more lethal suicide attempts than females with BPD, an effect not observed among the MDD sample. Our findings suggest that higher rates of suicidal behavior in BPD may be due to a specific effect of BPD on males, leading to more dangerous suicidal behaviors. This effect, together with the larger proportion of males in the BPD group compared with the MDD group may lead to higher rates of reported attempted and completed suicide.     

Serum BDNF levels in suicide attempters related to psychosocial stressors: a comparative study with depression

Although many studies have examined the neurobiological aspects of suicide, the molecular mechanisms and pathophysiologic mechanisms associated with suicide remain unclear. In this study, it is aimed to investigate whether there is a difference in serum brain-derived neurotrophic factor (BDNF) levels among suicide attempters without a major psychiatric disorder, compared to major depressive disorder patients and healthy subjects. It was undertaken with the hypothesis that suicide per se lowers serum BDNF levels, since it is a source of stress. The study was carried out in Celal Bayar University Hospital, Manisa, Turkey. Ten suicide attempters, 24 patients with major depressive disorder and 26 subjects without any psychiatric diagnosis and any psychiatric treatment were included in the study. All subjects were asked to give their written consent. Blood samples were collected at the baseline. Serum BDNF was kept at -70 degrees C before testing, and assayed with an ELISA kit (Promega; Madison, Wisc., USA) after dilution with the block and sample solution provided with the kit. The data were subjected to the Kruskal-Wallis test for nonparametric analysis of variance. Mean serum BDNF levels were significantly lower in the suicide group (21.2 +/- 12.4 ng/ml) and the major depressive disorder group (21.2 +/- 11.3 ng/ml) than the control group (31.4 +/- 8.8 ng/ml; p = 0.004). These results suggest that BDNF may play an important role in the neurobiology of suicidal behavior. BDNF levels may be a biological marker for suicidal behavior. To investigate the role of BDNF in suicide, further studies with a wider sample size and a variety of psychiatric diagnoses accompanying suicide attempt are needed.     

A history of major depressive disorder influences intent to die in violent suicide attempters

BACKGROUND: The inconsistency of the results obtained in biological studies of suicidal behavior may be due to the use of broad categories lacking validity. In previous genetic studies, in which we identified an association between a serotonin-related gene and violent suicide attempts, we suggested that a history of major depressive disorder (MDD) might influence this association. In this study, we aimed to clarify the relationships between the violence of suicide attempts, intent to die, and depression in a large sample of suicide attempters. METHOD: We investigated intent to die, according to history of violent suicide attempts and MDD, in 502 consecutively admitted suicide attempters. We characterized patients in terms of lifetime DSM-IV Axis I diagnoses, suicidal intent (Beck Suicide Intent Scale), and history of violent suicide attempts. RESULTS: Suicidal intent, for both the last suicide attempt before admission and the most lethal suicide attempt, was higher in those with history of MDD (p =.03 and p =.04, respectively) but was not affected by history of violent suicide attempt. In violent suicide attempters, suicidal intent was higher in patients with a history of MDD than in patients with no such history (p =.04 for last suicide attempt and p =.02 for most lethal attempt), whereas MDD had no effect on suicidal intent in nonviolent suicide attempters. CONCLUSION: Violent suicide attempters constitute a heterogeneous group in terms of suicidal intent. Our results suggest that biological and genetic studies should take into account the method used to attempt suicide, intent to die, and history of MDD.     

Personality and suicidal behavior in depressed patients

The relationship between personality and suicidal behavior was evaluated in 53 patients with primary major depressive disorder. Mean borderline personality scale scores on the Millon Clinical Multiaxial Inventory (MCMI) differed between suicide attempters and non-attempters. The frequency of personality disorder diagnoses, especially borderline personality disorder, was not higher in the suicide attempters. Clinical and theoretical implications of these findings are discussed.     

Clinical predictors of suicidal acts after major depression in bipolar disorder: a prospective study

Objective:  This study determined the clinical predictors of suicidal behavior during a 2-year follow-up of patients with bipolar disorder presenting with a major depressive episode (MDE).
Method:  Sixty four patients with DSM-III-R bipolar disorder were assessed at presentation for treatment of an MDE. Correlates of past suicidal behavior were determined by comparing patients with and without a history of suicide attempts using a t -test, Wilcoxon test or chi-squared test of independence on individual explanatory variables. Putative predictors of attempts during the follow-up period were tested separately using Cox proportional hazards regression analysis.
Results:  Twelve of 64 patients had at least one suicide attempt in the follow-up period, five of them attempted in the first 2 months and seven around or shortly after the 1-year follow-up visit. All attempters had a history of past suicide attempts. Most predictors of future suicidal behavior were correlates of past suicidal behavior. Family history of suicide acts and comorbid borderline personality disorder predicted early attempts, while younger age, high hostility scores, number of past attempts, subjective pessimism as reflected in depression and suicidal ideation, and few reported reasons for living predicted suicidal acts during the whole period.
Conclusion:  In this data set of bipolar patients we noted an intriguing picture of two clusters of suicide attempts. Hostility was the strongest risk factor. These findings may have implications in both the identification of at-risk patients and the timing of clinical interventions including aggressive pharmacotherapeutic prophylaxis to prevent relapse or recurrence of depressive symptomatology.     

Psychiatric diagnoses in minority female adolescent suicide attempters

Psychiatric diagnoses were examined using the Schedule for Affective Disorders and Schizophrenia for School-Aged Children semistructured interview among three groups of minority adolescent females aged 12 to 17:61 suicide attempters, 31 psychiatrically disturbed nonattempters, and 23 nonattempting, nondisturbed girls. Major or minor depressive disorder was found in 42% of the suicide attempters; conduct disorder in 46%; multiple diagnoses in 38%, no diagnosis in 13%. These rates were very similar to those found in disturbed nonattempters. Only one symptom, suicidal ideation, distinguished attempters from disturbed nonattempters, while many symptoms distinguished these two groups from nondisturbed nonattempters.     

Depressive characteristics of adult psychiatric inpatients with a history of multiple versus one or no suicide attempts

Background: A growing body of research suggests that individuals with a history of multiple suicide attempts exhibit more severe psychopathology than individuals with only one or no previous suicide attempts. Given the strong link between diagnoses of major depression and suicide risk, our primary goal was to determine which specific depressive characteristics differentiate multiple attempters from patients with one or no previous attempts. Methods: Participants were 121 depressed adult psychiatric inpatients. Participants were administered diagnostic interviews to assess the course and characteristics of their depression history as well as measures of suicidal ideation, suicide attempts, depressive symptoms, hopelessness, and dysfunctional attitudes. Results: Patients with a history of multiple suicide attempts exhibited higher levels of suicidal ideation and depressive symptoms, but not hopelessness or dysfunctional attitudes, than the other two groups. In addition, multiple attempters reported an earlier age of major depression onset. Conclusions: The current results add to a growing body of research suggesting that multiple attempters may represent a distinct patient population. Depression and Anxiety, 2009. Published 2008 Wiley‐Liss, Inc.     

Alexithymia and suicidal behavior

A number of factors including hopelessness have been identified as amplifying suicide risk. Alexithymia has recently been investigated as a predictor of suicidal behavior. The prevalence of the personality trait alexithymia in suicide attempters as well as other predictors of suicidal behavior were investigated in this study. One hundred suicide attempters were compared to 60 healthy controls on the measures of hopelessness, alexithymia, depression and suicidal ideation. First-timers and repetitive suicide attempters, males and females, married and unmarried suicide attempters were compared to each other in the suicide attempter group. The correlations of hopelessness, depression and alexithymia with suicidal intent and suicide lethality were investigated. The suicide attempter group did not display significantly higher scores on the alexithymia measure, compared to healthy controls. Alexithymia neither seemed to be a prevalent personality trait in suicide attempters nor a sensitive predictor of suicidality. The subscales of Toronto Alexithymia Scale measuring difficulty in identification and expression of feelings also did not reveal a significant difference between the two groups. Suicide attempters were more depressive, more hopeless and displayed greater suicidal ideation than healthy controls. Severity of depression was a stronger predictor of suicidal intent than hopelessness in the suicide attempter group. The lethality of the suicide attempt did not correlate with any of the psychometric measures. These findings propose that difficulty in the identification and articulation of feelings does not comprise a risk factor for suicidal behavior.     

Psychiatric Diagnoses and Comorbidity in Relation to Suicidal Behavior Among Psychiatrically Hospitalized Adolescents

This study examined relations between suicidal behavior history (i.e., no suicidality, suicidal ideation, single attempters, and multiple attempters) and psychiatric functioning. Adolescents, aged 12-17, admitted to an inpatient psychiatric unit, were categorized by suicidal behavior history based on self- and clinician-report data. Groups were examined for differences in suicidal ideation and psychiatric diagnosis. Severity of suicidal ideation increased with severity of suicidal behavior history. Females were disproportionately represented among multiple attempters. Multiple attempters were more likely to be diagnosed with at least one externalizing disorder, particularly substance use disorders, and to have more than one comorbid diagnosis than adolescents with no suicidal behavior or a history of ideation only. Clinicians should be alerted to the particularly high-risk nature of adolescents with multiple suicide attempts.     

Attempted suicide in those with personality disorders

Summary From a sample of 499 patients admitted to hospitals for suicide attempts, a subsample of 182 suicide attempters who described histories of illicit activities or who were diagnosed with DSM-II antisocial, drug or alcohol personality disorders were compared with another sample of 109 suicide attempters diagnosed as having depressive disorders. The former group of unsocialized attempters obtained similar depression inventory scores as the diagnosed depressive attempters. However, the index attempts of the unsocialized group were made with less suicidal intent than those of the diagnosed depressive patients, and they made more prior suicide attempts than the diagnosed depressive patients.     

Relationship between self-disclosure and serious suicidal behavior

The ability to predict which suicidal patient is at high risk for a serious attempt is an important clinical problem. On the basis of our clinical research, we hypothesized that self-disclosure may be an important personality variable differentiating suicide attempters and completers. We assessed 80 patients with depressive disorder, divided into four groups of 20 each: suicidal ideation only, nonserious suicide attempts, severe suicide attempts, and no suicidal behavior. Comparisons were also made with 20 healthy controls. All subjects completed Jourad's Self-Disclosure Questionnaire (JSDQ), as well as scales measuring depression/anxiety and hopelessness. The lack of willingness for self-disclosure significantly differentiated the serious attempters from the suicide ideators and mild attempters. The relationship of self-disclosure and more lethal suicide attempts did not appear to be mediated by depression, anxiety, or hopelessness. This preliminary study indicates that self-disclosure may be a promising field for assessment, therapy, and prevention in suicidal patients. Further studies are needed to investigate related variables, wider patients groups, and the use of different instruments.