广州市精神病医院50年住院病人自杀危险因素的病例对照研究

目的:识别精神分裂症住院病人自杀的潜在危险因素,为探讨如何进一步预防住院精神病人的自杀提供依据。方法:对广州市精神病医院1956-2005年住院精神病人自杀进行回顾性分析,并对其中的精神分裂症病人按同性别、同诊断、相同或相近年龄、住院进行1:1匹配的病例对照研究。结果:共有77例住院精神病人发生自杀,自杀发生率为133.1/10万(95%CI103.4-162.85/10万)。多数自杀者为精神分裂症病人(64例,占83.1%),多数自杀者采取自缢的方式(59例,占76.6%),多数病人的自杀行为发生在病房内(52例,占67.5%);自杀组的住院次数明显高于对照组(2.13±1.89/1.23±0.75,P=0.001);自杀组本次住院前1月及住院期间的自杀未遂次数明显高于对照组(0.39±0.85/0.09±0.39,0.59±1.52/0.00±0.00,P=0.017,0.003)。自杀组有罪恶观念、心境抑郁者多于对照组(18.8%/3.1%,28.1%/6.3%,P=0.006,0.004);住院精神分裂症病人的罪恶观念、心境抑郁、本次住院前1月有自杀意念和自杀未遂是其自杀行为发生的危险因素(β=2.407、1.566、1.201、1.643)。结论:该院50年住院病人的自杀发生率与国外近似,精神分裂症病人自杀的危险因素是罪恶观念、心境抑郁、住院前1月自杀意念和自杀未遂。     

住院精神分裂症患者的自杀行为

目的 :了解精神分裂症患者自杀意念和自杀未遂的发生率及特征。方法 :通过自编自杀行为调查表对 177例连续入院的精神分裂症患者的自杀行为进行研究。结果 :自杀意念发生率为 47 46% (84例 ) ,已往出现过且目前也存在自杀意念者为 3 0 95 % ,仅目前存在或仅既往出现者分别为 2 6 19%和42 86% ;自杀意念短暂出现者为 9 2 9% ,持续一周者为 5 0 0 0 % ,持续两周以上者为 10 71% ;自杀意念严重者为 3 1 67% ;11 91%有自杀意念的患者对自杀意念能控制 ,9 5 2 %的患者不能控制 ,78 5 7%的患者表示不确定。自杀未遂的发生率为 15 82 % (2 8例 ) ,其中 1次者占 64 2 8% ,2次者占 17 86% ,3次及 3次以上者占 17 86%。 77 78%自杀未遂发生在发病期 ;自杀方式多为服用精神科药物 (4 4 44 % ) ;发生地点多在家中 (86 67% ) ;实施自杀未遂行为前 ,71 11%患者明确表达或暗示过其自杀意图 ;60 %患者未作过准备 ,准备不充分者为 3 7 78% ,仅 2 2 2 %的患者有充分准备 ;15 5 6%患者留有遗言。结论 :自杀意念是导致精神分裂症患者死亡的主要因素之一 ,临床工作中应提高警惕 ,及时干预     

北京市心理援助热线青少年来电者自杀意念的危险因素

目的:探索心理援助热线青少年来电者自杀意念的危险因素。方法:2018-2021年北京市心理援助热线的青少年来电者(11～18岁)纳入本研究,收集人口学资料,询问来电者在来电前2周内是否有自杀想法来评估自杀意念,并评估自杀相关的危险因素,如抑郁情绪、希望感、痛苦感等。采用logistic回归分析,探索青少年来电者自杀意念的危险因素。结果:本研究共纳入19 341例来电。77.9%(15 072例)青少年来电者报告该次来电前2周内有自杀意念。女性(OR=1.12,95%CI:1.01～1.24)、年纪轻(OR=1.30,95%CI:1.14～1.49)、有急性生活事件(OR=1.34,95%CI:1.23～1.47)、慢性生活事件(OR=1.31,95%CI:1.19～1.44)、既往自杀未遂史(OR=2.61,95%CI:2.35～2.91)、痛苦感高(OR=1.85,95%CI:1.67～2.04)和抑郁程度高(OR=2.71,95%CI:2.43～3.01)是青少年来电者自杀意念的独立危险因素,而高希望感(OR=0.45,95%CI:0.41～0.50)则是青少年来电者自杀意念的保护...     

浏阳市农村重性抑郁发作患者自杀意念与自杀未遂及影响因素分析

目的: 探讨农村社区重性抑郁发作患者中自杀意念与自杀未遂的阳性率及其影响因素.方法: 采用分层多级随机抽样方法调查浏阳市≥15岁农村常居居民7347人,以定式临床检查(Structured Clinical Interview-I/P,SCID-I/P)为诊断工具进行了抑郁症的筛查及诊断,共发现并确诊重性抑郁发作患者234人,均符合美国精神障碍分类诊断标准(DSM-IV),调查其社会人口学资料及相关危险因素情况.结果: 自杀意念与自杀未遂总阳性率达37.2%,女性高于男性(40.5% vs.31.4%,χ2=10.375,P=0.035).再婚、离异和丧偶者阳性率高于未婚或初婚者(50.0% vs.34.0%,Z=2.577,P=0.010).抑郁症的其他症状表现也与自杀意念和自杀未遂有关.多元logistic回归分析结果提示婚姻状况为再婚、离异或丧偶(OR=1.803,95%CI:1.220～2.532)和无价值感或自罪感症状阳性者(OR=2.056,95%CI:1.139～3.711)自杀意念和自杀未遂发生率较高,兴趣或愉快感缺失症状阳性与自杀意念和自杀未遂呈负相关(OR=0.397,95%CI:0.185～0.851).结论: 重性抑郁发作患者的自杀意念与自杀未遂阳性率较高,性别和婚姻状况对自杀意念与自杀未遂有影响,抑郁症的其他症状表现如无价值感或自罪感和自杀意念和兴趣或愉快感缺失也与自杀未遂有密切关系.     

儿童期虐待对中专学生自杀意念和自杀态度的影响

目的:探讨儿童期虐待对中专学生自杀态度和自杀意念的影响。方法:对符合入组标准的受虐待组学生和对照组学生各90名进行自杀态度问卷和自杀意念量表的测评,比较两组之间自杀态度和自杀意念的差异,并进行相关分析。结果:受虐待组学生在一周内及一年内自杀意念发生率分别为14·4%和32·2%,明显高于对照组学生(2·2%和14·4%,χ2=7·27、13·12,P<0·01);准自杀行为和自杀未遂行为发生率(15·6%)高于对照组学生(3·3%,χ2=6·50,P<0·05)。受虐待组学生对自杀行为、对自杀者及安乐死持肯定或理解态度者明显高于对照组(46·7%对18·9%,56·7%对35·6%);受虐待组学生对自杀越是持肯定态度,自杀意念也越强(r=0·38~0·55,P<0·01)。结论:儿童期虐待经历可使中专学生对自杀态度产生异乎寻常的变化,使受虐待者更容易产生自杀意念,发生自杀行为。     

北京心理援助热线来电者自杀未遂的相关因素

目的:探讨心理援助热线来电者自杀未遂行为的发生情况及其相关因素,为制定自杀热线干预措施提供依据。方法:北京市心理援助热线接线员在2002-2008年接听全部有效来电时,询问来电者在2周内是否实施过自杀行为,使用抑郁症诊断筛查量表评估其抑郁情绪,询问来电者是否有过酒精或其他物质滥用或依赖、有无常见精神症状、既往自杀未遂史、急性和慢性生活事件、希望程度等与自杀行为有关因素。结果:有22 415个来电者被纳入研究。362个(1.6%)来电者报告了2周内实施过自杀行为,女性233人,男性129人。在控制了人口学因素等变量后,既往自杀未遂史(OR=4.43,95%CI:3.37-5.83)、无望(OR=2.01,95%CI:1.52-2.67)、物质滥用(OR=1.97,95%CI:1.48-2.62)、急性生活事件(OR=1.94,95%CI:1.49-2.52)及严重抑郁情绪(OR=1.45,95%CI:1.08-1.95)与来电者实施自杀未遂行为有关联。结论:心理援助热线来电者自杀未遂行为发生率较高,对该群体的自杀干预要注重既往自杀未遂史、物质使用及生活事件的应对。     

军人自杀意念的相关因素

目的:探索军人自杀意念现患率及自杀意念的相关因素。方法:通过分层随机抽样方法于2015年5-8月选取军人2071名,使用自编一般人口学情况调查问卷、贝克抑郁问卷(BDI)的条目7进行调查,条目7得分≥1分者纳入自杀意念组。采用多因素logistic回归分析探讨自杀意念的相关因素。结果:2071名军人中,条目7得分≥1分者有382人(占18.4%)。自杀意念的危险因素为家族有自杀史(OR=42.97,95%CI=29.14~63.35)、周围出现过自杀事件(OR=2.46,95%CI=1.75~3.46)、饮酒(OR=1.64,95%CI=1.31~2.07)、受教育程度(OR=1.38,95%CI=1.01~1.90);保护因素为军兵种(OR=0.60,95%CI=0.50~0.72)及现驻地(OR=0.15,95%CI=0.03~0.64)。结论:在军人自杀预防中,应重视有家族自杀史、周围出现过自杀事件、饮酒、受教育程度低、空军、驻地在艰苦边远地区的人群。     

高中生自杀意念现状及其影响因素的调查分析

采用自评抑郁量表(SDS)、青少年自杀意念量表(SIQ)、自杀态度问卷量表(QSA)评定了2 836名高中生的抑郁水平、自杀意念和自杀态度,运用因素分析的方法探讨影响高中生自杀意念的主要因素。结果发现:(1)有6.3%的学生存在明显的自杀意念。(2)高中生自杀意念存在年级的差异,年级间有自杀意念的关系是:高一、高二大于高三。(3)高中生自杀意念存在性别的差异,男生比女生有较多的自杀意念。(4)高中生自杀意念存在宗教信仰的差异,有宗教信仰比无宗教信仰高中生有较多的自杀意念。(5)抑郁、自杀态度、领悟社会支持、家庭亲密度和适应性、自动思维、自尊是影响高中生自杀意念的重要因素。(6)抑郁、对自杀者家属的态度、自动思维、自尊共4个因子与自杀意念呈正相关;对自杀行为性质的认识、对安乐死的态度、领悟社会支持、家庭亲密度和适应性共5个因子与自杀意念呈负相关。     

自杀未遂者的随访研究

目的：了解自杀未遂者一年之后自杀死亡、自杀未遂与自杀意念发生的情况，一年内生活事件发生的情况以及随访时的情绪状态，探讨自杀意念的相关危险因素。方法：对60例自杀未遂者在一年后进行随访调查，使用生活事件量表、抑郁焦虑自评量表评定一年内生活事件发生的情况以及随访当时焦虑、抑郁的情况。结果：60例随访自杀未遂者无一例发生自杀死亡的情况，有4例发生（6．67％）自杀未遂行为，在随访调查时仍有自杀意念者有11例（18．3％）。60例随访自杀未遂者的焦虑分、抑郁分和生活事件紧张总值分均明显下降，有自杀意念组的各量表分高于无自杀意念组。结论：自杀未遂者一年后的自杀未遂发生率和自杀意念发生率是较高的，与年龄、躯体疾病、生活事件和焦虑抑郁情绪等因素有关。     

北京某综合大学一年级学生自杀意念影响因素分析

目的: 调查大学生自杀意念的风险因素,探讨干预策略.方法: 采用整群抽样法,对北京某综合大学9个院系的所有一年级学生进行现况调查,使用Beck抑郁问卷、Beck焦虑问卷、Beck无望问卷、青年健康危害行为问卷(YRBS)、人格障碍诊断问卷-4(PDQ-4)和自编的一般情况问卷调查大学生自杀意念及相关心理行为问题.采用多因素logistic回归分析对一学年内自杀意念和一周内自杀意念的影响因素进行分析.结果: 共2055人填写了问卷,一学年内自杀意念的报告率8.1%,危险因素按OR值大小排列依次为有物质滥用(OR=4.37,95%CI:2.27-8.41)、一学年内有过明显抑郁情绪(OR=3.21,95%CI:2.20-4.68)、一学年内使用过远程求助(OR=1.78,95%CI:1.13-2.81)、一周内存在明显抑郁情绪(OR=2.14,95%CI:1.36-3.37)、分裂样人格因子分(OR=1.21,95%CI:1.07-1.37)、边缘人格因子分(OR=1.23,95%CI:1.09-1.38);一周内自杀意念的报告率5.5%,危险因素按OR值大小排列依次为一周内存在明显抑郁情绪(OR=4.62,95%CI:2.86-7.46)、阳性精神障碍家族史(OR=2.96,95%CI:1.34-6.56)、一学年内有过明显的抑郁情绪(OR=2.35,95%CI:1.49-3.69)、女性(OR=1.65,95%CI:1.09-2.52)、边缘人格因子分(OR=1.50,95%CI:1.30-1.72)、分裂型人格因子分(OR=1.17,95%CI:1.03-1.34).文科专业显示为一学年内自杀意念的保护因素(OR=0.63,95%CI:0.41-0.95).大一学生一学年内寻求精神卫生服务的比例占12.5%,9.8%使用远程求助方式.在使用当面求助方式上女性多于男性(4.8%/2.9%,x2=4.42,P:0.035);报告有自杀意念者一学年内总体求助、当面求助、远程求助比例均高于无自杀意念者(22.5%/11.3%、7.4%/3.2%、18.2%/8.9%,x2=23.0、10.3、19.7,P＜0.01).结论: 大学生自杀风险的筛查指标除自杀意念外还应考虑纳入抑郁、物质滥用、人格特点、阳性精神障碍家族史.大学生精神卫生服务宜从鼓励求助行为、主动提供延伸式服务、大力发展网络精神卫生服务三方面人手,提高服务质量.     

Suicidal behavior in bipolar mood disorder: clinical characteristics of attempters and nonattempters

OBJECTIVE: Bipolar Disorder is associated with a higher frequency of attempted suicide than most other psychiatric disorders. The reasons are unknown. This study compared bipolar subjects with a history of a suicide attempt to those without such a history, assessing suicidal behavior qualitatively and quantitatively, and examining possible demographic, psychopathologic and familial risk factors. METHODS: Patients (ages 18 to 75) with a DSM III-R Bipolar Disorder (n = 44) diagnosis determined by a structured interview for Axis I disorders were enrolled. Acute psychopathology, hopelessness, protective factors, and traits of aggression and impulsivity were measured. The number, method and degree of medical damage was assessed for suicide attempts, life-time. RESULTS: Bipolar suicide attempters had more life-time episodes of major depression, and twice as many were in a current depressive or mixed episode, compared to bipolar nonattempters. Attempters reported more suicidal ideation immediately prior to admission, and fewer reasons for living even when the most recent suicide attempt preceded the index hospitalization by more than six months. Attempters had more lifetime aggression and were more likely to be male. However, attempters did not differ from nonattempters on lifetime impulsivity. LIMITATIONS: The generalizability of the results is limited because this is a study of inpatients with a history of suicide attempts. Patients with Bipolar I and NOS Disorders were pooled and a larger sample is needed to look at differences. We could not assess psychopathology immediately prior to the suicide attempt because, only half of the suicide attempters had made attempts in the six months prior to admission. Patients with current comorbid substance abuse were excluded. No suicide completers were studied. CONCLUSIONS: Bipolar subjects with a history of suicide attempt experience more episodes of depression, and react to them by having severe suicidal ideation. Their diathesis for acting on feelings of anger or suicidal ideation is suggested by a higher level of lifetime aggression and a pattern of repeated suicide attempts.     

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.     

Suicidal behaviour in adolescence and subsequent mental health outcomes in young adulthood

BACKGROUND: The aim of this study was to examine the linkages between suicidal ideation and attempt in adolescence and subsequent suicidal behaviours and mental health in young adulthood. METHOD: Data were gathered during the course of a 25-year longitudinal study of a birth cohort of 1265 New Zealand children. The information collected included: (a) measures of suicidal thoughts and attempts in adolescence (< 18 years); (b) measures of suicidal ideation, suicide attempt, major depression, anxiety disorders, and substance use disorders in young adulthood (18-25 years); and (c) measures of childhood and family background, individual characteristics, and mental disorders in adolescence. RESULTS: After statistical adjustment for confounding factors, suicide attempt in adolescence was associated with increased risks of subsequent suicidal ideation (OR 5.7) suicide attempt (OR 17.8) and major depression (OR 1.5). Those reporting suicidal ideation without suicide attempt showed moderate increases in risks of later suicidal ideation (OR 2.5), suicide attempt (OR 2.0) and major depression (OR 1.6). In addition, there was evidence of an interactive relationship in which suicidal behaviour in adolescence was associated with increased risks of later substance use disorders in females but not males. CONCLUSIONS: Young people reporting suicidal ideation or making a suicide attempt are an at-risk population for subsequent suicidal behaviour and depression. Further research is needed into the reasons for suicidal adolescent females being at greater risk of later substance use disorder.     

Predictors of Continued Suicidal Behavior in Adolescents Following a Suicide Attempt

Describes adolescents who attempt suicide and their risk for ongoing suicidal behavior. Fifty-eight adolescents (53 female) who attempted suicide received a baseline evaluation that was analyzed to identify factors that were associated with continued suicidal ideation and reattempt. At a 3-month follow-up assessment, 45% reported continued suicidal ideation and 12% reported a repeat attempt. Baseline measures of family functioning, feelings of hopelessness, and abilities to regulate affect were associated with suicidal ideation at follow-up but not as strongly as depressed mood. After controlling for depressive symptoms, the association between family functioning and continued suicidal behavior was no longer significant. Depressed mood at baseline was most strongly associated with both continued suicidal ideation and reattempt.     

Life events and suicidal ideation and behavior: A systematic review

Despite the sustained theoretical and empirical interest over the past 40 years in the association between life events and suicidal ideation and behavior, the literature in this area has yet to be systematically reviewed. The current article provides a comprehensive review of the empirical literature pertaining to life events in relation to at least one aspect of suicidal ideation and behavior (i.e., suicidal ideation, plans, attempts, degree of suicidal intent, medical severity of attempt, repeat versus first lifetime attempt status, and death by suicide). A total of 95 articles meeting inclusion criteria were identified by a literature search using Medline and PsycINFO. Evidence for an association between negative life events and suicidal ideation and behavior was generally consistent, with strongest support found for more severe than with less severe forms of suicidal ideation and behavior. Support for an inverse relation between positive events and suicidal ideation and behavior was generally lacking. Although there is general support for life stressors as a risk factor for suicidal ideation and behavior, interpretation of these findings is constrained by methodological limitations prevalent in much of the literature, particularly in the case of suicidal ideation and suicide plans. Recommendations for future research are provided.     

Suicidal behavior among middle-class adolescents who seek crisis services

The goal of this study was to assess suicidal behavior and risk factors among 1,616 predominantly middle-class adolescents who were seeking crisis services, either residential or nonresidential. Across recruitment sites, 22.1% reported a past suicide attempt; half reported suicidal ideation in the month prior to seeking services. Attempters were significantly more likely than nonattempters to report suicidal ideation (64.2%), family suicidal behavior (50.5%), and more than twice as likely to have been depressed (37.3%), frequently used alcohol (13.2%), frequently used drugs (10.6%), run away (30.9%), belonged to a gang (6.1%), and destroyed property (5.8%). Suicidal behavior among predominantly White, middle-class adolescents who have sought crisis services appears similar to patterns found among minority youths in Los Angeles and New York City. © 1996 John Wiley & Sons, Inc.     

Family history of suicidal behavior and early traumatic experiences: additive effect on suicidality and course of bipolar illness?

BACKGROUND: Bipolar disorder (BD) is associated with a high prevalence of suicide attempt and completion. Family history of suicidal behavior and personal history of childhood abuse are reported risk factors for suicide among BD subjects. METHODS: BD individuals with family history of suicidal behavior and personal history of childhood abuse (BD-BOTH), BD individuals with family history of suicidal behavior or personal history of childhood abuse (BD-ONE), and BD individuals with neither of these two risk factors (BD-NONE) were compared with regard to demographic variables and clinical measures. RESULTS: Almost 70% of the sample had a history of a previous suicide attempt. There were significantly higher rates of previous suicide attempts in the BD-BOTH and BD-ONE relative to the BD-NONE group. BD-BOTH were significantly younger at the time of their first suicide attempt and had higher number of suicide attempts compared with BD-NONE. BD-BOTH were significantly younger at the time of their first episode of mood disorder and first psychiatric hospitalization and had significantly higher rates of substance use and borderline personality disorders compared to BD-NONE. LIMITATIONS: Retrospective study. Use of semi-structured interview for the assessment of risk factors. CONCLUSIONS: BD individuals with a familial liability for suicidal behavior and exposed to physical and/or sexual abuse during childhood are at a greater risk to have a more impaired course of bipolar illness and greater suicidality compared to those subjects with either only one or none of these risk factors. Prospective studies are needed to confirm these findings.     

Utility of the MCMI-II in assessing suicide risk

The MCMI-II profiles of 40 psychiatric inpatients admitted for suicidal ideation and 40 patients admitted for a suicide attempt were compared. Subjects in each group were matched on sex, history of previous attempts, and other demographic variables. While the results indicate very few differences between the MCMI-II profiles of these two groups of patients, suicide attemptors scored significantly higher on Scale Y (Desirability), which suggests greater tendencies toward denial of problem areas. Patients with suicidal ideation yielded a mean profile with elevations on Scale 2 (Avoidant), 8A (Passive-Aggressive), 8B (Self-Defeating), C (Borderline), D (Dysthymia), and Z (Debasement). These results are discussed in terms of a stress-vulnerability model of suicidal behavior with suggestions made for expanding on the findings in future studies.     

抑郁症患者自杀态度与自杀意念的关系研究

目的探讨抑郁症患者自杀态度与自杀意念的关系。方法采用自杀态度问卷(Q SA)和B eck自杀意念量表中文版(BS I-CV)对334名抑郁症住院患者进行调查。结果抑郁症患者自杀态度的4个因子均分都在2.5~3.5之间;其与自杀意念强度、自杀危险程度呈一定负相关关系(P<0.05);结构方程模型拟合表明,自杀态度通过自杀意念强度影响自杀危险程度(近1周:χ2=2870.04,P<0.05,NNF I=0.88,CF I=0.89;最消沉抑郁时:χ2=1599.41,P<0.05,NNF I=0.94,CF I=0.95);在"近1周"和"最消沉"2个时间段,自杀态度对自杀危险程度的间接影响作用分别为0.308和0.410,P<0.05。结论自杀态度通过自杀意念强度对自杀危险产生影响。     

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.