Characteristics of HIV patients who attempt suicide

OBJECTIVE: To examine the risk factors for suicidal behaviour in human immunodeficiency virus (HIV) positive patients. METHOD: HIV substance dependent positive patients who had attempted suicide were compared with HIV substance dependent positive patients who had never attempted suicide for suicide risk factors. RESULTS: Among the 149 HIV positive patients examined almost half had attempted suicide. Significantly more HIV positive patients who had attempted suicide were female. Attempters were significantly younger than non-attempters. Significantly more of the attempters had a family history of suicidal behaviour. Attempters also reported significantly more childhood trauma, scored significantly higher for neuroticism, had experienced significantly more comorbidity with depression, and more of them had received antidepressant medication. CONCLUSION: These data suggest that both distal and proximal risk factors are involved in suicidal behaviour in HIV positive substance dependent patients.     

Correlates of suicide attempt history in bipolar disorder: a stress-diathesis perspective

Objectives:  Distinguishing clinical characteristics of bipolar patients who have made a suicide attempt may help to identify at-risk individuals. We sought to identify such factors and to consider them within a stress-diathesis model of suicidal behavior.
Methods:  Patients with bipolar disorder (N = 96) were compared with respect to the presence or absence at baseline evaluation of a history of suicide attempt. We used multiple logistic regression analysis to assess the unique associations of independent variables to history of a past suicide attempt.
Results:  The regression analysis showed that a history of suicide attempt in bipolar disorder was associated with greater recent suicidal ideation, more psychiatric hospitalizations, lifetime aggressive traits and an earlier age at onset of a first mood episode.
Conclusions:  Aggressive traits and early treatment of mood disorders, especially major depressive episodes, are potential targets for suicide prevention in bipolar disorder.     

Comparisons of Prisoners Who Make or Do Not Make Suicide Attempts and Further Who Make One or Multiple Attempts

Suicidal behavior among prisoners is a major problem. The objective of this study was to compare prisoners who have made an attempt at suicide vs non-attempters and further to compare single vs multiple suicide attempts. Among 1,537 prisoners, 200 (13%) had a lifetime history of attempting suicide and 92 (6%) had made multiple attempts. Those who had made multiple or single attempts were compared on socio-demographic, developmental, personality, forensic, and psychiatric variables. In a re-analysis we also compared non-attempters with attempters in this larger sample. The comparison showed that prisoners who had made multiple attempts had experienced significantly more childhood trauma, were more introverted, less resilient, had a history of self-mutilation, and had more suicidal ideation. Anger and hostility scores and criminal and violence histories significantly differentiated prisoners who had attempted from those who had never attempted but they did not differentiate multiple from single attempters. Having a history of multiple attempts may be indicative of more severe psychopathology in prisoners, as found in other populations. These findings may be helpful in predicting which prisoner is at increased risk of exhibiting suicidal behavior while incarcerated and after release.     

Neurocognition and suicidal behaviour in an Irish population with major psychotic disorders

OBJECTIVES: Although neurocognitive deficits are seen as core to schizophrenia the association between suicidality and neurocognition has received little attention. Our aim was to examine the relationship between neurocognitive variables and suicidal behaviour in patients with schizophrenia and schizoaffective disorder. METHODS: Seventy-eight patients with DSM-IV diagnoses of schizophrenia or schizoaffective disorder were categorised as either having attempted suicide or not having attempted suicide based on clinical interview and chart review. Attempters and non-attempters were compared on an extensive neuropsychological battery examining pre-morbid and current general cognitive functioning, episodic memory, and executive functioning. RESULTS: Suicide attempters tended to out perform non-attempters across all areas of executive functioning, and showed significantly better performances on measures of attention and verbal fluency. After controlling for relevant clinical and demographic variables, the differences between attempters and non-attempters remained significant for measures of attention (F = 4.97, p = 0.03) and verbal fluency (F = 4.28, p = 0.04). CONCLUSION: This study adds to existing data that suicide attempters with schizophrenia or schizoaffective disorder may have higher cognitive functioning than non-attempters. In particular, the preservation of higher executive function may influence the ability to initiate and plan suicidal behaviour.     

A comparison of life events between suicidal adolescents with major depression and borderline personality disorder

The current study compared the correlations of different types of stressful life events (SLE) between suicidal adolescents with major depressive disorder (MDD) and suicidal adolescents with borderline personality disorder (BPD). Both groups were referred following an attempted suicide. Twenty adolescents with MDD and 20 adolescents with BPD who were consecutively referred to an outpatient clinic following a suicide attempt were evaluated. A community control group of adolescents with no lifetime history of suicidal behavior was also assessed. The following measurements were employed: the Suicide Risk Scale (SRS) Beck Depression Inventory (BDI), the Life Events Checklist (LEC), and the Childhood Sexual Abuse Questionnaire (CSEQ). Both groups of suicidal subjects reported more SLE in general and more physical abuse than community controls in the 12 months before the suicide attempt. The MDD adolescents had more lifetime death-related SLE than the BPD and control groups, while the BPD adolescents reported more lifetime sex abuse-related SLE than the other two groups. Thus, suicidal behavior in general may be related to the amount of SLE. However, different disease-specific life events may precipitate suicide attempts in adolescents with MDD and BPD.     

Clinical significance of lifetime panic spectrum symptoms in the treatment of patients with bipolar I disorder

BACKGROUND: Given the observed association between panic disorder and bipolar disorder and the potential negative influence of panic symptoms on the course of bipolar illness, we were interested in the effects of what we have defined as "panic spectrum" conditions on the clinical course and treatment outcome in patients with bipolar I (BPI) disorder. We hypothesized that lifetime panic spectrum features would be associated with higher levels of suicidal ideation and a poorer response to acute treatment of the index mood episode in this patient population. METHODS: A sample of 66 patients with BPI disorder completed a self-report measure of lifetime panic-agoraphobic spectrum symptoms. Patients falling above and below a predefined clinical threshold for panic spectrum were compared for clinical characteristics, the presence of suicidal ideation during acute treatment, and acute treatment response. RESULTS: Half of this outpatient sample reported panic spectrum features above the predefined threshold. These lifetime features were associated with more prior depressive episodes, higher levels of depressive symptoms, and greater suicidal ideation during the acute-treatment phase. Patients with BPI disorder who reported high lifetime panic-agoraphobic spectrum symptom scores took 27 weeks longer than those who reported low scores to remit with acute treatment (44 vs 17 weeks, respectively). CONCLUSIONS: The presence of lifetime panic spectrum symptoms in this sample of patients with BPI disorder was associated with greater levels of depression, more suicidal ideation, and a marked (6-month) delay in time to remission with acute treatment. Alternate treatment strategies are needed for patients with BPI disorder who endorse lifetime panic spectrum features.     

Clinical characteristics of adolescent psychiatric inpatients who have attempted suicide

 The clinical characteristics of 191 adolescent inpatients were examined in relation to frequency of previous suicide attempts, predictors of suicide attempts prior to hospitalization, and lifetime suicide attempts. Overall, more than 50% of the adolescent inpatients had attempted suicide during their lifetime, and of these more than half (58%) had made more than one attempt. Approximately half of the suicide attempters had made a serious attempt prior to hospitalization. Girls reported higher levels of depressive symptoms and suicidal ideation than boys, in addition to having attempted suicide prior to hospitalization (33%) or during lifetime (37%) more often than the boys (13% and 26%, respectively). Although about two thirds of the adolescent inpatients reported that they had received some help after a suicide attempt, approximately half of the repeaters had not received any help. The results of multivariate analyses showed that suicide attempts made prior to hospitalization were predicted by depressive symptom levels and a clinical diagnosis of depressive disorder, whereas frequency of lifetime suicide attempts was predicted by suicidal ideation levels and having a family member or a friend who had attempted (or committed) suicide. The high prevalence of lifetime and repeated suicide attempts among the psychiatric inpatients underscores the importance of identifying risk factors in the clinical evaluation of adolescent suicide attempters. Accepted: 1 April 1998     

Correlates of Lifetime Suicide Attempts Among Individuals with Affective Disorders in a Chinese Rural Community

The aim of this study was to compare the demographic and clinical characteristics of individuals with affective disorders who had attempted suicide at some time in their lives and those who had not made a suicide attempt. In a Chinese rural community, individuals with suicide attempt (N = 30) and those without suicide attempt (N = 166) were assessed with Present State Examination (PSE). Attempters had a significantly higher level of family economic status, higher rate of lifetime depressed mood and hopelessness, and delusions than nonattempters. The logistic regression models also indicated that depressed mood and hopelessness were the most important predictors of suicide attempts. No significant difference in treatment condition was found between attempters and non-attempters. Early identification and interventions focusing on reducing depressed mood, hopelessness, and controlling psychotic symptoms may be helpful in reducing the risk of suicide attempts among individuals with affective disorders residing in the community.     

Suicidal attempts in bipolar disorder: results from an observational study (EMBLEM)

Bellivier F, Yon L, Luquiens A, Azorin J‐M, Bertsch J, Gerard S, Reed C, Lukasiewicz M. Suicidal attempts in bipolar disorder: results from an observational study (EMBLEM).
Bipolar Disord 2011: 13: 377–386. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objectives: To compare patients with and without a history of suicidal attempts in a large cohort of patients with bipolar disorder and to identify variables that are associated with suicidal behavior. Methods: European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) is a two‐year, prospective, observational study that enrolled 3,684 adult patients with bipolar disorder and initiated or changed oral treatment for an acute manic/mixed episode. Of those, 2,416 patients were eligible for the two‐year follow‐up. Only baseline characteristics were studied in the present study, included sociodemographic data, psychiatric history and comorbidities, history of suicide attempts, history of substance use problems, compliance with treatment, inpatient admissions, and functional status. Symptom severity was assessed using the Clinical Global Impression–Bipolar Disorder (CGI‐BP) scale, the Young Mania Rating Scale (YMRS), and the 5‐item Hamilton Depression Rating Scale (HAMD‐5). A logistic regression model identified baseline variables independently associated with a history of suicidal behavior. Results: Of the 2,219 patients who provided data on their lifetime history of suicide attempts, 663 (29.9%) had a history of suicidal behavior (at least one attempt). Baseline factors associated with a history of suicidal behavior included female gender, a history of alcohol abuse, a history of substance abuse, young age at first treatment for a mood episode, longer disease duration, greater depressive symptom severity (HAMD‐5 total score), current benzodiazepine use, higher overall symptom severity (CGI‐BP: mania and overall score), and poor compliance. Conclusions: These factors may be considered as potential characteristics to identify subjects at risk for suicidal behavior throughout the course of bipolar disorder.     

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.     

Comorbid anxiety in bipolar disorder: does it have an independent effect on suicidality?

Objective:  Comorbid anxiety disorder is reported to increase suicidality in bipolar disorder. However, studies of the impact of anxiety disorders on suicidal behavior in mood disorders have shown mixed results. The presence of personality disorders, often comorbid with anxiety and bipolar disorders, may explain these inconsistencies. This study examined the impact of comorbid Cluster B personality disorder and anxiety disorder on suicidality in bipolar disorder.
Methods:  A total of 116 depressed bipolar patients with and without lifetime anxiety disorder were compared. Multiple regression analysis tested the association of comorbid anxiety disorder with past suicide attempts and severity of suicidal ideation, adjusting for the effect of Cluster B personality disorder. The specific effect of panic disorder was also explored.
Results:  Bipolar patients with and without anxiety disorders did not differ in the rate of past suicide attempt. Suicidal ideation was less severe in those with anxiety disorders. In multiple regression analysis, anxiety disorder was not associated with past suicide attempts or with the severity of suicidal ideation, whereas Cluster B personality disorder was associated with both. The results were comparable when comorbid panic disorder was examined.
Conclusions:  Comorbid Cluster B personality disorder appears to exert a stronger influence on suicidality than comorbid anxiety disorder in persons with bipolar disorder. Assessment of suicide risk in patients with bipolar disorder should include evaluation and treatment of Cluster B psychopathology.     

Association between familial suicidal behavior and frequency of attempts among depressed suicide attempters

Objective: Only a few studies have examined whether a family history of suicide influences the severity of suicidal acts and the results have been inconsistent. The current study aimed to examine whether a family history of suicidal acts predicts severity of suicide attempts. Method: 190 suicide attempters aged 18–75 years with a lifetime history of major depression were assessed for first‐degree family history of suicidality and severity of suicide attempts (number and lethality of prior suicide attempts and age at first attempt). Results: Regression analyses indicate that a positive family history of suicidal behaviors predicts a greater number of suicide attempts. Reasons for living predict number and lethality of prior attempts. Conclusion: It is critical to assess for family history of suicidal behavior when treating depressed suicide attempters as it may serve as an indicator of the risk of repeat suicide attempt and as a guide for treatment.     

Reduced dopamine function in depressed patients is related to suicidal behavior but not its lethality

Several lines of evidence suggest a role for dopamine in the control of suicidal behaviour. Previously, we suggested an involvement of D2-dopaminergic function in the biology of suicide by demonstrating a smaller growth hormone (GH) response to apomorphine, a dopaminergic agonist, in depressed patients who later died by suicide. The purpose of the present study was to assess GH response to apomorphine in major depressed in-patients with a history of highly lethal suicide attempt compared to depressed patients with a low lethal lifetime suicide attempt history and non-attempters. The study was performed in a sample of 26 male depressed in-patients with a history of suicide attempt compared to 26 male depressed non-attempters. We observed a significant difference between suicide attempters and non-attempters (for GH peak, 6.3+/-5.1 ng/ml vs 15.8+/-14.2 ng/ml, F=10.3, df=1, 50, P=0.002). Moreover, GH peak responses to apomorphine did not differ between depressed patients with a high lethal lifetime suicide attempt history and patients who made low lethal lifetime suicide attempt. In conclusion, the results of the present study support a role for dopamine in the biology of suicidal behaviour. More specifically, an impaired GH response to apomorphine could be a marker of suicide risk.     

Anxiety in major depression: relationship to suicide attempts

OBJECTIVE: This study was an examination of the relationship of lifetime panic disorder and anxiety symptoms at index hospitalization to a history of a suicide attempt in patients with a major depressive episode. METHOD: A total of 272 inpatients with at least one major depressive episode, with or without a history of a suicide attempt, were entered into the study. They were given structured diagnostic interviews for axis I and axis II disorders. Suicide attempt history, current psychopathology, and traits of aggression and impulsivity were also assessed. RESULTS: The rates of panic disorder did not differ in the suicide attempters and nonattempters. Agitation, psychic anxiety, and hypochondriasis were more severe in the nonattempter group. A multivariate analysis confirmed that this effect was independent of aggression and impulsivity. CONCLUSIONS: Comorbid panic disorder in patients with major depression does not seem to increase the risk for lifetime suicide attempt. The presence of greater anxiety in the nonattempters warrants further investigation.     

Active and Passive Problem Solving as Moderators of the Relation Between Negative Life Event Stress and Suicidal Ideation Among Suicide Attempters and Non-Attempters

This study examined whether active problem solving would buffer against, whereas passive problem solving would exacerbate, the association of negative life stress with suicidal ideation. Young adult college students (73 females, M_age = 19.0) from a diverse urban public university, with (n = 37) and without (n = 59) a suicide attempt history completed measures of life stress, problem solving, hopelessness, depression, and suicidal ideation. Hierarchical linear regressions were conducted to test moderating roles of active and passive problem solving, along with suicide attempt history, on the relation between negative life event stress and suicidal ideation. There was a weaker relation between life stress and suicidal ideation at high and average levels of relevant problem solving than at low levels, and this was the case primarily for suicide attempters but not for non-attempters. Individuals with a past attempt produced more passive solutions than non-attempters, but among attempters, even passive problem solving buffered the association of life stress with suicidal ideation. Relevant problem solving in the face of life stress may be especially important for individuals vulnerable to suicidal ideation due to an attempt history. Among such at-risk individuals, generating even passive solutions in the face of life stress may be more adaptive than generating few solutions. Thus, clinical interventions with suicide attempters that focus on generating solutions to problems, even if these are initially passive, may help mitigate the effect of life stress on suicidal ideation.     

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.     

Post-traumatic stress disorder among adolescents with bipolar disorder and its relationship to suicidality

OBJECTIVES: The aims of this cross-sectional pilot study were to ascertain the rates of post-traumatic stress disorder (PTSD) among adolescents with bipolar disorder (BPD) and major depressive disorder (MDD) relative to a comparison group comprised of non-affectively ill patients, and to determine whether PTSD is related to suicidal ideation and attempts. The impetus for the study was born of clinical impressions derived in the course of routine clinical practice. METHODS: Patients were screened by a single interviewer for BPD, MDD and PTSD, panic disorder, obsessive-compulsive disorder (OCD) and social phobia using the apposite modules from the Structured Clinical Interview for DSM-IV (SCID) and histories of suicidal ideation and attempts. The data were subjected to analysis using a logistic regression model. RESULTS: The database included 34 patients with BPD, 79 with MDD and 26 with a non-affective disorder. The risk for PTSD for a patient with BPD significantly exceeded that for a patient with MDD [odds ratio (OR) = 4.9, 95% confidence interval (CI) = 1.9-12.2, p = 0.001]. Patients with PTSD had an insignificantly increased risk for suicidal ideation (OR = 2.8, 95% CI = 0.9-8.9, p = 0.069), and a 4.5-fold significantly increased risk of having had a suicide attempt (OR = 4.5, 95% CI = 1.7-11.7, p = 0.002). The relationship between PTSD and suicide attempts remained significant even after controlling for the confounding effects of concurrent panic disorder, OCD and social phobia (OR = 3.4, 95% CI = 1.1-10.0, p = 0.023). CONCLUSIONS: Patients with BPD have a greater risk for PTSD than those with MDD. Post-traumatic stress disorder is significantly related to history of suicide attempts.     

Suicidal behavior in patients with schizophrenia and other psychotic disorders.

OBJECTIVE: Patients with schizophrenia are known to be at high risk for suicide attempts and dying by suicide. However, little research has been conducted to determine whether the risk for suicidal behavior is elevated among patients with psychosis in general. METHOD: This study evaluated 1-month and lifetime rates of suicidal behavior among 1,048 consecutively admitted psychiatric inpatients (ages 18 to 55 years) with DSM-III-R psychotic disorders. Demographic, clinical, and diagnostic correlates of suicidal behavior were examined. RESULTS: A high rate of suicidal behavior was found in the group: 30.2% reported a lifetime history of suicide attempts, and 7.2% reported a suicide attempt in the month before admission. The highest 1-month and lifetime rates were found in patients with schizoaffective disorder and major depression with psychotic features. Ratings of the medical dangerousness of the most recent suicide attempt on the basis of the extent of physical injury were higher in patients with schizophrenia spectrum psychoses. Agreement was high between emergency room assessments and semistructured interview assessments of suicidal behavior. CONCLUSIONS: Rates of suicidal behavior were high across a broad spectrum of patients with psychotic disorders; patients with a history of a current or past major depressive episode (as a part of major depressive disorder or schizoaffective disorder) were at a greater risk for suicide attempts, but patients with schizophrenia, on average, made more medically dangerous attempts. Risk factors for suicidal behavior in patients with psychosis appear to vary compared to those for the general population.     

Are structural brain abnormalities associated with suicidal behavior in patients with psychotic disorders?

Suicide represents a major health problem world-wide. Nevertheless, the understanding of the neurobiological underpinnings of suicidal behavior remains far from complete. We compared suicide attempters to non-attempters, and high vs. low lethality attempters, to identify brain regions associated with suicidal behavior in patients with psychotic disorders. 489 individuals with schizophrenia, schizoaffective disorder, or psychotic bipolar disorder I and 262 healthy controls enrolled in the B-SNIP study were studied. Groups were compared by attempt history and the highest medical lethality of previous suicide attempts. 97 patients had a history of a high lethality attempt, 51 of a low lethality attempt and 341 had no attempt history. Gray matter volumes were obtained from 3T structural MRI scans using FreeSurfer. ANCOVAs were used to examine differences between groups, followed by Hochberg multiple comparison correction. Compared to non-attempters, attempters had significantly less gray matter volume in bilateral inferior temporal and superior temporal cortices, left superior parietal, thalamus and supramarginal regions, right insula, superior frontal and rostral middle frontal regions. Among attempters, a history of high lethality attempts was associated with significantly smaller volumes in the left lingual gyrus and right cuneus. Compared to non-attempters, low lethality attempters had significant decreases in the left supramarginal gyrus, thalamus and the right insula. Structural brain abnormalities may distinguish suicide attempters from non-attempters and high from low lethality attempters among individuals with psychotic disorders. Regions in which differences were observed are part of neural circuitries that mediate inhibition, impulsivity and emotion, visceral, visual and auditory perception.