Clinical features of patients with treatment-emergent suicidal behavior following initiation of paroxetine therapy

BackgroundUnderstanding suicidal behavior is an important component of assessing suicidality in psychiatric patients. GlaxoSmithKline (GSK) conducted a meta-analysis of randomized, placebo-controlled trials to compare suicidality in adult patients treated with paroxetine vs. placebo. The goal was to identify emergent clinical characteristics of patients with definitive suicidal behavior (DSB: preparatory act, suicide attempt, completed suicide).MethodsThe dataset comprised 14,911 patients from 57 placebo-controlled paroxetine trials. Possible cases of suicidality were identified and were blindly reviewed by an expert panel, which categorized cases as suicidal or non-suicidal. DSB incidences were compared between paroxetine and placebo. Clinical narratives and case report forms for major depressive disorder (MDD) and anxiety disorder patients with DSB were reviewed. For MDD, rating scale items relating to suicidality, insomnia, agitation, and anxiety were examined.ResultsOverall (all indications) there were no differences between paroxetine and placebo for DSB (50/8958 [0.56%] vs. 40/5953 [0.67%], respectively; OR = 1.2 [CI 0.8, 1.9]; p = 0.483). However, in patients with major depressive disorder (MDD), the incidence of DSB was greater for paroxetine (11/3455 [0.32%] vs. 1/1978 [0.05%], OR = 6.7 [CI 1.1, 149.4]; p = 0.058). Review of the 11 paroxetine MDD cases revealed common clinical features: symptomatic improvement; younger age (18–30 years); psychosocial stressors; overdose as method; and absent/mild suicidal ideation at the visit prior to the event. There was no evidence for a consistent adverse event profile or onset of akathisia/agitation or a manic/mixed state. Anxiety disorder patients with DSB had a heterogeneous clinical picture.LimitationsLimitations to the study include the relatively small number of cases and the retrospective nature of the study.ConclusionsDSB incidence was similar between paroxetine and placebo overall, but a higher frequency of DSB was found for paroxetine in MDD patients, driven by young adults aged ≤ 30 years. Most MDD patients with DSB improved prior to the attempt and experienced a psychosocial stressor. Patients should receive careful monitoring for suicidality during paroxetine therapy.     

A compact VEGF signature associated with distant metastases and poor outcomes

Background

Suicidal thoughts and behaviours during antidepressant treatment, especially during the first weeks of treatment, have prompted warnings by regulatory bodies. The aim of the present study is to investigate the course and predictors of emergence and worsening of suicidal ideation during tricyclic antidepressant and serotonin reuptake inhibitor treatment.

Methods

In a multicentre part-randomised open-label study, 811 adult patients with moderate to severe unipolar depression were allocated to flexible dosage of escitalopram or nortriptyline for 12 weeks. The suicidality items of three standard measures were integrated in a suicidal ideation score. Increases in this score were classified as treatment emergent suicidal ideation (TESI) or treatment worsening suicidal ideation (TWOSI) according to the absence or presence of suicidal ideation at baseline.

Results

Suicidal ideation decreased during antidepressant treatment. Rates of TESI and TWOSI peaked in the fifth week. Severity of depression predicted TESI and TWOSI. In men, nortriptyline was associated with a 9.8-fold and 2.4-fold increase in TESI and TWOSI compared to escitalopram, respectively. Retirement and history of suicide attempts predicted TWOSI.

Conclusion

Increases in suicidal ideation were associated with depression severity and decreased during antidepressant treatment. In men, treatment with escitalopram is associated with lower risk of suicidal ideation compared to nortriptyline. Clinicians should remain alert to suicidal ideation beyond the initial weeks of antidepressant treatment.

Trial registration

EudraCT (No.2004-001723-38) and ISRCTN (No. 03693000).     

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.     

Agitated "unipolar" depression re-conceptualized as a depressive mixed state: implications for the antidepressant-suicide controversy

BACKGROUND: The nosologic status of agitated depression is unresolved. Are they unipolar (UP) or bipolar (BP)? Are they mixed states? Even more controversial is the notion that antidepressants might play some role in the suicidality of such patients (Akiskal and Mallya, 1987) [Akiskal, H.S., Mallya, G., 1987. Criteria for the "soft" bipolar spectrum: treatment implications. Psychopharmacol Bull. 23, 68-73]. METHODS: After excluding all patients with history of hypomanic episodes occurring outside the frame of a major depressive episode (MDE), even those with a shorter duration of hypomanic symptoms than stipulated in DSM-IV, the remaining consecutive 254 unipolar major depressive disorder (MDD) private adult (> 21 years old) outpatients were interviewed (off psychoactive drugs for 2 weeks) with the Structured Clinical Interview for DSM-IV (SCID-CV), the Hypomania Interview Guide (HIGH-C), and the Family History Screen. Intra-MDE hypomanic symptoms were systematically assessed, with > or = 3 such symptoms required for a diagnosis of depressive mixed state (DMX). Agitated depression was defined as an MDE with HIGH-C psychomotor agitation score > or = 2. Logistic regression was used to study associations and control for confounding variables. RESULTS: In this strictly defined unipolar sample, agitated depression was present in 19.7%. Compared with its non-agitated counterpart, it had significantly fewer recurrences, less chronicity, higher rate of family history for bipolar disorder, and DMX; and, among the intra-depressive non-euphoric hypomanic symptoms (in decreasing order of frequency), distractibility, racing/crowded thoughts, irritable mood, talkativeness, and risky behavior. The most striking finding was the robust association between agitated depression and DMX (OR = 36.9). Furthermore, patients with psychomotor agitation had significantly higher rate of weight loss and suicidal ideation. Of DMX symptoms, we found an association between suicidal ideation, psychomotor activation, and racing thoughts. Agitated depression was tested by forward stepwise logistic regression versus all variables significantly different in the pairwise comparisons, yielding DMX, talkativeness, and suicidal ideation as the independent significant positive predictors. LIMITATIONS: No suicidal ideation scale was used. CONCLUSIONS: Agitated depression emerges as a distinct affective syndrome with weight loss, pressure of speech, racing thoughts and suicidal ideation. Psychomotor activation and racing thoughts during MDD independently predicted suicidal ideation. In this "unipolar" MDD sample, agitated depression had a strong clustering of intra-episode non-euphoric hypomanic symptoms (i.e. DMX) which, coupled with its association with bipolar family history, support its link with the bipolar spectrum. Agitated depression is therefore best regarded as "pseudo-unipolar." These findings overall accord with classical German concepts of agitated depression as a mixed state. Given that these patients are typically activated along the lines of risk-taking behavior, Kraepelin's rubric of "excited (mixed) depression" appears to us the preferred terminology over "agitated depression". CLINICAL IMPLICATIONS: The data reported herein, placed in the setting of the literature reviewed in the discussion suggest that the reports of increased risk of suicidal ideation and/or behavior in some depressed patients treated by antidepressant monotherapy or combinations thereof might be attributed to baseline psychomotor activation/agitation as part of an unrecognized bipolar mixed state. Whether antidepressants induce de novo suicidality in MDD cannot be answered without adequately powered prospective double-blind studies, unlikely to be conducted because of ethical constraints. Nonetheless, we submit that agitated, activated, or otherwise excited depressions (which we consider as depressive mixed states) overlap considerably with the so-called antidepressant "activation syndrome." Furthermore, the rare occurrence of suicidality on antidepressants should not obscure the fact that the advent of the new antidepressants is associated with worldwide decline in suicide rates. We finally wish to point out that our formal nosology (i.e. DSM-IV and ICD-10), in its failure to recognize the bipolar nature of depressive mixed states, thereby fails to shield pseudo-unipolar patients from antidepressant monotherapy, which is inappropriate for such patients.     

Clinical correlates of anxious depression among elderly patients with depression

OBJECTIVE: The purpose of this study was to determine the clinical correlates of comorbid anxiety and depression in a sample of older patients with major depression. METHODS: 352 patients aged 59 and older with major depression were enrolled in the Study of Depression in Later Life at Duke University, of whom 148 met criteria for lifetime generalized anxiety disorder. Participants completed self-report assessments of performance in basic and instrumental activities of daily living, social support, suicidal ideation, life satisfaction, and stressful life events. Cognitive assessment was done with the Mini-Mental State Examination. RESULTS: The prevalence of lifetime anxiety in our depressed sample was 42%. Patients with anxious depression were significantly younger, and had greater suicidal ideation, more impairment of subjective social support, and more severe depressive symptoms. CONCLUSION: In elderly patients with anxious depression, psychosocial support and suicidal ideation should be assessed. Whether improvement of subjective social support leads to reduction in anxious depression should be investigated.     

Lack of association of serotonin-2A receptor gene polymorphism (T102C) with suicidal ideation and suicide

Serotonergic dysfunction has been implicated in the pathophysiology of affective disorders and suicidality. Especially the density of the 5-HT2A receptor was claimed as being increased in suicidality, proposed as an adaptive upregulation due to reduced serotonergic transmission. Recent studies have shown an association of allele C of the 5-HT2A-T102C polymorphism with suicidal ideation in patients with major depression. The purpose of this study was to test whether this proposed marker indicates susceptibility not only to suicidal ideation in depressed patients but also to suicidality as a syndrome. We investigated the 5-HT2A-T102C polymorphism in 131 suicide victims with unknown underlying psychiatric diagnoses, 84 patients with major depression with or without suicidal ideation, and 125 healthy controls. We were unable to find any association of genotype or allele frequencies to major depression, suicidal ideation, or suicide as a syndrome. Thus, our results suggest that this polymorphism may not commonly be involved in the susceptibility to suicidality. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:831-835, 2000.     

Peer Functioning,Family Dysfunction,and Psychological Symptoms in a Risk Factor Model for Adolescent Inpatients' Suicidal Ideation Severity

Examined models of suicidal ideation severity that include two psychosocial risk factors (i.e., peer and family functioning) and four domains of psychological symptoms (i.e., generalized anxiety, depression, conduct problems, and substance abuse/dependence). Participants were 96 psychiatric inpatients (32 boys, 64 girls), ages 12 to 17, who were hospitalized because of concerns of suicidality. Adolescents completed a structured diagnostic interview, measures of suicidal ideation, and several dimensions of family and peer functioning. Results supported a model in which greater levels of perceived peer rejection and lower levels of close friendship support were associated directly with more severe suicidal ideation. In addition, indirect pathways included deviant peer affiliation and global family dysfunction related to suicidal ideation via substance use and depression symptoms. The results are among the first to demonstrate relations between suicidal ideation and several areas of adolescent peer functioning, as well as divergent processes for peer and family predictors of suicidal ideation.     

Lack of association of serotonin‐2A receptor gene polymorphism (T102C) with suicidal ideation and suicide

Serotonergic dysfunction has been implicated in the pathophysiology of affective disorders and suicidality. Especially the density of the 5‐HT2A receptor was claimed as being increased in suicidality, proposed as an adaptive upregulation due to reduced serotonergic transmission. Recent studies have shown an association of allele C of the 5‐HT2A‐T102C polymorphism with suicidal ideation in patients with major depression. The purpose of this study was to test whether this proposed marker indicates susceptibility not only to suicidal ideation in depressed patients but also to suicidality as a syndrome. We investigated the 5‐HT2A‐T102C polymorphism in 131 suicide victims with unknown underlying psychiatric diagnoses, 84 patients with major depression with or without suicidal ideation, and 125 healthy controls. We were unable to find any association of genotype or allele frequencies to major depression, suicidal ideation, or suicide as a syndrome. Thus, our results suggest that this polymorphism may not commonly be involved in the susceptibility to suicidality. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:831–835, 2000. © 2000 Wiley‐Liss, Inc.     

Anxiety disorders and suicidal behaviours in adolescence and young adulthood: findings from a longitudinal study

BACKGROUND: The aim of this study was to estimate the extent to which anxiety disorders contribute to an increase in suicidal behaviour after controlling for both observed and non-observed sources of confounding. METHOD: Data were collected from the Christchurch Health and Development Study (CHDS), a 25-year longitudinal study of over 1000 participants. Measures of anxiety disorders [phobia, generalized anxiety disorder (GAD), panic disorder], major depression (MD), substance use disorders, conduct/antisocial personality disorder, stressful life events, unemployment, and suicidal ideation/attempts for subjects aged 16-18, 18-21 and 21-25 years were used to fit random and fixed effects regression models of the associations between anxiety disorders and suicidal behaviours. RESULTS: Anxiety disorders were strongly associated with suicidal ideation/attempts. Any single anxiety disorder increased the odds of suicidal ideation by 7.96 times [95% confidence interval (CI) 5.69-11.13] and increased the rate of suicide attempts by 5.85 times (95% CI 3.66-9.32). Control for co-occurring mental disorders, non-observed fixed confounding factors and life stress reduced these associations [suicidal ideation odds ratio (OR) 2.80, 95% CI 1.71-4.58; suicide attempts incidence rate ratio (IRR) 1.90, 95% CI 1.07-3.39]. Rates of suicidal behaviour also increased with the number of anxiety disorders. Estimates of the population attributable risk suggested that anxiety disorders accounted for 7-10% of the suicidality in the cohort. CONCLUSIONS: Anxiety disorders may be a risk factor for suicidality, even after controlling for confounding, with risks increasing with multiple anxiety disorders. Management of anxiety disorders may be an important component in strategies to reduce population rates of suicide.     

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。     

Psychological factors associated with the incidence and persistence of suicidal ideation

Background

Suicidal ideation has been identified as both a common antecedent and a significant risk factor for suicide attempt and completed suicide. However, little is known about the incidence and persistence of suicidal ideation in the general population and the associated risk factors.

Methods

A 12-month follow-up survey investigated 997 of the respondents who participated in the baseline territory-wide survey of adult population in Hong Kong. A set of baseline psychological factors was considered as predictors of first onset and persistence of suicidal ideation.

Results

Twelve-month incidence (1.9%) and persistence (6.2%) rates were estimated. Respondents with anxiety and lack of reasons for living were more likely to report a development of suicidal thoughts in the follow-up assessment, while respondents with higher level of average life distress and lower level of hope were at increased risk of continuing to have suicidal thoughts. Depression was found to partially mediate the effect of average life distress on persistent suicidality.

Limitations

Retention rate of the follow-up sample was about 50% only. Assessments of suicidal ideation were based on retrospective reports.

Conclusions

Psychological factors differentially predict first onset and persistence of suicidal ideation. It is of clinical value that depression partially mediated the effect of life distress on persistence of suicidality.     

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.     

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.     

Understanding the link between anxiety symptoms and suicidal ideation and behaviors in outpatients with bipolar disorder

BACKGROUND: Prior studies suggest an association between anxiety comorbidity and suicidal ideation and behaviors in bipolar disorder. However, the nature of this association remains unclear. METHODS: We examined a range of anxiety symptoms, including panic, phobic avoidance, anxiety sensitivity, worry and fear of negative evaluation, in 98 patients with bipolar disorder. We predicted that each anxiety dimension would be linked to greater suicidal ideation and behavior as measured by Linehan's Suicide Behaviors Questionnaire (SBQ), greater depressive rumination, and poorer emotional processing and expression. RESULTS: Each anxiety dimension except fear of negative evaluation was associated with greater SBQ score, greater rumination, and lower levels of emotional processing in univariate analyses. Depressive rumination was a significant predictor of higher SBQ scores in a stepwise multivariate model controlling for age, gender, bipolar subtype, and bipolar recovery status; the association between the anxiety symptom dimensions and SBQ score was found to be redundant with depressive rumination. Emotional processing emerged as protective against suicidal ideation and behaviors in men only, while emotional expression was a significant predictor of lower SBQ scores for women and for the full sample; however, emotional expression was not significantly correlated with anxiety symptoms. Confirmatory analyses examining only those in recovery or recovered (n=68) indicated that the link between rumination and suicidality was not explained by depression. LIMITATIONS: Interpretation is limited by the cross-sectional study design. CONCLUSIONS: These findings indicate that increased ruminations may mediate the association between anxiety and suicidal ideation/behavior. In men, lower emotional processing may also play a role in this relationship.     

Suicidal ideation and suicidal attempts in a population-based study of Chinese people: risk attributable to hopelessness, depression, and social factors

BACKGROUND: The population attributable fraction of hopelessness, depression and other risk factors for suicidal ideation and suicidal attempts in Asian population is unknown. Social support is often said to be a buffer against the effect of hopelessness and depression. METHODS: Suicidal ideation, suicidal attempts as well as demographic and psychometric data were delineated in a random and representative population sample of 2,219 Chinese people in Hong Kong. The population attributable fraction was used to determine the contribution of hopelessness, depression and other risk factors to suicidal ideation and attempts. RESULTS: Multivariate modelling shows that about 40% of suicidal ideation and attempts was attributable to depression and about 20% was attributable to hopelessness. Drug abuse and marital dissolution were also significant contributors to suicidality. The impact of hopelessness and depression was not affected by social support. LIMITATIONS: Suicidality was self-reported. CONCLUSIONS: Suicidal ideation and suicidal attempts were to a large extent attributable to depression and hopelessness, and, to a lesser extent, drug abuse and marital dissolution. Social support appeared to play little role as a buffer.     

Associations among depression,suicidal behavior,and quality of life in patients with human immunodeficiency virus

AIM: To investigate the potential associations among major depression, quality of life, and suicidal behavior in human immunodeficiency virus(HIV) patients. METHODS: A detailed MEDLINE search was carried out to identify all articles and book chapters in English published from January 1995 to January 2015. RESULTS: Based on the main findings, the prevalence of major depressive disorder(MDD) ranged from 14.0% to 27.2%. Furthermore, the prevalence of suicidal ideation varied from 13.6% to 31.0% whereas, attempted suicides were reported to range from 3.9% to 32.7%. Interestingly, various associated risk factors for both depression and suicide were identified in HIV patients. Finally, consistent associations were reported among MDD, suicidal ideation, and poor quality of life in individuals living with HIV. CONCLUSION: Although additional studies are needed to elucidate this complex association, our results suggest the importance of early detection of both MDD and suicidality in patients living with HIV.     

Fluoxetine: no association with suicidality in obsessive-compulsive disorder.

Since (a) obsessive-compulsive disorder (OCD) may involve serotonergic neural transmission abnormalities also though to be related to regulation of suicide and aggression, (b) comorbidity between OCD and depression is substantial, and (c) depression is a major risk factor for suicide, a comprehensive analysis of clinical trial data was undertaken to assess the potential association of fluoxetine, a serotonin uptake inhibitor, and suicidality (suicidal acts and ideation). Pooled data from clinical trials comparing fluoxetine (n = 266) and placebo (n = 89) in patients with DSM-IIIR OCD were analyzed retrospectively. No suicidal acts occurred during placebo lead-in or double-blind therapy. Mean Hamilton Depression Scale item 3 (suicide item) scores improved statistically significantly with fluoxetine compared with placebo. Worsening in suicidal ideation was statistically significantly more frequent with placebo than with fluoxetine. Emergence of substantial suicidal ideation (change in baseline item 3 score of 0 or 1 to 3 or 4) was numerically greater with placebo than with fluoxetine (3.6% vs. 1.7%; not statistically significant). The incidence of suicidality in fluoxetine-treated patients with OCD was low, compared favorably with rates in corresponding placebo-treated patients, and was well within the range of estimates in previous studies of patients with OCD. These controlled clinical trial results suggest no undue risk of suicidality in patients with OCD treated with fluoxetine.     

Suicidality and sleep disturbances

STUDY OBJECTIVES: A growing body of research indicates that sleep disturbances may be specifically linked to suicidal behaviors. It remains unclear, however, whether this link is largely explained by depressive symptoms. The present study investigated the relationship between suicidality, depression, and sleep complaints in a clinical outpatient setting. DESIGN AND SETTING: Upon admission, 176 outpatients completed measures on sleep disturbances, suicidal symptoms, and depression. Several sleep disturbances were evaluated with regard to suicidal ideation, including insomnia, nightmares, and sleep-related breathing symptoms. MEASUREMENTS AND RESULTS: Regression analyses revealed that insomnia and nightmare symptoms were associated with both depressive symptoms and suicidality. Sleep-related breathing symptoms were associated with depressive symptoms, but did not show an association with suicidal ideation. After controlling for depressive symptoms, only nightmares demonstrated an association with suicidal ideation. This relationship emerged as a nonsignificant trend (P = .06). Nightmares were particularly associated with suicidality among women compared with men. Posthoc analyses revealed that, after controlling for sex and depressive symptoms, nightmare symptoms were significantly associated with suicidality (P = .04). CONCLUSIONS: Although insomnia and nightmares were significantly associated with depressive and suicidal symptoms, after controlling for additional variables, such as depression and sex, only nightmares remained associated with suicidality. This association was slightly stronger among women compared with men.     

Association of psychosis with suicidality in pediatric bipolar I, II and bipolar NOS patients

BACKGROUND: Psychosis in pediatric mood disorder patients may be related to suicidal ideation. Bipolar (BP) adolescents are at high risk of completed suicide. We examined whether pediatric BP patients with psychosis have a higher prevalence of suicidality than non-psychotic BP patients. Based on previous findings in adult BP patients, we predicted that pediatric BP patients with psychotic symptoms would have higher prevalence of suicidality, higher occurrence of lifetime psychiatric hospitalizations and worse current Global Assessment of Functioning Scale (GAF) scores compared to non-psychotic BP patients. METHODS: We studied 43 BP children and adolescents (mean age +/- S.D = 11.2 +/- 2.8 y, range = 8-17) who did (n = 17) or did not have (n = 26) a lifetime history of psychotic symptoms. Indicators of suicidality (thoughts of death and suicidal ideation, plans, and attempts), psychiatric diagnoses, psychotic symptoms, psychiatric hospitalizations and GAF scores were assessed with the K-SADS-PL interview. LIMITATIONS: Small sample size, cross-sectional study and exclusion of substance abuse comorbidity. RESULTS: Pediatric BP patients with a lifetime history of psychotic symptoms compared to BP patients without psychosis were more likely to have thoughts of death (100% versus 69.2%, p = 0.01), suicidal ideation (94.1% versus 42.3%, p = 0.001) and suicidal plans (64.7% versus 15.4%, p = 0.002). Occurrence of psychiatric hospitalization was higher in psychotic BP patients compared to non-psychotic BP patients (82.4% versus 46.2%, p = 0.018). CONCLUSIONS: Psychotic symptoms in pediatric BP patients are associated with suicidal ideation and plans, and psychiatric hospitalizations. Psychotic symptoms are a risk factor for suicidality amongst pediatric BP patients.