Cerebrospinal fluid monoamine metabolites and suicide

Prospective studies of the serotonergic system and suicide report that low 5-hydroxyindolacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) and a history of attempted suicide predict suicide risk. Low CSF homovanillic acid (HVA) is reported to be associated with past and future lethality of suicide attempts but not with suicide. The interrelationships between monoamine metabolites, violent method, suicide intent and lethality of suicidal behaviour are complex. We hypothesized that CSF 5-HIAA and HVA levels are related to suicide intent, violence and lethality of suicidal behaviour. Fifteen male suicide attempters admitted to a psychiatric ward at the Karolinska University Hospital and eight healthy male volunteers were submitted to lumbar puncture and CSF 5-HIAA and HVA were assayed. Suicide intent with the Beck Suicide Intent Scale (SIS), lethality and violence of suicidal behaviour were assessed. All patients were followed up for causes of death. Six suicides and one fatal accident were identified with death certificates. Mean CSF 5-HIAA but not CSF HVA differed between suicides and survivors. Violent suicides had higher suicide intent and CSF 5-HIAA than non-violent suicides. In violent suicides, CSF 5-HIAA levels were negatively correlated with SIS. Greater suicide intent may be associated with greater aggressive intent and predicts a violent suicide method.     

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.     

Hopelessness,impulsiveness and intent among suicide attempters with major depression,alcohol dependence,or both

The present study examined differences in hopelessness, impulsiveness and suicide intent between suicide attempters with either major depression or alcohol dependence, comorbid major depression and alcohol dependence, and those without these disorders. A sample of 114 patients from consecutive cases of attempted suicide referred to a general hospital in Helsinki was interviewed and diagnosed according to DSM-III-R. Suicide intent was measured by the Beck Suicide Intent Scale (SIS) and hopelessness was assessed by the Beck Hopelessness Scale (HS). Impulsiveness of the suicide attempt was measured by two items of the SIS. Suicide attempters with major depression without comorbid alcohol dependence had higher suicide intent and lower impulsiveness than attempters with non-depressive alcohol dependence. Suicide attempts may differ between subjects with major depression, alcoholism or both disorders in terms of impulsiveness and suicide intent.     

Increased plasma nitric oxide level associated with suicide attempt in depressive patients

BACKGROUND: Nitric oxide (NO) is known to influence cerebral monoaminergic activity, including the activity of serotonin. We evaluated plasma NO metabolite (NO(x)) levels in depressive patients with and without a recent history of suicide attempt. METHOD: Plasma NO(x) levels were measured in 39 depressive patients who had recently attempted suicide, 44 non-suicidal depressed patients, and 70 normal controls. The severity of depression was measured with the Hamilton's Depression Rating Scale. The lethality of the suicide attempt was scored using Weisman and Worden's risk-rescue rating scale and Lethality Suicide Attempt Rating Scale. RESULTS: Plasma NO(x) levels were significantly higher in suicidal depressive patients than non-suicidal depressive patients or normal control subjects (Z=-2.472, p=0.013). However, higher plasma NO(x) levels in suicidal depressive patients were significantly related to a lower lethality of suicide attempts and lower severity of depression. CONCLUSIONS: Our study suggests that increased plasma NO(x) level is associated with suicide attempts in depressive patients. Moreover, higher plasma NO(x) level is related with suicide attempts in mild depressed patients. However, further studies are required to understand the role of NO system in depression and suicidal behavior.     

Suicide attempters in the emergency department before hospitalization in a psychiatric ward

PURPOSE. The study aims to compare the current suicidal risk of mood disorder patients who had just attempted suicide, as compared with those who had not attempted suicide, admitted to an emergency department (ED), and then hospitalized in a psychiatric unit. METHOD. One hundred sixty‐one mood disorder patients admitted to the ED were studied. A total of 22.4% of the participants were admitted for a suicide attempt. Patients were assessed for psychopathology and diagnosis. FINDINGS. Suicide attempters were nearly 12 times more likely to report ongoing suicidal ideation during the psychiatric evaluation in the ED than nonattempters. Men and women did not differ for current and previous suicide attempts or for ongoing suicidal ideation. PRACTICAL IMPLICATIONS. It is important to conduct a suicide risk assessment when individuals are admitted to an ED.     

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.     

Parental loss and reported childhood stress in young women who attempt suicide

For young women aged 18 to 30 years who attempted suicide, and whose suicide attempts were of widely differing physical threat to life, the experience of parental death and separation or divorce, and of reported childhood stress, was similar, irrespective of the lethality of the suicide attempt. Taken as a group, the suicide attempters reported significantly greater childhood stress and more often had experienced parental loss through separation or divorce than young women in a control group. The association between parental loss and suicidal behaviour did not appear to be an artefact of a primary relationship between parental loss and depression. Five of eight reported childhood stress factors significantly distinguished the suicidal and control subjects. Those who attempted suicide were more likely to report a childhood broken home, that their parents quarrelled often, that they had frequent disagreements with their parents, that they had poor physical health, and that they perceived their parents' character negatively.     

Suicide intent among parasuicide patients in Nicaragua: a surveillance and follow-up study.

This study examines suicide intent among parasuicide patients in a low-income country, Nicaragua, with special reference to gender patterns and future suicidal behavior. Using the Suicide Intent Scale (SIS), suicide intent was assessed in 204 persons presenting to hospital after parasuicide. Repetition was checked after a mean follow-up period of three years. The total SIS scores did not differ between women and men. However, a higher SIS score among women was significantly associated with older age, having children and use of pesticide as the parasuicide method. The overall method of suicide intent was low in Nicaragua compared to other countries, as was the nonfatal repetition rate (4.8% after three years). Subsequent suicides were found only in three men. Factor structures within the SIS disclosed supported the cross-cultural validity of the instrument. The level of suicide intent at the index attempt did not show any association with future suicidal behavior.     

Comparison of the suicidal behavior of adolescent inpatients with borderline personality disorder and major depression

The objective of the study was to examine the hypothesis that some forms of suicidal behavior among adolescents are related to helplessness and depression, whereas others are related to anger and impulsivity. Sixty-five adolescents were studied. Thirty-three had borderline personality disorder (BPD), of whom 17 had made a recent suicide attempt. Thirty-two had major depressive disorder (MDD), of whom 16 had made a recent suicide attempt. Assessments were made with the Child Suicide Potential Scale, the Beck Depression Inventory, the Beck Hopelessness Scale, the Multidimensional Anger Inventory, the Overt Aggression Scale, the Impulsiveness-Control Scale, and the Suicide Intent Scale. Adolescents with BPD had more anger, aggression, and impulsiveness than those with MDD, but similar levels of depression and hopelessness. Suicidal versus nonsuicidal adolescents were more depressed, hopeless, and aggressive, but not more angry or impulsive. There were no significant differences in impulsiveness for the MDD suicidal group versus the MDD nonsuicidal group, but the suicidal BPD adolescents were significantly more impulsive than the nonsuicidal BPD adolescents. In the subjects with BPD, impulsiveness and aggression correlated significantly and positively with suicidal behavior. In the subjects with MDD, no such correlations were seen. In both diagnostic groups, depression and hopelessness correlated positively and significantly with suicidal behavior. Anger did not correlate with suicidal behavior in either of the groups. The suicidal subjects with MDD had significantly higher suicidal intent scores than the suicidal adolescents with BPD. We conclude that the nature of suicidal behavior in adolescents with BPD differs from that seen in MDD with respect to the role of anger and aggression.     

Suicide in the elderly

In the vast majority of countries the suicide rate of elderly persons (referring to those aged 65 years and above) is significantly higher than in younger age groups. In the US, by age 80 the suicide rate ranges from 3/100 000 among African American women to 60/100 000 among Caucasian men. Although in all age groups men have higher suicide rates than women, the difference is the most striking in older men living in industrialized countries. In the US the elderly have the highest suicide rate of all age groups, with men accounting for 81% of completed suicides in late-life. It seems that certain life events such as widowhood pose a higher risk for suicide on men than women. It is also possible that the aging process has different effects among men than women and/or elderly women may possess distinct protective factors that could explain the dramatic gender difference. The clinical profile of depressed elderly suicide victims suggests that, if treated for depression, these patients would have had a favorable prognosis. In older people suicidal ideation, suicide attempt, and completed suicide occur most frequently in the context of major depression. Studies have observed that depression in elderly suicide victims is more often without comorbid substance abuse or personality disorders than in younger age groups. Furthermore, while the elderly carry out high lethality attempts, the time to intervene may be longer as the elderly are less impulsive, contemplating suicide for months. Psychological autopsy studies may overestimate the number of elderly suicides that occur in the first episode of late onset depression. It is possible that in a subgroup of suicidal elderly men previous depressive episodes may have been undetected. The detection of suicide in the elderly (especially in men) is more challenging, as they are less likely to communicate their depressed mood and overt suicide intent and are often present with symptoms of masked depression. Although 50% of elderly suicide victims visited their GP the month before their death, more than half of the visits were exclusively for physical complaints. Following an overview of epidemiology and risk factors, we report data on the development and preliminary testing of the Yale Evaluation of Elderly Suicidality Scale and summarize interventions that can be effective in treating suicidal elderly. Finally, we briefly describe two prevention and treatment studies that are currently underway in primary care settings. The aim of these studies is to determine whether the improved detection of depression, improved compliance, and state of-art pharmacotherapy and/or psychotherapy will reduce the prevalence of depressive symptoms, hopelessness and suicidal ideation. These studies aim to investigate whether all the above decrease the rate of suicide attempts and lethal suicide in older adults.     

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.     

An examination of suicidal intent in patients with multiple sclerosis

OBJECTIVE: To examine neurologic and psychiatric correlates of suicidal intent in a community sample of 140 patients with MS. METHODS: Patients with (28.6%) and without lifetime suicidal intent were compared across MS disease-related and psychiatric variables. All subjects were interviewed with 1) the Structured Clinical Interview for DSM-IV Axis 1 disorders (SCID-IV) to determine lifetime prevalence of major depression and anxiety disorders; and 2) the Social Stress and Support Interview to assess psychological stressors. Suicidal intent was documented with questions from the SCID-IV and Beck Suicide Scale. Patients also completed the Hospital Anxiety and Depression Scale and cognitive testing. RESULTS: Suicidal patients were significantly more likely to live alone, have a family history of mental illness, report more social stress, and have lifetime diagnoses of major depression, anxiety disorder, comorbid depression-anxiety disorder, and alcohol abuse disorder. By logistic regression analysis, the severity of major depression, alcohol abuse, and living alone had an 85% predictive accuracy for suicidal intent. A third of suicidal patients had not received psychological help. Two-thirds of subjects with current major depression, all suicidal, had not received antidepressant medication. CONCLUSIONS: Suicidal intent, a potential harbinger for suicide, is common in MS and is strongly associated with major depression, alcohol abuse, and social isolation. Suicidal intent is a potentially treatable cause of morbidity and mortality in MS.     

Risk factors for suicide in melancholia A case-record evaluation of 89 suicides and their controls

Eighty-nine inpatients with a primary severe depression and melancholia who had committed suicide were investigated. They were admitted to the Department of Psychiatry, Lund, Sweden between 1956–1969 and died before 1984. Matched controls were selected. Case records were evaluated at index admission to find suicidal risk factors in melancholia. Prospective ratings were compared. Women committing suicide had higher scores than their controls on the items unmarried, non-compliance and suicide attempt but lower ratings on disharmonic childhood and non-severe physical disease. Men committing suicide had higher scores on the items heredity for psychosis and a brittle or sensitive personality. For the latter item suicide was related to life-weariness. Suicide attempt was related to acute onset and lack of psychomotor retardation. Two suicidal processes were proposed for men: one related to aggression and one not. Social factors seem less important in the prediction of suicide in melancholia than in depression in general.     

Factors influencing suicidal ideation among Japanese adults: from the national survey by the Cabinet Office

Aim: Suicide prevention is of pressing importance in Japan, and grappling with this problem necessitates clarifying the causes of suicidal ideation. The purpose of the present study was to investigate several factors influencing suicidal ideation. This was done through analyzing factors examined in prior research and accessing suicide sites. Methods: A total of 1080 randomly selected adults were asked about stress, stress release, social support sources, depression, access of suicides sites, and suicidal ideation. Results: Around 6% of men in their 20s and 30s as well as 7% of people with suicide ideations had accessed suicide sites on the web. Those with suicide ideations were more likely to access suicide sites than those without. There was no sex difference in suicide ideations. The results concerning factors influencing past‐year suicide ideations revealed that there were age and sex differences in these factors. Conclusion: For men in their 20s through their 50s, accessing suicide sites influenced suicidal ideations through depression, and for women in the same age bracket, emotional support influenced suicidal ideations through depression. For men and women over the age of 60, depression strongly influenced suicidal ideations.     

Suicidal communication signifies suicidal intent in Chinese completed suicides

Background

Recognizing suicidal communication from the distressful catharsis in a high-risk group with suicidal tendencies is essential for suicide prevention. This study analyzes whether suicidal communication can indicate the severity of suicidal intent. Various types of suicidal communication are defined, and their clinical significance is further explored.

Method

A comprehensive analysis of the psychological autopsy data of 200 victims of completed suicide, including their general socio-demographic status, suicidal communication methods, previous suicide attempts, mental disorders, and psychosocial situation.

Results

Our results showed that 39.5% of all the subjects were suicidal communicators, 23.0% had previously attempted suicide, and 14.0% left suicide notes; 32.4% of 142 subjects free of physical disease suffered from mental disorders. Suicidal communication included verbal communication, behavioral communication, and suicidal notes. Younger people with a higher level of education were more inclined to communicate their suicidal intent by leaving a suicide note. Suicide notes, but not previous suicide attempts or psychosocial situation, were significantly correlated with suicidal intent. Suicidal communicators showed higher depression scores than non-communicators. Those who suffered from mood disorders with higher levels of both depression and suicidal intent were more likely to expose their intent through behavioral communication.

Conclusions

The present study provides strong evidence that suicidal communication can indicate the severity of suicidal intent. Current findings help interpret high-risk, self-destructive behavior and consequently provide the theoretical basis for a feasible suicide prevention program.     

Association between serotonin-related gene polymorphisms and suicidal behavior in depressive patients

BACKGROUND: Several studies have suggested that there is a substantial genetic contribution to suicidal behavior. Genes encoding proteins involved in serotonergic transmission are major candidates in association studies of suicidal behavior. In this study, we aimed to investigate the 5-HT2A receptor (5HTR2A) and tryptophan hydroxylase (TPH) genes for association with suicidal behavior in depressive patients. METHODS: Patients with major depression who had recently attempted suicide (n=191) and control subjects (n=193) were genotyped for 5HTR2A 102T/C, and TPH 218A/C. The lethality of the suicide attempt was measured using the Risk-Rescue Rating (RRR) and Lethality Suicide Attempt Rating Scale (LSARS). The severity of depression was measured using the Hamilton Depression Rating Scale (HDRS). RESULTS: There were no significant differences in the genotype distributions or allelic frequencies in the two serotonergic polymorphisms between suicide attempters and normal controls. None of the two serotonergic polymorphisms was correlated with lethality. CONCLUSIONS: We concluded that these polymorphisms may not be associated with susceptibility to suicidal behavior in our Korean population. Our results were in line with most previous studies. More work is needed to replicate these findings. Our future studies aim at identifying other genetic associations.     

Subjective psychological well-being (WHO-5) in assessment of the severity of suicide attempt

An objective way to measure the severity of suicide attempt is to use different psychometric scales. Aspects of suicide risk like suicidal intent, depression, hopelessness and well-being can be assessed and different practical scales are in use to facilitate the risk assessment procedure. The aims of current study were: 1) to analyse the association between the severity of suicide attempt measured by suicidal intent scale and characteristics of emotional status of suicide attempters measured by depression, hopelessness and well-being scales in different gender and age groups; 2) to test the applicability of well-being measured by the World Health Organisation well-being index (WHO-5) in suicide risk assessment. The data on suicide attempters (n=469) was obtained in Estonia (Tallinn) by the WHO Suicide Prevention-Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS) methodology. Different psychometric scales were used to measure suicidal intent (Pierce Suicidal Intent Scale) and emotional status (Beck Depression Inventory for depression, Beck Hopelessness Scale for hopelessness, WHO-5 for well-being). All psychometric scales correlated well with each other (P<0.05). Low level of well-being associated with high level of suicidal intent, depression and hopelessness. Suicidal intent correlated the most strongly with well-being. Analysis by gender and age groups revealed also significant correlations with two exceptions only: correlation between suicidal intent and hopelessness did not reach the significant level in males and in older adults (40+). The WHO-5 well-being scale, which is a short and emotionally positively loaded instrument measuring protective factors, can be used in settings without psychological/psychiatric expertise in preliminary suicide risk assessment.     

Psychotic-spectrum symptoms,trauma, and posttraumatic stress disorder among suicidal inner-city women

This study explored psychotic-spectrum symptoms, trauma, posttraumatic stress disorder (PTSD), and suicidal intent among low-income inner-city women who were admitted to a community hospital after a suicide attempt. Measures included the Brief Symptom Inventory, the Traumatic Stress Schedule, the National Women's Study PTSD module, and the Suicide Intent Scale. Psychotic-spectrum symptoms, trauma, and PTSD were significantly correlated. Trauma and psychotic- spectrum symptoms, but not PTSD, were associated with suicidal intent, although the effect sizes were small. Psychotic symptoms mediated the relationship between PTSD and suicidal intent. These results emphasize the need for attention to all of these variables in assessing clinical complications and comorbid conditions.     

Suicidal behavior in schizophrenia: characteristics of individuals who had and had not attempted suicide.

OBJECTIVE: This study compares demographic and clinical characteristics of 52 individuals with schizophrenia or schizoaffective disorder who had attempted suicide with those of 104 individuals with schizophrenia or schizoaffective disorder who had not made a suicide attempt. METHOD: Participants were interviewed with the Diagnostic Interview for Genetic Studies. RESULTS: Most suicide attempts were of moderate to severe lethality, required medical attention, and involved significant suicidal intent. Individuals who had and had not attempted suicide did not differ with respect to demographic variables, duration of illness, rate of depression, or substance abuse. The two groups are affected differentially when depressed. CONCLUSIONS: Biopsychosocial assessments and interventions are essential for reducing the risk for suicidal behavior in individuals with schizophrenia.     

Are children and adolescents who have suicidal thoughts different from those who attempt suicide?

In this study we inquire whether children and adolescents with suicidal ideation can be differentiated from children who attempt suicide on the basis of clinical symptoms or social grounds. From a total of 2181 consecutive outpatient referrals to a child and adolescent psychiatry service, 258 young persons who exhibited suicidal ideation are compared with 82 who had actually attempted suicide. We were unable to differentiate children with suicidal thoughts from those who attempted suicide on the basis of clinical symptoms alone. Both groups had similar high levels of symptoms of depression, anxiety, sleep disorder, and irritability. Conduct disorders were less common in both groups but 22% of the attempters abused illicit drugs or alcohol. Suicide attempts were more likely to be associated with chronic family discord and substance abuse. For boys, the odds of suicidal attempts were substantially increased if the subject had experienced loss. Results are discussed with reference to antecedents that may increase the odds of suicidal attempt and suggestions for future research are outlined.