Gender differences in depression: findings from the STAR*D study

BACKGROUND: Epidemiologic research consistently reports gender differences in the rates and course of major depressive disorder (MDD). The STAR*D (Sequenced Treatment Alternatives to Relieve Depression) multicenter trial provides a unique opportunity to explore gender differences in outpatients with nonpsychotic MDD. METHODS: This sample included the first 1500 outpatients with MDD who enrolled in STAR*D. Nearly two-thirds of the sample (62.8%) were women. Baseline sociodemographic factors, comorbidities, and illness characteristics were analyzed by gender. RESULTS: Women (62.8% of the sample) had a younger age at onset of the first major depressive episode. They commonly reported concurrent symptoms consistent with anxiety disorders, somatoform disorder, and bulimia as well as atypical symptoms. Alcohol and drug abuses were more common in men. LIMITATIONS: This report is a subpopulation of the entire STAR*D sample. These exploratory analyses aimed to identify potential gender differences for further hypothesis testing. CONCLUSIONS: The gender-specific rate of MDD in this study population is proportional to rates found in community samples with a 1.7:1 prevalence of MDD in women vs. men which argues against increased treatment seeking in women.     

Planning of suicide attempts among depressed inpatients ages 50 and over

BACKGROUND: Suicidal behavior is heterogeneous; suicide attempts can be impulsive (lower planned) or reflect forethought and preparation (higher planned). Lower planned and higher planned attempts may have different correlates that require different prevention strategies. Based on a model of suicide planning relevant to middle-aged and older adults, we tested the following hypotheses: physical illness burden, decreased functional capacity, hopelessness, and living alone are associated with suicide attempts that are more extensively planned; lower cognitive functioning is associated with suicide attempts that are more impulsive. METHODS: Subjects were 117 inpatients ages 50 and over diagnosed with major depression based on semi-structured clinical research interviews, the medical record, plus other records when available. All subjects had attempted suicide within 1 month of admission. The degree of planning prior to the suicide attempt was quantified using Beck's Suicide Intent Scale. Multivariate linear regression analysis identified correlates of planning. RESULTS: As hypothesized, lower cognitive functioning was associated with lower levels of planning. Contrary to the hypothesis, impaired physical self-care was associated with lower (not higher) planning. Results pertaining to living alone were equivocal. LIMITATIONS: The study was limited by the cross-sectional research design and unclear generalizability to completed suicide or to racial/ethnic minorities. CONCLUSIONS: Depressed patients with lower cognitive functioning and impairments in physical self-care may be especially vulnerable to impulsive suicidal behavior. The potential role of living alone in higher planned suicidal acts requires further investigation.     

Clinical correlates and symptom patterns of anxious depression among patients with major depressive disorder in STAR*D

BACKGROUND: Anxious depression, defined as Major Depressive Disorder (MDD) with high levels of anxiety symptoms, may represent a relatively common depressive subtype, with distinctive features. OBJECTIVE: The objective of this study was to determine the prevalence of anxious depression and to define its clinical correlates and symptom patterns. METHOD: Baseline clinical and sociodemographic data were collected on 1450 subjects participating in the STAR*D study. A baseline Hamilton Rating Scale for Depression (HAM-D) Anxiety/ Somatization factor score of > or =7 was considered indicative of anxious depression. The types and degree of concurrent psychiatric symptoms were measured using the Psychiatric Diagnostic Screening Questionnaire (PDSQ), by recording the number of items endorsed by study participants for each diagnostic category. MDD symptoms were assessed by clinical telephone interview with the 30-item Inventory of Depressive Symptomatology (IDS-C30). RESULTS: The prevalence of anxious depression in this population was 46 %. Patients with anxious MDD were significantly more likely to be older, unemployed, less educated, more severely depressed, and to have suicidal ideation before and after adjustment for severity of depression. As far as concurrent psychiatric symptoms are concerned, patients with anxious depression were significantly more likely to endorse symptoms related to generalized anxiety, obsessive compulsive, panic, post-traumatic stress, agoraphobia, hypochondriasis, and somatoform disorders before and after adjustment for severity of depression. Anxious-depression individuals were also significantly less likely to endorse IDS-C30 items concerning atypical features, and were significantly more likely to endorse items concerning melancholic/endogenous depression features. CONCLUSION: This study supports specific clinical and sociodemographic correlates of MDD associated with high levels of anxiety (anxious depression).     

Self-incineration: a controlled comparison of in-patient suicide attempts. Clinical features and history of self-harm

A systematic survey of in-patient accidents and injuries in an inner London hospital over 9 years established that, after incisions and overdoses, self-incineration was one of the commoner methods of violent self-harm. A case-controlled study of in-patient suicide attempts compared a series of 12 self-incinerators with 12 patients using other methods. Irrespective of method, the suicide attempt was predominantly a psychotic act of young single people with chronic, severe disorders and considerable past parasuicide, in a setting of escalating self-harm. Younger age, greater psychiatric morbidity, absence of alcoholism, a history of childhood arson, past and current self-burning were the features specific to self-incineration, which had a 25% mortality rate.     

Family history of completed suicide and characteristics of major depressive disorder: a STAR*D (sequenced treatment alternatives to relieve depression) study

BACKGROUND: Clinicians routinely ask patients with non-psychotic major depressive disorder (MDD) about their family history of suicide. It is unknown, however, whether patients with a family member who committed suicide differ from those without such a history. METHODS: Patients were recruited for the STAR*D multicenter trial. At baseline, patients were asked to report first-degree relatives who had died from suicide. Differences in demographic and clinical features for patients with and without a family history of suicide were assessed. RESULTS: Patients with a family history of suicide (n=142/4001; 3.5%) were more likely to have a family history of MDD, bipolar disorder, or any mood disorder, and familial substance abuse disorder, but not suicidal thoughts as compared to those without such a history. The group with familial suicide had a more pessimistic view of the future and an earlier age of onset of MDD. No other meaningful differences were found in depressive symptoms, severity, recurrence, depressive subtype, or daily function. CONCLUSIONS: A history of completed suicide in a family member was associated with minimal clinical differences in the cross-sectional presentation of outpatients with MDD. Limitations of the study include lack of information about family members who had attempted suicide and the age of the probands when their family member died. STAR*D assessments were limited to those needed to ascertain diagnosis and treatment response and did not include a broader range of psychological measures.     

A comparison of baseline sociodemographic and clinical characteristics between major depressive disorder patients with and without diabetes: a STAR*D report

BACKGROUND: Patients with major depressive disorder (MDD) have high rates of medical comorbidities which can impair MDD treatment. Yet little is known regarding associations between the presence of a serious comorbidity and MDD treatment. The purpose of this study was to examine the baseline sociodemographic and clinical characteristics of MDD outpatients with and without diabetes mellitus to evaluate possible associations between these characteristics and the presence of comorbid diabetes. METHODS: We gathered baseline sociodemographic and clinical data for 4041 participants with non-psychotic MDD who enrolled in the STAR*D, a large-scale depression treatment protocol, and made comparisons between participants with and without diabetes. RESULTS: Participants with diabetes were more likely to be male, older, black, Hispanic, unemployed, and have less education, a lower income, higher mental functioning, lower physical functioning, atypical features, increased appetite, psychomotor slowing and leaden paralysis, and were less likely to have concurrent alcohol abuse/dependence, mood reactivity or problems with concentration. We found no significant differences between groups regarding depression severity. LIMITATIONS: The primary limitation is the lack of a clinical diagnosis of diabetes. CONCLUSIONS: We found no difference in depression severity between participants with and without diabetes. Diabetes was associated with physical symptoms of depression. Thus treatments for these participants should be directed toward these symptoms.     

Predictors of suicide relative to other deaths in patients with suicide attempts and suicide ideation: a 30-year prospective study

Background

Although there is a large literature that prospectively examines predictors of suicide, low base rates of suicide and imprecision of measurement hinder definitive conclusions from being drawn.

Method

This study examined predictors of suicide relative to other types of death in a sample of 297 patients who had been hospitalized for suicide ideation or a suicide attempt between 1970 and 1975 and who were confirmed dead in 2005. Many predictors were measured using well-validated assessment instruments.

Results

Fifty-five patients had died by suicide. Univariate predictors of an increased risk for eventual suicide included younger age, completion of at least a high school degree, a diagnosis of a psychotic disorder, taking active precautions against discovery during the attempt, and a non-zero score on the suicide item of the Beck Depression Inventory, whereas African American ethnicity was associated with a decreased risk of eventual suicide. Variables that remained significant in a multivariate analysis included younger age, African American ethnicity, and taking active precautions against discovery during the attempt. Risk factors did not vary as a function of whether eventual suicide occurred less than or more than five years after the initial evaluation or by attempter v. ideator status.

Limitations

Despite the attempt to maximize statistical power by following a high-risk sample for 30 years, the number of deaths by suicide was still relatively low.

Conclusions

Taking active precautions against discovery of a suicide attempt has the potential to be an important predictor of eventual suicide and should be assessed by clinicians. Future prospective studies should assess predictors at multiple time points to gain a richer clinical picture of the circumstances surrounding deaths by suicide.     

Suicide attempts: differences between unipolar and bipolar patients and among groups with different lethality risk

BACKGROUND: The present naturalistic study aimed to distinguish between suicide attempts (SAs) of bipolar and unipolar patients, and among SAs characterized by different lethality risk. METHODS: The records of 2395 consecutive admissions to our psychiatric intensive care unit (PICU) were assessed for presence of suicide attempt (SA). Cases of SA were rated for symptom severity with the brief psychiatric rating scale (BPRS), the scale for the assessment of positive symptoms (SAPS), the scale for the assessment of negative symptoms (SANS), the mini mental state examination (MMSE), the global assessment of functioning scale (GAF) and the clinical global impression (CGI). An original questionnaire was administered to explore clinical aspects related with suicidal behavior. RESULTS: Among 2395 admissions, 80 (3.3%) had attempted suicide. Fifty-three cases (66.2%) suffered from a mood episode, including 22 (27.5%) with unipolar depression and 31 (38.7%) with bipolar depression (types I and II combined) or mixed state, while 27 (33.8%) cases received other diagnoses. Forty-eight (60%) cases had attempted suicide prior to the index episode. Ten cases (12.5%) had a relative who attempted or committed suicide. Thirty-nine cases (48.7%) described their SA as impulsive. Twenty cases (25.0%) reported alcohol ingestion before SA. In comparison with women, men used more violent methods. Cases characterized by a non-lethal risk SA had higher BPRS psychotic cluster and SAPS scores than cases with either low or high lethal risk SA. Bipolar cases were over-represented in the high lethality risk group. BPRS anxiety-depressive cluster score was higher in unipolar than in bipolar cases. LIMITATIONS: The sample may not be representative of all patients with SA. The questionnaire has not been standardized for use in psychiatric populations. CONCLUSIONS: The higher proportion of high lethal risk SA in bipolar cases suggests that the risk of completed suicide is higher in bipolar disorder than in unipolar depression. The risk of lethality in SA was not associated with the intensity of symptoms of anxiety and depression.     

Differences in suicide risk correlates and history of suicide ideation and attempts as a function of disability type

Background

Disability status is associated with correlates of suicide risk (perceived burdensomeness, thwarted belongingness, negative future disposition, felt stigma, suicidal ideation, and suicide attempts).

Aims

This study aimed to examine whether suicide-related correlates differ significantly as a function of disability type.

Methods

Individuals with mobility and vision disabilities (N = 102) completed semistructured interviews and online-based questionnaires. Analysis of variance/analysis of covaiance and Fisher's exact tests were conducted to examine whether mean levels of suicide-related correlates differed significantly between individuals with blindness/low vision (n = 63) versus mobility-related (n = 39) disabilities.

Results

No significant between-group differences were observed for most outcomes; however, individuals with vision disabilities reported higher mean levels of felt stigma and positive future disposition than those with mobility-related disabilities.

Limitations

The limited representation of disabilities among participants precludes generalization to individuals with other forms of disability and the cross-sectional design prevents inference about causality.

Conclusions

Interventions targeting cognitive processes that underlie suicide risk may be applicable to people with mobility and vision disabilities.     

Recent life events preceding suicide attempts in a personality disorder sample: findings from the collaborative longitudinal personality disorders study

Few studies have examined the relationship between life events, suicide attempts, and personality disorders (PDs), in spite of the strong associations between PDs and suicidal behavior, and the poor coping strategies often exhibited by these individuals. The authors examined whether participants with PDs who attempted suicide during the first 3 years of a prospective, longitudinal study were more likely to experience specific life events in the month during and preceding the suicide attempt. Of 489 participants with PDs, 61 attempted suicide during the 3-year, follow-up interval. Results indicated that negative life events, particularly those pertaining to love-marriage or crime-legal matters, were significant predictors of suicide attempts, even after controlling for baseline diagnoses of borderline PD, major depressive disorders, substance use disorders, and a history of childhood sexual abuse. Therefore, certain types of negative life events are unique risk factors for imminent suicide attempts among individuals with PDs.     

Childhood experiences of loss and suicide attempts: significance in depressive states of major depressed and dysthymic or adjustment disordered patients.

Three hundred and twenty-eight patients aged 45 years and over with major depression, dysthymic disorder or adjustment disorder with depressed mood (according to DSM-III) were asked about childhood loss experiences (death of one or both parents or at least 1 year's separation) and their current state of health. No statistically significant relationships were found between experiences of loss in childhood and type of depression, sex and age at first episode. However, there was an increased incidence of suicide attempts in patients with experiences of loss in childhood, both by separation and by death of parents. The increased suicidal tendency could mainly be attributed to loss of the father.     

Prediction of suicide ideation and attempts among adolescents using a brief performance-based test

Suicide is a leading cause of death that is difficult to predict because clinical assessment has relied almost exclusively on individuals' self-report of suicidal thoughts. This is problematic because there often is motivation to conceal such thoughts. The authors tested the ability of the Self-Injury Implicit Association Test (SI-IAT), a reaction-time measure of implicit associations between self-injury and oneself, to detect and predict suicide ideation and attempts. Participants were adolescents who were nonsuicidal (n = 38), suicide ideators (n = 37), or recent suicide attempters (n = 14). Analyses revealed large between-group differences on the SI-IAT, with nonsuicidal adolescents showing large negative associations between self-injury and themselves, suicide ideators showing small positive associations, and suicide attempters showing large positive associations on this performance-based test. The SI-IAT accurately predicted current suicide ideation and attempt status as well as future suicide ideation, and it incrementally improved prediction of these outcomes above and beyond the use of known risk factors. Future research is needed to refine this assessment method and to further develop and examine performance-based assessment of suicide risk in clinical settings.     

Startle amplitude during unpleasant pictures is greater in veterans with a history of multiple‐suicide attempts and predicts a future suicide attempt

Recent studies demonstrate that veterans exhibit higher suicide risk compared with the general U.S. population. A prior suicide attempt is a well‐documented predictor of suicide death. Despite increased attention to clinical risk factors of suicide and efforts to develop psychosocial interventions to reduce suicide risk, the underlying biological factors that confer this risk are not well understood. This study examined affect‐modulated startle (AMS) during a series of intermixed unpleasant, neutral, and pleasant pictures in a sample of 108 demographically‐matched veterans at low (passive ideators: n = 26) and high risk (active ideators: n = 29; single attempters: n = 28; and multiple attempters: n = 25) for suicide based on the Columbia Suicide Severity Rating Scale. An exploratory aim involved a longitudinal component in a subset of the high‐risk sample that went on to participate in a randomized 6‐month clinical trial. We investigated whether baseline AMS predicts a subsequent suicide attempt at 12‐month follow‐up. Compared with the other three groups, multiple attempters showed greater startle potentiation during unpleasant pictures and deficient overall startle habituation from early to later trials. The groups did not differ in startle during neutral or pleasant pictures, or self‐reported picture valence. Greater startle during unpleasant pictures was associated with greater emotion dysregulation as measured by the Difficulties in Emotion Regulation Scale and a future suicide attempt assessed prospectively at 12‐month follow‐up. These findings suggest that startle potentiation during unpleasant pictures in multiple‐suicide attempters is a promising psychophysiological biomarker of suicide risk and underscore the clinical importance of targeting emotion dysregulation in the treatment of patients at‐risk for suicide.     

Oral d-fenfluramine test in treatment-refractory depression. Plasma prolactin response compared in patients with and without suicide attempts and in a healthy reference group

BACKGROUND: Fenfluramine (d-FEN) has been used as a serotonin challenge agent to assess central serotonin availability. Blunted serum prolactin (PRL) response to d-FEN has been reported in depressed patients, in suicide-prone patients, and in patients with aggression and personality disorders. We have analyzed suicidality in relation to central serotonergic events by comparing the PRL response to d-FEN in chronically depressed patients with and without suicide attempts and in healthy volunteers. METHODS: In 56 inpatients (10 patients with and 46 without suicide attempts) with at least 2 years of treatment-refractory depression (TRD) (DSM-IV) and a reference group of 30 healthy adults, the PRL response after an oral dose of 30 mg d-FEN was followed for 5 h. RESULTS: Controlling for group differences in age, sex, and weight, the PRL response to d-FEN did not differ significantly between the three groups. Far from confirming the hypothesis of a blunted PRL response in depressed patients, our results suggest: (1) that duration and treatment resistance of depression may affect the PRL secretion, and (2) that TRD and major depression may differ in biological relationship to suicidal behavior. LIMITATIONS: The findings require corroboration in larger and more closely matched study populations. The fenfluramine concentration was not analyzed in blood. CONCLUSIONS: PRL responses to d-FEN challenge did not differ between TRD patients with and without suicidality and the healthy reference group. Chronicity/treatment refractoriness per se may be related to a serotonergic mechanism.