Defense styles in depressed suicide attempters

Defense styles may discriminate between depressed patients with or without recent suicide attempts. The aim of the present study was to identify which defense mechanisms are associated with recent suicide attempts in depression. The Defense Style Questionnaire (DSQ) was rated at admission by 156 depressed inpatients with (n = 60) or without (n = 96) recent suicide attempt. Depression intensity was correlated negatively with mature style, humor and sublimation and positively with projection. Although it was not significantly different in terms of sociodemographic and depression variables, recent suicide attempters had higher scores on immature style, especially acting out, passive agression, autistic fantasy and projection. Prospective assessment of defense styles and suicide attempts should be carried out to determine whether these differences are a cause of imminent suicide attempts in depression. If so, the DSQ may be used in clinical practice to help discriminate depressed patients with high risk of imminent suicide attempt.     

Adequacy of antidepressant treatment after discharge and the occurrence of suicidal acts in major depression: a prospective study

OBJECTIVE: Suicide attempts predict repeat attempts and suicide completion. Major depression requiring hospitalization is a risk factor for suicidal acts, particularly in the 2 years following discharge. The authors prospectively studied the adequacy of antidepressant treatment and its impact on suicidal acts in the 2 years after hospitalization for major depression. METHOD: Patients (N=136) with major depression were interviewed at 3 months, 1 year, and 2 years after admission. At each interview, the presence of major depression and suicidal acts and the adequacy of antidepressant treatment were assessed. Cox's proportional hazards analysis with time-varying covariates was used to model the risk of a suicide attempt during the follow-up period. RESULTS: Major depression in the follow-up period increased the risk of a suicide attempt sevenfold. For each suicide attempt in a subject's history, the risk for an attempt in the follow-up period increased by 30%. Antidepressant treatment during the follow-up period was mostly inadequate. Consequently, a relationship between adequacy of antidepressant treatment during follow-up and the risk of a suicide attempt could not be found. Furthermore, subjects with a history of a suicide attempt at baseline were not treated more vigorously than nonattempters. CONCLUSIONS: Antidepressant treatment of depressed patients is strikingly inadequate, even in suicide attempters, known to be at higher risk for suicidal acts. This deficiency undermines the ability to measure the antisuicidal effects of antidepressants in naturalistic studies. Controlled studies of antidepressants are needed to evaluate effects on suicidal acts.     

Increased suicidality in depression: group or subgroup characteristic?

A lifetime history of depressive episodes and suicide attempts was ascertained from 172 depressed patients admitted to a psychiatric inpatient service. Fifty-five of these patients had made at least one suicide attempt. The correlation of depressive episodes and the total number of suicide attempts for this group was close to zero. However, when the data were converted into rate measures (number of episodes or attempts per year), the correlations were very high and significant. It appears that approximately one-third of severely depressed, hospitalized patients have a history of suicide attempts and, once a suicide attempt has occurred, the patient is at high risk for more suicide attempts if future depressions occur. Within the group of depressives with a history of suicide attempt, the risk of suicidal behavior is evenly distributed. No evidence in favor of a "hypervulnerable" subgroup was found.     

Suicidal behaviour and electrodermal activity in depressive inpatients.

Within the context of a habituation experiment, the electrodermal activity (EDA) of suicidal depressed patients was measured. Twenty-four patients had a suicide attempt in their most recent history; these attempts were divided into attempts with violent or nonviolent methods. All the patients who had used a violent method habituated quickly, as was the case for 4 of 5 patients who committed suicide in the year following the experiment. Just as many patients who used nonviolent methods habituated quickly or slowly. There was no indication that age, sex or medication had any influence. For 18 of these 24 patients, comparable groups, in terms of age and sex distribution, were formed containing either nonsuicidal depressed patients or patients with suicidal thoughts. No differences between groups concerning any of the EDA variables could be found. In accordance with these results, EDA cannot be considered to be a valid predictor for suicide-proneness. The relations between violent suicide attempts and nonreactivity should, however, be further examined and the group of nonreactive patients in EDA should be treated as a risk group for clinical reasons.     

Depressed patients who suicide at their first attempt have had few admissions

A prior suicide attempt is generally considered to be an indicator of increased future suicide risk. However, approximately 50% of psychiatric patients who commit suicide have made no previous suicide attempt. Thus, an effort was made to detect other predictors of future suicide risk in this group. The records of 100 psychiatric patient suicides were examined. Patients who completed suicide at their first attempt (n = 57) were compared with patients who suicided after a previous attempt (n = 43). There were no significant differences between the two groups on any of the sociodemographic or clinical variables examined. However, patients with a primary psychiatric diagnosis of an effective disorder who committed suicide at their first attempt had had significantly less admissions than depressed patients who committed suicide after a previous attempt. The clinical implication is that the absence of many prior admissions in a depressed patient is not an indicator of low suicide risk.     

Suicidality in panic disorder: a comparison with schizophrenic, depressed, and other anxiety disorder outpatients

Recent findings by Weissman, Klerman, Markowitz, and Ouellette (1989) that subjects with panic disorder, with and without comorbid conditions, may be at increased risk for suicide attempts have been controversial. In an attempt to further investigate this finding, we utilized the original National Institute of Mental Health Epidemiological Catchment Area (ECA) suicide questions in an outpatient psychiatric clinic. We examined patients with panic disorder (n = 101). other anxiety disorders (n = 47), schizophrenia (n = 22). and major depression (n = 19). No significant differences were found among all four groups on any of the ECA suicide ideation questions. Only two (2%) of the panic disorder patients and none of the other groups made a suicide attempt in the past year. While 17% of patients with panic disorder and 9% of patients with other anxiety disorders reported having made a suicide attempt at some other time in their life, the schizophrenic (33%) and depressed groups (40%) reported significantly greater histories of suicide attempts. In a forward stepwise regression analysis for panic disorder patients, a history of substance abuse and comorbid depression predicted suicidality. The actual clinical risk for suicide attempts in panic disorder patients appears to occur when they suffer with comorbid diagnoses. These results highlight the need to aggressively treat panic disorder patients so they do not suffer the all-too-common sequelae of depression and substance abuse.     

Risk factors related to lifetime suicide attempts in acutely admitted bipolar disorder inpatients

Finseth PI, Morken G, Andreassen OA, Malt UF, Vaaler AE. Risk factors related to lifetime suicide attempts in acutely admitted bipolar disorder inpatients.
Bipolar Disord 2012: 14: 727–734. © 2012 The Authors.
Journal compilation © 2012 John Wiley & Sons A/S. Objective: The main aim of this study was to assess possible clinical characteristics of acutely admitted bipolar I disorder (BD‐I) and bipolar II disorder (BD‐II) inpatients at high risk of suicide by comparing patients who had made one or several serious suicide attempts with patients who had not. Methods: A total of 206 consecutive patients (mean age 42 ± 15 years; 54.9% women) with DSM–IV diagnosed BD‐I (n = 140) and BD‐II (n = 66) acutely admitted to a single psychiatric hospital department from November 2002 through June 2009 were included. Using a detailed retrospective questionnaire, patients with a history of a serious suicide attempt were compared to those with no history of a suicide attempt. Results: Ninety‐three patients (45.1%) had a history of one or more serious suicide attempts. These constituted 60 (42.9%) of the BD‐I patients and 33 (50%) of the BD‐II patients (no significant difference). Lifetime suicide attempt was associated with a higher number of hospitalizations due to depression (p < 0.0001), antidepressant (AD)‐induced hypomania/mania (p = 0.033), AD‐ and/or alcohol‐induced affective episodes (p = 0.009), alcohol and/or substance use (p = 0.002), and a family history of alcohol abuse and/or affective disorder (p = 0.01). Suicide attempt was negatively associated with a higher Positive and Negative Syndrome Scale for Schizophrenia (PANSS) Positive Subscale score (p = 0.022) and more hospitalizations due to mania (p = 0.006). Conclusions: The lifetime suicide attempt rate in BD inpatients is high. Risk factors of suicide attempts were: (i) a predominant depressive course of illness, (ii) comorbid alcohol and substance use disorders, and (iii) a history of AD‐ and/or alcohol‐induced affective episodes. Risk‐reducing factors were a preponderant manic or psychotic course of the illness. These risk factors may be signs of a clinical subgroup at risk of suicidal behaviour, and seem to be important for suicide risk assessment in acutely admitted BD patients.     

Depressed Suicide Attempters with Posttraumatic Stress Disorder

Posttraumatic stress disorder and major depressive disorder are well-established risk factors for suicidal behavior. This study compared depressed suicide attempters with and without comorbid posttraumatic stress disorder with respect to additional diagnoses, global functioning, depressive symptoms, substance abuse, history of traumatic exposure, and suicidal behavior. Adult patients consecutively admitted to a general hospital after a suicide attempt were interviewed and assessed for DSM-IV diagnosis and clinical correlates. Sixty-four patients (71%) were diagnosed with depression; of them, 21 patients (32%) had posttraumatic stress disorder. There were no group differences in social adjustment, depressive symptoms, or suicidal intent. However, the group with comorbid depression and posttraumatic stress disorder had more additional Axis I diagnoses, a higher degree of childhood trauma exposure, and more often reported previous suicide attempts, non-suicidal self-harm, and vengeful suicidal motives. These findings underline the clinical importance of diagnosis and treatment of posttraumatic stress disorder in suicide attempters.     

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.     

Extended suicide attempt: psychopathology, personality and risk factors

Delinquency among depressed patients plays a minor role in criminal behavior. Among the most tragic associations between depression and criminality are cases of extended suicide or suicide attempt. We studied psychopathology, personality, and psychosocial stressors of 9 Austrian females who committed a serious extended suicide attempt. They were admitted for treatment at a special department of the Justizanstalt Wien-Josefstadt, Aussenstelle Wilhelmsh?he. Patients were diagnosed according to ICD-10 as severely depressed with (n = 6) or without (n = 3) psychotic features. After stabilization we diagnosed the following personality disorders: anxious-avoidant (n = 5), paranoid (n = 1), combined (n = 1) and borderline type (n = 1). Traits of the typus melancholicus were found in 5 patients. Seven females were pretreated before the offence by a psychiatrist or a psychologist; 4 of them had committed at least one suicide attempt in the past. Main psychosocial stressors mentioned by patients in the context of the offence were overstrain, marital and/or financial problems. One female killed her child under the influence of acoustic hallucinations. Patients with traits of the melancholic type showed an altruistic and hypernomic motive for killing as well as a psychotic identification with the victim, whereas in the other cases egocentric motives were in the forefront. Potential risk factors for an extended suicide attempt will be discussed.     

Two generations of Slovenian suicidal adolescent inpatients

BACKGROUND: The political and socio-economic situation in Slovenia, a former Yugoslav republic, a country in transition and a country with a high suicide rate, which joined the European Union in 2004, has changed steadily since the beginning of the 1970s. Literature shows constancy in suicide statistics in Slovenia during these times. AIM: The present study examines whether the suicidal adolescent inpatient population in Slovenia reflects recent social changes and upheavals. METHOD: Data on two groups of patients admitted to a specialized adolescent psychiatry department after attempting suicide were collected. The first group (n = 74) were patients admitted from 1975 to 1977, the second group (n = 73) from 2002 to 2004. They were compared on general characteristics, family and living circumstances, risk behaviors, suicide attempts and diagnoses. RESULTS: The comparison revealed statistically significant differences between groups on educational level, number of siblings, frequency of smoking and psychoactive medication misuse as well as number of previous suicide attempts. No differences were found in other family and living circumstances, methods used in the index suicide attempt, other risk behaviors or diagnoses. CONCLUSIONS: The post-independence suicidal inpatient population in Slovenia shows a tendency towards higher morbidity, but has changed less than expected considering the vast changes in the society. These results suggest a certain constancy in adolescent suicidal behavior.     

Treatment of suicide attempters prior to hospital admission

OBJECTIVE: Numerous authors have reported serious shortcomings in the treatment of suicidal patients. This study examined the treatment suicide attempters admitted to a psychiatric hospital in Switzerland had received prior to the suicide attempt. METHOD: Thirty-one patients were admitted to this hospital within a year, representing 36 suicide attempts, which corresponds to 6.5% of the annual admission number. Three of these patients were admitted twice, and one patient was admitted three times. Information on previous treatment was collected in personal interviews and included medication, and its dosage, at 1 month and 2 weeks prior to the suicide attempt, and whether the patient had received psychotherapy. In addition, details of the psychosocial event and the means of the suicide attempt were recorded. RESULTS: Twenty-one patients had been prescribed psychotropic drugs in 24 events, but only in 17 events concerning 15 patients, antidepressants were prescribed prior to hospitalisation. Antipsychotics and benzodiazepines were prescribed in 6 and 21 events, respectively (including 8 events with hypnotics). None of the patients was treated with lithium. In 19 events, 16 patients had received psychotherapy prior to admission. In 32 events, psychotropic drugs were used for the suicide attempt. CONCLUSION: The findings confirm the undertreatment of patients attempting suicide reported by other authors. In spite of the majority of patients being under psychiatric care, no adequate pharmacotherapy had been prescribed particularly for depressed patients.     

Possible precipitants of psychiatric hospitalization in patients with major depression: results from the Jerusalem Collaborative Depression Project.

In spite of substantial advances in the treatment of major depression by pharmacotherapy and other means, a significant number of depressed patients require hospitalization. In the context of the Jerusalem Collaborative Depression Project, possible precipitants of psychiatric hospitalization were sought in a cohort of patients (n = 107) who were admitted to hospitals in the Jerusalem area during a 14-month period because of a depressive episode. The patients fulfilled DSM III-R criteria for major depression, single or recurrent; bipolar 1 disorder, depressed or mixed; bipolar 2, depressed. The cohort encompassed more than two thirds of potential subjects admitted during this period with the ICD-9 equivalents of the specified diagnoses (as reported to the Israel Ministry of Health National Psychiatric Case Register) and were similar to the entire potential population in terms of their diagnostic breakdown. The patients underwent extensive socio-demographic and clinical evaluation that included detailed documentation of treatment received prior to hospitalization. Notwithstanding the absence of a comparison group of depressed patients who were not hospitalized, a number of potential precipitants were identified. These included older age (55.2% > 60 years, 20.6% > 70 years), immigration to Israel during the preceding 5 years (34.7%), concomitant physical illness (60%) which was associated with moderate to severe disability in 41% and poor quality of antidepressant pharmacotherapy prior to hospitalisation (only 24.3% received an adequate trial of antidepressant medication). Further evaluation of these and other potential factors could facilitate targeting of patient groups at particular risk for hospitalization and reduce the need for it.     

Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials: an analysis of the Food and Drug Administration database

The assumption that depressed patients who are assigned to placebo in antidepressant clinical trials are exposed to substantial morbidity and mortality is not based on research data. We assessed suicides, suicide attempts, and depressive symptom reduction in studies of 7 new antidepressants using the Food and Drug Administration database. Among 19,639 participating patients, 34 committed suicide (0.8% per year), and 130 attempted suicide (2.9% per year). Rates of suicide and attempted suicide did not differ significantly among the placebo- and drug-treated groups. Annual rates of suicide and attempted suicide were 0.4% and 2.7% with placebo, 0.7% and 3.4% with active comparators, and 0.8% and 2.8% with investigational antidepressants, respectively. Symptom reduction was 40.7% with investigational drugs (n = 4,510), 41.7% with active comparators (n = 1,416), and 30.9% with placebo (n = 2,805). These data may help inform discussions about the use of placebo in antidepressant clinical trials.     

Antidepressant drug therapy and suicide in severely depressed children and adults: A case-control study

CONTEXT: The Food and Drug Administration has issued a boxed warning concerning increased suicidal ideation and behavior associated with antidepressant drug treatment in children and adolescents. It is unknown whether antidepressant agents increase the risk of suicide death in children or adults. OBJECTIVE: To estimate the relative risk of suicide attempt and suicide death in severely depressed children and adults treated with antidepressant drugs vs those not treated with antidepressant drugs. DESIGN: Matched case-control study. SETTING: Outpatient treatment settings in the United States. PARTICIPANTS: Medicaid beneficiaries from all 50 states who received inpatient treatment for depression, excluding patients treated for pregnancy, bipolar disorder, schizophrenia or other psychoses, mental retardation, dementia, or delirium. Controls were matched to cases for age, sex, race or ethnicity, state of residence, substance use disorder, recent suicide attempt, number of days since hospital discharge, and recent treatment with antipsychotic, anxiolytic/hypnotic, mood stabilizer, and stimulant medications. MAIN OUTCOME MEASURES: Suicide attempts and suicide deaths. RESULTS: In adults (aged 19-64 years), antidepressant drug treatment was not significantly associated with suicide attempts (odds ratio [OR], 1.10; 95% confidence interval [CI], 0.86-1.39 [521 cases and 2394 controls]) or suicide deaths (OR, 0.90; 95% CI, 0.52-1.55 [86 cases and 396 controls]). However, in children and adolescents (aged 6-18 years), antidepressant drug treatment was significantly associated with suicide attempts (OR, 1.52; 95% CI, 1.12-2.07 [263 cases and 1241 controls]) and suicide deaths (OR, 15.62; 95% CI, 1.65-infinity [8 cases and 39 controls]). CONCLUSIONS: In these high-risk patients, antidepressant drug treatment does not seem to be related to suicide attempts and death in adults but might be related in children and adolescents. These findings support careful clinical monitoring during antidepressant drug treatment of severely depressed young people.     

Positron emission tomography of regional brain metabolic responses to a serotonergic challenge and lethality of suicide attempts in major depression

BACKGROUND: Lower serotonergic activity correlates with high-lethality suicide attempts in major depression. Postmortem studies of serotonin receptors in suicides localize changes to the ventral prefrontal cortex (PFC). We studied serotonergic response in ventral PFC in depressed patients surviving a high-lethality suicide attempt. METHODS: Depressed patients with a history of a high-lethality suicide attempt (n = 16) were compared with those with low-lethality attempts (n = 9) for level of depression, suicidal intent and ideation, impulsivity, aggression, and neuropsychological test performance. Subjects were scanned while medication free after a single-blind placebo and after fenfluramine hydrochloride administration on a second day. Brain responses were measured by positron emission tomography imaging of fludeoxyglucose F 18 and serial prolactin levels. Scans were compared by means of statistical parametric mapping. Correlations of changes in relative regional cerebral uptake (rCMRglu) with clinical and neuropsychological measures were assessed. RESULTS: Depressed high-lethality suicide attempters had lower rCMRglu in ventral, medial, and lateral PFC compared with low-lethality attempters. This difference was more pronounced after fenfluramine administration. Lower ventromedial PFC activity was associated with lower lifetime impulsivity, higher suicidal intent (planning), and higher-lethality suicide attempts. Higher verbal fluency was positively correlated with rCMRglu in the same regions. CONCLUSIONS: Prefrontal localized hypofunction and impaired serotonergic responsivity are proportional to the lethality of the suicide attempt and may mediate the effects of suicide intent and impulsivity on lethality. Positron emission tomographic neuroreceptor studies are needed to determine whether postmortem serotonin receptor findings are also present in vivo and contribute to the abnormal rCMRglu responses.     

Patients in intensive care after a suicide attempt with legal drugs - risk profile and course

Little is known about the risk profile and the further history of patients who attempted suicide by severe medicinal intoxication.All patients residing in Basel (n = 190) admitted to the intensive care unit between 01/01/1998 and 12/31/2001 because of a suicide attempt with legal drugs were investigated regarding psychopathology and sociodemographic features. Also, until the end of 2005, further suicide attempts as well as potential cases of death were followed up.All 190 patients had psychiatric disorders. Compared to the general population, female sex, single status, low educational level, unemployment and invalidity were found significantly more often. Until the end of 2005 almost half of 118 patients followed up in our outpatient department committed further suicide attempts. 28 patients died, 6 of these by suicide.These patients should preferably not be prescribed medication with a low therapeutic range and they should receive intensive follow-up care.     

An empirical study on the "cathartic effect" of attempted suicide

A cathartic effect of attempted suicide has been suggested, but few data are available to validate the concept. In this study we report on the relation between presuicidal and postsuicidal mood conditions in a group of 25 hospitalized suicide attempters and 50 control patients who were depressed but not suicidal. A significant decrease in depression was demonstrated to occur in the suicidal patients within a few days of hospitalization. This was not the case in depressed patients without prior suicide attempts. The drop in depression ratings can, therefore, be attributed to the suicide attempt. Possible explanatory factors are discussed. These findings indicate that the diagnosis of a suicide attempt in the absence of depression can only be reliably made on the basis of data pertaining to the presuicidal mood condition.