Attempted suicide predicts suicide risk in mood disorders

Suicide risk was studied in a sample of 346 mood disorder inpatients, 92 of whom were admitted after a current suicide attempt. The overall suicide mortality after a mean observation period of 6 years was 8%. The potential of attempted suicide to predict suicide risk in hospitalized patients with mood disorders was studied by survival analysis after subgrouping on the basis of whether a current suicide attempt had occurred or not. The suicide risk the first year after attempting suicide was 12% (11/92), compared with 2% (4/254) in the mood disorder subgroup with no current suicide attempt. The long-range suicide risk after a current suicide attempt in depression was 15% (14/92) as compared with 5% (13/254) among those without a current suicide attempt. It is concluded that a current suicide attempt in mood disorder inpatients predicts suicide risk particularly within the first year and should be taken very seriously.     

Atypical antipsychotics and suicide in mood and anxiety disorders

Abstract:  Globally, a million people commit suicide every year, and 10–20 million attempt it. Mood disorders, especially major depressive disorder (MDD) and bipolar disorder, are the most common psychiatric conditions associated with suicide. Primary (psychiatric and physical illness), secondary (psychosocial), and tertiary (demographic) risk factors for suicide have been identified. Comorbid psychiatric illness, particularly anxiety symptoms or disorders, significantly increase the risk of suicidal behavior. Current standard risk assessments and precautions may be of limited value, while assessing the severity of anxiety and agitation may be more effective in identifying patients at risk. Lithium is the medication that has most consistently demonstrated an antisuicidal effect. The effects of antidepressants and conventional antipsychotics on suicide risk are uncertain, but atypical antipsychotics appear promising. Atypical antipsychotics have beneficial effects on depressed mood both in patients with MDD and in patients with bipolar disorder. In addition, data in patients with schizophrenia have demonstrated a significant improvement in the incidence of suicidal behavior with clozapine compared with olanzapine. Electroconvulsive therapy appears to have an acute benefit on suicidality.     

Association study of early-immediate genes in childhood-onset mood disorders and suicide attempt

Childhood-onset mood disorders (COMD) are serious affective disorders with deleterious developmental sequelae including interpersonal dysfunction, psychotic symptoms and suicidal behavior. The current study examines 10 markers from two early-immediate genes for association with COMD and suicide attempt (SA) - HOMER1 and human neuronal pentraxin II (NPTX2). We examined individuals diagnosed with COMD versus matched controls, as well as individuals with COMD and a history of at least one lifetime SA versus COMD participants with no history of SA. No significant genotypic association was noted between any of the single nucleotide polymorphisms (SNPs) and COMD. Our sample yielded a nominally significant allelic association between the HOMER1 rs7713917 SNP and COMD. We report significant genotype associations between HOMER1 rs2290639 and SA , and between NPTX2 markers rs705315 and rs1681248 and SA, findings that remained statistically significant after multiple test correction. A three-way interaction was observed among HOMER1 rs4704560, rs2290639 and NPTX2 rs705318. The associations we describe for HOMER1 and NPTX2 with SA should be considered preliminary until replicated.     

Comparison of characteristics of suicide attempters with schizophrenia spectrum disorders and those with mood disorders in Japan

Suicidality in patients with schizophrenia is high. To clarify the characteristics of suicidal behavior in patients with schizophrenia, we investigated suicide attempters with schizophrenia spectrum disorders in comparison with patients with mood disorders. One hundred patients with schizophrenia spectrum disorders and 155 patients with mood disorders admitted to an emergency department after a suicide attempt were interviewed in detail on items concerning 1) demographic characteristics, 2) previous suicidal behavior, and 3) index suicidal behavior. Differences between the two groups were subsequently analyzed. Patients with schizophrenia spectrum disorders showed a lower incidence of previous deliberate self-harm, and a higher incidence of a subsequent suicide attempt more than 1 year after the previous suicide attempt as well as a higher lethality of index suicide attempt compared to patients with mood disorders. Furthermore, the most common motive for making a suicide attempt in patients with schizophrenia spectrum disorders was having a mental problem. This study revealed the factors associated with suicide attempts among Japanese patients with schizophrenia spectrum disorders, and the nature of these factors makes it difficult to predict future attempts. This makes clear the importance of continuous long-term follow-up with careful attention to the mental symptoms and psychological burden for such patients.     

The effect of electroconvulsive therapy on suicide risk in patients with mood disorders.

OBJECTIVE: To discuss the effect of electroconvulsive therapy (ECT) on suicide risk in patients with mood disorders. METHOD: A review of the available data on the short-term and long-term effects of ECT on suicide mortality among patients with mood disorders. CONCLUSION: ECT has an acute but not a long-term beneficial effect on suicidality. Due to the significant limitations of studies in this area, however, the data need to be interpreted with caution.     

Indicators of suicide over 10 years in a specialist mood disorders unit sample.

BACKGROUND: There are few firm data to guide the clinician in identifying individual depressed patients who may be at high risk for completing suicide. In particular, there have been few prospective studies of well-characterized depressed patients to determine indicators of such future events. METHOD: Eight hundred thirteen patients with a major depressive episode (DSM-III, DSM-III-R, or DSM-IV criteria) were assessed in detail in a specialist Mood Disorders Unit (MDU) over a 10-year period. Follow-up at the end of that period (mean = 5.1 years) confirmed that 31 patients (3.8%) had completed suicide. The suicide completers were compared on a broad range of clinical and demographic variables obtained at baseline with (1) the total remaining depressed sample, (2) 31 age- and sex-matched subjects who were confirmed to be alive and had never attempted suicide, and (3) 24 age- and sex-matched living subjects who had made at least 1 suicide attempt. RESULTS: The most consistent finding, across all 3 comparisons, was that the suicide completers were more likely to have been inpatients at the time of the index MDU assessment. Other characteristics of completers were a greater number of prior admissions for depression, being older and in a relationship, and being male and married or female and single. Somewhat paradoxically, suicide completers also evidenced fewer previous suicide attempts and less suicidal ideation compared with living subjects who had attempted suicide at the time of index assessment. CONCLUSION: Overall, we were able to find few predictors of later suicide in this sample. Those who completed suicide demonstrated evidence of more severe illness over a lifetime (for example, having more admissions). but revealed less suicidal ideation at the time of the index MDU assessment. While these features were statistically significant, they are of limited usefulness in predicting suicide in an individual patient.     

The impact of attempted suicide on the symptoms and course of mood disorders

BACKGROUND: Case-controlled studies have produced conflicting results on the relief of depression following attempted suicide. This study examined the impact of attempted suicide on the symptoms and course of mood disorders. METHOD: Of 2800 inpatients reviewed retrospectively, 40 depressed patients who had attempted suicide immediately before admission and 40 depressed but nonsuicidal control patients satisfied entry criteria for the study. The overall severity of their depression had been rated by the treating psychiatrists before the attempted suicide or at admission using the DSM-III-R (or DSM-IV) severity scale. The severity of depression at 1 week after admission was evaluated by reviewing medical records. For categorical analysis, improvement was defined as a reduction of one or more categories on the DSM-III-R (or DSM-IV) severity scale. We assigned scores of 1-6 to this scale to enable quantitative comparisons. RESULTS: Both categorical and dimensional analyses demonstrated that depression was significantly (p <.05) more likely to improve within 1 week of admission among suicidal unipolar patients than among nonsuicidal unipolar patients. Logistic regression analyses revealed that a unipolar course was significantly (p =.023) associated with the improvement of depression. Of the 15 patients showing postsuicidal improvement of depression, 5 (33%) relapsed within 1 month. No significant predictors of their relapses were detected. Of 7 patients with postsuicidal manic switching, 4 (57%) experienced a switch-down into depression. CONCLUSION: This study suggests that unipolar depression is significantly improved after attempted suicide, but also that depressed patients showing postsuicidal improvement or manic switching are likely to undergo relapse or switch-down into depression within a short period.     

Risk for suicide in schizophrenia and other psychotic and nonpsychotic disorders

To determine the rate of suicide in young, early phase schizophrenics and other psychotic disorders, and to analyze risk factors for suicide, a large sample of patients was prospectively assessed at index hospitalization and then followed up systematically after discharge. Thirty-six patients committed suicide and these patients were compared with those who did not commit suicide for major diagnostic and prognostic factors. Results indicated the following: a) During early years, schizophrenics and other types of psychotic patients were more likely to commit suicide than nonpsychotic patients. b) Similarly, among depressives, psychotic depressed patients were more likely to commit suicide than nonpsychotic depressed patients. c) Schizophrenics and other psychotic patients were especially vulnerable to suicide within the first 6 years of their first hospitalization. d) Among the combined sample of psychotic patients (schizophrenic and other psychotic patients), those at greater risk for suicide were unmarried, white, high IQ, male patients with a more gradual onset of disorder and were of "chronic" Research Diagnostic Criteria subtypes.     

Effect of acute alcohol use on the lethality of suicide attempts in patients with mood disorders

Acute alcohol use is an important risk factor for attempted and completed suicide. We evaluated the effect of acute alcohol intake on the lethality of suicide attempts to test the hypothesis that acute alcohol intoxication is associated with more lethal suicide attempts. This retrospective study included 317 suicide attempters enrolled in mood disorders protocols. Demographic and clinical parameters were assessed. The use of alcohol at the time of the most lethal suicide attempt was determined. On the basis of their responses participants were classified into three groups: participants who reported “Enough alcohol intake to impair judgment, reality testing and diminish responsibility” or “Intentional intake of alcohol in order to facilitate implementation of attempt” were included in the group “Alcohol” (A); participants who reported “Some alcohol intake prior to but not related to attempt, reportedly not enough to impair judgment, reality testing” were included in the group “Some Alcohol” (SA); and participants who reported “No alcohol intake immediately prior to attempt” were included in the group “No Alcohol” (NA). Lethality of the most lethal suicide attempts was higher in the A group compared to the SA and NA groups. Prevalence of patients with alcohol use disorders was higher in the A group compared to the SA and NA groups. SA participants reported more reasons for living and lower suicide intent scores at the time of their most lethal suicide attempt compared to the A and NA groups. Acute alcohol use increases the lethality of suicide attempts in individuals with mood disorders.     

Neuroplasticity in mood disorders

Neuroimaging and neuropathological studies of major depressive disorder (MDD) and bipolar disorder (BD) have identified abnormalities of brain structure in areas of the prefrontal cortex, amygdala, striatum, hippocampus, parahippocampal gyrus, and raphe nucleus. These structural imaging abnormalities persist across illness episodes, and preliminary evidence suggests they may in some cases arise prior to the onset of depressive episodes in subjects at high familial risk for MDD. In other cases, the magnitude of abnormality is reportedly correlated with time spent depressed. Postmortem histopathological studies of these regions have shown abnormal reductions of synaptic markers and glial cells, and, in rare cases, reductions in neurons in MDD and BD. Many of the regions affected by these structural abnormalities show increased glucose metabolism during depressive episodes. Because the glucose metabolic signal is dominated by glutamatergic transmission, these data support other evidence that excitatory amino acid transmission is elevated in limbic-cortical-striatal-pallidal-thalamic circuits during depression. Some of the subject samples in which these metabolic abnormalities have been demonstrated were also shown to manifest abnormally elevated stressed plasma cortisol levels. The co-occurrence of increased glutamatergic transmission and Cortisol hypersecretion raises the possibility that the gray matter volumetric reductions in these depressed subjects are partly accounted for by processes homologous to the dendritic atrophy induced by chronic stress in adult rodents, which depends upon interactions between elevated glucocorticoid secretion and N-meihyl-D-aspartate (NMDA)-glutamate receptor stimulation. Some mood-stabilizing and antidepressant drugs that exert neurotrophic effects in rodents appear to reverse or attenuate the gray matter volume abnormalities in humans with mood disorders. These neurotrophic effects may be integrally related to the therapeutic effects of such agents, because the regions affected by structural abnormalities in mood disorders are known to play major roles in modulating the endocrine, autonomic, behavioral, and emotional experiential responses to stressors.     

Family history of suicidal behavior and mood disorders in probands with mood disorders

OBJECTIVE: First-degree relatives of persons with mood disorder who attempt suicide are at greater risk for mood disorders and attempted or completed suicide. This study examined the shared and distinctive factors associated with familial mood disorders and familial suicidal behavior. METHOD: First-degree relatives' history of DSM-IV-defined mood disorder and suicidal behavior was recorded for 457 mood disorder probands, of whom 81% were inpatients and 62% were female. Probands' lifetime severity of aggression and impulsivity were rated, and probands' reports of childhood physical or sexual abuse, suicide attempts, and age at onset of mood disorder were recorded. Univariate and multivariate analyses were carried out to identify predictors of suicidal acts in first-degree relatives. RESULTS: A total of 23.2% of the probands with mood disorder who had attempted suicide had a first-degree relative with a history of suicidal behavior, compared with 13.2% of the probands with mood disorder who had not attempted suicide (odds ratio=1.99, 95% CI=1.21-3.26). Thirty percent (30.8%) of the first-degree relatives with a diagnosis of mood disorder also manifested suicidal behavior, compared with 6.6% of the first-degree relatives with no mood disorder diagnosis (odds ratio=6.25, 95% CI=3.44-11.35). Probands with and without a history of suicide attempts did not differ in the incidence of mood disorder in first-degree relatives (50.6% versus 48.1%). Rates of reported childhood abuse and severity of lifetime aggression were higher in probands with a family history of suicidal behavior. Earlier age at onset of mood disorder in probands was associated with greater lifetime severity of aggression and higher rates of reported childhood abuse, mood disorder in first-degree relatives, and suicidal behavior in first-degree relatives. CONCLUSIONS: Risk for suicidal behavior in families of probands with mood disorders appears related to early onset of mood disorders, aggressive/impulsive traits, and reported childhood abuse in probands. Studies of such clinical features in at-risk relatives are under way to determine the relative transmission of these clinical features.     

Postpartum mood disorders

Depression is a common disorder in women of childbearing age. Many women experience depressive symptoms during the postpartum period, ranging from mild postpartum blues to significant mood disorders such as postpartum depression and postpartum psychosis. The ‘baby blues‘ are extremely common, affecting 30-75% of new mothers. This form of postpartum mood change is self-limited and requires no specific treatment other than education and support. While less common, occurring in 10-15% of births, postpartum depression has the potential for significant impact on both the health of the mother and baby. Unfortunately, affective illness in women frequently goes unrecognized and untreated. While there are effective pharmacological treatments for postpartum depression, the treatments for postpartum depression are often not utilized due to concerns about lactation. Postpartum psychosis is extremely rare, affecting one to two women per 1000 births; each case represents a true psychiatric emergency. Identifying and treating postpartum affective illness in women is critical to the health of both mother and infant. This paper reviews the literature on the diagnosis and treatment of mood disorders in the postpartum period: postpartum blues, postpartum depression and postpartum psychosis.     

Postpartum mood disorders

Depression is a common disorder in women of childbearing age. Many women experience depressive symptoms during the postpartum period, ranging from mild postpartum blues to significant mood disorders such as postpartum depression and postpartum psychosis. The 'baby blues' are extremely common, affecting 30-75% of new mothers. This form of postpartum mood change is self-limited and requires no specific treatment other than education and support. While less common, occurring in 10-15% of births, postpartum depression has the potential for significant impact on both the health of the mother and baby. Unfortunately, affective illness in women frequently goes unrecognized and untreated. While there are effective pharmacological treatments for postpartum depression, the treatments for postpartum depression are often not utilized due to concerns about lactation. Postpartum psychosis is extremely rare, affecting one to two women per 1000 births; each case represents a true psychiatric emergency. Identifying and treating postpartum affective illness in women is critical to the health of both mother and infant. This paper reviews the literature on the diagnosis and treatment of mood disorders in the postpartum period: postpartum blues, postpartum depression and postpartum psychosis.