Incidence and method of suicide mortality in patients with schizophrenia: a Nationwide Cohort Study

Purpose

Suicide is a leading cause of death in patients with schizophrenia. This nationwide cohort study investigated the incidence of each suicide method in patients with schizophrenia compared with the general population.

Methods

In total, records of 174,039 patients with schizophrenia were obtained from the National Health Insurance Research Database in Taiwan from 2001 to 2016. This schizophrenia cohort was linked with the national mortality database, and 26,926 patients died during this follow-up period. Of the deceased, 3033 had died by suicide. Univariate Cox regression was used to estimate the demographic variables associated with suicide. We estimated the difference in the proportion of each suicide method used in patients with schizophrenia compared with the general population. The incidence and standardized mortality ratio (SMR) of each suicide method were calculated and stratified based on sex.

Results

Patients aged 25–34 years exhibited the highest suicide risk. Compared with the general population, patients with schizophrenia were more likely to commit suicide by jumping and drowning and less likely to use charcoal-burning and hanging. Women showed a higher incidence of suicide by drowning and jumping than did men. Comorbidity with substance use disorders (SUDs) was associated with a high suicide SMR (26.9, 95% confidence interval [CI] = 23.4–28.9), particularly for suicide by jumping (61.2, 95% CI = 48.3–76.3).

Conclusions

Patients with schizophrenia had higher suicide rates for all methods than did the general population. Suicide method differed based on sex. Patients with SUDs exhibit a high SMR for each suicide method and warrant intensive clinical attention.

     

Prevalence and identification of alcohol use disorders among severe mental illness inpatients in Taiwan

Aims:  A higher prevalence of alcohol use disorders (AUD) among psychiatric patients has been reported previously and the identification rate is relatively low. This study was designed to investigate the prevalence and identification of AUD among acute psychiatric inpatients with severe mental illness in a psychiatric hospital in Taiwan.
Methods:  In a two-phase case identification strategy, the Alcohol Use Disorders Identification Test (AUDIT) was used as the first phase screening tool and the Structured Clinical Interview for DSM-IV-TR as the second phase diagnostic interview. The definition of identification was diagnosis of AUD on medical record at discharge.
Results:  Of 400 respondents, 42 screened positive and 358 screened negative. All screen-positive respondents and 35 screen-negative respondents entered the second phase interview. The weighted lifetime prevalence of alcohol dependence was 8.3% (95% confidence interval [CI]: 4.6–11.9%); alcohol abuse, 1.5% (95%CI: 0.2–2.8%); and AUD, 9.8% (95%CI: 5.7–13.8%). The overall identification rate of AUD by medical staff was 28.2% (0% for alcohol abuse and 33.3% for alcohol dependence). Patients with mood disorders were prone to being undetected as having AUD.
Conclusion:  AUD comorbidity was common among inpatients with severe mental illness in Taiwan and was easily neglected by medical staff. It is necessary to use a validated screening questionnaire, such as AUDIT, to detect high-risk patients and then give appropriate interventions to enhance treatment outcome.     

Cognitive impairment in later life in patients with early-onset bipolar disorder

OBJECTIVES: Cognitive impairment may interfere with psychosocial functioning in bipolar disorder (BD). There is limited information regarding the cognitive function of elderly bipolar patients with onset at a young age. The present study aimed to investigate the frequency and the determinants of cognitive impairment in elderly early-onset bipolar patients. METHODS: Using the Clock-drawing Test (CDT), the Mini Mental State Examination (MMSE), and the Cognitive Abilities Screening Instrument (CASI), we examined euthymic patients with bipolar I disorder in Taiwan, aged 60 years and older. Clinical data were obtained by reviewing medical records and personal interviews with patients and their family members. The onset of BD prior to the age of 40 years is defined as 'early-onset'. RESULTS: Of the 52 early-onset patients, 42.3% were determined to have cognitive impairment by exhibiting either abnormal CDT or education-adjusted MMSE scores. In a multiple regression model, years of education and the age at the last manic/hypomanic (but not depressive) episode accounted for the greatest variance in both MMSE and CASI scores. While educational level and the age at the last manic/hypomanic episode were not considered in the regression model, onset with depressive syndrome and current age explained 21.5% of the variance in MMSE scores. Age at the first depressive episode, the first manic episode before the age of 40 years, and comorbid diabetes accounted for 16.7% of the variance in CASI scores. CONCLUSIONS: There appeared to be a sizable proportion of elderly early-onset bipolar patients having cognitive impairment. It is suggested that clinical manifestation of first-onset affective episode and impact of medical comorbidity affect the cognition of early-onset BD in later life.     

Brief alcoholism screening questionnaire: establishment and validity in Taiwanese.

BACKGROUND AND PURPOSE: There has been a marked increase in the prevalence of alcoholism in the Taiwanese population over the past 6 decades. This study was designed to establish a Taiwanese Brief Alcoholism Screening Questionnaire (BASQ) for use in early detection in medical and public health settings. METHODS: Interview data were collected from the database of the Taiwan Psychiatric Epidemiological Project (TPEP). The TPEP interviews had been conducted using the Chinese-modified version of the Diagnostic Interview Schedule (DIS-CM) that included a section on alcoholism diagnosis. Data collected from a community sample of 13,373 subjects was used in this study. Twenty nine DIS-CM items for alcoholism diagnosis were entered into an analytic model with 7 statistical filters to identify cross-cultural items. A brief alcoholism screening questionnaire was constructed using these selected items. The validity of the questionnaire was tested in subjects (n = 457) recruited from a local medical center, a hospital clinic, and an alcoholism clinic of a psychiatric center. RESULTS: Four cross-cultural items were identified and the BASQ was constructed. This BASQ had a best cut-off point of 3 with adequate sensitivity (0.86 to 0.88), specificity (0.88 to 0.89), and positive prediction rate (0.90 to 0.91). It detected a varying prevalence of alcoholism (10.1 to 90.3%) in diverse clinical settings. CONCLUSIONS: A 4-item BASQ was established with adequate validity for clinical and public health application in the early detection of alcoholism in Taiwanese subjects.     

Self-Reported Flushing and Genotypes of ALDH2, ADH2, and ADH3 among Taiwanese Han

The aims of this study are to investigate whether self-reported facial flushing postalcohol consumption (PAC) among subjects with ALDH2*1/*1 can be attributed to ADH2 or ADH3 and whether the prediction of ALDH2 genotype can be improved by examining the combination of flushing and other accompanying reactions of PAC sensitivity. Fifty-eight subjects of Han ancestry in Taiwan were interviewed for alcohol-sensitivity reactions and their blood samples were genotyped for ALDH2, ADH2, and ADH3. For subjects with ALDH2*1/*1 ( n = 46), 70% reported to have no flushing PAC and 30% reported flushing PAC. When subjects with ALDH2*1/*1 had ADH2*1/*1 ( n = 11), all reported to have no flushing; otherwise, 35% (for ADH2*1/*2, n = 17) and 44% (for ADH2*2/*2, n = 18) reported flushing. For subjects with ALDH2*1/*1 and at least one ADH2*2 allele, the genotype of ADH3 was not associated with self-reported flushing. PAC flushers with ALDH2M/M (50%) were more likely to report nausea than those with ALDH2*1/*2 (8%). The probability of ALDH2*1/*1 given flushing reported was 0.29, while the probability of ALDH2*1/*1 given both flushing and nausea reported was 0.71. The results indicate that self-reported flushing is determined by both ALDH2 and ADH2 and that prediction of ALDH2 genotype on the basis of self-reported flushing and nausea can help identify subjects at increased risk for alcoholism.     

Low Frequency of the ADH2*2 Allele among Atayal Natives of Taiwan with Alcohol Use Disorders

Genetic variation at two polymorphic alcohol dehydrogenase loci, ADH2 and ADH3, and at the polymorphic mitochondrial aldehyde dehydrogenase locus, ALDH2, may influence the risk of developing alcoholism by modulating the rate of elimination of ethanol and the rate of formation and elimination of acetaldehyde. Populations differ in allele frequencies at these loci. We determined the genotypes at all three of these loci in Atayal natives of Taiwan. The frequencies of ADH2'2, ADH3'1, and ALDH2'1 alleles (0.91, 0.99, and 0.95, respectively) were significantly higher among the Atayal than among a predominantly Han Chinese population from Taiwan. Among the Atayal, the group with alcohol use disorders (alcohol dependence and alcohol abuse) had a significantly lower frequency of the ADH2'2 allele (0.82) than those without alcohol use disorders (0.91). The ADH2*2 allele encodes the β2 subunit; isozymes containing β₂ sub-units oxidize alcohol faster in vitro than the β₁β₁ isozyme encoded by ADH2*1. Thus, the simplest explanation for these data is that individuals with a β2 isozymes have a higher rate of ethanol oxidation, which is a deterrent to alcohol abuse and dependence in some individuals. The Atayal with alcohol use disorders also had a lower frequency of ALDH2*2 than the controls; this allele is known to be responsible for the alcohol-flush reaction among Asians, and thereby deters drinking.     

Outcome following a first manic episode: cross-national US and Taiwan comparison

OBJECTIVES: Bipolar disorder (BD) is recognized as a significant psychiatric condition worldwide, yet little is known about cross-national differences in the course of illness. This information might clarify features of the disorder that are illness versus culturally specific. Therefore, the aim of this study was to identify differential and shared outcome predictors in first-episode manic bipolar patients in Cincinnati, OH, USA and Taipei, Taiwan. METHODS: DSM-IV bipolar patients were identified at the time of their first manic or mixed episode and were prospectively followed in a naturalistic, longitudinal study for one year. Patients were recruited from a first psychiatric hospitalization at university-affiliated, urban hospitals in Taipei and Cincinnati. The primary outcome measures were remission, recovery, recurrence and percent of follow-up spent with affective symptoms and syndromes. Treatment adherence was also assessed, as were a number of possible mediator variables. RESULTS: The two patient groups showed a number of significant differences in index clinical presentation on characteristics previously associated with outcome in other studies (e.g., substance abuse). The patients in Taipei showed significantly better outcome on virtually all measures. Some of these findings reflected differences in index (mediator) variables, whereas others persisted after controlling for potential baseline confounds. CONCLUSIONS: The early course of BD varies between Chinese and American patients. Some of this variance results from demographic and clinical cross-national differences in premorbid variables. Other sources of variance remain to be identified.     

Oxidative status in patients with alcohol dependence: a clinical study in Taiwan

The aim of this study is to examine the relationship between alcohol dependence and oxidative status. The biochemical parameters and antioxidants status were measured among 28 patients with alcohol dependence. Nineteen healthy persons without drinking problem were recruited as the control subjects. The activities of aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyltransferase (gamma-GT), and levels of cholesterol, triglyceride (TG), and uric acid were significantly increased in the specimen of patients compared with control. Serum malondialdehyde (MDA) levels of the patients were found to be significantly increased compared with controls and decreased after abstinence. Superoxide dismutase (SOD) and glutathione peroxidase (GPX) activities were, respectively, 86% and 37% lower in alcoholic patients. After 14 d of abstinence, SOD activity was significantly reduced by 85%, CAT by 52%, and GPX by 54%, whereas no change was found in activity of glutathione reductase (GR). The duration of alcohol dependence is significantly correlated with the levels of MDA. In addition, the activity of CAT was significantly correlated with MDA levels. The results of this study suggest that oxidative stress occurred during alcohol dependence and subsequently affected the antioxidants mechanisms.     

A retrospective analysis of risk and protective factors for natural death in bipolar disorder

OBJECTIVE: Many of the prior mortality studies on bipolar disorder have emerged primarily from the larger health service groups, with a tendency to focus on suicide alone. This study examines personal and clinical characteristics of bipolar patients in Taiwan in order to identify the factors associated with early natural death. METHOD: Bipolar patients admitted to a psychiatric hospital in Taiwan between 1987 and 2002 were retrospectively followed through record linkage for cause of death. One living bipolar individual was matched to each deceased patient as a control subject for age, gender, and date of index admission. Clinical data and the results of laboratory examinations during the last period of hospitalization were obtained through a review of medical records. RESULTS: In a total of 60 natural deaths, the principal cause was circulatory disease (33.3%). Conditional logistic regressions revealed that the variables most strongly associated with natural deaths were years of antipsychotic treatment prior to the last visit (95% CI for odds ratio [OR] = 0.77 to 0.98), serum alanine aminotransferase levels (95% CI for OR = 1.02 to 1.25), and leukocyte counts (95% CI for OR = 1.01 to 2.50). Years of lithium treatment (95% CI for OR = 0.74 to 0.97) may be substituted for antipsychotic treatment as a protective factor. CONCLUSIONS: Systemic inflammation and nonhepatic tissue damage during the acute phase of bipolar disorder may be risk factors for early natural death. Psychiatric treatment, including medication with antipsychotics or lithium, could be a factor in protecting against early natural death.     

Risk factors for completed suicide in bipolar disorder

BACKGROUND: Because Chinese bipolar patients in Taiwan, unlike Western patients, exhibit low comorbidity of substance abuse disorders, this retrospective and controlled study of completed suicide in bipolar patients explored the risk period and other risk factors for such an outcome. METHOD: All acute inpatients with bipolar I disorder (DSM-IV) were followed from date of admission after January 1, 1985, until December 31, 1996, in regard to their death. The patients were followed by record linkage to the Death Certification System in Taiwan, which was issued throughout 1996. Nineteen female and 24 male patients died as a result of suicide within this period. Forty-one of 43 of the total number of patients were matched with 1 living bipolar individual (as a control subject) for age, sex, and date of admission. Demographic data, family history, and clinical characteristics were collected from the patients' medical records and were formally confirmed at every admission. RESULTS: The lifetime prevalence of alcohol/drug use disorders was 14.6% in suicide completers. Thirty suicide completers (69.8%) revealed duration of illness of at least 7 years at the time of death. The latency period from the presumed time of onset to completing suicide averaged 12.2 years. The mean age at the first suicide attempt was 31.1 years among 43 completers and 10 living controls who had ever attempted suicide. Conditional logistic regression revealed a strong association of suicide (p < .001) with the following factors: onset with mood-congruent psychotic feature (adjusted odds ratio [OR] = 0.18, 95% confidence interval [CI] = 0.04 to 0.74), positive first-degree family history of completed suicide (adjusted OR = 15.08, 95% CI = 1.39 to 163.50), and making a suicide attempt at least once in 7 years of illness (adjusted OR = 4.96, 95% CI = 1.03 to 23.83). There appeared to be no significant difference in fasting levels of serum cholesterol or blood sugar between the suicide completers and the living controls. CONCLUSION: The first 7 to 12 years subsequent to onset of affective illness and age less than 35 years may be the high-risk periods for suicide in bipolar disorder. Those bipolar disorder patients who have a first-degree family history of suicide and who have more suicide attempts (at least once in 7 years of illness) are likely to commit suicide. Symptomatology (e.g., mood congruence of psychotic features) at the time of presumed disease onset may potentially differentiate subgroups of bipolar patients with various levels of suicide risk.