Treatment of Mental Disorders in Seven Physicians Committing Suicide

Through psychological autopsy seven cases of physician suicide were studied. All seven victims received a diagnosis of current mood disorder, two of them bipolar disorder. Five had suffered a disabling physical condition. None of the victims had had adequate treatment with antidepressant or mood-stabilizing drugs, nor had they been in psychotherapy. Current adequate treatment for depression seems to be as rare among physician victims as among suicides with major depressive disorders in the population.

Regional gray matter, white matter, and cerebrospinal fluid distributions in schizophrenic patients, their siblings, and controls

BACKGROUND

Cortical gray matter volume reductions and cerebrospinal fluid (CSF) volume increases are robust correlates of schizophrenia, but their sources have not been established conclusively.

METHODS

Structured diagnostic interviews and magnetic resonance imaging scans of the brain were obtained on 75 psychotic probands (63 with schizophrenia and 12 with schizoaffective disorder), ascertained so as to be representative of all such probands in a Helsinki, Finland, birth cohort; 60 of their nonpsychotic full siblings; and 56 demographically similar control subjects without a personal or family history of treated psychiatric morbidity.

RESULTS

Patients with schizophrenia and their siblings exhibited significant reductions in cortical gray matter volume and significant increases in sulcal CSF volume compared with controls. The patients, but not their siblings, also exhibited significant reductions in white matter volume and significant increases in ventricular CSF volume. Regional effects were most robust when component volumes were expressed as percentages of overall regional volumes; in this case, for patient and sibling groups, gray matter volume reductions and sulcal CSF volume increases were significantly more pronounced in the frontal and temporal lobes than in the remainder of the brain. None of the group differences varied significantly by sex or hemisphere.

CONCLUSIONS

Structural alterations of the cerebral cortex, particularly in the frontal and temporal lobes, are present in patients with schizophrenia and in some of their siblings without schizophrenia; such changes are thus likely to reflect genetic (or shared environmental) effects. Ventricular enlargement is unique to the clinical phenotype and is thus likely to be affected primarily by nonshared causative factors.

Inadequate dosaging in general practice of tricyclic vs. other antidepressants for depression

Several prescription database studies suggest major differences between antidepressants in the proportion of patients in general practice treated with doses likely to elicit a true drug response. However, in these studies it has been difficult to differentiate prescriptions for depression from those for other indications, or to distinguish lower starting doses from the final treatment doses. We investigated possible differences between types of antidepressant in the proportions of patients receiving adequate treatment doses for depression from the primary health care services of Helsinki. Doctors at 22 (71%) of the 31 health centres in Helsinki were surveyed with regard to their antidepressant prescriptions over a period of 2 working weeks. There were marked differences in dosaging adequacy between the various types of antidepressant prescribed for depression at final treatment doses. Overall, 71% of the prescriptions for the tricyclic antidepressants, but only 13% of those for the other antidepressants, mainly selective serotonin reuptake inhibitors, were for low doses that are generally considered to be ineffective (P<0.001). These findings endorse the emerging perception that, in general practice, tricyclic antidepressants are usually prescribed for depression in too low doses, and that a greater reliance on other antidepressants would probably improve the effectiveness of treatment in primary health care.

Randomized trial of physical exercise alone or combined with bright light on mood and health-related quality of life

BACKGROUND

So-called atypical depressive symptoms (carbohydrate craving, prolonged sleep, weight gain, increased appetite) frequently emerge in association with low illumination to which people are ordinarily exposed indoors, or even outdoors at extreme latitudes in wintertime. Our objective was to analyse the effect of physical exercise alone or combined with bright light on mood and the health-related quality of life during winter.

METHODS

We carried out a randomized controlled trial on 120 indoor employees in southern Finland between November and January. The subjects were allocated to supervised fitness training under bright (2500-4000 lx) or ordinary (400-600 lx) light conditions in a gym 2-3 times weekly for 8 weeks, or supervised relaxation training once a week over the same period as active placebo. We collected questionnaire data on the changes in mood and health-related quality of life after 4 and 8 weeks of training, and after 4 months follow-up.

RESULTS

Fitness training in bright light resulted in greater relief from atypical depressive symptoms and more vitality than in ordinary room light. Compared with relaxation alone, the former regime improved general mental health and social functioning in addition to the improvement in depressive symptoms and vitality, whereas the latter only increased vitality.

CONCLUSIONS

Supervised physical exercise combined with exposure to bright light appears to be an effective intervention for improving mood and certain aspects of the health-related quality of life in wintertime. This effect appears unrelated to the history of season-dependent symptoms, being noticeable among healthy individuals.

Seasonal affective disorder

Seasonal affective disorder (SAD) is a form of recurrent depressive or bipolar disorder, with episodes that vary in severity. Seasonal patterns of depressive episodes are common, but SAD seems to be less common than such patterns suggest. SAD was at first believed to be related to abnormal melatonin metabolism, but later findings did not support this hypothesis. Studies of brain serotonin function support the hypothesis of disturbed activity. The short-allele polymorphism for serotonin transporter is more common in patients with SAD than in healthy people. Atypical depressive symptoms commonly precede impaired functioning, and somatic symptoms are frequently the presenting complaint at visits to family physicians. The best treatment regimens include 2500 Ix of artificial light exposure in the morning. When patients seem to have no response or to prefer another treatment, antidepressants should be considered.

Concordance for sex and the pseudoautosomal gene hypothesis revisited: no evidence of increased sex concordance in a nationwide Finnish sample of siblings with paternally derived schizophrenia

OBJECTIVE

This study set out to determine, in a homogeneous sample with nationwide coverage in Finland, whether siblings treated for schizophrenia are more often of the same sex than expected by chance, and whether this is especially so when the disorder is transmitted by their fathers.

METHOD

Finnish social and health insurance files as well as hospital discharge registers were searched for probands with schizophrenia from a birth cohort spanning 30 years. Nuclear families were identified by cross-linkage with the national birth register, and the sex distribution observed in multiply affected sibships was compared with expected distributions by maximum likelihood analysis.

RESULTS

In the subset of multiply affected sibships with one parent who had schizophrenia (84 fathers and 120 mothers), the observed sex distribution did not deviate from the expected pattern. However, a small and marginally significant excess of sex concordance emerged from the total sample of 1,942 sibships in which there were at least two affected members, irrespective of the parents' affection status.

CONCLUSIONS

The results indicate that no above-chance sex concordance in sibships multiply affected with paternally transmitted schizophrenia is present in the genetically homogeneous population of Finland. In view of a virtually unbiased and complete ascertainment procedure and sample sizes one to two orders of magnitude larger than those in previous studies, the authors attribute prior findings of such a concordance to sampling artifacts or chance fluctuations and finally conclude that except for regional genetic isolates, there is no epidemiologic evidence that a gene accounting for substantial susceptibility to schizophrenia in a greater proportion of cases resides in the pseudoautosomal region of the sex chromosomes.

Linkage analysis of putative schizophrenia gene candidate regions on chromosomes 3p, 5q, 6p, 8p, 20p and 22q in a population-based sampled Finnish family set

During the past decade numerous studies have been published describing chromosomal regions potentially linked with schizophrenia. Unfortunately, none of these studies has been able to conclusively identify any specific gene that predisposes to schizophrenia. Typically evidence for linkage is seen on large chromosomal regions, as expected, containing tens or even hundreds of genes. Furthermore, attempts to replicate the findings have rarely been successful leaving a confusion about the existence of predisposing genes for schizophrenia in a particular region of the genome. We have carried out linkage analysis in a set of 62 pedigrees rising from a genetically isolated population of Finland with markers on six chromosomal regions earlier suggested to harbor predisposing genes for schizophrenia, namely 3p, 5q, 6p, 8p, 20p, and 22q. We were not able to find significant evidence for linkage on any of these chromosomal regions. However, some support for linkage was found on all studied chromosomal regions, except 3p.

Attitudes towards genetic testing: analysis of contradictions

A survey study was conducted among 1169 people to evaluate attitudes towards genetic testing in Finland. Here we present an analysis of the contradictions detected in people's attitudes towards genetic testing. This analysis focuses on the approval of genetic testing as an individual choice and on the confidence in control of the process of genetic testing and its implications. Our analysis indicated that some of the respondents have contradictory attitudes towards genetic testing. It is proposed that contradictory attitudes towards genetic testing should be given greater significance both in scientific studies on attitudes towards genetic testing as well as in the health care context, e.g. in genetic counselling.

Assignment of the locus for PLO-SL, a frontal-lobe dementia with bone cysts, to 19q13

PLO-SL (polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy) is a recessively inherited disorder characterized by systemic bone cysts and progressive presenile frontal-lobe dementia, resulting in death at <50 years of age. Since the 1960s, approximately 160 cases have been reported, mainly in Japan and Finland. The pathogenesis of the disease is unknown. In this article, we report the assignment of the locus for PLO-SL, by random genome screening using a modification of the haplotype-sharing method, in patients from a genetically isolated population. By screening five patient samples from 2 Finnish families, followed by linkage analysis of 12 Finnish families, 3 Swedish families, and 1 Norwegian family, we were able to assign the PLO-SL locus to a 9-cM interval between markers D19S191 and D19S420 on chromosome 19q13. The critical region was further restricted, to approximately 1.8 Mb, by linkage-disequilibrium analysis of the Finnish families. According to the haplotype analysis, one Swedish and one Norwegian PLO-SL family are not linked to the chromosome 19 locus, suggesting that PLO-SL is a heterogeneous disease. In this chromosomal region, one potential candidate gene for PLO-SL, the gene encoding amyloid precursor-like protein 1, was analyzed, but no mutations were detected in the coding region.

Disability pensions in severely disturbed in-patient adolescents. Twenty-year prospective study

BACKGROUND

Knowledge of working capacity from adolescence until adulthood among severely disturbed in-patients is scarce.

METHOD

In a follow-up study of 61 adolescent in-patients, we studied associations between being on a disability pension 20 years after hospitalisation, and the patients' psychopathology and treatment-related factors during the hospitalisation and seven-year follow-up.

RESULTS

Of the former in-patients, 27% had not been on a disability pension, 20% had short-term pension periods, and 53% were pensioned. Subjects whose overall psychosocial functioning had improved and who had not utilised in-patient services until the seven-year follow-up, had a better prognosis in terms of working capacity. Half of the subjects who had not been on pension during the follow-up had received a diagnosis of conduct disorder at discharge, and half of those pensioned had a psychotic disorder.

CONCLUSIONS

The patients' level of psychosocial functioning and capability to work in young adulthood were associated with long-term prognosis in terms of working capacity. Adolescence seems to be the critical time for intensive psychiatric care combined with vocational rehabilitation programmes.

The genetic epidemiology of schizophrenia in a Finnish twin cohort. A population-based modeling study

BACKGROUND

The magnitude of heritability of schizophrenia remains controversial, due in part to limitations of estimates derived from index twin pairs exclusively. We applied structural equation modeling in a total population of twins to determine the significance and magnitudes of the genetic and environmental contributions to schizophrenia.

METHODS

All monozygotic (1180 male and 1315 female pairs) and same-sex dizygotic (2765 male and 2613 female pairs) twins born from 1940 to 1957 in Finland were screened for nonorganic psychotic disorder diagnoses as recorded on an inpatient or outpatient basis or from an eligibility review for a disability pension.

RESULTS

The lifetime prevalence of schizophrenia was 2.0%, with a marginally higher prevalence in men (2.2%) than women (1.8%). Model fitting indicated that 83% of the variance in liability was due to additive genetic factors, and the remaining 17% was due to unique environmental factors. Sex-limitation modeling revealed no evidence of sex-specific genetic effects and no sex difference in the magnitude of heritability. A multiple threshold model incorporating affective and other psychoses as a phenotype intermediate between schizophrenia and no diagnosis was rejected.

CONCLUSIONS

In a population-based twin study of schizophrenia, heritability was estimated at 83%, with the remaining variance in liability attributed to environmental factors not shared in common among co-twins. Despite the notable limitation of using diagnoses ascertained through treatment contacts, the heritability estimate in this study is almost identical to those reported in recent studies of index pairs using standardized applications of DSM-III or later criteria.

Employment status influences the weekly patterns of suicide among alcohol misusers

As part of the National Suicide Prevention Project in Finland, a nationwide psychological autopsy study, all suicide victims (n = 1397) over a 12-month period were investigated concerning factors associated with any variation in suicide frequency between weekdays and weekends. In particular, employment status was expected to have influenced the weekly pattern of alcohol misuse, and thereby to have caused clustering of suicides at weekends among the employed. Among suicide victims who had misused alcohol, those in employment were significantly more likely to have committed suicide during the weekend that those without work (52% vs. 34%, p < 0.001). In logistic regression analysis, employment was the only independent variable significantly associated with suicide at the weekend. According to forensic chemical analysis, those classified as misusers had frequently used alcohol at the time of suicide, regardless of the weekday, and slightly more often if employed. The clustering of suicides at weekends among employed alcohol misusers is probably explained by a weekly pattern in the use of alcohol, which suggests that besides the established risk factors for suicide among alcohol misusers, the act of using alcohol per se also contributes to the suicidal act.

Medical surveillance often precedes suicide among female physicians in Finland. A case-control study

Official medical surveillance among Finnish physicians who had committed suicide in 1983-1994 was investigated. Definite cases of suicide (ICD categories E950-E959) (n = 50) were compared with a living age- and sex-adjusted control group of physicians (n = 200). All National Board of Health (NBH) documents relating to official surveillance in 1983-1994 were examined. Seven cases of surveillance (three males, four females) were found among suicide cases and only one in controls, the relative odds thus being 28 (95% confidence interval 4.3 to 636). All suicide victims had had several major problems, including mental and somatic disorders and difficulties in their personal relationships. The risk of suicide was especially high among female physicians under surveillance. However, only in one case did disbarment from the medical profession seem to be a crucial factor preceding a suicide.

Suppression of melatonin secretion by bright light in seasonal affective disorder

Eleven patients with winter seasonal affective disorder and 10 healthy controls were exposed to light of 3300 lux for 5 min and for 1 hour respectively on consecutive evenings at 22:00 hours during winter and summer. In the winter, the measurements were undertaken both before and after the treatment with bright light for 2 weeks. In the summer, there was no treatment. Melatonin concentration in saliva and subjective sleepiness were measured at 22:00 and 23:00 hours on each test. There was no significant difference in the suppression of melatonin in response to the light tests between the patients and the controls. Exposure to light reduced the level of subjective sleepiness more among the patients compared to the control subjects. This reduction was not associated with the change in melatonin secretion nor the improvement in depressive symptoms.

Psychosocial functioning in adolescent psychiatric patients: a prospective study on changes in psychosocial functioning among severely and moderately impaired adolescent out-patients

Changes in psychosocial functioning during out-patient treatment among 73 adolescent male and 100 female subjects, aged 12 to 19 years, were studied. The mean number of total treatment sessions was 15 sessions among the severely impaired and 14 sessions among the moderately impaired patients. The level of psychosocial functioning improved among the severely impaired (Global Assessment Scale (GAS) at treatment entry 3.9 vs. 4.7 at the last session, 95% CI, -1.085 to -0.577) and the moderately impaired patients (GAS 5.5 vs. 6.0, 95% CI, -0.682 to -0.355). The improvement was highly dependent on the psychiatric diagnosis. The level of psychosocial impairment improved in about two-thirds of subjects with adjustment and non-comorbid mood disorders, in about one-third of those with non-comorbid personality disorders, and in about a quarter of those with disruptive disorders. Careful diagnostic evaluation and assessment of psychosocial functioning are essential elements in the development of adolescent psychiatric services.

Acceptance of genetic testing in a general population: age, education and gender differences

The aim of the study was to analyze effects of age, education and gender on acceptance of genetic testing. Subjects, n = 1967 aged 15-69, were a stratified random sample of the Finnish population. One thousand, one hundred and sixty nine subjects, 530 men and 639 women, returned the questionnaire. The majority of the respondents approved of the availability of genetic testing. Young, aged 15-24, were more favourable towards testing and more willing to undergo suggested tests, but they were also more worried than others about the misuse of test results. Men aged 45-69 with only basic education were more in favour of mandatory genetic testing than other respondents. Respondents with university education were more critical towards genetic testing and expressed their worry about eugenics more often than other education groups. In conclusion, there are age, education and gender related differences in acceptance of genetic testing which need to be taken into account when considering screening programmes and informing the public.

Suicide mortality among medical doctors in Finland: are females more prone to suicide than their male colleagues?

BACKGROUND

Suicide mortality among medical practitioners is in many countries significantly higher compared with other professionals and the general population. Differences between male and female physicians are difficult to estimate reliably because previous comparisons are mainly based on crude mortality rates.

METHODS

Age-specific mortality rates were calculated for physicians, other professionals and the general population, males and females separately, as well as standardized mortality ratios (SMR) comparing physicians with the other groups. Crude mortality rates were calculated for the specialist groups.

RESULTS

The SMR for male (female) physicians was 0.9 (2.4) compared with the general male (female) population and 2.4 (3.7) compared with other male (female) professionals. The SMR between male and female physicians was 1.2 (95% CI 0.9-1.7).

CONCLUSIONS

Our results do not support the claim that female physicians have a greater risk of suicide than their male colleagues, but are concordant with previous observations of a higher suicide rate in female physicians compared with the general population and other female professionals.

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.

Psychological defense styles in late adolescence and young adulthood: a follow-up study

OBJECTIVE

The aims of this follow-up study were to examine in both sexes (1) the stability of defense styles from late adolescence to early adulthood and (2) the ability of adolescent defense styles to predict later psychiatric symptoms.

METHOD

Defense styles were examined using the Defense Style Questionnaire. Five hundred sixteen high school students (337 females and 179 males) completed the questionnaire at 15 through 19 years of age, and again 5 years later. In the follow-up examination the General Health Questionnaire was used to assess psychiatric disturbance.

RESULTS

Neurotic and immature defense style scores decreased significantly in both sexes, whereas mature defense style scores did not change significantly. Females had significantly higher neurotic defense style scores than males in both late adolescence and young adulthood. Psychiatric disturbance at follow-up was associated positively with baseline immature defense style scores in both sexes, and negatively with baseline mature defense style scores in females.

CONCLUSIONS

Development of defenses was apparent as a decrease in neurotic and immature defense style scores. In both sexes, immaturity of defenses in late adolescence predicted psychiatric symptoms in young adulthood.

Schizophrenia in the genetic isolate of Finland

We compared the features of schizophrenia in the homogeneous population of Finland (population about 5,000,000) and in an internal isolate in northeastern Finland inhabited in the 1680s by a small group of founders (current population about 18,000) in a register-based epidemiological study. We identified all cases with a diagnosis of schizophrenia in Finland born between 1940-1969 using three national computerized registers and found a total of 267 schizophrenia patients in the internal isolate and 29,124 in Finland. The lifetime prevalence was 2.21% in the internal isolate and 1.21% in Finland, respectively. The age-corrected lifetime risk was 3.2% in the internal isolate and 1.1% in the whole country. The risk of schizophrenia to siblings in the internal isolate was 6.4% (95% confidence interval 0.052, 0.078), 9.1% (95% CI 0.062, 0.130), and 6.8% (95% CI 0.028, 0.135) given 1, 2, or 3 affected siblings, and for all Finland 4.2% (95% CI 0.036, 0.043), 6.4% (95% CI 0.058, 0.071), and 8.7% (95% CI 0.068, 0.107) given 1, 2, or 3, affected siblings, respectively. The mean number of children in schizophrenia families and thus the number of families having at least two affected individuals were clearly higher in the isolate (24.9% vs 9.2%). We did not find any other epidemiological features differing between these two regions. It seems that the family material collected from the internal isolate is a representative subsample from the entire country and hopefully it enables easier identification of at least some predisposing genes for schizophrenia due to its unique population structure.

Suicides among physicians, engineers and teachers: the prevalence of reported depression, admissions to hospital and contributory causes of death

The number of admissions to hospital, reported diagnoses, prevalence of reported depression and contributory causes of death among Finnish physicians, engineers and teachers who committed completed suicide between 1986 and 1993 were studied. The data for hospital admissions with diagnoses were obtained from the Finnish Hospital Discharge Register. Thin-layer chromatography was used to detect drugs in the liver, a dual-column gas chromatographic method was used for screening and quantification of drugs in the blood sample, and a head-space chromatographic method was used to measure blood alcohol levels. Physicians had more somatic diagnoses than the reference groups, and the prevalence of reported depression was higher among females than males. A minority of the depressed subjects had been admitted to hospital, although depression was observed to be the most prevalent contributory cause of death in all of the groups studied. The physicians used solid or liquid substances, especially barbiturates, as the main method of suicide. It is possible that depression in physicians, especially in male subjects, is undertreated in psychiatric hospitals.

Differences between urban and rural suicides

As part of a nation-wide psychological autopsy we examined the differences in DSM-III-R mental disorders, recent life events and other characteristics between urban (n = 143) and rural (n = 85) completed suicides in a random sample of 229 cases from the National Suicide Prevention Project in Finland for the period 1987-1988. Psychoactive substance use disorders (48% vs. 34%), cluster B personality disorders (24% vs. 9%) and psychiatric comorbidity (66% vs. 42%) were found more commonly among urban than rural suicides. Urban suicides were also more often reported to be preceded by a recent separation (25% vs. 8%), whereas rural suicide victims tended to have lacked a close companion of the opposite sex (36% vs. 18%) and to have had physical disorders (56% vs. 40%). Overall, urban and rural suicides may vary with regard to the prevalence of some mental disorders, their comorbidity, and physical disorders, as well as the preceding life situation. This variation may also imply the need for differences in strategies for suicide prevention in each setting.

Suicide among military conscripts in Finland: a psychological autopsy study

This study describes suicides during compulsory military service and compares them with other young male suicides as part of a nationwide psychological autopsy study of all suicides in Finland during a single year. The victims' relatives and attending health care personnel were interviewed, and data from records were collected. Five of the seven conscript suicides had a depressive syndrome, often of short duration. Two victims previously had suicidal thoughts or attempted suicide. The most common suicide method was with firearms. Compared with other young male suicides, physical illness in conjunction with a psychiatric diagnosis was less common in the conscript victims. Civilian male suicides tended to have more substance abuse and more severe psychological impairment. They also committed suicide under the influence of alcohol more often than conscripts. Interpersonal separation was more often the precipitating event of the suicide among the conscripts than among the other suicides. Conscripts should be encouraged to utilize health and social services when they have psychosocial problems or even minor psychiatric symptoms.

Suicides after pregnancy in Finland, 1987-94: register linkage study

OBJECTIVE

To determine rates of suicide associated with pregnancy by the type of pregnancy.

DESIGN

Register linkage study. Information on suicides in women of reproductive age was linked with the Finnish birth, abortion, and hospital discharge registers to find out how many women who committed suicide had had a completed pregnancy during her last year of life.

SETTING

Nationwide data from Finland.

SUBJECTS

Women who committed suicide in 1987-94.

RESULTS

There were 73 suicides associated with pregnancy, representing 5.4% of all suicides in women in this age group. The mean annual suicide rate was 11.3 per 100,000. The suicide rate associated with birth was significantly lower (5.9) and the rates associated with miscarriage (18.1) and induced abortion (34.7) were significantly higher than in the population. The risk associated with birth was higher among teenagers and that associated with abortion was increased in all age groups. Women who had committed a suicide tended to come from lower social classes and were more likely to be unmarried than other women who had had a completed pregnancy.

CONCLUSIONS

The increased risk of suicide after an induced abortion indicates either common risk factors for both or harmful effects of induced abortion on mental health.