Suicide: a four-pathway clinical-biochemical model

Association between low plasma levels of cholesterol and relapse in cocaine addicts

OBJECTIVE

In light of recent studies suggesting the existence of associations between low concentrations of cholesterol and various psychiatric disorders, we decided to explore relationships between cholesterol levels and relapse rates in a group of cocaine addicts who had undergone inpatient detoxification.

METHODS

The total cholesterol levels of 38 non-opiate-dependent and non-alcohol-dependent cocaine addicts were determined while they were hospitalized. Drug use was subsequently assessed 3, 6, and 12 months after patients were discharged from the hospital.

RESULTS

Comparisons of the cholesterol levels (obtained during hospitalization) of relapsers and nonrelapsers by analyses of covariance with age and weight as covariates revealed significantly lower cholesterol values in patients who relapsed at 3 months (p =.046), 6 months (p =.030), and 12 months (p =.019) after discharge.

CONCLUSIONS

This study showed an association between a low total cholesterol level and relapse rates in detoxified cocaine addicts. Reasons for the predictive value of low cholesterol levels for relapse for up to 1 year after cholesterol measurements were made are unclear. These data are preliminary and in need of replication.

Impulsivity and phase of illness in bipolar disorder

BACKGROUND

Impulsivity is prominent in bipolar disorder, but there is little quantitative information relating it to phase of illness.

METHODS

We measured impulsivity in patients with bipolar disorder who had not met episode criteria for at least 6 months, patients who were manic, and healthy control subjects. Impulsivity was measured using the Barratt Impulsiveness Scale (BIS) and performance on the computerized Immediate Memory-Remote Memory Task (IMT-DMT), based on the Continuous Performance Test, which has been shown to reflect risk of impulsivity in other populations.

RESULTS

BIS scores in euthymic and manic bipolar subjects were identical, and were significantly elevated compared to controls. Commission errors (impulsive responses) on the IMT-DMT were elevated in manic subjects but were identical to controls in euthymic subjects. Measures of impulsivity did not appear related to depressive symptoms.

LIMITATIONS

The number of subjects was too small for detailed investigation of the role of comorbidities; subjects were receiving pharmacological treatments.

CONCLUSIONS

Impulsivity has state- and trait-related aspects in bipolar disorder.

Suicidality, impulsivity and aggression--is there a link to 5HIAA concentration in the cerebrospinal fluid?

In biological suicide research, low cerebrospinal fluid-5-hydroxyindolacetic acid (CSF-5HIAA) concentrations have been associated with suicidality, aggression and impulsivity. However, it frequently appears that the interpretation of existing study results is flawed. The analysis of various published findings suggests that contaminating factors like impulsivity or depressive symptoms in suicide attempters are often not taken into consideration at the time of suicide. The seemingly 'robust' association of low CSF-5HIAA concentration with 'suicidality' and 'aggression' is in fact rather weak. Reported associations of subgroups of suicidal behavior (e.g. violent suicide attempts) with low CSF-5HIAA concentrations are likely to represent somewhat premature translations of findings from studies that have flaws in methodology. Furthermore, the perception of 'suicidal behavior' as autoaggressive behavior or inwardly directed aggression in the view of the authors may not be useful in biological suicide research. The construct of aggressivity is insufficiently defined, resulting in difficulties to interpret empirical data. Some evidence exists, however, that reduced CSF-5HIAA concentrations might be related to certain depressive symptoms and changes in impulsivity. More carefully designed studies are required to overcome the existing methodological shortcomings.

The depressed suicidal patient. Assessment and treatment

Depressive disorders are associated with significant psychosocial impairment and disability. Depression should be thoroughly evaluated, as should current and past suicidality and potential risk factors for suicide. Mortality by suicide characterizes the course of major affective disorders in approximately 15% of those suffering from these illnesses. Several neurobiological correlates of suicidality have been discovered. Treatment of depression with suicidality may involve hospitalization, pharmacotherapy, electroconvulsive therapy, and psychotherapy. Special populations include children and adolescents, the elderly, medically ill patients, patients with comorbid personality disorders, and patients with comorbid substance abuse disorders. Clinicians encountering patients with depressive disorders should be proficient in the assessment and treatment of depression with suicidality.

Stress system alterations and mood disorders in suicidal patients. A review

Stress system alterations, in particular HPA axis hyperactivations, are fairly well documented in suicide victims and in depressed suicide attempters who subsequently complete suicide. In suicide attempters with no documented completed suicide, the results are more inconsistent. This may depend on differences in studies due to diagnostic heterogeneity among suicide attempters, and the time between the suicide attempt and the examination. Recent data suggests differences in the stress system between depressed patients with a recent suicide attempt and depressed patients in general. The field merits further examination, with thorough examinations of genotypes, actual suicide attempts and stress in combination with examinations of the stress system.

Cholesterol and triglyceride levels in the serum of muricidal male Wistar rats: indices of mitochondrial benzodiazepine receptors?

Cholesterol and triglyceride levels were studied in the serum of aggressive muricidal and non-muricidal male Wistar rats. The muricidal behavior was either spontaneous or induced by a long-term isolation or by adrenalectomy. Cholesterol levels were slightly higher in the whole population of muricidal rats; this was mainly observed in spontaneously and in adrenalectomized muricidal rats, as compared to non-muricidal rats of the same series. As regards triglyceride levels, they were significantly higher in the whole population of muricidal rats, mainly in isolation- and adrenalectomy-induced muricidal rats; the ratio of triglycerides to body weight was higher in the serum of muricidal rats of all series. The possible significance of these results is discussed in light of the data of the literature and related to the functional role of either mitochondrial benzodiazepine receptors or serotonin.

Suicide and unemployment in Italy, 1982-1994

OBJECTIVE

To investigate whether either the condition of being unemployed, or changes in unemployment rates are associated with suicide risk.

DESIGN

Administrative data for suicide according to occupational status have been analysed considering three employment categories: employed, seeking new job (unemployed), seeking first job (never employed). Comparison of suicide rates by economic position and correlation between suicide and unemployment rates have been made.

SUBJECTS AND SETTINGS

20,457 deaths by suicide registered in Italy among economically active people from 1982 to 1994.

MAIN OUTCOME MEASURES

Change over time in suicide rates by economic position; coefficient of aggravation according to occupational status.

RESULTS

Suicide rates among the unemployed are clearly and constantly higher than those among the employed: up to three times higher among men, and twice as high among women. Among the unemployed a clear and significant rise in suicide rates in both sexes took place over the study period; suicide rates among the employed showed a less marked increase. The rise in suicide rates was accompanied by a concurrent rise in unemployment rate percentage. Men seem to be affected most by this change in unemployment rate percentage; women are subject to less evident influences and variations.

CONCLUSION

Different suicidal behaviour trends among unemployed compared with employed people indicate that unemployment (and above all the prospect of not having access to a working role) acts as a contributing factor for suicide. Unemployment, even if symptomatic of a mental disorder, should therefore always be taken into consideration as a risk factor for suicide: the potentially lethal consequences of its negative influence on both self esteem and the ability to use supportive networks in a efficient way is an element to which great attention should be paid.

New onset and remission of suicidal ideation among a depressed adult sample

BACKGROUND

Previous research has demonstrated that suicidal ideation often predicts suicide completion.

METHODS

The present study examined clinical and phenomenological variables associated with the presence, development and remission of suicidal ideation among depressed adults. The sample (n = 81) was derived from subjects enrolled in the Duke Clinical Research Center for the Study of Depression in Late Life.

RESULTS

Greater pessimistic thinking at baseline predicted the development of suicidal ideation one year later and the older a person was when he or she first experienced depression, the more likely he or she was to report remission from suicidal ideation one year following onset.

LIMITATIONS

Longitudinal analyses were based on relatively small samples. Variables that were not significant in these analyses might be in a larger sample.

CONCLUSIONS

The longitudinal design of this study mitigates limitations associated with cross-sectional or retrospective designs and advances our understanding of a clinical profile associated with the development and remission of suicidal thoughts.

Suicide attempts among formerly hospitalized adolescents: a prospective naturalistic study of risk during the first 5 years after discharge

OBJECTIVE

To examine risk for suicide attempts among 180 consecutively referred adolescents during the first 5 years after discharge from an inpatient psychiatry unit.

METHOD

In a prospective naturalistic study, adolescents were assessed at psychiatric hospitalization and semiannually thereafter for up to 5 years with semistructured psychiatric diagnostic interviews and self-report questionnaires.

RESULTS

Approximately 25% of the adolescents attempted suicide and no adolescents completed suicide within the first 5 years after discharge. The first 6 months to 1 year after discharge represented the period of highest risk. The number of prior attempts was the strongest predictor of posthospitalization attempts. Affective disorders by themselves did not predict later suicide attempts but were related to posthospitalization attempts when accompanied by a history of past suicide attempts. Independent of psychiatric diagnoses, severity of depressive symptoms and trait anxiety also predicted suicide attempts. Similar to the effect with affective disorders, depressive symptoms were most strongly related to posthospitalization suicidality among adolescents with a prior history of suicide attempts.

CONCLUSIONS

Particularly among youths with prior suicidal behavior, clinicians should be alert to the above constellation of psychiatric predictors of posthospitalization suicidal behavior.