Prevention of depression and suicide by education and medication: impact on male suicidality. An update from the Gotland study

Gender issues in youth suicidal behaviour

There are gender differences in youth suicidal behaviour that are evident in childhood and persist throughout adolescence and young adulthood. In Western countries, young females are twice as likely as males to report suicidal ideation and suicide attempt behaviour. However, despite the fact that females make more suicide attempts, males are three- to fourfold more likely to die by suicide than females. This paper reviews the epidemiological evidence for gender differences in suicidal ideation, attempted suicide and completed suicide among young people and explores possible reasons for the observed differences. These reasons include differences in methods, intent, ascertainment, the cultural acceptability of suicide, psychopathology (including substance abuse, mood disorder, externalizing behaviours and propensity to violence), and psychosocial differences between males and females. While it is often suggested that gender differences in youth suicidal behaviour may be explained solely or predominantly by method choice, careful examination suggests that the issues are much more complex. In fact, females may enjoy more protection from suicide than males in a number of areas.

Philosophy for managers? An exploration of what the great philosophers can do to assist ethical decision making

Ethics is attracting increasing attention in management of both public- and private-sector organisations. For managers within health-care systems, ethical issues can be most acute, especially given the human nights issues involved in new legislation. This paper explores some of the ways in which philosophy may potentially offer guidelines to managers faced with the need to make decisions ethically. It draws on a small number of philosophical perspectives to demonstrate how they can assist in informing ethical decision making, and illustrates its arguments through one topic, suicide prevention, an area of relevance to health managers but one that is beset by some of the most profound ethical dilemmas. The ways in which philosophy may assist in decision making in this one example are, it is argued, generalisable to many other health issues where complicated decisions have to be made. The paper develops a philosophical framework consisting of the ethical considerations of "self-love", "humanity", "the value of human life" and "duty to others" and demonstrates, through the use of two hypothetical case studies, how these can be applied to a decision-making process so as to reduce inconsistencies in attitudes and practice.

An assessment of suicide in an urban VA Medical Center

This study characterizes those patients of an urban VA Medical Center (VAMC) who had committed suicide. A cause-of-death search of the 1,075 veterans from the VAMC's case rolls who died during 1998 was conducted. For confirmed and suspected suicides, a chart review was conducted, noting psychiatric history and recent contact with the VAMC. Nineteen patients were either confirmed or suspected suicides. Few of these patients had made recent contact with the VAMC, although the majority of them had received psychiatric services from the VA at some time. The proportion of deaths due to suicide was similar in African American and White patients. Rates of suicide were elevated, primarily because of the high proportion of patients receiving psychiatric treatment. Elderly suicides were less likely to have had psychiatric services or previous psychiatric diagnoses than were younger suicides. Patients with past contact with psychiatric services may be especially at risk of suicide, particularly as contact with these services diminishes. Elderly patients in medical settings with undiagnosed or undertreated psychiatric disorders are also likely to have elevated risk for suicide. These findings demonstrate the importance of acknowledging that risk factors for suicide are specific to sites or populations; this information can be used in allocating resources for developing site-specific strategies for prevention.

Early detection strategies for untreated first-episode psychosis

Some studies in first-episode schizophrenia correlate shorter duration of untreated psychosis (DUP) with better prognosis, suggesting that timing of treatment may be important. A three-site prospective clinical trial in Norway and Denmark is underway to investigate the effect of the timing of treatment in first-episode psychosis. One health care sector (Rogaland, Norway) is experimental and has developed an early detection (ED) system to reduce DUP. Two other sectors (Ullevål, Norway, and Roskilde, Denmark) are comparison sectors and rely on existing detection and referral systems for first-episode cases. The study ultimately will compare early detected with usual detected patients. This paper describes the study's major independent intervention variable, i.e. a comprehensive education and detection system to change DUP in first onset psychosis. System variables and first results from the four-year inclusion period (1997-2000) are described. It includes targeted information towards the general public, health professionals and schools, and ED teams to recruit appropriate patients into treatment as soon as possible. This plus easy access to psychiatric services via ED teams systematically changed referral patterns of first-episode schizophrenia. DUP was reduced by 1.5 years (mean) from before the time the ED system was instituted (to 0.5 years). The ED strategies appear to be effective and to influence directly the community's help-seeking behaviour.

Major depression: does a gender-based down-rating of suicide risk challenge its diagnostic validity?

OBJECTIVE

This paper will summarize the authors' research that disproved the accepted lifetime suicide risk in major depression. It will then explore the pivotal issue of gender in understanding suicide risk in depression and raise questions as to whether this is adequately reflected in the current diagnostic construct of this condition.

METHOD

The methods of two recent papers published by the authors are briefly recounted. In the first of these papers, an age-specific algorithm was developed to reflect the necessary mathematical relationship between the prevalence of major depression, total population suicide rates and suicide risk in depression. It allowed for deaths in each age group from other causes, corrected for official underreporting, and was calculated on the entire population of the USA. In the second paper this methodology was further refined and applied to gender and age data.

RESULTS

The suicide risk in major depression as it is currently defined diagnostically is of the order of 3.4% rather than the previously accepted figure of 15%. However, a single figure is misleading as it averages two highly disparate figures of almost 7% for men and only 1% for women. In youths (< age 25) the male: female ratio is even higher (10:1).

CONCLUSIONS

Among sufferers of major depression, men and those who have been hospitalized have a much greater risk of suicide. These findings are sensitive to diagnostic inclusivity (the algorithm's denominator) which raises the question as to whether women with a depressive illness are more likely to be correctly identified than male sufferers? An argument is made for a gender-based nosological revision of the diagnostic criteria. In the interim, given the treatable morbidity of depression and the availability of safe, well-tolerated antidepressants, there is a prima facie case for lowering our threshold of treatment in men and youths presenting with a history of anger dyscontrol, or substance abuse, who have decompensated from previous levels of functioning and who show features of either typical or atypical depression.

Major demographic, social and economic factors associated to suicide rates in Latvia 1980-98

OBJECTIVE

The aim of this study is to analyse the dynamics of suicide rates in Latvia 1980-98, when dramatic social and economical changes took place. Special attention is given to demographic risk groups and major socioeconomic correlates influencing the dynamics of suicide rates.

METHOD

Descriptive statistics of suicide rates and major social and economical correlates.

RESULTS

During 1980-98 there were rapid swings of suicide rates. The increase was generated mainly by males reaching a maximum of 72 per 100 000 population in 1993. The sudden drop in gross domestic product, the rapid increase in first-time alcohol psychosis and the percentage of people unemployed did not correspond strictly with the dynamics of suicide rates.

CONCLUSION

Demographic and socioeconomic factors could not explain sufficiently the rapid changes in suicide rates in Latvia during the years 1980-98; psychological factors also have to be considered.

Preventing suicide and premature death by education and treatment

Suicide is a leading cause of mortality. It is, in principle, preventable - given the fact that we possess effective treatments for depressive illness, the major contributor to such mortality. Nonetheless, complex logistic problems have prevented the institution of successful suicide prevention programs. The present review summarizes the author's work on the island of Gotland in Sweden, where the small size of the population permitted the institution of an educational and treatment program aimed at the general medical practitioners. The program was successful in reducing suicide rates by 60%. This was accompanied by reduction of different indices measuring depressive morbidity. Prevention was successful for as long as the program was instituted. The author provides his reflections on the public health implications of his data - particularly for Eastern Europe which is experiencing widespread stress in the workplace and in economic situations. More hypothetically, he presents his views on a serotonin-mediated 'male suicide syndrome'.

Lifetime suicide risk in major depression: sex and age determinants

BACKGROUND

Recent work has demonstrated that the lifetime suicide risk for patients with DSM IV Major Depression cannot mathematically approximate the accepted figure of 15%. Gender and age significantly affect both the prevalence of major depression and suicide risk.

METHODS

Gender and age stratified calculations were made on the entire population of the USA in 1994 using a mathematical algorithm. Sex specific corrections for under-reporting were incorporated into the design.

RESULTS

The lifetime suicide risks for men and women were 7% and 1%, respectively. The combined risk was 3.4%. The male:female ratio for suicide risk in major depression was 10:1 for youths under 25, and 5.6:1 for adults.

CONCLUSIONS

Suicide in major depression is predominantly a male problem, although complacency towards female sufferers is to be avoided. Diagnosis of major depression is of limited help in predicting suicide risk compared to case specific factors. The male experience of depression that leads to suicide is often not identified as a legitimate medical complaint by either sufferers or professionals. Increasing help-accessing by males is a priority.

CLINICAL IMPLICATIONS

Patients with a history of hospitalisation; comorbidity, especially for substance abuse; and who are male, require greater vigilance for suicide risk. It may be that for males the threshold for diagnosing and treating major depression needs to be lowered.

LIMITATIONS

This research is based on a mathematical algorithm to approximate a life-long longitudinal study that identifies community cases of depression. Our findings therefore rely on the validity of the statistics used. Extrapolation is limited to populations with an actual suicide rate of 17/100,000 or less and a lifetime prevalence of major depression of 17% or more.

Decreasing tendency of seasonality in suicide may indicate lowering rate of depressive suicides in the population

The seasonality of suicide is well known and a repeatedly demonstrated phenomenon. The authors analyzed the seasonality of 148 suicide events on Gotland between 1981 and 1996. A marked and significant seasonality with a spring and summer peak was found between 1981 and 1989, when the prescription of antidepressants was relatively low and stable. However, this seasonality disappeared in the period between 1990 and 1996, when prescription of antidepressants increased dramatically, indicating that more and more depressed patients were pharmacologically treated. As the seasonality of suicide in the population is the reflection of the seasonal nature of depressive suicides, the result suggests that a decreasing tendency of seasonality in suicide may indicate the lowering rate of depressive suicides in the given population.

Antidepressants and suicide mortality

BACKGROUND

This paper presents a nationwide analysis of suicide mortality in Finland from 1990 to 1995, when the total use of antidepressants, especially that by selective serotonin reuptake inhibitors (SSRIs) expanded in the country.

METHODS

Suicide rate was analysed by various methods including that by intake of antidepressants. Various antidepressants were compared by calculating fatal toxicity indices (FTI) by relating number of fatal poisonings by a drug to its consumption.

RESULTS

The expanded use of antidepressants coincided with an increased number of deaths caused by these drugs. The proportion of suicides committed by use of antidepressants among all suicides increased from 5.6% to 8.4%. The total suicide rate, however, declined significantly. This was mainly accounted for by the reduced suicide rates by hanging and carbomonoxide poisoning, which outnumbered the increased figures of suicides by poisoning. On the whole, 82% of suicides by antidepressants were committed by use of tricyclics. Use of doxepin and amitriptyline remained steady, and their FTIs were constantly high. The lowest FTIs were associated with fluoxetine, citalopram, mianserin and moclobemide.

LIMITATIONS

The method ignores causality between the increased use of SSRIs and suicide mortality. Various factors affecting risk of suicide or choice of a method remain outside the scope of the data.

CONCLUSION

The increased use of SSRIs coincided with a significant decline in suicide mortality. However, suicides by use of antidepressants showed an upward trend. Therefore, in suicide prevention, risks and benefits of antidepressants should be considered in choosing treatment for depressive patients.

Recognition of depression and prevention of suicide: the role of general practitioners and general physicians

Suicide is a major health problem throughout the world. After briefly describing the risk factors for suicide, the author focuses on depression, which is the major cause of suicide. Depression is a common illness, treatable not only in psychiatric settings, but also in primary care and general medicine. Consequently, physicians other than psychiatrists (primarily general practitioners) have an important role in suicide prevention.