Suicide risk in mood disorders

Do comorbid anxiety disorders impact treatment planning for outpatients with major depressive disorder?

Research indicates that depressed patients with comorbid anxiety disorders have a poorer long-term course of illness, are less responsive to treatment, and may experience greater deficits in psychosocial functioning, when compared with depressed patients without comorbid anxiety disorders. The objective of this study was to examine, through use of a large, well-characterized clinical database, how clinicians may modify treatment recommendations in depressed outpatients when anxiety disorders are present. A group of 346 case records, derived from the Methods to Improve Diagnostic Assessment and Services (MIDAS) project at Rhode Island Hospital, were examined to determine what treatment recommendations were made immediately after diagnosis. Psychopharmacological and psychotherapeutic treatments were classified to capture differences in recommendations between groups. Demographic and clinical characteristics were compared for patients with (n=248) and without (n=98) comorbid anxiety disorders. Utilizing logistic regression models, we found patients with anxiety disorders had a greater number of psychopharmacological therapies included as part of their initial treatment plan, but no differences were found in initial psychotherapeutic interventions. Our results indicate that practitioners are making unique recommendations based on comorbid anxiety diagnoses, but outcome studies are now needed to determine the most effective treatment methods for this patient population.

Smoking, nicotine and neuropsychiatric disorders

Tobacco smoking is an extremely addictive and harmful form of nicotine (NIC) consumption, but unfortunately also the most prevalent. Although disproportionately high frequencies of smoking and its health consequences among psychiatric patients are widely known, the neurobiological background of this epidemiological association is still obscure. The diverse neuroactive effects of NIC and some other major tobacco smoke constituents in the central nervous system may underlie this association. This present paper summarizes the pharmacology of NIC and its receptors (nAChR) based on a systematic review of the literature. The role of the brain's reward system(s) in NIC addiction and the results of functional and structural neuroimaging studies on smoking-related states and behaviors (i.e. dependence, craving, withdrawal) are also discussed. In addition, the epidemiological, neurobiological, and genetic aspects of smoking in several specific neuropsychiatric disorders are reviewed and the clinical relevance of smoking in these disease states addressed.

Prevalence of suicide risk factors and suicide-related outcomes in the National Mental Health Study, Colombia

A community survey in 4,426 adults was undertaken as part of the World Mental Health Survey Initiative reporting the prevalence and risk factors for suicide-related outcomes in Colombia. Lifetime prevalence estimates of suicide ideation, plans, attempts, and risk factors for suicide-related outcomes were assessed. Retrospective reports of disorders age-of-onset were used to study associations between primary mental disorders and first onset of suicide-related outcomes. Risks of plans and attempts were highest with ideation early age-of-onset and within the first year. The highest risk for ideation and attempt among ideators occurred in the 18-29 age group. After first employment (defined as the first paid job accepted by the respondent) and presence of mental disorders constituted risk factors. Impulse-control disorders were strongest diagnostic predictors.

Association between terror attacks and suicide attempts

Based on Durkheim's 'Control theory,' we explored the association between frequency of terror attacks in Israel and the frequency of suicide attempts admitted to the Emergency Room of a major general hospital in Tel-Aviv (1999-2004). Analysis of the six-year study period as a whole revealed no significant correlation between the variables, with the exception of one 11-month segment within it (December 2000-October 2001) that did show a statistically significant positive correlation, and in opposition to Durkeim's hypothesis. It is suggested that suicide attempts as a phenomena should be seen as a product of a multivariate model, in which the social context plays a role as well.

Atypical depression is associated with suicide attempt in bipolar disorder

OBJECTIVE

There is a dearth of research focusing on factors associated with suicide attempts. High rates of atypical depression have been reported in studies including unipolar and bipolar II patients. In this study, the association between suicide attempt and atypical depression, in addition to other major risk factors, was evaluated in 390 bipolar I and II out-patients.

METHOD

Variables were defined according to DSM-IV criteria, and assessed with a Structured Interview for DSM-IV (axis I and II). History of suicide attempt was obtained through interviews with patients and relatives. Attempters and non-attempters were compared using univariate and multivariate analysis.

RESULTS

Attempters showed significantly higher rates of atypical depression, family history of completed suicide, depression at index episode and cluster B personality disorder.

CONCLUSION

Our results highlight the relevance of atypical depression in bipolar disorder. A more accurate identification of potential attempters may contribute to the development of effective preventive treatment strategies.

Affective temperaments, as measured by TEMPS-A, among nonviolent suicide attempters

BACKGROUND

The aim of this study was to investigate the role of affective temperaments in suicidal behavior.

METHOD

Using the standardized Hungarian version of the full-scale 110-item version of the TEMPS-A autoquestionnaire we compared the affective temperament-profiles of 150 consecutively investigated nonviolent suicide attempters (106 females and 44 males) and 302 age, sex and education matched normal controls (216 females and 86 males).

RESULTS

Compared to controls, both female and male suicide attempters scored significantly higher in the four of the five affective temperaments, containing more or less depressive component (depressive, cyclothymic, irritable and anxious). On the other hand, however, no significant difference between the suicide attempters and controls was found for the hyperthymic temperament. Significantly higher rate of suicide attempters (90.0%) than controls (21.5%) have had some kind of dominant (mean score+2SD or above) affective temperament. Compared to controls, depressive, cyclothymic, irritable and anxious temperaments were significantly more frequent and hyperthymic temperament was nonsignificantly less common among suicide attempters.

CONCLUSIONS

The findings support the strong relationship between depression and suicidal behavior even on temperamental level, and suggest that hyperthymic temperament does not have predisposing role for suicidal behavior at least in the case of nonviolent suicide attempters.

LIMITATION

As only nonviolent suicide attempters were studied, our findings should pertain only for this patient-population.

Medicating mood with maintenance in mind: bipolar depression pharmacotherapy

OBJECTIVES

Bipolar depression is a core feature of bipolar disorder, a phase in which many patients spend the majority of time and one that confers a significant degree of burden and risk. The purpose of this paper is to briefly review the evidence base for the pharmacotherapy of bipolar depression and to discuss the recommendations for its optimal management.

METHODS

A detailed literature review was undertaken with a particular emphasis on pharmacological treatment strategies for bipolar depression across the acute and maintenance phases of the illness. Electronic library and Web-based searches were performed using recognised tools (MEDLINE, PubMED, EMBASE and PsychINFO) to identify the pertinent literature. A summary of the evidence base is outlined and then distilled into broad clinical recommendations to guide the pharmacological management of bipolar depression.

RESULTS

Partitioning treatment into acute and maintenance therapy is difficult based on the paucity of current evidence. The evidence from treatment trials favours the use of lithium and lamotrigine as first-line treatment in preference to valproate, and indicates that, for acute episodes, quetiapine and olanzapine have perhaps achieved equivalence at least in terms of efficacy. However, the effectiveness of the atypical antipsychotics in maintenance therapy is constrained by the potential for significant side effects of individual agents and the lack of both long-term research data and clinical experience in treating bipolar disorder as compared to other agents. Conversely, lithium and the anticonvulsants are generally slower to effect symptomatic change, and this limits their usefulness.

CONCLUSIONS

There has been a tendency for research trials of bipolar depression to differentiate the illness cross-sectionally into the acute and maintenance phases of bipolar depression; however, in clinical terms, bipolar depression invariably follows a longitudinal course in which the phases of illness are inextricably linked, and useful acute treatments are typically continued in maintenance. Therefore, when medicating mood in acute bipolar depression it is imperative to keep maintenance in mind as it is this aspect of treatment that determines long-term success.

A review of panic and suicide in bipolar disorder: does comorbidity increase risk?

INTRODUCTION

Bipolar mood disorder carries a serious suicide risk. Panic disorder, which also confers an independent risk of suicide and psychiatric comorbidity, in general has been found to amplify suicidality in mood-disordered patients. This article assesses the available literature on how panic and suicide relate to each other in bipolar mood-disordered patients.

METHODS

We conducted a search on Medline and PsycINFO using the keywords "anxiety", "attempted suicide", "completed suicide", "mortality", "self-harm" in combination with "bipolar", "manic depression" and "panic". Twenty-four articles were included in the evaluation.

RESULTS

14 papers support increased risk, 9 papers do not support increased risk, and 3 papers are inconclusive.

CONCLUSIONS

The presence of comorbid panic disorder in individuals with bipolar disorder may confer an increased risk of suicide risk. Some papers' reviewed have conflicting conclusions but the majority of papers support an increased risk. This is consistent with a recent (2008) literature review supporting increased risk of suicide in bipolar patients with comorbid anxiety disorders. Future research should study specific bipolar subgroups, focus on anxiety and panic symptoms rather than diagnosis, and look at the role of specific pharmacological treatment in patients with comorbid mood and anxiety disorders.

Circulating endothelial progenitor cells and depression: a possible novel link between heart and soul

Although depression is known to be an independent risk factor for cardiovascular disorders, the mechanisms behind this connection are not well understood. However, the reduction in the number of endothelial progenitor cells (EPCs) in patients with cardiovascular risk factors has led us to hypothesize that depression influences the number of EPCs. EPCs labeled with CD34, CD133 and vascular endothelial growth factor receptor-2 (VEGFR2) antibodies were counted by flow cytometry in the peripheral blood (PB) of 33 patients with a current episode of major depression and of 16 control subjects. Mature (CD34+/VEGFR2+) and immature (CD133+/VEGFR2+) EPC counts were decreased in patients (vs controls; P<0.01 for both comparisons), and there was a significant inverse relationship between EPC levels and the severity of depressive symptoms (P<0.01 for both EPC phenotypes). Additionally, we assayed the plasma levels of VEGF, C-reactive protein (CRP) and tumor necrosis factor (TNF)-alpha and observed significantly elevated TNF-alpha concentrations in patients (vs controls; P<0.05) and, moreover, a significant inverse correlation between TNF-alpha and EPC levels (P<0.05). Moreover, by means of a quantitative RT-PCR approach, we measured CD34, CD133 and VEGFR2 mRNA levels of PB samples and found a net trend toward a decrease in all the investigated EPC-specific mRNA levels in patients as compared with controls. However, statistical significance was reached only for VEGFR2 and CD133 levels (P<0.01 for both markers). This is the first paper that demonstrates evidence of decreased numbers of circulating EPCs in patients with a current episode of major depression.

Recreational drug use and suicidality among Italian young adults

The aim of the study was to explore recreational drug use patterns among a sample of Italian young adults and to examine the role of substance misuse on suicidality. Three hundred and forty Italian young adults between 19 and 30 years of age completed measures of suicidality (Reasons for Living Inventory, Beck Hopelessness Scale, and Suicide Score Scale), depression (Zung Depression Scale), problem drinking (Michigan Alcohol Screening Test), and drug use (Drug Abuse Screening Test). Respondents were classified as problem drug users and drinkers (14.7% and 24.1%, respectively), and men were overrepresented in both groups. Alcohol and drugs misuse was significantly associated with reasons for living, hopelessness, suicidal attitudes, and depression. A multiple regression analysis resulted in four models predictive of suicide risk and four predictors were extracted--the Drug Abuse Screening Test, the Zung Depression Scale, and Loss of Motivation as positive predictors of suicide risk with Survival and Coping Beliefs as negative predictors.

A prediction rule for diagnosing hypomania

BACKGROUND

Missing the diagnosis of past hypomania, and thus of bipolar II disorder, is common. Study aim was to find a 'prediction rule' for facilitating the diagnosis of past hypomania.

METHODS

In an outpatient psychiatry private practice (non-tertiary care), a consecutive sample of 275 bipolar II disorder (BP-II) remitted patients, and consecutive, independent, sample of 138 major depressive disorder (MDD) remitted patients, had been interviewed for different study goals during follow-up visits by a senior bipolar-trained psychiatrist. Using the Structured Clinical Interview for DSM-IV, modified and validated by Benazzi and Akiskal [Benazzi F (2007). Lancet 369: 935-945] to improve the probing for past hypomania, patients had been questioned about the most common symptoms and duration of recent threshold and subthreshold hypomanic episodes. The sample was retrospective in nature. A prediction rule was tested. This is a score resulting from the sum of the weighted scores of each hypomanic symptom which was an independent predictor of hypomania. Its cutoff score for discriminating hypomania was based on the highest figure of correctly classified hypomanias and on the most balanced combination of sensitivity and specificity. A second, independent sample of 138 BP-II and 71 MDD remitted outpatients was tested to replicate the findings.

RESULTS

By univariate logistic regression, hypomanic symptoms distinguishing BP-II and MDD included 'increase in goal-directed activity' (overactivity) (OR=28.3), 'elevated mood' (OR=14.9), 'increased talkativeness' (OR=9.2), 'inflated self-esteem', 'decreased need for sleep', 'excessive risky activities', and 'irritable mood'. By multivariable logistic regression, the independent predictors of hypomania resulted 'increase in goal-directed activity' (OR=14.9, weighted score=15), 'elevated mood' (OR=7.5, weighted score=7), 'increased talkativeness' (OR=3.6, weighted score=4); 'irritable mood', 'inflated self-esteem', 'decreased need for sleep', and 'excessive risky activities' had ORs between 2.04 and 2.39, with a weighted score=2. The prediction rule showed that the cutpoint score > or = 21 had the highest figure of correctly classified hypomanias (88%, ROC area=0.94), showing the most balanced combination of sensitivity (87%) and specificity (89%). This prediction rule, tested on the second sample, found that the same cutoff score > or =21 correctly classified the highest figure of hypomanias (94%, ROC area=0.97), showing the most balanced combination of sensitivity (93%) and specificity (95%). To cross this cutoff score, overactivity was always required (as the sum of the scores of elevated mood and of the other symptoms did not reach this cutoff). However, scores 10 to 20 correctly classified only slightly lower figures of hypomanias.

CONCLUSIONS

A prediction rule for hypomania was tested. The scores of overactivity plus at least some hypomanic symptom (among elevated mood, irritability, inflated self-esteem, less sleep, talkativeness, excessive risky activities) correctly classified 88% of hypomanias. Instead, elevated mood without overactivity, plus even all the other symptoms, did not reach the best figure of correctly classified. However, lower cutoff scores, up to 10, classified slightly lower figures of hypomanias, but with less balanced combinations of sensitivity and specificity. These findings may have diagnostic utility, because BP-II versus MDD is likely to be a more severe disorder. This prediction rule, if replicated and fine-tuned in different settings, may help clinicians better probing past hypomania, thus reducing the common misdiagnosis of BP-II as MDD.

Assessment and treatment of suicide risk in bipolar disorders

Completed suicide and suicide attempts are major issues in the management of bipolar disorders. There is evidence that suicide rates among these patients are more than 20-fold higher than the general population and, furthermore, suicidal behavior is much more lethal in bipolar disorder than in the general population. Patients with mood disorders may sometimes exhibit highly perturbed mixed states, which usually increase the risk of suicide. Such states are particularly frequent in bipolar II patients, especially if patients are treated with antidepressant monotherapy (unprotected by mood stabilizers), when depression switches into mania (or vice versa), or when depression lifts and functioning approaches normality. Researchers worldwide agree that treatment involving lithium is the best way to protect patients from suicide risk. Psychosocial activities, including psychoeducation, can protect bipolar patients either directly or, more probably, indirectly by increasing adherence to treatment and helping in daily difficulties that otherwise may lead to demoralization or hopelessness. An extensive understanding of the psychosocial circumstances and the psychopathology of bipolar patients (including temperament) may help clinicians describe the clinical picture accurately and prevent suicidal behavior in these patients.

Risk factors associated with lifetime suicide attempts in bipolar I patients: findings from a French National Cohort

Risk factors that may be associated with suicide attempts in bipolar disorder are still a matter of debate. We compared demographic, illness course, clinical, and temperamental features of suicide attempters vs those of nonattempters in a large sample of bipolar I patients admitted for an index manic episode. One thousand ninety patients (attempters = 382, nonattempters = 708) were included in the study. Multivariate analysis evidenced 8 risk factors associated with lifetime suicide attempts as follows: multiple hospitalizations, depressive or mixed polarity of first episode, presence of stressful life events before illness onset, younger age at onset, no free intervals between episodes, female sex, higher number of previous episodes, and cyclothymic temperament. These characteristics may help identify subjects at risk for suicide attempt throughout the course of bipolar disorder. We finally propose to integrate such characteristics into a stress-diathesis model of suicidal behavior, adapted to bipolar patients.

Suicidal attempters and non-attempters with bipolar disorder in Iran

This is the study of the prevalence of suicidal attempt and its demographic association in bipolar disorder (BPD) subjects in an emergency department in a non-Western culture. The subjects were 176 adults with DSM-IV BPD-type I (BPD-I). The mean age was 30.2 years and 66.2% of them were male. About 33.9% of the subjects made a suicidal attempt at least once in their life. The majority of suicide attempters (69.8%) had only one suicidal attempt. Lifetime suicidal attempts were not associated with age, gender, level of education, residential area, and type of occupation. The rate of suicidal attempt in the bipolar patients is very high and it is very similar to the rates reported in other cultures. It seems that the association of suicidal attempt in BPD is less related to the culture than the disorder itself.

Psychotherapeutic intervention and suicide risk reduction in bipolar disorder: a review of the evidence

BACKGROUND

25-50% of bipolar patients attempt suicide at least once in their lifetime and completed suicide in this population is about 1% annually, about 60 times the rate of the general population. Psychotherapy may be an effective adjunctive option in preventing suicide in bipolar patients. It has been suggested that interpersonal, cognitive and behavioural techniques may be effective in controlling mood shifts, increasing compliance with pharmacotherapy, and maintaining morale in the face of therapeutic adversity and incomplete response. The aim of our study was to systematically review the literature concerning the efficacy of psychosocial interventions in reducing the risk for attempting or committing suicide.

METHODS

We searched MEDLINE with the combination of the key words 'psychotherapy' or 'psychoeducation' or 'cognitive therapy' or 'behavio(u)ral therapy', 'cognitive-behavio(u)ral' or 'family therapy' or 'social rhythm' or 'rhythm' with 'suicide' and 'bipolar', limited to English language papers published between 1990 and January 2008. Papers were selected based on the criterium that they provided definite data on the role of psychotherapy in suicide prevention, and specifically in bipolar disorder.

RESULTS

Our search returned 481 references, of which 17 were selected based on the above criteria. The selected papers were classified according to the area of suicide prevention they were dealing with as 1. Psychosocial and demographic factors, 2. Psychological profile and 3. Efficacy of psychotherapies.

DISCUSSION

Our paper summarizes specific features and correlates of suicide in bipolar patients and possible targets of psychosocial intervention in the prevention of suicide in bipolar patients. Although studies researching the effect of psychosocial interventions on suicidal behaviour are virtually non-existent, hard data concerning the effectiveness of psychosocial interventions in bipolar disorder are emerging, but still suffer from methodological drawbacks.

Psychopharmacological treatment before suicide attempt among patients admitted to a psychiatric intensive care unit

BACKGROUND

It is difficult to assess the effectiveness of treatments in lowering suicide incidence.

METHODS

To ascertain the impact of antidepressants (AD) on suicidal behavior, we compared the psychopharmacological treatment taken in the previous 3 months by cases who had made or not a suicide attempt (SA) just before their admission to a hospital.

RESULTS

In comparison with not SA cases, SA cases were more likely to have received AD and benzodiazepines (BZD) before hospitalization. On the contrary, they were less likely to have received antipsychotics, antiepileptic mood stabilizers, and lithium. Similar results were observed when the analysis was restricted to cases with a diagnosis of Major Depression, Bipolar Depression or Bipolar Mixed state, Schizoaffective Disorder, Depressive or Mixed type. Previous AD treatment seemed to be not related to the severity of psychopathology in general or to the severity of depressive and anxiety symptoms.

CONCLUSIONS

The results suggest that the use of AD in patients with mood disorders is not associated with a reduction of SA rate. Rather, it is not possible to exclude that AD or BZD can induce, worsen, or precipitate suicidal behavior in some patients, especially in those affected by mood disorders with Depressive or Mixed features. The results must be considered preliminary since this is an open, non-randomized, non-controlled study that was carried out at a single facility.

Suicide in the Kurdistan Region of Iraq, state of the art

In recent years the, incidence of suicide in Kurdistan has been increasing, especially among females, to a degree it cannot be neglected. Consequently, attention was given to this phenomena and the aggressive method of suicide used by young peoples, especially females, in Kurdistan. In attempt to obtain an objective picture of the frequently media-reported suicide among youths and women in the Kurdistan Region of Iraq. The responsible authorities and medical service units in the region were visited to collect information, and the available data were explored to produce a state-of-the-art overview on the subject. Because of insufficient documentation and lack of systematic registration, the data on suicide were scattered and difficult to evaluate. However, the findings did confirm that suicide exists as a serious problem in the society in Kurdistan, particularly among females. Urgent attention is demanded from the responsible authorities and organizations concerned in the region. Further research is needed to investigate the exact extent of suicide and its correlates in the society in Kurdistan, in order to plan for effective preventive measures.

Assessing and managing suicidal behaviour in the primary care setting: A model for an integrated regional suicide prevention strategy

Although suicide rates are decreasing in most countries, suicide is still a major health concern. Our aim was to introduce a complex, integrative, regional suicide prevention strategy. Based on reviewing the literature and on our previous studies we developed a suicide prevention model, which includes recognition, risk assessment and intervention. The main steps of the model are the recognition of warning signs (communicative or behavioural), exploration of crisis situation and/or psychopathologic symptoms, assessment of protective and risk factors, estimation of suicide risk and a plan for management of suicidal patients through different levels of interventions. In the management of suicidal behaviour, the complex stress-diathesis model has to be adjusted by considering biological markers and psycho-social factors. Only after the assessment of these factors can primary care professionals, as gatekeepers, manage suicidal patients effectively by using adequate psychopharmacotherapeutic and psychotherapeutic interventions in the recognition, treatment and prevention of suicidal behaviour.

Are antidepressants warranted in the treatment of patients who present suicidal behavior?

OBJECTIVE

The aim of the study was to ascertain the clinical course of patients admitted to a psychiatric intensive care unit (PICU) just after a suicide attempt (SA) and to evaluate the effectiveness of 2nd generation antipsychotics and mood stabilizers in these patients.

METHODS

We examined all the 129 patients discharged in a three-year period, who had been admitted after a SA and considered in the analysis the 82 cases non-transferred (in the first 72 h) to other PICUs for administrative or logistic reasons. Among them, 47 received a complete neuropsychiatric assessment. We distinguished between patients who had been treated with Antidepressants (AD) or not in the three months preceding hospitalization.

RESULTS

We treated all patients with mood stabilizers and 2nd generation antipsychotics. Only one patient was treated with AD in the course of current hospitalization. Both cases treated and not treated with AD before admission improved significantly, especially in symptoms of anxiety and depression, as well as in suicidality. The suicidal risk abated without AD treatment.

CONCLUSIONS

In patients with impending suicide risk, AD should not be considered standard treatment. Mood stabilizers and 2nd generation antipsychotics can be effective.

Specific depressive symptoms and disorders as associates and predictors of suicidal acts across adolescence

OBJECTIVE

To examine the role of depressive symptoms and disorders as associates and predictors of suicidal acts across adolescence.

METHOD

A representative sample of Norwegian school students (N = 2464, mean age 13.7 years) in grades 8 and 9 was reassessed after one year (T2) with the same questionnaire. All high scorers of depressive symptoms on the Mood and Feelings Questionnaire (MFQ) at T2 were defined as cases. One control from low or middle scorers, matched for age and gender, was randomly assigned to every two cases. This subset (n = 345) was diagnostically assessed by face-to-face K-SADS-PL interviews (mean age = 14.9 years). The same subset was reassessed after 5 years (T3) by using the same questionnaire (n = 252, mean age = 20.0 years) and telephone K-SADS-PL interviews (n = 242). The participation rate was 76.9% (n = 265).

RESULTS

Cognitive symptoms dominated the depressive symptom profile among suicide attempters, irrespective of age and time. Among younger adolescents, suicidal thoughts and acts of self-harm without suicidal intent were associated with suicidal acts. Recurrent thoughts about death, hopelessness, disturbed concentration and middle insomnia were associates of suicidal acts among older adolescents. Worthlessness by 15 years was a significant predictor of suicidal acts between 15 to 20 years. MDD and a depressive episode, not otherwise specified, continued to be significant associates among younger adolescents, while dysthymia by 15 years remained a predictor of suicidal acts between 15 to 20 years, even when controlled for depressive symptoms.

CONCLUSIONS

Self-harm without suicidal intent, middle insomnia, cognitive depressive symptoms and a formal psychiatric diagnosis of any depressive disorder should alert professionals in the risk assessment of suicidal adolescents.

Prevalence and correlates of suicidality among Indian women with post-partum psychosis in an inpatient setting

OBJECTIVE

The aims of the present study were twofold: first, to determine the prevalence of suicidal ideation and suicide attempts among women inpatients with post-partum-onset psychosis; and second, to describe the clinical, childbirth-related and demographic correlates of suicidal ideation in this group.

METHOD

A total of 82 post-partum women consecutively admitted to the psychiatric unit of the National Institute of Mental Health and Neurosciences, India during 18 months were assessed using the Comprehensive Psychopathology Rating Scale (CPRS) for psychopathology and suicidality.

RESULTS

Thirty-one women (38%) reported suicidal ideation, of whom 15 (18%) had attempted suicide in the current episode. Suicidal ideation and suicide attempts were more frequent in women with depression, an insidious onset of the current illness and those with higher scores on the depressive dimension. On logistic regression analysis, however, only higher scores on the depressive symptom dimension of CPRS, irrespective of diagnosis, emerged as significant (p<0.001). Suicidal ideation was also significantly associated with ideas of harm to the infant (p<0.05).

CONCLUSIONS

There is a high prevalence of suicidal ideation and suicide attempts in this group of patients. Depressive symptoms in post-partum psychosis appear to be the most important risk factor predicting suicidal ideation and attempts.

The contemporary face of bipolar illness: complex diagnostic and therapeutic challenges

Manic depression, or bipolar disorder, is a multifaceted illness with an inevitably complex treatment. The current article summarizes the current status of our knowledge and practice concerning its diagnosis and treatment. While the prototypic clinical picture concerns the "classic" bipolar disorder, today mixed episodes with incomplete recovery and significant psychosocial impairment are more frequent. The clinical picture of these mixed episodes is variable, eludes contemporary classification systems, and possibly includes a constellation of mental syndromes currently classified elsewhere. Treatment includes the careful combination of lithium, antiepileptics, atypical antipsychotics, and antidepressants, but not all of the agents in these broad categories are effective for the treatment of bipolar disorder.

Completed versus attempted suicide in psychiatric patients: a psychological autopsy study

The aims of this study were to identify specific risk factors associated with completed suicide in a sample of suicide victims diagnosed with mental illness and to discriminate completed suicides from attempted suicide in individuals who did not kill themselves for at least the next 2 years after the index attempt. Ninety-four adults (34 women; 60 men; mean age = 50.81 [SD = 18.08]) admitted to the Division of Psychiatry of the Department of Neurosciences of the University of Parma who died by suicide between 1994-2004 were matched for sex and age (+/- 2 years) with 94 outpatients (mean age = 50.70 [SD = 18.08]) who made at least one suicide attempt during the years of the study. Data were gathered by proxy-based interviews with referring psychiatrists and general practitioners and from examination of medical records. Suicide victims were more likely to be not married, have poor social support (OR = 5.28), and have more voluntary and compulsory admissions to hospitals (1 admission: OR = 5.44; > 1 admissions: OR= 8.84) than suicide attempters. Suicide victims were also less likely to have had stressful life events during their childhood and adolescence (OR = 0.09) and to be divorced or widowed than were the attempters.

Duloxetine and suicide attempts: a possible relation

The possible increase of suicidal ideation with some antidepressants is still a matter of debate. We are reporting two cases of suicidal attempt that occurred concomitantly with the use of Duloxetine. To our knowledge there is no prior publication about a possible Duloxetine related increase in the risk of suicidality.

Prevalence and risk factors associated with suicide ideation and attempts in korean college students

OBJECTIVE

Suicide is a leading cause of death in college age students. Identification of the associated risk factors has important implications for how to prevent and respond to this population; however, few studies have been performed on this topic in this age group. The purpose of this study was to evaluate the prevalence and risk factors associated with suicide ideation and attempts in college students.

METHODS

Three hundred sixty-eight college students participated in this cross-sectional observational study. The recent (over two weeks) suicide ideation and lifetime suicide attempts were defined according to Moscicki's suicide behavior index. Sociodemographic variables were assessed and psychopathology measured using the Beck Depression Inventory, the Bipolar Spectrum Diagnostic Scale and the Alcohol Use Disorders Identification Test. A hierarchical multiple logistic regression analysis was used to identify the significant risk factors related to suicide ideation and attempts.

RESULTS

The two-week prevalence of suicidal ideation was 9.8%, and the lifetime prevalence of suicide attempts was 3.3%. The univariate analysis showed that students who had more severe depression (p<0.001), a higher probability for bipolar disorder (p<0.001) and decrement of academic achievement (p<0.005) were more likely to have suicide ideation. Those with factors such as severe depression (p<0.05), a higher probability of bipolar disorder (p<0.001), a low socioeconomic status (p<0.001), who lived alone (p<0.01), and were female (p<0.05) had a higher risk for suicide attempts. The most important predictors of suicide ideation, by the logistic regression analysis, were depression, probability for bipolar disorder and academic achievement, and the risks identified for suicide attempts were socioeconomic status and probability of bipolar disorder.

CONCLUSION

Suicide ideation and attempts were common in college students. The results of this study suggest that early identification and management of mood disorders and other sociodemographic risk factors may have implications for intervention and prevention.

Cannabis use and the Risk Behavior Syndrome in Italian University Students: Are They Related to Suicide Risk?

The aim of this study was to examine the association of cannabis use with risky behaviors and suicide risk in university students. A convenience sample of 246 students was recruited from four universities in Rome during the 2004 academic year. Participants completed the Zung scales for anxiety and depression, the Suicide Score Scale, and an ad hoc questionnaire assessing risky behaviors. The findings indicated a widespread use of cannabis among students and its association with risky behaviors, anxiety and depression, and suicide risk. A regression tree analysis resulted in 3 splits indicating that the Zung Self-Rating Depression Scale is a good predictor of suicide risk, discriminating individuals at lower risk from those at higher risk. Individuals at higher risk for suicide could also be discriminated by self-reported lifetime drug use. Limitations of the study are related to the small sample size and use of a convenience sample.

Suicide risk in depression and bipolar disorder: Do impulsiveness-aggressiveness and pharmacotherapy predict suicidal intent?

The aims of the present study were to examine clinical, personality, and sociodemographic predictors of suicide risk in a sample of inpatients affected by major affective disorders. The participants were 74 inpatients affected by major depressive disorder or bipolar disorder-I. Patients completed a semi-structured interview, the Beck Hopelessness Scale, the Aggression Questionnaire, the Barratt Impulsiveness Scale, and the Hamilton scales for depression and anxiety. Over 52% of the patients were high suicide risks. Those at risk reported more severe depressive-anxious symptomatology, more impulsivity and more hostility. Impulsivity, the use of antidepressants, anxiety/somatization, and the use of mood stabilizers (a negative predictor) resulted in accurate predicting of suicide intent. Impulsivity and antidepressant use were the strongest predictors even after controlling for several sociodemographic and clinical variables.

Bipolar spectrum disorder: differential diagnosis and treatment

Bipolar disorder commonly presents as a recurrent mood disorder characterized by frequent depressive episodes. Although manic or hypomanic phases are required for the diagnosis to be made based on current diagnostic criteria, a wider expression of mood instability and other historical features or family history may suggest the presence of a bipolar spectrum illness. This article covers the diagnostic issues related to bipolar disorder and the spectrum concept of the illness. A new definition of bipolar spectrum disorder is suggested, and treatment principles and options are discussed. Primary care providers often encounter patients who have depression and mood problems, placing them in a key position for the diagnosis and treatment of this psychiatric illness.

Bipolar pharmacotherapy and suicidal behavior Part 2. The impact of antidepressants

Antidepressant-induced mania and cycle acceleration is a potential risk in bipolar patients. Another serious risk of antidepressants, that of increasing suicidal behavior, has been identified in some affectively ill populations. However, there is a dearth of knowledge about the effects of antidepressants on suicidal behavior specifically in bipolar patients.

METHODS

Retrospective chart review of 405 veterans with bipolar disorder followed for a mean of three years, with month by month systematic assessment of current pharmacotherapy and suicide completion, attempt or hospitalization for suicidality. Chi-squared comparison of (log) rates of suicidal events during mood stabilizer monotherapy, antidepressant monotherapy, and combination of mood stabilizer and antidepressant.

RESULTS

Suicidal behavior event rates (per 100 patient years) were greatest during treatment with antidepressant monotherapy (25.92), least during mood stabilizer monotherapy (3.48), and intermediate during mood stabilizer + antidepressant combination treatment (9.75). These differences were statistically significant.

LIMITATIONS

In a clinical setting, antidepressants may have been prescribed because patients were deemed at greater risk of suicidality.

CONCLUSIONS

During treatment with antidepressants (even when coupled with mood stabilizers), patients with bipolar disorder have significantly higher rates of non-lethal suicidal behavior compared to those on mood stabilizers without antidepressants, and thus require careful monitoring.

Prediction and prevention of suicide in patients with unipolar depression and anxiety

Epidemiological data suggest that between 59 and 87% of suicide victims suffered from major depression while up to 15% of these patients will eventually commit suicide. Male gender, previous suicide attempt(s), comorbid mental disorders, adverse life-situations, acute psycho-social stressors etc. also constitute robust risk factors. Anxiety and minor depression present with a low to moderate increase in suicide risk but anxiety-depression comorbidity increases this risk dramatically Contrary to the traditional psychoanalytic approach which considers suicide as a retrospective murder or an aggression turned in-wards, more recent studies suggest that the motivations to commit suicide may vary and are often too obscure. Neurobiological data suggest that low brain serotonin activity might play a key role along with the tryptophan hydroxylase gene. Social factors include social support networks, religion etc. It is proven that most suicide victims had asked for professional help just before committing suicide, however they were either not diagnosed (particularly males) or the treatment they received was inappropriate or inadequate. The conclusion is that promoting suicide prevention requires the improving of training and skills of both psychiatrists and many non-psychiatrists and especially GPs in recognizing and treating depression and anxiety. A shift of focus of attention is required in primary care to detect potentially suicidal patients presenting with psychological problems. The proper use of antidepressants, after a careful diagnostic evaluation, is important and recent studies suggest that successful acute and long-term antidepressant pharmacotherapy reduces suicide morbidity and mortality.