Suicide in subtypes of primary major depression

Comparing suicide completion rates in bipolar I versus bipolar II disorder: A systematic review and meta-analysis

BACKGROUND

Bipolar disorder (BD) has a high disease burden and the highest mortality risk in BD comes from suicide. Bipolar disorder type II (BD-II) has been described as a milder form of bipolar disorder; however, extant literature is inconsistent with this description and instead describe illness burden and notably suicidality comparable to persons with bipolar I disorder (BD-I). Towards quantifying the hazard of BD-II, herein we aim via systematic review and meta-analysis to evaluate the rates of completed suicide in BD-I and BD-II.

METHOD

We conducted a literature search on PubMed, OVID (Embase, Medline) and PsychINFO databases from inception to June 30th, 2023, according to PRISMA guidelines. Articles were selected based on the predetermined eligibility criteria. A meta-analysis was performed, comparing the risk of completed suicide between individuals diagnosed with BD-I to BD-II.

RESULTS

Four out of eight studies reported higher suicide completion rates in persons living with BD-II when compared to persons living with BD-I; however, two of the studies reported non-significance. Two studies reported significantly higher suicide completion rates for BD-I than BD-II. The pooled odds ratio of BD-II suicide rates to BD-I was 1.00 [95 % CI = 0.75, 1.34].

LIMITATIONS

The overarching limitation is the small number of studies and heterogeneity of studies that report on suicide completion in BD-I and BD-II.

CONCLUSION

Our study underscores the severity of BD-II, with a risk for suicide not dissimilar from BD-I. The greater propensity to depression, comorbidity and rapid-cycling course reported in BD-II are contributing factors to the significant mortality hazard in BD-II.

Bipolar Disorders in the Emergency Department

Affective disorders affect the way that people think and feel and are classified into unipolar disorders and bipolar disorders. Bipolar disorders represent a spectrum of these chronic mental health illnesses. Patients with bipolar disorder have high recurrence of acute symptoms, and on average spend 20% of their life in exacerbations characterized by mania, depression, or psychosis. Given the increased morbidity and mortality associated with bipolar disorders, it is imperative that the emergency physician remain vigilant when these patients seek emergency care.

Disclosure of suicidal ideation and behaviours: A systematic review and meta-analysis of prevalence

Disclosure of suicidal ideation and behaviours, defined as thoughts, plans, or attempts, to other people provides opportunity for intervention and prevention. This study is the first to meta-analyze all available studies to estimate the prevalence of disclosure, to whom people disclose, and examine factors that influence disclosure. Databases were searched for studies reporting samples of people who had experienced suicidal ideation or behaviours (including those who had died by suicide) and whether they had disclosed this. Almost 100 studies (k = 94, N participants = 1,044,629) were included in the overall prevalance analysis. The results showed less than half of people disclosed suicidal ideation or behaviour: 45.9% (95%CI 41.9-49.9%, PI 12.3-81.8%; k = 94). High heterogeneity, common to prevalence studies, was found (Q[93] = 130,584, p < .001; I² = 99.9%). No publication bias was detected. Removing outliers did not change the prevalence estimate, but provided tighter prediction intervals: 45.6% (95%CI 43.4-47.9%, PI 35.8-55.7%; k = 33). Disclosure was related to higher prevalence of psychiatric disorders, female gender, and a longer timeframe of suicidal ideation or behaviour. Prevalence of disclosure was lower among people who died by suicide, relative to community samples, and lower when reported verbally rather than written online. Disclosure, and proportions of disclosures, to family members, was numerically higher than to friends or professionals, but could not be directly compared. In conclusion, between 50 and 60% of people do not disclose their suicidal ideation and behaviours to other people, and therefore remain unidentified and potentially untreated.

Do psychological interventions reduce symptoms of depression for patients with bipolar I or II disorder? A meta-analysis

BACKGROUND

Psychological therapies may play an important role in the treatment of bipolar disorders. Several meta-analyses that examine the effectiveness of psychotherapies for patients with bipolar disorder include conclusions about the impact upon bipolar depression. However, these tend not to consider differences in depression outcome depending upon whether the therapy primarily targets acute depression, nor severity of baseline depression. This may affect the conclusions drawn about the effectiveness of these therapies for acute bipolar depression treatment.

OBJECTIVES

This meta-analysis explored the effectiveness of psychological therapies in reducing bipolar depression, in particular examining whether: (1) the effect of therapy is greater when baseline depressive symptoms are more severe, and (2) the effect of therapy is greater when the primary focus of the therapy is the treatment of acute bipolar depression?

DATA SOURCES

A systematic search was conducted using the following electronic databases; Cochrane Controlled Register of Trials (1996), MEDLINE (1966 onwards), EMBASE (1980 onwards), PsycINFO (1974 onwards), Scopus, Web of Science and Clinical Trials Registries (listed at:https://www.hhs.gov/ohrp/international/clinical-trial-registries/index.html).

ELIGIBILITY CRITERIA

Eligible studies were randomized controlled trials evaluating a psychological intervention for adults diagnosed with Bipolar I or II disorder. The comparators were usual care, wait-list, placebo, active treatment control. Post-treatment depression status was required to be measured continuously using a validated self- or observer- report measure, or categorically by a validated diagnostic instrument or clinical diagnosis by a suitably qualified person.

DATA EXTRACTION AND SYNTHESIS

Titles and abstracts were screened, followed by full texts. Two reviewers conducted each stage until agreement was reached, and both independently extracted study information. Means, standard deviations (SDs) and number of participants were retrieved from articles and used to perform a meta-analysis. The primary outcome was depressive symptom score.

RESULTS

The database search identified 6388 studies. After removing the duplicates, 3298 studies remained, of which, 28 studies were included in the qualitative review and 22 in the meta-analysis. Effect sizes range from -1.99 [-2.50, -1.49] to 0.89 [-0.12, 1.90]. There was low quality evidence of a significant effect on symptoms of depression for cognitive behavioral therapy and dialectical behavior therapy. Trials of psychoeducation, mindfulness-based therapy, family therapy and interpersonal and social rhythm therapy showed no evidence of any effect on depression. We found no significant relationship between baseline depression score and depression outcome post-treatment when we controlled for therapy type and comparator. The result also showed that the effect sizes for studies targeting acute depression to be tightly clustered around a small overall effect size.

CONCLUSIONS

Some psychological therapies may reduce acute bipolar depression although this conclusion should be viewed with caution given the low quality of evidence. More research using similar therapy types and comparators is needed to better understand the relationship between depression status at baseline and outcome.

Controlling Noncommunicable Diseases in Transitional Economies: Mental Illness in Suicide Attempters in Singapore-An Exploratory Analysis

BACKGROUND

Mental illness is a pertinent risk factor related to suicide. However, research indicates there might be underdiagnosis of mental illness in Asian suicide attempters; this phenomenon is concerning. This study explored prediction of diagnosis of mental illness in suicide attempters in Singapore using available variables.

METHODS

Three years of medical records related to suicide attempters (N = 462) who were admitted to the emergency department of a large teaching hospital in Singapore were subjected to analysis. Of the sample, 25% were diagnosed with mental illness; 70.6% were females and 29.4% were males; 62.6% were Chinese, 15.4% Malays, and 16.0% Indians. Their age ranged from 12 to 86 (M = 29.37, SD = 12.89). All available variables were subjected to regression analyses.

FINDINGS

The full model was significant in predicting cases with and without diagnosis of mental illness and accurately classified 79% of suicide attempters with diagnosis of mental illness.

CONCLUSIONS

The findings were discussed in regard to clinical implications in diagnosis and primary prevention.

Association between completed suicide and bipolar disorder: A systematic review of the literature

BACKGROUND

Completed suicide is a major cause of death in bipolar disorder (BD) patients.

OBJECTIVE

The aim of this paper is to provide an overall review of the existing literature of completed suicide in BD patients, including clinical and genetic data DATA SOURCES: We performed a systematic review of English and non-English articles published on MEDLINE/PubMed, PsycInfo and Cochrane database (1970-2017). Additional studies were identified by contacting clinical experts, searching bibliographies, major textbooks and website of World Health Organization. Initially we did a broad search for the association of bipolar disorder and suicide and we were narrowing the search in terms included "bipolar disorder" and "completed suicide".

STUDY SELECTION

Inclusion criteria were articles about completed suicide in patients with BD. Articles exclusively focusing on suicide attempts and suicidal behaviour have been excluded. We used PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) consensus for drafting this systematic review.

RESULTS

The initial search generated 2806 articles and a total of 61 meeting our inclusion criteria. We reviewed epidemiological data, genetic factors, risk factors and treatment of completed suicide in BD. Suicide rates in BD vary between studies but our analyses show that they are approximately 20-30-fold greater than in general population. The highest risk of successful suicide was observed in BD-II subjects. The heritability of completed suicide is about 40% and some genes related to major neurotransmitter systems have been associated with suicide. Lithium is the only treatment that has shown anti-suicide potential.

LIMITATIONS

The most important limitation of the present review is the limited existing literature on completed suicide in BD.

CONCLUSIONS

BD patients are at high risk for suicide. It is possible to identify some factors related to completed suicide, such as early onset, family history of suicide among first-degree relatives, previous attempted suicides, comorbidities and treatment. However it is necessary to promote research on this serious health problem.

Self-poisoning suicide deaths in people with bipolar disorder: characterizing a subgroup and identifying treatment patterns

OBJECTIVE

To characterize self-poisoning suicide deaths in BD compared to other suicide decedents.

METHODS

Extracted coroner data from all suicide deaths (n = 3319) in Toronto, Canada from 1998 to 2012. Analyses of demographics, clinical history, recent stressors, and suicide details were conducted in 5 subgroups of suicide decedents: BD self-poisoning, BD other methods, non-BD self-poisoning, non-BD other methods, and unipolar depression self-poisoning. Toxicology results for lethal and present substances were also compared between BD and non-BD self-poisoning subgroups as well as between BD and unipolar depression self-poisoning subgroups.

RESULTS

Among BD suicide decedents, self-poisoning was significantly associated with female sex, past suicide attempts, and comorbid substance abuse. In both the BD and non-BD self-poisoning groups, opioids were the most common class of lethal medication. For both groups, benzodiazepines and antidepressants were the most common medications present at time of death, and in 23% of the BD group, an antidepressant was present without a mood stabilizer or antipsychotic. Only 31% of the BD group had any mood stabilizer present, with carbamazepine being most common. No antidepressant, mood stabilizer, or antipsychotic was present in 15.5% of the BD group. Relative to unipolar depression self-poisoning group, the BD self-poisoning group evidenced higher proportion of previous suicide attempt(s) and psychiatry/ER visits in the previous week.

CONCLUSION

People with BD who die by suicide via self-poisoning comprise a distinct but understudied group. The predominant absence of guideline-concordant pharmacologic care comprises a crucial target for future policy and knowledge translation efforts.

The communication of suicidal intentions: a meta-analysis

BACKGROUND

Among the myths that are often cited about suicide is that 'people who talk about killing themselves rarely die by suicide', but the evidence seems to contradict this statement. The aim of this study was to conduct a meta-analysis of studies reporting a prevalence of suicide communication (SC), and to examine the diagnostic accuracy of SC towards suicide in case-control reports.

METHOD

Eligible studies had to examine data relative to completed suicides and report the prevalence of SC. Data relative to sample characteristics, study definition, modality and recipient of the SC were coded.

RESULTS

We included 36 studies, conducted on a total of 14 601 completed suicides. The overall proportion of SC was 44.5% [95% confidence interval (CI) 35.4-53.8], with large heterogeneity (I 2 = 98.8%) and significant publication bias. The prevalence of SC was negatively associated with the detection of verbal communication as the sole means of SC and, positively, with study methodological quality. Based on seven case-control studies, SC was associated with an odds ratio of 4.66 for suicide (95% CI 3.00-7.25) and was characterized by sufficient diagnostic accuracy only if studies on adolescents were removed.

CONCLUSION

Available data suggest that SC occurs in nearly half of subjects who go on to die by suicide, but this figure is likely to be an underestimate given the operational definitions of SC. At present, SC seems associated with overall insufficient accuracy towards subsequent suicide, although further rigorous studies are warranted to draw definite conclusions on this issue.

Diagnoses and prescriptions of antidepressants in suicides: Register findings from the Friuli Venezia Giulia Region, Italy, 2002-2008

OBJECTIVE

To explore to what extent and under which diagnoses individuals who committed suicide had received psychiatric in-patient care, and how many had previously committed non-lethal self-harm. To investigate the antidepressant treatment received by these individuals.

METHODS

Case-control study based on a health register.

RESULTS

Psychiatric hospitalisation was found in 31.2% of the cases and 2.3% of the controls, and was a strong predictor for suicide with an odds ratio (OR) = 19.5. This did not differ significantly between diagnostic categories (except anxiety disorders with OR = 5.3). Non-lethal self-harm in the study period was committed by 14.3% of the cases and 0.14% of the controls, and was twice as common in female cases than in male cases. Previous self-harm was a very strong independent predictor for suicide with OR = 53.1 when a single episode of self-harm had occurred, and OR = 98.0 for repeated episodes (adjusted for age, gender and hospitalisation). Only 16.1% of the cases were currently on antidepressant medication at the time of suicide.

CONCLUSIONS

Few of the suicides had previously been psychiatric in-patients. Even fewer had current prescriptions for antidepressants. This suggests that better diagnosis and treatment of psychiatric patients is an important suicide preventive intervention.

Epidemiology, neurobiology and pharmacological interventions related to suicide deaths and suicide attempts in bipolar disorder: Part I of a report of the International Society for Bipolar Disorders Task Force on Suicide in Bipolar Disorder

OBJECTIVES

Bipolar disorder is associated with elevated risk of suicide attempts and deaths. Key aims of the International Society for Bipolar Disorders Task Force on Suicide included examining the extant literature on epidemiology, neurobiology and pharmacotherapy related to suicide attempts and deaths in bipolar disorder.

METHODS

Systematic review of studies from 1 January 1980 to 30 May 2014 examining suicide attempts or deaths in bipolar disorder, with a specific focus on the incidence and characterization of suicide attempts and deaths, genetic and non-genetic biological studies and pharmacotherapy studies specific to bipolar disorder. We conducted pooled, weighted analyses of suicide rates.

RESULTS

The pooled suicide rate in bipolar disorder is 164 per 100,000 person-years (95% confidence interval = [5, 324]). Sex-specific data on suicide rates identified a 1.7:1 ratio in men compared to women. People with bipolar disorder account for 3.4-14% of all suicide deaths, with self-poisoning and hanging being the most common methods. Epidemiological studies report that 23-26% of people with bipolar disorder attempt suicide, with higher rates in clinical samples. There are numerous genetic associations with suicide attempts and deaths in bipolar disorder, but few replication studies. Data on treatment with lithium or anticonvulsants are strongly suggestive for prevention of suicide attempts and deaths, but additional data are required before relative anti-suicide effects can be confirmed. There were limited data on potential anti-suicide effects of treatment with antipsychotics or antidepressants.

CONCLUSION

This analysis identified a lower estimated suicide rate in bipolar disorder than what was previously published. Understanding the overall risk of suicide deaths and attempts, and the most common methods, are important building blocks to greater awareness and improved interventions for suicide prevention in bipolar disorder. Replication of genetic findings and stronger prospective data on treatment options are required before more decisive conclusions can be made regarding the neurobiology and specific treatment of suicide risk in bipolar disorder.

Suicide in bipolar disorder: characteristics and subgroups

OBJECTIVES

The development of more sophisticated models for understanding suicide among people with bipolar disorder (BD) requires diagnosis-specific data. The present study aimed to elucidate differences between people who die by suicide with and without BD, and to identify subgroups within those with BD.

METHODS

Data on all suicide deaths in the city of Toronto from 1998 to 2010 were extracted from the Office of the Chief Coroner of Ontario, including demographics, clinical variables, recent stressors, and details of the suicide. Comparisons of person- and suicide-specific variables between suicide deaths among those with BD (n = 170) and those without (n = 2,716) were conducted, and a cluster analysis was performed among the BD suicide group only.

RESULTS

Those in the BD suicide group were more likely than those in the non-BD suicide group to be female [odds ratio (OR) = 1.75, 95% confidence interval (CI): 1.27-2.42; p = 0.001], to have made a past suicide attempt (OR = 2.01, 95% CI: 1.45-2.80; p < 0.0001), and to have had recent contact with psychiatric or emergency services (OR = 1.59, 95% CI: 1.00-2.52; p = 0.049). Five clusters were identified within the BD group, with differences between clusters in age; sex; marital status; living circumstances; past suicide attempts; substance abuse; interpersonal, employment/financial, and legal/police stressors; and rates of death by fall/jump or self-poisoning.

CONCLUSIONS

The present findings identified differences between BD and non-BD suicide groups, providing support to the utilization of an illness-specific approach to better understanding suicide in BD. Subgroups of BD suicide deaths, if replicated, should also be incorporated into the design and analysis of future studies of suicide in BD.

Suicide in first episode psychosis: a nationwide cohort study

BACKGROUND

Relatively little is known about suicide in diagnostic subtypes of first episode psychosis (FEP). Our aim was to assess suicide rates and potential risk factors for suicide in FEP.

METHODS

This is a national register-based cohort study of patients born in 1973-1978 in Sweden and who were hospitalized with a FEP between ages 15 and 30years (n=2819). The patients were followed from date of discharge until death, emigration, or 31st of December 2008. The suicide rates for six diagnostic subtypes of FEP were calculated. Suicide incidence rate ratios (IRRs) were calculated to evaluate the association between suicide and psychiatric, familial, social, and demographic factors.

RESULTS

In total 121 patients died by suicide. The overall suicide rate was 4.3 (95% confidence interval [CI] 3.5-5.0) per 1000person-years. The highest suicide rates were found in depressive disorder with psychotic symptoms and in delusional disorder. In an adjusted model, the strongest risk factors for suicide were self-harm (IRR 2.7, CI 1.7-4.4) or a conviction for violent crime (IRR 2.0, CI 1.3-3.2). Also having a first-degree relative with a schizophrenia/bipolar diagnosis (IRR 2.1, CI 1.2-3.6) or substance use disorder (IRR 2.0, CI 1.2-3.2) were significant risk factors for suicide.

CONCLUSIONS

Impulsive behavior such as self-harm as well as having a family history of severe mental disorder or substance use are important risk factors for suicide in FEP.

Suicidal behaviour in mood disorders--who, when, and why?

OBJECTIVE

About one-half to two-thirds of all suicides are by people who suffer from mood disorders; preventing suicides among those who suffer from them is thus central for suicide prevention. Understanding factors underlying suicide risk is necessary for rational preventive decisions.

METHOD

The literature on risk factors for completed and attempted suicide among subjects with depressive and bipolar disorders (BDs) was reviewed.

RESULTS

Lifetime risk of completed suicide among psychiatric patients with mood disorders is likely between 5% and 6%, with BDs, and possibly somewhat higher risk than patients with major depressive disorder. Longitudinal and psychological autopsy studies indicate suicidal acts usually take place during major depressive episodes (MDEs) or mixed illness episodes. Incidence of suicide attempts is about 20- to 40-fold, compared with euthymia, during these episodes, and duration of these high-risk states is therefore an important determinant of overall risk. Substance use and cluster B personality disorders also markedly increase risk of suicidal acts during mood episodes. Other major risk factors include hopelessness and presence of impulsive-aggressive traits. Both childhood adversity and recent adverse life events are likely to increase risk of suicide attempts, and suicidal acts are predicted by poor perceived social support. Understanding suicidal thinking and decision making is necessary for advancing treatment and prevention.

CONCLUSION

Among subjects with mood disorders, suicidal acts usually occur during MDEs or mixed episodes concurrent with comorbid disorders. Nevertheless, illness factors can only in part explain suicidal behaviour. Illness factors, difficulty controlling impulsive and aggressive responses, plus predisposing early exposures and life situations result in a process of suicidal thinking, planning, and acts.

Differentiating bipolar I and II disorders and the likely contribution of DSM-5 classification to their cleavage

Current diagnostic criteria define bipolar I (BP I) and bipolar II (BP II) disorders as distinct conditions, differing only slightly by clinical features. This review seeks to identify commonalities and differentiating features across the two sub-types, and emphasize that differences in causes and treatments are likely to be highly dependent on the diagnostic criteria used to define and differentiate the two conditions. We undertake a literature review of candidate clinical features that might be anticipated to vary or be shared across BP I and BP II disorders, and consider the impact of DSM definition on such applied findings. Studies respecting DSM-IV differentiation of BP I and BP II disorders have generated relatively few differences across the conditions, which may reflect definitional similarity or commonalities across the two conditions. As DSM-5 decision rules are similar to those used by DSM-IV to differentiate BP I and BP II disorders, we argue for application studies employing DSM-5 decisions to examine the differential impact of three features that weight BP I assignment (i.e. psychosis, hospitalization and/or impairment) and examine other sets of differentiating criteria.

Suicide in Hungary-epidemiological and clinical perspectives

Annual suicide rates of Hungary were unexpectedly high in the previous century. In our narrative review, we try to depict, with presentation of the raw data, the main descriptive epidemiological features of the Hungarian suicide scene of the past decades. Accordingly, we present the annual suicide rates of the period mentioned and also data on how they varied by gender, age, urban vs. rural living, seasons, marital status, etc. Furthermore, the overview of trends of other factors that may have influenced suicidal behavior (e.g., alcohol and tobacco consumption, antidepressant prescription, unemployment rate) in the past decades is appended as well. Based on raw data and also on results of the relevant papers of Hungarian suicidology we tried to explain the observable trends of the Hungarian suicide rate. Eventually, we discuss the results, the possibilities, and the future tasks of suicide prevention in Hungary.

A longitudinal population-based study exploring treatment utilization and suicidal ideation and behavior in major depressive disorder

BACKGROUND

This study aimed to longitudinally examine the relationship between treatment utilization and suicidal behavior among people with major depressive disorder in a nationally representative sample.

METHODS

Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (Wave 1: N=43,093; Wave 2: N=34,653). Suicidal and non-suicidal individuals at Wave 1 were compared based on subsequent treatment utilization. Suicidal behavior at Wave 2 was compared between people with major depressive disorder who had sought treatment at Wave 1 versus those that had not.

RESULTS

Individuals with past year major depressive disorder at Wave 1 who attempted suicide were more likely to be hospitalized at follow up compared to non-suicidal people with major depressive disorder [adjusted odds ratio (AOR)=4.46; 95% confidence interval [95% CI]: 2.54-7.85]; however, they were not more likely to seek other forms of treatment. Among those with past year major depressive disorder who sought treatment at baseline, visiting an emergency room (AOR=3.08; 95% CI: 1.61-5.89) and being hospitalized (AOR=2.41; 95% CI: 1.13-5.14), was associated with an increased likelihood of attempting suicide within 3 years even after adjusting for mental disorder comorbidity, depression severity, and previous suicidal behavior.

LIMITATIONS

Unable to draw conclusions about completed suicide or adequacy of treatment.

CONCLUSIONS

Suicidal behavior does not lead individuals with major depressive disorder to seek treatment with professionals or use antidepressant medications; instead, they are more likely to use emergency services. These findings suggest that treatment efforts for people with major depressive disorder who are suicidal need improvement.

Development of the Risk Assessment Suicidality Scale (RASS): a population-based study

BACKGROUND

Suicide and suicide attempts are significant and costly public health problems. In order to prevent suicidal and other self-injurious behaviors, research on the multiple factors involved in these behaviors with comprehensive and user-friendly instruments is necessary. The aim of the current study was to construct a self-report instrument with emphasis on items describing suicide-related behavior itself rather than strongly related clinical features on the basis of a general population study.

METHODS

Twelve items comprising a new scale were applied to 734 subjects from the general population (40.6% males and 59.4% females) aged 40.8±11.5 along with the STAI and the CES-D.

RESULTS

The scoring method was developed on the basis of frequency table of responses to the individual scale items. The factor analysis returned 3 factors explaining 59.19% of total variance (Intention, Life, and History). The Cronbach's alpha was 0.85 for the Intention, 0.69 for the Life and 0.52 for the History subscale.

LIMITATION

The findings need replication in clinical and epidemiologic studies.

CONCLUSION

The RASS is a reliable and valid instrument which might prove valuable in the assessment of suicidal risk in the general population as well as in mental patients.

Understanding suicide risk: identification of high-risk groups during high-risk times

BACKGROUND

The assessment of suicide risk is a complex task for mental health professionals. Certain demographic groups are associated with completed suicide including males, divorced adults, and Caucasians. However, demographic variables alone provide a crude assessment of suicide risk. Psychiatric diagnosis and recent life events might improve the identification of high-risk individuals.

METHOD

The current study evaluated 148 individuals who died by suicide compared with 257 adults who died suddenly from accidents or medical problems. Psychological autopsy was used to assess Axis I psychiatric diagnosis and recent stressful life events.

RESULTS

Suicide completers were significantly more likely than comparison subjects to have a depressive disorder, a substance abuse disorder, and to have experienced interpersonal conflict in the months leading up to their death. A discriminant function analysis revealed that the combination of demographic variables, recent stressful life events, and psychiatric diagnoses best discriminated between suicide completers and comparison subjects.

CONCLUSIONS

Proper assessment of suicide risk should include a comprehensive evaluation of demographic characteristics, recent life stressors, and psychiatric diagnosis.

The emerging modern face of mood disorders: a didactic editorial with a detailed presentation of data and definitions

The present work represents a detailed description of our current understanding and knowledge of the epidemiology, etiopathogenesis and clinical manifestations of mood disorders, their comorbidity and overlap, and the effect of variables such as gender and age. This review article is largely based on the 'Mood disorders' chapter of the Wikibooks Textbook of Psychiatry http://en.wikibooks.org/wiki/Textbook_of_Psychiatry/Mood_Disorders.

Diagnosis and therapy of depression in primary care

A depresszió a külföldi és hazai felmérések szerint is a leggyakoribb pszichiátriai tünetegyüttes. Nyugat-Európában a major depresszió élettartam-prevalenciája 13%, egyéves prevalenciája 4% körül alakul. Magyarországon is hasonló a súlyos depresszió előfordulási aránya; a családorvosnál megjelenő betegek mintegy 5–8%-ánál diagnosztizálható valamilyen depresszív zavar. A megbetegedés nők körében és az életkor előrehaladtával gyakrabban fordul elő. Az Egészségügyi Világszervezet szerint a depresszió jelenleg a harmadik leggyakoribb munkaképesség-csökkenésért felelős betegség. A kórkép jelentőségét növeli, hogy nagymértékben rontja az életminőséget, gyakran társul szorongással, alvászavarokkal, alkohol- és drogfüggőséggel, valamint egyes szomatikus kórképekkel. A depresszió az öngyilkosság legfőbb rizikófaktora. A depresszió szűrésében, diagnosztizálásában nagy szerep jut a családorvosnak. Nemcsak a levert hangulatról, szomorúságról, öngyilkossági gondolatokról panaszkodó beteg esetén kell depresszióra gondolni, hanem szervi betegséggel nem magyarázható egyéb tünetek, fejfájás, fáradékonyság, hasi fájdalom, gastrointestinalis panaszok, testsúlyváltozás esetén is. A családorvosnak megfelelő ismeretekkel kell rendelkeznie a különböző terápiás lehetőségekről – pszichoterápiás módszerekről, antidepresszív gyógyszerekről, egyéb terápiás lehetőségekről –, hogy betegét hatékonyan tudja kezelni, szükség esetén a pszichológussal, pszichiáter szakorvossal együttműködve. Jelen közleményünkben bemutatjuk a depresszió jelentőségét és előfordulási gyakoriságát vizsgáló irodalmi adatokat, valamint összefoglaljuk a depresszió diagnosztikus és terápiás lehetőségeit a családorvosi gyakorlatban.

Risk factors for suicide in Hungary: a case-control study

BACKGROUND

Hungary previously had one of the highest suicide rates in the world, but experienced major social and economic changes from 1990 onwards. We aimed to investigate the antecedents of suicide in Hungary. We hypothesised that suicide in Hungary would be associated with both risk factors for suicide as identified in Western studies, and experiences related to social and economic restructuring.

METHODS

We carried out a controlled psychological autopsy study. Informants for 194 cases (suicide deaths in Budapest and Pest County 2002-2004) and 194 controls were interviewed by clinicians using a detailed schedule.

RESULTS

Many of the demographic and clinical risk factors associated with suicide in other settings were also associated with suicide in Hungary; for example, being unmarried or having no current relationship, lack of other social contacts, low educational attainment, history of self-harm, current diagnosis of affective disorder (including bipolar disorder) or personality disorder, and experiencing a recent major adverse life event. A number of variables reflecting experiences since economic restructuring were also associated with suicide; for example, unemployment, concern over work prospects, changes in living standards, practising religion. Just 20% of cases with evidence of depression at the time of death had received antidepressants.

CONCLUSION

Suicide rates in Hungary are falling. Our study identified a number of risk factors related to individual-level demographic and clinical characteristics, and possibly recent societal change. Improved management of psychiatric disorder and self-harm may result in further reductions in suicide rates.

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.

Are high-lethality suicide attempters with bipolar disorder a distinct phenotype?

Because Bipolar Disorder (BD) individuals making highly lethal suicide attempts have greater injury burden and risk for suicide, early identification is critical. BD patients were classified as high- or low-lethality attempters. High-lethality attempts required inpatient medical treatment. Mixed effects logistic regression models and permutation analyses examined correlations between lethality, number, and order of attempts. High-lethality attempters reported greater suicidal intent and more previous attempts. Multiple attempters showed no pattern of incremental lethality increase with subsequent attempts, but individuals with early high-lethality attempts more often made high-lethality attempts later. A subset of high-lethality attempters make only high-lethality attempts. However, presence of previous low-lethality attempts does not indicate that risk for more lethal, possibly successful, attempts is reduced.

Antidepressant prescription and suicide rates: effect of age and gender

To determine whether the effect of antidepressant exposure on suicide rate is modified by age and gender in Hungary, annual antidepressant prescription rates and suicide rates of about 10 million inhabitants between 1999-2005 were analyzed by age and gender groups. The suicide rate was inversely related to the increased use of antidepressants in both genders. The strongest association was found in the oldest age groups, where the increase in antidepressant use was highest, while there was no association in the under 20 or 50-69 age groups in either gender. Antidepressant prescription rate was related to suicide rate after controlling for divorce rate or unemployment rate, but not after controlling for alcohol consumption rate.

Bipolar disorder and suicide: research synthesis and clinical translation

Attempted suicide and suicide are prevalent in individuals with bipolar disorder (BD). Extant evidence indicates that history of suicide attempts, percentage of time spent in a depressed state, and hostility are factors associated with suicide attempts and completed suicide. Childhood adversity (eg, sexual and physical abuse) is emerging as a risk factor for suicide attempts in adults with BD. The pertinacity of medical comorbidity (eg, obesity, metabolic syndrome) in the bipolar population is further underscored by its preliminary association with suicidality. Biomarkers such as cerebrospinal fluid monoamine metabolite levels may be predictive of suicide attempts and lethality in BD. Compelling evidence supports an antisuicide effect of long-term lithium prophylaxis; lithium's salutary effect is mediated primarily by reduced lethality of suicidal acts. Conventional unimodal antidepressants may engender or exacerbate suicidality in susceptible individuals with BD. A nascent database suggests that adjunctive psychosocial interventions may further reduce suicide risk in bipolar individuals.

Does first episode polarity predict risk for suicide attempt in bipolar disorder?

BACKGROUND

Defining bipolar disorder (BD) subtypes with increased risk of suicidal behavior may help clinical management. We tested the hypothesis that the polarity of a patient's first mood episode would be a marker for BD subtypes with differential risk for suicidality.

METHODS

One hundred thirteen subjects with DSM-IV defined BD were classified based on whether their first reported episode was manic/hypomanic (FM) or depressed (FD). They were compared on demographic and clinical variables. Logistic regression adjusting for potential confounds tested the association between first episode polarity and history of suicide attempt.

RESULTS

Multiple logistic regression analysis showed that FD group membership was associated with eightfold odds of a past suicide attempt, adjusting for years ill and total number of lifetime major depressive episodes.

LIMITATIONS

Sample size, retrospective design, recall bias, assessment during a mood episode, and imprecise recall of hypomania.

CONCLUSIONS

Polarity of patients' first reported mood episode suggested a depression-prone subtype with a greater probability of past suicide attempt. The FM group had more alcoholism and psychosis, but less likelihood of past suicide attempt. Validation of these putative subtypes requires prospective study.

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.

Facteurs associés au risque suicidaire chez les jeunes consultants d’un centre de prévention sanitaire et sociale

The association between suicidal risk and various psychological or biographical factors in teenagers or young adults is already well documented. Yet, the role of stressful life events or contexts during childhood or of the recent past, as well as the respective weight of such determinants, has to be specified.

METHODS

One thousand one hundred and thirty-nine individuals, aged 16 to 25, who consecutively consulted in a preventive health center supported by the National Health Insurance System, located in Seine-Saint-Denis (a French department characterized by an unfavourable socio-economic context) on the occasion of a free work up were invited to fill out several self-administered questionnaires, aimed at assessing especially the level of psychosocial distress (Golberg's GHQ-28) and the level of hopelessness (Beck's hopelessness scale). They were also invited to meet a psychologist for a semi-structured interview, when the day of their consultation coincided with one of the three days a week the psychologist was present in the center; the interview was aimed at collecting information upon the biographical context and ancient or recent life events and to determine the level of suicidal risk, on the basis of a scale of suicidal ideation [Ducher's Suicidal Risk Scale (ERSD)]. The concurrent validity of the later has already been previously tested and positive correlation coefficients were found with Beck Depression Inventory, Hamilton's Depression Rating Scale and Beck's Hopelessness Scale.

RESULTS

One thousand and four records could be analysed, as regards self-administered questionnaires, and among those, 576 as regards the interview with the psychologist and data related to suicidal risk. The studied population included 61.3% of females and 59.3% of individuals aged 20 to 25: mean age was comparable in males and females. GHQ-28 global score and sub-scores (somatisation, anxiety, social dysfunction and depressive mood) were all higher in women (all the p<0.001). A high suicidal risk (ERSD score 4) was found in 24.1% of the studied population. Subjects presenting with a high suicidal risk were characterized by higher levels of GHQ-28 psychosocial distress and GHQ-28 sub-scores as well as hopelessness (all the p<0.001). Several biographical antecedents during childhood were significantly associated with suicidal risk: unknown father (p<0.001), death of parents (p<0.001), separation from parents (p<0.001), severe quarrel between parents (p<0.001), money problems within the family (p<0.007), disorders related with alcohol consumption in parents (p<0.016), drug addiction within the family (p<0.001). Other predictors were several recent stressful events or contexts: violence within the family (p<0.001), social isolation (p<0.001), lack of self-esteem of (p<0.002), school difficulties (p<0.001), educational failure (p<0.001); as well as the notion of a consumption of drugs (p=0,001) or medications: neuroleptics (p<0.015), antidepressants (p=0.001) and tranquilizers (p<0.001). A series of univariate regression analyses allowed to compute the Odds Ratios (OR) and the 95% Confidence Intervals (95% CI) of the sub-group characterized by a high suicidal risk for each socio-demographic, psychological and biographical independent variable, linked to suicidal risk at a threshold of p<0.10. A multiple regression analysis was then performed in 2 steps: in a first step, independent variables were pooled by blocks, according to their nature (psychological characteristics, relational deficiencies among biographical antecedents, other stressful conditions among antecedents, stressful conditions among recent biographical context, recent consumption of drugs or medications); in a second step, all the independent variables which still remained associated with suicidal risk within each block were included in a final multiple regression analysis. Five variables continued to independently predict a high suicidal risk: hopelessness at Beck's scale (OR=4.09), depressive mood at GHQ-28 (OR=3.75), the notion of an unknown father (OR=2.95), the notion of a recent destabilizing event other than a school problem or an aggression (OR=1.90) and the notion of an educational failure (OR=1.78).

CONCLUSION

These results confirm previous scientific data on this topic and underline that childhood context, educational course, psychological vulnerability and the occurrence of recent stressful life events combine their effects, enhancing the risk of a suicidal attempt. They can be useful for better sensitising educational as well as social and health care circles, for settling more efficient screening and preventive programs.

More tryptophan hydroxylase in the brainstem dorsal raphe nucleus in depressed suicides

Deficient serotonin neurotransmission in suicide is indicated by reduced brainstem serotonin (5-HT) and 5-hydroxyindoleacetic acid (5-HIAA), fewer 5-HT(1A) autoreceptors and reduced cortical serotonin transporter binding in suicide victims. Tryptophan hydroxylase (TPH) is the rate-limiting enzyme in the synthesis of 5-HT, and alterations in TPH could explain some of these findings. We sought to determine the amount of TPH immunoreactivity (TPH-IR) in the dorsal (DRN) and median (MRN) raphe nuclei in suicides and controls. Brainstems of suicide victims and controls (n = 11 pairs) were collected at autopsy, matched for age, sex and postmortem interval, frozen and sectioned (20 microm). Immunoautoradiography, using an antibody to label TPH, was performed, slides exposed to film and autoradiograms quantified by a computer-based image analysis system. We examined sections every 1000 microm throughout the whole length of the nucleus, performing statistical analysis only on those subjects for whom the raphe was complete (n = 8 pairs). TPH-IR (microCi/g) was higher in suicides than controls (S: 300.8 +/- 70.8 vs. C: 259.6 +/- 40.7, t = 2.57, df = 7, P = 0.04) in the dorsal raphe nucleus (DRN), and not different between suicides and controls (S: 251.3 +/- 44.2 vs. C: 235.9 +/- 27.4, t = 1.49, df = 7, P = 0.18) in the MRN. DRN TPH-IR was higher in male suicide victims (MS) compared to male controls (MC; MS: 318.4 +/- 54.4 vs. MC: 271.9 +/- 22.5, t = 2.66, df = 6, P = 0.03). The analysis of TPH-IR area and density at each DRN rostrocaudal levels showed higher area and density in suicides compared to controls in the rostral DRN and lower area and density in the caudal DRN. TPH-IR, an index of the amount of TPH enzyme, in the DRN is higher in depressed suicides. More TPH may be an upregulatory homeostatic response to impaired serotonin release or less autoreceptor activation. Alternatively, the serotonin impairment in suicide may be due to hypofunctional serotonin-synthesizing enzyme.

The Psychology and Neurobiology of Suicidal Behavior

Suicide is a leading cause of death, but it is not well understood or well researched. Our purpose in this review is to summarize extant knowledge on neurobiological and psychological factors involved in suicide, with specific goals of identifying areas particularly in need of future research and of articulating an initial agenda that may guide future research. We conclude that from both neurobiological and psychological perspectives, extant research findings converge on the view that two general categories of risk for suicide can be identified: (a) dysregulated impulse control; and (b) propensity to intense psychological pain (e.g., social isolation, hopelessness), often in the context of mental disorders, especially mood disorders. Each of these categories of risk is underlain at least to some degree by specific genetic and neurobiological factors; these factors in general are not well characterized, though there is emerging consensus that most if not all reside in or affect the serotonergic system. We encourage future theorizing that is conceptually precise, as well as epistemically broad, about the specific preconditions of serious suicidal behavior, explaining the daunting array of suicide-related facts from the molecular to the cultural level.

Pharmacotherapy of suicidal behavior in bipolar disorder

Patients with Bipolar Disorder (BD) are at particularly high risk for both attempted and completed suicides. The period of highest risk for completed suicide is during the 2 years following discharge from a hospitalization. To date, pharmacological studies of suicidal behavior in BD have been quite limited. While strong evidence has been found regarding the anti-suicidal effects of lithium, evidence for such properties in other commonly prescribed medications for BD, including anticonvulsants, SSRIs and anti-psychotics, has been largely unexplored. Considering the high risk of suicidal acts in patients with BD, further research on the pharmacotherapy of suicidal behavior is crucial.

Suicide in bipolar I disorder in Finland: psychological autopsy findings from the National Suicide Prevention Project in Finland

Suicide mortality in bipolar disorders is high, but little is known about the conditions preceding these fatal acts. The Research phase of the National Suicide Prevention Project in Finland comprised a nationwide psychological autopsy study of suicides (N = 1397) in Finland in 1987-88. In a series of studies, all of the 31 suicides with bipolar I disorder were comprehensively investigated. These suicides usually occurred during a depressive phase, but many male victims also suffered from comorbid alcohol use disorders. Despite contact with psychiatric care, most subjects had not received adequate treatment nor adhered to it. In most cases, suicide occurred after a recent adverse life change. More than half had communicated their intent to next of kin or attending personnel before death.

Bipolar disorders and suicidal behaviour

Major depressive disorder is the leading cause of suicide, particularly in the absence of adequate treatment. The aim of this paper is to analyse the relationship between different forms of major mood disorders and suicidal behaviour. Population-based epidemiological surveys as well as clinical studies on the clinically explorable suicide risk factors in bipolar and unipolar depressive disorders are reviewed. The present literature shows that patients with bipolar disorders are at higher risk of attempted and completed suicide than that of patients with unipolar major depression. Contrasting only bipolar I and bipolar II patients, current findings indicate that the rate of prior suicide attempt is higher in bipolar II patients, and bipolar II disorder is overrepresented in depressed suicide victims. Among patients with different clinical manifestations of major mood disorders (unipolar major depression. bipolar I and bipolar II disorder), bipolar patients in general, and bipolar II subjects in particular carry the highest risk of suicide.

Physician-assisted suicide: the role of mental health professionals

A review of the literature was conducted to better understand the (potential) role of mental health professionals in physician-assisted suicide. Numerous studies indicate that depression is one of the most commonly encountered psychiatric illnesses in primary care settings. Yet, depression consistently goes undetected and undiagnosed by nonpsychiatrically trained primary care physicians. Noting the well-studied link between depression and suicide, it is necessary to question giving sole responsibility of assisting patients in making end-of-life treatment decisions to these physicians. Unfortunately, the use of mental health consultation by these physicians is not a common occurrence. Greater involvement of mental health professionals in this emerging and debated area is advocated. Beyond describing mental health professionals' role in the assessment of patient competency or decision making capacity, other areas of potential involvement are described. A discussion of ethical principles relevant to this area follows, along with comments on the training necessary to adequately serve patient needs.

Can better recognition and treatment of depression reduce suicide rates? A brief review

Depression, the major cause of suicide, is prevalent but an under-detected, underdiagnosed and, under-treated illness and it is particularly true for depressed suicide victims. However, several studies consistently show that successful treatment of depression not only relieves depressive symptoms, but also decreases and makes suicidality vanish. If the rate of treated depressions in the population increases gradually, at a given point it will appear in the decline of the suicide rates. Although absolute evidence is lacking at present, recent reports from some European countries strongly suggest that increasing utilisation of antidepressants is one of the most important contributing factors in the decrease in suicide rates.

Suicidal behavior in bipolar mood disorder: clinical characteristics of attempters and nonattempters

OBJECTIVE

Bipolar Disorder is associated with a higher frequency of attempted suicide than most other psychiatric disorders. The reasons are unknown. This study compared bipolar subjects with a history of a suicide attempt to those without such a history, assessing suicidal behavior qualitatively and quantitatively, and examining possible demographic, psychopathologic and familial risk factors.

METHODS

Patients (ages 18 to 75) with a DSM III-R Bipolar Disorder (n = 44) diagnosis determined by a structured interview for Axis I disorders were enrolled. Acute psychopathology, hopelessness, protective factors, and traits of aggression and impulsivity were measured. The number, method and degree of medical damage was assessed for suicide attempts, life-time.

RESULTS

Bipolar suicide attempters had more life-time episodes of major depression, and twice as many were in a current depressive or mixed episode, compared to bipolar nonattempters. Attempters reported more suicidal ideation immediately prior to admission, and fewer reasons for living even when the most recent suicide attempt preceded the index hospitalization by more than six months. Attempters had more lifetime aggression and were more likely to be male. However, attempters did not differ from nonattempters on lifetime impulsivity.

LIMITATIONS

The generalizability of the results is limited because this is a study of inpatients with a history of suicide attempts. Patients with Bipolar I and NOS Disorders were pooled and a larger sample is needed to look at differences. We could not assess psychopathology immediately prior to the suicide attempt because, only half of the suicide attempters had made attempts in the six months prior to admission. Patients with current comorbid substance abuse were excluded. No suicide completers were studied.

CONCLUSIONS

Bipolar subjects with a history of suicide attempt experience more episodes of depression, and react to them by having severe suicidal ideation. Their diathesis for acting on feelings of anger or suicidal ideation is suggested by a higher level of lifetime aggression and a pattern of repeated suicide attempts.

Bipolar II disorder and suicidal behavior

Despite the fact that the nosologic position of bipolar II disorder continues to be debated, several lines of research indicate that it is a distinct nosologic category that should be separated from both bipolar I and unipolar major depression. This review of the authors' and others' work demonstrates that the lifetime risk of suicide attempts is highest in bipolar II and lowest in unipolar patients, whereas risk is intermediate in bipolar I patients. Moreover, two reports show that bipolar II patients are over represented among suicide victims. Clinicians must take great care in not missing this diagnosis, which, when untreated, has ominous prognostic implications.

Impact of comorbid affective and alcohol use disorders on suicidal ideation and attempts

The effect of concurrent affective and alcohol use disorders on suicidal ideation and behavior was investigated. The Diagnostic Interview Schedule Version III-R (DIS) was administered to 307 adult veteran men ranging in age from 23 to 78. Participants were classified into one of four groups based on their final DIS diagnosis-lifetime unipolar depression and lifetime bipolar I disorder with or without a lifetime alcohol use disorder. Logistic regression analyses indicated that veterans with a major affective disorder were at greater risk for suicidality than veterans without an affective disorder. However, veterans with unipolar depression were at no greater risk for suicidality than those with bipolar I disorder. Unipolar and bipolar I disorders with a concurrent alcohol use disorder were always associated with an increased risk for suicidality.

Characteristics of suicidal attempts in major depression versus adjustment reactions

BACKGROUND

The aim of this present study was to compare the characteristics of suicidal attempts of patients with major depression (MD) and adjustment reaction (AR).

METHOD

Sixty-nine patients with MD and 86 with AR admitted to the Moscow Institute of Emergency Help after the first suicide attempts were studied. All the attempters were interviewed by at least by two psychiatrists and the diagnosis was made according to agreement and to ICD-9CM criteria.

RESULTS

Differences between the two groups were found with regard to social-demographic, clinical-psychological and suicidal characteristics: the AR patients were less educated, had lower social status and in most cases were unmarried, compared with the MD patients. A large number (51.2% of the attempters in the AR group and 34.8% in the MD group) had an unstable parental family, early orphanhood or an emotionally deprived childhood. No differences were found in the methods of the suicidal attempts between the groups. Suicidal attempts under alcohol abuse occurred more often among the AR group (34.9 vs. 10.1%). The interval from the beginning of the disorder until the suicidal attempt was significantly shorter within the AR group. In this group the suicidal attempts were not planned, in comparison with the MD group.

LIMITATION

The sample is a selected study, because the research included only inpatients with AR and MD after their first suicidal attempt.

CONCLUSION

We believe that our data may be important for improving the assessment of suicidal risk and in planning treatment strategies for prevention of repeated suicidal attempts.

The prevalence of affective and anxiety disorders in primary care practice in Hungary

The lifetime and point prevalence of affective and anxiety disorders were investigated with the aid of the DIS questionnaire in 15 primary care practices among patients aged 18 to 60. According to the DSM-III-R criteria, 43% of the eligible 301 patients had had some kind of affective or anxiety disorder till the time of the assessment. Major depression was found to be the most common lifetime diagnosis (18%). At the time of the investigation 15% of the patients were suffering from affective or anxiety disorder (point prevalence) calling for clinical therapy. Females had significantly higher numbers of lifetime and point diagnoses of affective and anxiety disorders. Sixty percent of patients failed to report psychiatric complaints to their doctor, and in social phobia this figure was as high as 87%. Our results are in accordance with international findings and underline the need to diagnose and treat psychiatric patients already at the stage of the primary care service.

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

Depression is an endemic disease with high morbidity, and a high mortality in depression-related suicide. Suicidal tendencies, especially among males, are increasing today in East European countries. General practitioners are considered to have a very important role in the prevention and treatment of depression. Matters of depression are more openly discussed in society. Patients showing up in primary care are nowadays less reluctant to see depression as a causative factor behind their symptoms. Taboos concerning the stigma of depression and suicidality are weaker. In spite of this, important problems still exist regarding poor diagnostic and treatment routines in primary care and the inability of depressive and suicidal men to seek for help or to be recognized. In the years 1983-1984, the Swedish Committee for Prevention and Treatment of Depression (PTD) offered an educational programme to all general practitioners (GPs) on the Swedish island of Gotland. During the 1980s this education was shown to lead to a significant decrease in inpatient care, morbidity, suicide, mortality and costs of depressive illness on the island. The use of anxiolytic and sedative medication decreased and that of antidepressant medication increased. This all showed that an educational programme in primary care on depression and suicide was effective. However, the effects faded and, unexpectedly, the number of male suicides was almost unaffected by the educational programme and by the GPs' ability to diagnose and treat depression. Repeated educational activities during the 1990s again led to a decrease in suicides, mainly in females. Also, the increase in antidepressant prescriptions following GP education in the 1990s was mostly in the treatment of female patients. One of the reasons was that few suicidal males are known to the medical services although many of these people are known to the police and social welfare services. The reasons why depressed and suicidal men do not show up in the medical services are discussed, and found to lie in the differences between the male and the female depressive syndrome, leading to difficulties in reaching, diagnosing and treating these patients. Strategies for finding and treating suicidal depressives are discussed. One conclusion is that males are as often depressed as females, but in different ways, and that one of the reasons behind the dramatic over-representation of males amongst suicide victims may be found in the low rate of diagnosis and treatment of the male depressive syndrome, (hit J Psych Clin Pract 1997; 1: 39-46).

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.

Suicide in non-major depressions

We compared depressive suicides who had unipolar depression not fulfilling the diagnostic criteria of major depression (non-major depressions) with suicides who had major depression. A random sample of 229 suicides representing all suicides in Finland within a 12-month period were comprehensively examined using the psychological autopsy method and diagnosed according to DSM-III-R criteria. We included in this study all cases of current depressive disorder not otherwise specified (n = 48), adjustment disorder with depressed mood (n = 6) and dysthymia (n = 4). These 58 cases of suicide in non-major depressions were compared with the suicides with unipolar major depression (n = 71) in the same random sample. The non-major depressive victims were younger, and comprised more males, more cases with psychoactive substance use disorders, more secondary depressives, and more cases not having contact with health care, or cases not having communicated suicidal intent despite such contact. Recent life events were also reported more common among those with non-major depressions, particularly during the final week. The findings suggest that suicides in major depression and in unipolar depressions not fulfilling the criteria for major depression are likely to differ in several clinically relevant characteristics besides depressive symptomatology.

Depression and suicide on Gotland. An intensive study of all suicides before and after a depression-training programme for general practitioners

In 1983 and 1984, the Swedish Committee for the Prevention and Treatment of Depression (PTD) organised a postgraduate training programme on the diagnosis and treatment to all the general practitioners on Gotland, Sweden. In the following years, the frequency of suicide and inpatient care for depression decreased significantly, as well as the frequency of sick leave for depression. The results of the Gotland study have provided evidence for the view that early recognition and adequate treatment of depression is one essential method of suicide prevention (Rutz et al., 1989; Rutz et al., 1992). A detailed retrospective clinical analysis, of all 115 consecutive suicide victims on Gotland between 1981 and 1992 presented in this study, showed that male gender and violent methods were overrepresented. 50 suicides had a DSM-III-R axis I diagnosis and half of them (n = 25) had primary major depression. Bipolar II disorder was relatively overrepresented in this sample. After the PTD programme, the proportion of depressive suicides was significantly lower than before. This finding strongly suggests that the significant decrease in the suicide rate after the PTD programme is a direct result of the robust decrease in depressive suicides of the area served by trained GPs. The practical importance of this finding is briefly discussed.

An economic evaluation of manic-depressive illness--1991

In 1991, the costs for manic-depressive illness, which has a lifetime prevalence of 1.3% among adult Americans, totaled $45 billion. Costs were broken down into their direct and indirect components. Direct costs totaling $7 billion consist of expenditures for inpatient and outpatient care, which are treatment related, as well as nontreatment-related expenditures such as those for the criminal justice system used by individuals with manic-depressive illness. Indirect costs, which were $38 billion, include the lost productivity of both wage-earners ($17 billion) and homemakers ($3 billion), individuals who are in institutions ($3 billion) or who have committed suicide ($8 billion), and caregivers who take care of manic-depressive family members ($6 billion). The method for determining each expenditure is provided, and the implications of these staggering costs are discussed. These calculations rely heavily on methods and data bases that were developed for the accompanying paper on the costs of schizophrenia.