Suicidal behavior in patients with major depression and comorbid personality disorders

Differences in antipsychotic treatment between depressive patients with and without a suicide attempt

BACKGROUND

Depressed suicide attempters are, according to some earlier studies, treated more often with antipsychotics than depressive non-suicide attempters. Cluster B personality disorders, especially borderline personality disorder, are associated with a high suicide risk, and antipsychotics are commonly used for the reduction of symptoms. However, no previous study has taken comorbid personality disorders into account when assessing the use of antipsychotics in patients with unipolar depression. Therefore, the aim of this study was to investigate the clinical selection of pharmacotherapy in unipolar depression with and without a previous suicide attempt, taking into account potential confounders such as cluster B personality disorders.

METHODS

The study sample consisted of 247 patients with unipolar depression. The study was approved by the Regional Ethical Review Board in Lund, Sweden. Study participants were recruited from 4 different secondary psychiatric care clinics in Sweden and were diagnosed according to the DSM-IV-TR with the MINI and SCID II. Previous and ongoing psychiatric treatments were investigated in detail and medical records were assessed.

RESULTS

Thirty percent of the patients had made previous suicide attempts. Depressed suicide attempters underwent both lifetime treatment with antipsychotics and an ongoing antipsychotic treatment significantly more often than non-attempters. Significances remained after a regression analysis, adjusting for cluster B personality disorders, symptom severity, age at the onset of depression, and lifetime psychotic symptoms.

CONCLUSIONS

This is the first study to consider the effect of comorbidity with cluster B personality disorders when comparing treatment of depressive suicide and non-suicide attempters. Our findings suggest that suicide attempters are more frequently treated with antipsychotics compared to non-suicide attempters, regardless of cluster B personality disorder comorbidity. These findings are important for clinicians to consider and would also be relevant to future studies evaluating reduction of suicide risk with antipsychotics in patients with psychiatric comorbidity and a history of attempted suicide.

Clinical Differences Between Single and Multiple Suicide Attempters, Suicide Ideators, and Non-suicidal Inpatients

Single suicide attempters (SSAs) and multiple suicide attempters (MSAs) represent distinct subgroups of individuals with specific risk factors and clinical characteristics. This retrospective study on a sample of 397 adult psychiatric inpatients analyzed the main sociodemographic and clinical differences between SSAs and MSAs and the possible differences between SSAs, MSAs, and psychiatric patients with and without suicidal ideation (SI). Clinical variables collected included psychiatric diagnoses (Mini International Neuropsychiatric Interview), presence of substance use, current suicide risk status (Columbia Suicide Severity Rating Scale), Clinical Global Impression at admission, Global Assessment of Functioning improvement between admission and discharge, age at onset of psychiatric illness, duration of untreated illness in years, number of hospitalizations in psychiatric settings, and lethality of the most severe suicide attempt. A multinomial logistic regression model with groups showed that MSAs had a higher lethality of their last suicide attempt as compared to SSAs. In addition, MSAs had distinct sociodemographic characteristics compared to both SSAs and patients with SI. Although the study was limited by the relatively small sample size and retrospective nature, the present results suggest that identifying MSAs could be useful in predicting suicide risk and designing ad hoc prevention strategies.

Predicting Nonsuicidal Self-Injury in Borderline Personality Disorder Using Ecological Momentary Assessment

Borderline personality disorder (BPD) is a highly comorbid disorder, and these comorbidities increase the impairment associated with BPD. For example, depression, which occurs in the majority of individuals with BPD, increases the likelihood of an individual with BPD to engage in nonsuicidal self-injury (NSSI). Little research, however, has investigated potential mechanisms of NSSI engagement in this population. The current study aimed to fill this gap by examining momentary experiences, levels of distress tolerance, and NSSI among 51 individuals meeting current diagnostic criteria for BPD and a comorbid depressive disorder. Using data from an ecological momentary assessment across 7 days, it was found that daily urges to hurt oneself and impulsive urges, but not daily negative affect or aggressive urges, predicted NSSI occurrence. Furthermore, low levels of distress tolerance was a stronger predictor of NSSI behavior than daily experiences. These findings have important implications with regard to state versus trait dispositions in NSSI engagement among those with BPD and depression.

Predicting Suicidal Ideation among Psychiatric Patients: The Tridimensional Personality Theory Perspective

The main objective of the present study was to enrich our understanding regarding the role of personality traits in the explanation of suicidal ideation among psychiatric patients. It employed Cloniger's Tridimensional Personality Theory in order to draw a personality profile that predicts suicidal ideation among this population. A total of 172 psychiatric outpatients participated in the study. Subjects were randomly selected from a psychiatric clinic in northern Israel. All subjects were evaluated individually with three measures: the Tridimensional Personality Questionnaire (Cloninger, 1987; TPQ); the Beck Suicide Inventory (Beck, Steer, Handerson,&Skeie, 1991; BSI); and the Structured Clinical Interview for Axis I DSM-IV Disorders (SCID; First, Spitzer, Gibbon,&Williams, 1994). Data analysis was conducted using the Linear Structural Relations (LISREL VI) program. The findings of the present study indicate that among psychiatric patients, suicidal ideation can be explained by the combination of five personality traits: impulsiveness, stoic rigidity, confidence, disorderliness, and, indirectly, pessimism through confidence and rigidity.

The independent effects of child sexual abuse and impulsivity on lifetime suicide attempts among female patients

Child sexual abuse (CSA) is a causal agent in many negative adulthood outcomes, including the risk for life-threatening behaviors such as suicide ideation and suicide attempts. Traumatic events such as CSA may pose risk in the healthy development of cognitive and emotional functioning during childhood. In fact, high impulsivity, a risk factor for suicidal behavior, is characteristic of CSA victims. The current study aims to understand the relations among CSA, impulsivity, and frequency of lifetime suicide attempts among a female patient sample admitted for suicidal behavior. Participants included 177 female patients between the ages of 18 and 63 years admitted at two hospitals in Buenos Aires, Argentina. Number of previous suicide attempts and CSA were assessed via structured interviews, while impulsivity was assessed with the Barratt Impulsiveness Scale (BIS-11). A model of structural equations was employed to evaluate the role of impulsivity in the relation between CSA and suicide attempts. CSA (β=.18, p<.05) and impulsivity (β=.24, p<.05) were associated with the number of previous suicide attempts. However, impulsivity was not significantly associated with CSA (β=.09, p>.05). CSA and impulsivity are independently associated with lifetime suicide attempts among female patients with recent suicidal behavior.

A Primer on Rational Suicide and Other Forms of Hastened Death

This article provides an overview of the major mental health issues involved in the debate over rational suicide and other forms of hastened death. In doing so, it covers the arguments for including counseling psychologists and other mental health professionals in discussions about hastened death; highlights the relevant empirical research associated with the topic, with special attention given to the studies involving psychologists and areas needing more investigation; and reviews the implications for practice and training and provides direction for those counseling psychologists who are working with persons who may be rational in their decisions to hasten death.

Comorbid panic disorder as an independent risk factor for suicide attempts in depressed outpatients

OBJECTIVE

Although comorbid panic disorder is associated with more severe symptoms and poorer therapeutic response in depressive patients, the relationship between panic disorder and risk of suicide attempt has not been confirmed. This study aimed to examine the relationship between comorbid panic disorder and clinical characteristics associated with suicidal risk as well as the likelihood of suicide attempt.

METHOD

A total of 223 outpatients with current major depressive disorder participated in the study. Both subjects with panic disorder (33%) and those without panic disorder (67%) were compared based on history of suicide attempts, current psychopathologies, and traits of impulsivity and anger.

RESULTS

Subjects with panic disorder had higher levels of impulsivity, depression, and hopelessness and were more likely to report a history of suicide attempts. Subjects with panic disorder were younger at the time of first suicide attempt than those without panic disorder. Logistic regression analyses indicated that comorbid panic disorder was significantly associated with a history of suicide attempts after adjusting for other clinical correlates (odds ratio = 2.8; p < 0.01).

CONCLUSIONS

These findings suggest that comorbid panic disorder in patients with major depressive disorder may be associated with a more severe burden of illness and may independently increase the likelihood of suicide attempt.

Differences and similarities of risk factors for suicidal ideation and attempts among patients with depressive or bipolar disorders

BACKGROUND

Substantial literature exists on risk factors for suicidal behaviour. However, their comparative strength, independence and specificity for either suicidal ideation or suicide attempt(s) remain unclear.

METHODS

The Helsinki University Psychiatric Consortium (HUPC) Study surveyed 287 psychiatric care patients with ICD-10-DCR depressive or bipolar disorders about lifetime suicidal behaviour, developmental history and attachment style, personality and psychological traits, current and lifetime symptom profiles, and life events. Psychiatric records were used to confirm diagnosis and complement information on suicide attempts. Multinomial regression models predicting lifetime suicidal ideation and single or repeated suicide attempts were generated.

RESULTS

Overall, 21.6% patients had no lifetime suicidal behaviour, 33.8% had lifetime suicide ideation without attempts, and 17.1% had a single and 27.5% repeated suicide attempts. In univariate analyses, lifetime suicidal behaviour was associated with numerous factors. In multivariate models, suicidal ideation was independently predicted by younger age, severe depressive disorder, bipolar disorder type II/nos, hopelessness, and childhood physical abuse. Repeated suicide attempts were independently predicted by younger age, female sex, severe depressive disorder with or without psychotic symptoms, bipolar disorder type II/nos, alcohol use disorder, borderline personality disorder traits, and childhood physical abuse.

LIMITATIONS

Cross-sectional and retrospective study design, utilization of clinical diagnoses, and relatively low response rate.

CONCLUSIONS

Risk factors for suicidal ideation and attempts may diverge both qualitatively and in terms of dose response. When effects of risk factors from multiple domains are concurrently examined, proximal clinical characteristics remain the most robust. All risk factors cluster into the group of repeated attempters.

Pathways from life-historical events and borderline personality disorder to symptomatic disorders among suicidal psychiatric patients: A study of structural equation modeling

AIMS

Suicidal behavior (SB) is a major mental health problem. The research has identified many factors related to SB, such as problems in the developmental period and psychiatric and personality disorders. However, the interrelation of these factors has not been clearly delineated.

METHODS

The subjects were 155 patients consecutively admitted with SB to a psychiatric center in Tokyo. Structured interviews, including the Structured Clinical Interview for DSM-IV (SCID)-I and SCID-II, were conducted to determine characteristics of the SB-related factors. To illustrate their interrelation, this study applied the technique of structural equation modeling. The latent constructs of life-historical events, borderline personality disorder (BPD) features and three symptomatic disorders (depression, anxiety disorders and substance dependence) were aligned in the chronological order of their manifestation, and connected one another within the model. Indicator variables of life-historical events were maltreatment in the developmental period and early onset of problematic behaviors. Indicators of BPD features and symptomatic disorders included the scales composed of the items in the SCID-I and II.

RESULTS

The constructed model with favorable goodness-of-fit indices confirmed that BPD features had a mediating role in which they were influenced by life-historical events, and exerted an influence on the symptomatic disorders. Outside the BPD-mediating paths, the model suggested three clinically interpretable links between life-historical events and symptomatic disorders.

CONCLUSIONS

The model of this study demonstrated the pathways from life-historical events and BPD to symptomatic disorders, and indicated a generating process of psychiatric comorbidity among suicidal patients. The wide-range view this study portrayed has important clinical implications, and deserves further substantiation by future studies.

Adjunctive lithium treatment in the prevention of suicidal behavior in patients with depression and comorbid personality disorders

OBJECTIVE

Patients with both major depression and personality disorders have a high risk of suicidal behavior. Lithium is meant to have anti-suicidal properties in patients with affective disorders. The anti-suicidal effect of lithium in patients with affective disorders and comorbid personality disorders has not been investigated yet.

METHODS

A post-hoc analysis of a subsample of patients with depression and comorbid personality disorder (PD) and a recent suicide attempt (n = 19) from the prospective, placebo-controlled lithium intervention study (N = 167), was conducted.

RESULTS

Three patients in the lithium group (n = 8) and two patients in the placebo group (n = 11) presented a suicide attempt throughout the course of the study. No differences related to suicidal behavior could be detected between the placebo group and the group with lithium intervention.

CONCLUSIONS

On the basis of the small sample size, among patients with comorbid PD, lithium does not seem to have an effect on suicidal behavior in contrast to patients with affective disorders without comorbid PD.

Telemonitoring with respect to mood disorders and information and communication technologies: overview and presentation of the PSYCHE project

This paper reviews what we know about prediction in relation to mood disorders from the perspective of clinical, biological, and physiological markers. It then also presents how information and communication technologies have developed in the field of mood disorders, from the first steps, for example, the transition from paper and pencil to more sophisticated methods, to the development of ecological momentary assessment methods and, more recently, wearable systems. These recent developments have paved the way for the use of integrative approaches capable of assessing multiple variables. The PSYCHE project stands for Personalised monitoring SYstems for Care in mental HEalth.

Suicide attempts in major depressed patients with personality disorder

Suicide attempters who met criteria for borderline personality disorder (BPD) comorbid with major depressive disorder (MDD) were compared to both suicide attempters suffering from MDD alone and to attempters with comorbid MDD and other personality disorders (PD). Participants were 239 (158 patients with comorbid PD and 81 patients with MDD without comorbidity) inpatients consecutively admitted after a suicide attempt made in the last 24 hours. Suicide attempters with comorbid MDD and BPD had more frequent previous suicide attempts and were more likely to have a history of aggressive behaviors and alcohol and drug use disorders compared with patients suffering from MDD without Axis II comorbidity.

Suicidal risk factors of recurrent major depression in Han Chinese women

The relationship between suicidality and major depression is complex. Socio- demography, clinical features, comorbidity, clinical symptoms, and stressful life events are important factors influencing suicide in major depression, but these are not well defined. Thus, the aim of the present study was to assess the associations between the above-mentioned factors and suicide ideation, suicide plan, and suicide attempt in 6008 Han Chinese women with recurrent major depression (MD). Patients with any suicidality had significantly more MD symptoms, a significantly greater number of stressful life events, a positive family history of MD, a greater number of episodes, a significant experience of melancholia, and earlier age of onset. Comorbidity with dysthymia, generalized anxiety disorder (GAD), social phobia, and animal phobia was seen in suicidal patients. The present findings indicate that specific factors act to increase the likelihood of suicide in MD. Our results may help improve the clinical assessment of suicide risk in depressed patients, especially for women.

Individuals with single versus multiple suicide attempts over 10years of prospective follow-up

BACKGROUND

The study attempted to identify characteristics that differentiate multiple suicide attempters from single attempters in individuals with personality disorders (PDs) and/or major depression.

METHOD

Participants were 431 participants enrolled in the Collaborative Longitudinal Study of Personality Disorders from July 1996 to June 2008. Suicide attempts were assessed with the Longitudinal Interval Follow-up Evaluation at 6 and 12months, then yearly through 10years. Logistic regression was used to compare single attempters to multiple attempters on Axis I and II psychiatric disorders and personality trait variables.

RESULTS

Twenty-one percent of participants attempted suicide during the 10years of observation, with 39 (9.0%) reporting a single suicide attempt and 54 (12.5%) reporting multiple suicide attempts. Although no significant differences in were found in baseline Axis I disorders, multiple attempters were significantly more likely to meet criteria for borderline personality disorder and to have higher impulsivity scores than single attempters.

CONCLUSION

These results underscore the importance of considering both personality disorders and traits in the assessment of suicidality.

The incremental validity of borderline personality disorder relative to major depressive disorder for suicidal ideation and deliberate self-harm in adolescents

Few studies have examined the relation between suicide-related behaviors and Borderline Personality Disorder (BPD) in adolescent samples. The current study investigated the incremental validity of BPD relative to Major Depressive Disorder (MDD) for suicide-related behaviors in a psychiatric sample of adolescents at the cross-sectional level of analysis. The sample included N = 156 consecutive admissions (55.1% female; M age = 15.47; SD = 1.41), to the adolescent treatment program of an inpatient treatment facility. Of the sample 19.2% (n = 30) met criteria for BPD on the Child Interview for DSM-IV Borderline Personality Disorder and 39.1% (n = 61) met criteria for MDD on the Computerized Diagnostic Interview Schedule for Children-IV. Results showed that BPD conferred additional risk for suicidal ideation and deliberate self-harm. Our findings support the clinical impression that BPD should be evaluated in inpatient samples of adolescents either through intake interviews or more structured assessments.

A comparison of the clinical characteristics of women with recurrent major depression with and without suicidal symptomatology

BACKGROUND

The relationship between recurrent major depression (MD) in women and suicidality is complex. We investigated the extent to which patients who suffered with various forms of suicidal symptomatology can be distinguished from those subjects without such symptoms.

METHOD

We examined the clinical features of the worst episode in 1970 Han Chinese women with recurrent DSM-IV MD between the ages of 30 and 60 years from across China. Student's t tests, and logistic and multiple logistic regression models were used to determine the association between suicidality and other clinical features of MD.

RESULTS

Suicidal symptomatology is significantly associated with a more severe form of MD, as indexed by both the number of episodes and number of MD symptoms. Patients reporting suicidal thoughts, plans or attempts experienced a significantly greater number of stressful life events. The depressive symptom most strongly associated with lifetime suicide attempt was feelings of worthlessness (odds ratio 4.25, 95% confidence interval 2.9-6.3). Excessive guilt, diminished concentration and impaired decision-making were also significantly associated with a suicide attempt.

CONCLUSIONS

This study contributes to the existing literature on risk factors for suicidal symptomatology in depressed women. Identifying specific depressive symptoms and co-morbid psychiatric disorders may help improve the clinical assessment of suicide risk in depressed patients. These findings could be helpful in identifying those who need more intense treatment strategies in order to prevent suicide.

Post-hospitalization course and predictive signs of suicidal behavior of suicidal patients admitted to a psychiatric hospital: a 2-year prospective follow-up study

BACKGROUND

Suicidal patients admitted to a psychiatric hospital are considered to be at risk of suicidal behavior (SB) and suicide. The present study aimed to seek predictors of SB recurrence of the high-risk patients by examining their post-hospitalization course.

METHOD

The design was 2-year prospective follow-up study of patients consecutively admitted with SB to a psychiatric center in Tokyo. The DSM-IV diagnoses and SB-related features of subjects were determined in structured interviews. Subsequently, the subjects underwent a series of follow-up assessments at 6-month intervals. The assessment included inquiries into SB recurrence, its accompanying suicidal intent (SI) and SF-8 health survey. Analyses of serial change over time in the follow-up data and Cox proportional hazards regression analyses of SB recurrence were performed.

RESULTS

106 patients participated in this study. The dropout rate during the follow-up was 9%. Within 2 years, incidences of SB as a whole, SB with certain SI (suicide attempt) and suicide were 67% (95% CI 58 - 75%), 38% (95% CI 29 - 47%) and 6% (95% CI 3 - 12%), respectively. Younger age, number of lifetime SBs and maltreatment in the developmental period were predictive of SB as a whole, and younger age and hopelessness prior to index admission were predictive of suicide attempt. Regarding diagnostic variables, anxiety disorders and personality disorders appeared to have predictive value for SB. Additionally, poor physical health assessed during the follow-up was indicated as a possible short-term predictor of SB recurrence.

CONCLUSIONS

This study demonstrated a high incidence of SB and suicide and possible predictors of SB recurrence in the post-hospitalization period of psychiatric suicidal patients. Specialized interventions should be developed to reduce the suicide risk of this patient population.

Sociodemographic and psychopathological risk factors in repeated suicide attempts: gender differences in a prospective study

BACKGROUND

The prevention of the repetition of suicide attempts is an important feature of the care of attempters but current data fail to give actual predictors of repetition. The aim of this study was to characterize sociodemographic and psychopathological features and risk factors associated with future repetition of suicide attempts in two years. The study focused on differences between men and women.

METHODS

273 participants selected in psychiatric emergency units after their admission for a suicide attempt (index) were included in the study. Subsequent suicide attempts occurring within a two year follow-up were identified from the regional observatory of suicide attempts. At inclusion, sociodemographic variables and psychopathological data were collected. In particular, psychometric evaluations were performed using the following scales: BDI-SF, SIS, BIS and BDHI. The lifetime history of suicide attempt was also noted.

RESULTS

Repetition of suicide attempt in 2 years was associated with current follow up and treatment, a personal history of multiple suicide attempt, post traumatic stress disorder, current recurrent psychotic syndrome and substance misuse. Specific features of men and women repeaters have been identified. Men repeaters were characterized by substance use disorders whereas the re-attempt in women was associated with current follow up and treatment, post traumatic stress disorder and higher BDI-SF score.

CONCLUSIONS

Repeaters must be considered as a specific population among suicide attempters and gender differences must be taken into account in this particular population in order to promote more personalized prevention programs for suicidal recurrence and completed suicide.

Life events as precipitants of suicide attempts among first-time suicide attempters, repeaters, and non-attempters

The aims of this study were to investigate risk factors for suicide attempts and propose a model explaining the associations among life events and suicide status. We assessed 263 subjects admitted following a suicide attempt to the Division of Psychiatry of the Department of Neurosciences of the University of Parma and compared them with 263 non-attempter clinical control subjects. Attempters reported significantly more adverse life events both in the last 6 months, and between the ages of 0-15 years than non-attempters. A multinomial logistic regression analysis with stepwise forward entry indicated that the best model to explain suicide status was one which included life events in the last 6 months, life events during age 0-15 years, and their interaction. First-time attempter status (vs. non-attempters) was more likely to be linked to life events in the last 6 months, the interaction between life events in the last 6 months and life events during age 0-15 years, and low social support. Those attempters with one or more prior attempts (repeat attempters) were more likely than non-attempters to be linked to the interaction between life events in the last 6 months and life events during age 0-15 years, and to higher rates of psychopharmacological treatment before the index admission. Guided by these findings, monitoring the impact of early-life and recent events in vulnerable individuals should be part of risk assessment and treatment.

Substance use/abuse and suicidal behavior in young adult women: a population-based study

Associations between substance use variables and suicidal behavior were analyzed in an urban population sample from ("the Women and Alcohol in Gothenburg" study). In Phase I, 20-year-old women (n = 2,069) completed a screening questionnaire. Interviews were carried out with a stratified sample (n = 560). Data, collected in 1995 and 2000, were analyzed using logistic regression to generate odds ratios. Drug use, but not risky alcohol consumption, was associated with suicidal thoughts after adjusting for current depression. Study limitations and implications for suicide prevention are discussed. The study was funded by the Swedish Research Council and the Alcohol Research Council of Sweden.

Unplanned versus planned suicide attempters, precipitants, methods, and an association with mental disorders in a Korea-based community sample

BACKGROUND

Studies have consistently reported that a considerable proportion of suicidal attempts are unplanned. We have performed the first direct comparison between planned and unplanned attempts including associated methods and precipitants.

METHOD

A total of 6510 adults, who had been randomly selected through a one-person-per-household method, completed interviews (response rate 81.7%). All were interviewed using the K-CIDI and a questionnaire for suicide.

RESULTS

Two hundred and eight subjects reported a suicide attempt in their lifetime, one-third of which had been unplanned. These individuals exhibited a lower level of education; however, no significant differences were found with regard to age, gender, marital and economic status. Further, 84.0% of unplanned attempters experienced previous suicidal ideation, experiencing their first attempt 1.9 years before ideation. Additionally, 94.4% of unplanned attempters had precipitants for attempts such as familial conflict and it was also found that methods such as the use of chemical agents or falling were three times more common in unplanned than planned attempters. With respect to unplanned attempters, they exhibited a significant association with alcohol use disorder, major depressive disorder, posttraumatic stress disorder, and bipolar disorder. In particular, bipolar disorder was found to be 3.5 times higher in these individuals.

CONCLUSIONS

Results have revealed that unplanned suicide attempters experience suicidal ideation and precipitants prior to their attempt. Further, attempts were associated with affective and alcohol use disorders. Therefore, in order to reduce the number of suicidal attempts, it may be useful to evaluate suicidal ideation concurrent to the treatment of existing mental disorders.

A population-based longitudinal study of risk factors for suicide attempts in major depressive disorder

No longitudinal study has examined risk factors for future suicide attempts in major depressive disorder in a nationally representative sample. The objective of this study was to investigate baseline sociodemographic characteristics, comorbid mental disorders, specific depressive symptoms, and previous suicidal behavior as potential risk factors for suicide attempts at 3 years follow-up. Data came from the national epidemiologic survey on alcohol and related conditions (NESARC), a large nationally representative longitudinal survey of mental illness in adults [Wave 1 (2001-2002); Wave 2 (2004-2005) n=34,653]. Logistic regression examined associations between risk factors present at Wave 1 and suicide attempts at Wave 2 (n=169) among individuals with major depressive disorder at baseline assessment (n=6004). Risk factors for incident suicide attempts at Wave 2 (n=63) were identified among those with major depressive disorder at Wave 1 and no lifetime history of suicide attempts (n=5170). Results revealed specific comorbid anxiety, personality, and substance use disorders to be associated with incident suicide attempts at Wave 2. Comorbid borderline personality disorder was strongly associated with suicide attempts in all models. Several comorbid disorders were strongly associated with suicide attempts at Wave 2 even after adjusting for previous suicidal behavior, notably posttraumatic stress disorder (adjusted odds ratio (AOR)=2.20; 95% confidence interval (95% CI) 1.27-3.83) and dependent personality disorder (AOR=4.43; 95% CI 1.93-10.18). These findings suggest that mental illness comorbidity confers an increased risk of future suicide attempts in major depressive disorder that is not solely accounted for by past suicidal behavior.

Clinical challenges in the assessment and management of suicidal behaviour in patients with bordeline personality disorder

Self-injurious and suicidal behaviours are highly prevalent in patients with borderline personality disorder (BPD) and the risk of completed suicide is high. Borderline patients often present with heterogeneous clinical pictures and widespread comorbidity complicating clinical assessments and management. This calls for increased efforts in systematic evaluation and monitoring of self-harming and suicidal behaviours; these behaviours should be addressed actively as high priority treatment targets. Early drop-out is common for BPD patients in treatment but is possible to counteract by fostering a strong therapeutic relationship through adopting a realistic, but consistent and supportive approach carefully avoiding reinforcement of suicidal behaviours. Suicidal crises should primarily be managed in an outpatient setting giving priority to keeping the patient safe adopting a safety plan procedure, while helping the patient as quickly as possible to return emotionally to a more acceptable level of arousal and mental functioning. Pharmacological treatments should primarily be used for management of comorbid conditions, but may possibly also be helpful when used to reduce specific symptoms such as anger, hostility and impulsivity. There is currently a range of different integrated short-term and long-term psychological treatments in different stages of development and some of them have been shown to be efficacious in reducing suicidal behaviours; notably dialectical behaviour therapy and mentalization-based therapy.

Pathways to high-lethality suicide attempts in individuals with borderline personality disorder

The purpose of this study was to develop and test a model of high-lethality suicide attempts (HLSA) in individuals with Borderline Personality Disorder (BPD). An increased number of prior suicide attempts, substance use immediately prior to the attempt, and objective planning were proposed to lead directly to a HLSA, while aggression and impulsivity were hypothesized to lead indirectly to a HLSA through their associations with prior attempts. Path analysis revealed a revised model in which impulsivity was found to be significantly associated with both the lethality of the most recent attempt and the number of prior attempts. These results are discussed in terms of trait and crescendo models of suicidal behavior and their implications for suicide risk assessment among individuals with BPD.

No cathartic effect in suicide attempters admitted to the emergency department

The goal of the present study was to test the hypothesis that suicide attempts have a cathartic effect. We retrospectively investigated sociodemographic and clinical characteristics of suicide attempters admitted to the emergency department of a university hospital who were referred for a psychiatric assessment. The participants were 158 consecutive patients admitted to the emergency department because of a suicide attempt between January, 2006, and February, 2007; controls were 360 consecutive psychiatric referrals who did not report suicidal behavior. More than 70% of suicide attempters were coded on the triage classification system as critical/urgent. Loglinear analysis indicated that the risk of suicidal ideation was 9 times higher (p <0.001) and the risk of depressive mood was twice as high (p <0.001) among the attempters as in the control group of nonattempters, while their risk of anxiety (p <0.05) and agitation (p <0.05) was approximately half that of the nonattempters. The attempters also had a 5 times greater risk of being diagnosed with bipolar disorder (p <0.001) than the nonattempters. However, despite the fact that bipolar disorders were overrepresented in the group of attempters, suicidal ideation in the few hours after a suicide attempt was associated only with depressive mood. Based on these findings, it is recommended that psychiatric evaluation of suicide attempters in the emergency department should ideally include the use of psychometric instruments evaluating suicide ideation and suicide risk.

Severity of personality disorders and suicide attempt

OBJECTIVE

Severity of personality disorders (PDs) may be more useful in estimating suicide risk than the diagnosis of specific PDs. We hypothesized that suicide attempters with severe PD would present more attempts and attempts of greater severity/lethality.

METHOD

Four hundred and forty-six suicide attempters were assessed. PD diagnosis was made using the International Personality Disorder Questionnaire--Screening Questionnaire. PDs were classified using Tyrer and Johnson's classification of severity (no PD, simple PD, diffuse PD). Severity/lethality of attempts was measured with the Suicide Intent Scale, Risk-Rescue Rating Scale and Lethality Rating Scale.

RESULTS

Attempters with severe (diffuse) PD had more attempts than the other groups. After controlling for age and gender, this difference remained significant only for the younger age group and women. There was no relationship between severity of PDs and severity/lethality of attempts.

CONCLUSION

Younger female attempters with severe PD are prone to repeated attempts. However, the severity of PD was not related to the severity/lethality of suicide attempts.

Depressive characteristics of adult psychiatric inpatients with a history of multiple versus one or no suicide attempts

BACKGROUND

A growing body of research suggests that individuals with a history of multiple suicide attempts exhibit more severe psychopathology than individuals with only one or no previous suicide attempts. Given the strong link between diagnoses of major depression and suicide risk, our primary goal was to determine which specific depressive characteristics differentiate multiple attempters from patients with one or no previous attempts.

METHODS

Participants were 121 depressed adult psychiatric inpatients. Participants were administered diagnostic interviews to assess the course and characteristics of their depression history as well as measures of suicidal ideation, suicide attempts, depressive symptoms, hopelessness, and dysfunctional attitudes.

RESULTS

Patients with a history of multiple suicide attempts exhibited higher levels of suicidal ideation and depressive symptoms, but not hopelessness or dysfunctional attitudes, than the other two groups. In addition, multiple attempters reported an earlier age of major depression onset.

CONCLUSIONS

The current results add to a growing body of research suggesting that multiple attempters may represent a distinct patient population.

Childhood physical and sexual abuse in depressed patients with single and multiple suicide attempts

Research has shown both childhood physical and sexual abuse to be associated with later suicide attempts, although some studies have not supported these findings. However, few studies have investigated differences in physical and sexual abuse histories among single and multiple suicide attempters. The goals of the current study were two-fold: (a) to replicate previous findings of associations between childhood sexual and physical abuse and suicide attempts, and (b) to explore differences in reports of childhood physical and sexual abuse among single and multiple suicide attempters. While our results supported the findings that individuals with a history of suicide attempts are more likely to report histories of childhood physical and sexual abuse, we did not find a difference in reported abuse between single and multiple suicide attempters. Implications of these findings, as well as implications for future research, are discussed.

Cluster C personality disorders in major depressive episodes: the relationship between hostility and suicidal behavior

There is some evidence for an association between Cluster C Personality Disorders (CCPD) and suicidal behavior. We compared depressed inpatients with and without CCPD in terms of suicidal behavior and associated psychopathology. Cluster A or B personality disorder co-morbidity were exclusion criteria for both groups (cases and controls). Depressed inpatients with "pure" CCPD had higher levels of suicidal ideation but not more previous suicide attempts compared with patients without CCPD. Greater suicidal ideation in depressed patients with CCPD in our study was associated with more hostility. Future studies examining the relationship between suicidal ideation and hostility in CCPD may clarify whether treatment focused on hostility might be of use for decreasing suicidal ideation in depressed patients with CCPD (Spitzer, Williams, Gibbon et al., 1990).

A comparison of the medical lethality of suicide attempts in bipolar and major depressive disorders

OBJECTIVES

Among mood disorders, bipolar disorder (BPD) is often noted to involve the highest rates of suicide attempts and possibly of completion. This study sought to determine whether suicide attempters with BPD exhibit suicide attempts with higher lethality than attempters with major depressive disorder (MDD) and to explore differences in clinical features associated with suicidal acts.

METHODS

Mood disordered suicide attempters were interviewed about Axis I and II diagnoses, lifetime history of suicide attempts, suicidal intent, suicidal ideation, the medical lethality of their most severe suicide attempt, severity of depression, hopelessness, lifetime aggression, and impulsivity.

RESULTS

The maximum lethality of suicidal acts tended to be higher among BPD attempters compared with those with MDD. However, there were no differences in the number of suicide attempts, intent to die or suicidal ideation. Suicide attempters with BPD reported higher levels of aggression and impulsivity but less hopelessness compared with MDD attempters. These differences could not be explained by Cluster B personality disorder comorbidity. Of note, within the BPD group, but not the MDD group, males reported suicidal acts with higher lethality. Multivariate analyses suggested that risk for more lethal suicide attempts is associated with BPD and male sex and that bipolar males appear to be especially vulnerable to these behaviors.

CONCLUSIONS

Males with BPD make more lethal suicide attempts than females with BPD, an effect not observed among the MDD sample. Our findings suggest that higher rates of suicidal behavior in BPD may be due to a specific effect of BPD on males, leading to more dangerous suicidal behaviors. This effect, together with the larger proportion of males in the BPD group compared with the MDD group may lead to higher rates of reported attempted and completed suicide.

A prospective study of the association of cerebrospinal fluid monoamine metabolite levels with lethality of suicide attempts in patients with bipolar disorder

OBJECTIVES

Bipolar disorder is a severe illness that is associated with suicidal behavior. A biological predictor of highly lethal suicide attempts in patients with bipolar disorder would be valuable. We hypothesized that cerebrospinal fluid (CSF) monoamine metabolite levels are related to lethality of suicide attempts in bipolar patients and examined the relation between CSF 5-hydroxyindolacetic acid (5-HIAA), homovanillic acid (HVA), and 3-methoxy-4-hydroxyphenylglycol (MHPG) levels and maximum lethality of suicide attempts at baseline and during a 2-year follow up.

METHODS

Twenty-seven bipolar depressed patients participated in the study. Demographic and clinical parameters were examined and recorded. Lumbar punctures were performed and CSF 5-HIAA, HVA, and MHPG were assayed by high-performance liquid chromatography with electrochemical detection. Following discharge, patients were evaluated after 3 months, 1 year, and 2 years. Each follow-up interview included an in-depth assessment of suicidal behavior during the intervening time period.

RESULTS

Six subjects made suicide attempts during the 2-year follow-up. Bipolar patients who attempted suicide during the follow-up period had higher aggression and hostility scale scores compared to bipolar subjects who did not make a suicide attempt during the follow-up period. CSF 5-HIAA, HVA, and MHPG levels were negatively correlated with the maximum lethality of suicide attempts during the 2-year follow-up period.

CONCLUSIONS

Our finding is the first observation that CSF monoamine metabolite levels may be predictors of lethality of suicide attempts in patients with bipolar disorder. Further studies are necessary to answer the question whether CSF monoamine metabolite levels are clinically useful biochemical predictors of highly lethal suicide attempts or completed suicides.

Prospective studies of suicidal behavior in major depressive and bipolar disorders: what is the evidence for predictive risk factors?

OBJECTIVE

Prospective studies over the past 30 years have identified an array of predictive indicators for suicidal acts in mood disorders. However, prediction of suicidal behavior remains an elusive goal. This paper reviewed evidence from prospective studies for clinical factors that elevate risk of suicidal acts in that group.

METHOD

English language prospective studies of suicidal behavior in major depressive and bipolar disorders were examined.

RESULTS

The predictors with the best support were a past history of suicidal behavior and the presence of refractory or recurrent depressions. For other risk factors, there was either not enough data to consider them robust or findings were contradictory.

CONCLUSION

Future studies must not only be comprehensive in their inclusion of potentially contributing factors, but must also address their relative importance towards the goal of developing predictive models and enhance suicide prevention efforts.

Persönlichkeit, Persönlichkeitsstörungen und Depression

Personality is one of most frequently investigated fields in depression research and, despite changes in research paradigms, has not lost its relevance. Numerous results concerning the conceptualization of conspicuous personality traits, their aetiopathogenetic significance, and their effect on treatment and course have contributed to a better understanding of depression. Genetics and neurobiology provide new incentives for research in this field. We present an overview of aspects relevant to personality research in depression including personality types, personality traits, temperament factors, and personality disorders. Especially results on personality factors' effect on treatment and course of depression, integrating these results with different personality models in depression, and their consequences to treatment and further research of personality traits in depression are discussed.

Interpersonal precipitants and suicide attempts in borderline personality disorder

Borderline personality disorder (BPD) is often characterized by multiple low lethality suicide attempts triggered by seemingly minor incidents, and less commonly by high lethality attempts that are attributed to impulsiveness or comorbid major depression. The relationships among life events, impulsiveness, and type of suicidal behavior has hardly been studied in BPD and mood disorders. This study compared depressed attempters with and without BPD to identify specific suicide precipitants and risk factors in BPD and their relationship to severity of suicidal behavior. Attempters with comorbid BPD and major depressive disorder (MDD) had a higher number of lifetime suicide attempts; made their first attempt at a younger age; reported more interpersonal triggers; and had higher levels of lifetime aggression, hostility, and impulsivity, compared with attempters with major depression only. Environmental triggers of attempts in BPD are more likely to be interpersonal stressors. Lethality of attempts in BPD plus MDD is equal to that in MDD only, indicating that the seriousness of precipitants is unrelated to the lethality of the suicidal behavior. The differences between groups suggest that risk assessment and treatment should target both depression and personality disorder in those with combined illness.

Suicidal Behavior in Alcohol-Dependent Subjects: The Role of Personality Disorders

BACKGROUND

Comobidity of personality disorders (PDs) and alcohol dependence are considered to increase the risk for suicidal behavior. The aim of this study is to assess the influence of Diagnostic and Statistical Manual of Mental Disorder-fourth edition (DSM-IV) personality characteristics and comorbid axis I disorders on suicidal behavior in alcohol-dependent inpatients.

METHODS

Characteristics of alcohol dependence and suicidal behavior were obtained using the Semi-Structured Assessment on Genetics in Alcoholism (SSAGA). Personality disorder characteristics were assessed using the Structured Clinical Interview for DSM-IV Axis II Disorders.

RESULTS

Three-hundred seventy-six treatment-seeking alcohol-dependent subjects, of whom 55% were diagnosed to have a PD and approximately 25% had a history of at least 1 suicide attempt, were enrolled into the study. Subjects with PDs in all clusters reported a higher rate of suicide attempt history, depression episodes, and depression during the most serious attempt. As indicated by univariate and multivarate analysis, this pattern of suicide attempt characteristics was most pronounced in borderline disordered subjects and alcoholic individuals who live alone.

CONCLUSION

Subjects with alcohol dependence who have various comorbid PDs and depression deserve special attention in psychiatric care to prevent suicide. Psychotherapeutic strategies may have to be adapted to treat this high-risk population.

Personality traits as intermediary phenotypes in suicidal behavior: genetic issues

A genetic contribution to the risk of suicidal behavior is now supported by many studies. It probably involves specific factors acting on their own, independently of the genetic transmission of associated psychiatric disorders. A history of childhood maltreatment, adverse events, psychosocial stress, psychological traits and major psychiatric disorders all appear to contribute to the global risk of suicide attempt or completion. The interplay between previously identified risk factors, different as they are in nature and degree of complexity, still remains to be clarified. A stress-diathesis model has been proposed, where trait-like genetic and developmental risk factors (the diathesis) interact through still unknown mechanisms with actual (stress-related) factors to create the conditions for a suicidal gesture. Disentangling the effects of these risk factors, and specifically the effects of the genetic factors influencing these different pathological conditions, appears to be a difficult task. Indeed the results of candidate gene association studies suggest that genetic vulnerability factors for various related psychiatric phenotypes (major psychiatric disorders and personality traits) partly overlap with more specific factors predisposing to suicidal behavior. Personality traits are partly under genetic control and may be closer to the genetic effects than psychiatric syndromes. We review here the available data on the genetics of personality traits presumably involved in suicidal behavior, focusing on the association studies carried out with serotonin-related genes. We suggest that future studies on the genetic vulnerability to suicidal behavior should include the investigation of endophenotypes, with the aim of deciphering the mechanisms underlying the genetic susceptibility to these closely associated phenotypes.

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.

Assessing suicide risk in cluster C personality disorders

The aim of the study was to assess suicide risk in psychiatric outpatients with specific cluster C personality disorders (avoidant, dependent, and obsessive-compulsive). A sample of 142 psychiatric outpatients was used for the study. The sample was composed of 87 outpatients meeting diagnostic criteria for a personality disorder and 53 psychiatric outpatients meeting criteria for an axis I disorder only. The results showed that dependent, but not avoidant or obsessive-compulsive, personality disorders, as well as the clusters A and B personality disorders, were significantly associated with suicide attempts. This association remained significant after controlling for both a lifetime depressive disorder and severity of depression for the cluster A and the cluster B personality disorders, but not for dependent personality disorder. The results underline the importance of assessing suicide risk in patients with cluster A and cluster B personality disorders, while the assessment of suicide risk in patients with cluster C personality disorders seems to be irrelevant as long as assessment of a comorbid depressive disorder is appropriately conducted.

Patterns of axis II comorbidity in early-onset versus late-onset panic disorder in Japan

Early onset of psychiatric disorders has been reported to be associated with increased familial risk or more severe clinical symptoms. In this study, we specifically examine the association between clinical severity and early versus late onset in panic disorder. We hypothesize the existence of differences in rates of axis II disorders in these two groups that will relate to clinical severity. Subjects were a consecutive clinical case series of 105 panic disorder patients (age, 18.3 to 70.9 years). Thirty-one panic disorder patients were classified as early onset (age of onset < or = 25 years) and 74 as late onset (age of onset >25). We compared symptomatology and rates of comorbid axis II disorders (diagnosed by structured clinical interview) between the early- and the late-onset groups. We found a statistically significant increase in the number of suicide attempts and likelihood of comorbid axis II disorders in the early-onset group compared to the late-onset group. In logistic regression analyses, cluster B personality disorders (PDs), especially borderline and histrionic, were statistically significantly associated with the presence of suicide attempts. The following limitations are present: first, we have not taken into consideration comorbidity of other axis I disorders, especially major depression. Second, there is imprecision associated with efforts to date the onset of panic disorder retrospectively. We conclude that comorbid axis II disorders are more likely to occur in early-onset panic disorder patients. Cluster B PDs, especially borderline or histrionic, may be associated with a high frequency of suicide attempts in this group. In clinical practice, efforts to aggressively detect and treat axis II disorders in early-onset panic disorder patients are warranted.

Jugendliche in stationärer psychiatrischer Behandlung: Parasuizidale Symptome und psychische Störungen

Zusammenfassung. Psychische Störungen zählen zu den wichtigsten Ursachen für Parasuizide und Suizide. Dies gilt für das Erwachsenenalter und mit gewissen Abstrichen auch für das Jugendalter. Die häufigsten psychischen Störungen im Zusammenhang mit Suizidalität im Jugendalter sind akute Belastungsreaktionen, affektive Störungen, Substanzmissbrauch sowie Borderline-Syndrome und andere beginnende Persönlichkeitsstörungen. Essstörungen und Schizophrenien sind dagegen im Jugendalter noch nicht mit erhöhten Parasuiziden verknüpft. Anhand einer Gesamtstichprobe von 537 konsekutiv aufgenommenen und nach ICD-10 diagnostizierten stationär behandelten jugendpsychiatrischen Patienten konnten 163 mit parasuizidalen Symptomen bei Aufnahme ermittelt werden, die etwa zur Hälfte aus parasuizidalen Gedanken und parasuizidalen Handlungen bestanden. Der Anteil parasuizidaler Jugendlicher auf der Aufnahmestation lag bei etwa 66 %, auf der Therapiestation (Rottmannshöhe) bei etwa 30 %. Dies spricht für die Relevanz von Selektionsfaktoren bei Häufigkeits- und vermutlich auch Schweregradangaben von Suizidalität im stationären jugendpsychiatrischen Bereich.

Axis I and axis II disorders as predictors of prospective suicide attempts: findings from the collaborative longitudinal personality disorders study

This study examined diagnostic predictors of prospectively observed suicide attempts in a personality disorder (PD) sample. During 2 years of follow-up, 58 participants (9%) reported at least 1 definitive suicide attempt. Predictors that were examined include 4 PD diagnoses and selected Axis I diagnoses (baseline and course). Multivariate logistic regression analyses indicated that baseline borderline personality disorder (BPD) and drug use disorders significantly predicted prospective suicide attempts. Controlling for baseline BPD diagnosis, proportional hazards analyses showed that worsening in the course of major depressive disorder (MDD) and of substance use disorders in the month preceding the attempt were also significant predictors. Therefore, among individuals diagnosed with PDs. exacerbation of Axis I conditions, particularly MDD and substance use, heightens risk for a suicide attempt.

Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder

OBJECTIVE

This paper has 3 objectives. First, we review the epidemiologic evidence for the association between suicidal behaviour and suicide in individuals diagnosed with antisocial, borderline, or narcissistic personality disorder. Second, we examine whether any potentially modifiable risk factors are associated with these diagnoses, based on existing empirical evidence. Last, we discuss clinical approaches to assessing youth with antisocial, borderline, or narcissistic personality disorder presenting at risk for suicide.

METHOD

We reviewed the English-language literature for the last 12 years (from January 1, 1991, to December 31, 2002), using as search terms the names of the 3 disorders, as well as the key words suicide, suicidal behaviour, youth, and adolescents.

RESULTS

Patients with antisocial or borderline personality disorder are likely to be at increased risk for suicidal behaviour when they demonstrate such comorbid disorders as major depressive episodes or substance abuse disorders, when they experience recent negative life events, or when they have a history of childhood sexual abuse.

CONCLUSIONS

For patients with antisocial personality disorder, the risk of violence has to be judged in addition to the risk of suicide or self-harm. For patients with borderline personality disorder, interventions are determined by differentiating acute-on-chronic from chronic risk of suicidal behaviour. Finally, patients with narcissistic personality disorder can be at high risk for suicide during periods when they are not suffering from clinical depression. These episodes can seem to be unpredictable.

The incremental validity of passive-aggressive personality symptoms rivals or exceeds that of other personality symptoms in suicidal outpatients

We examined the incremental validity of passive-aggressive and other personality symptoms, by determining personality syndromes' ability to account for unique variance in distress and impairment as indexed by several Axis I-related symptoms. Two hundred fifty young adults, referred for suicidal behavior or ideation, completed the Millon Clinical Multiaxial Inventory (Millon, 1983) as well as several other symptom measures. The personality syndromes varied considerably in their ability to account for unique variance in Axis I-related symptoms. Several syndromes, including schizoid, schizotypal, and compulsive symptoms, showed relatively low incremental validity, whereas the incremental validity of passive-aggressive symptoms exceeded all others. The criterion of incremental validity represents an inclusive and persuasive means to evaluate personality disorder validity. On this criterion, passive-aggressive symptoms display high validity, and passive-aggressive personality disorder, in some form, may deserve inclusion on Axis II of future editions of Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association).

Suicidal and self-injurious behavior in personality disorder: controversies and treatment directions

Contrary to common clinical perceptions, individuals with personality disorders attempt and commit suicide at nearly the same rate as individuals with major depression. In particular, those with borderline personality disorder are at high risk for suicidal behavior and nonsuicidal self-injury. Yet there is significant controversy surrounding the diagnosis of borderline personality disorder in terms of its existence, its definition and symptom structure, its Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) axis location, and its importance as a contributing factor to suicidality and nonsuicidal self-injury. Furthermore, both suicidal and nonsuicidal self-harm is prominent in borderline personality disorder. There is often confusion between suicidal and nonsuicidal self-injury with one sometimes mistaken for the other. Nonsuicidal self-injury is sometimes met with hospitalization, because it is viewed as life threatening. Alternately, the potential lethality of suicidal behavior is underestimated, because it occurs in the context of multiple low lethality self-harm behaviors. It is possible to view these behaviors as distinct yet on a spectrum in borderline personality-disordered patients. With respect to treatment of self-injury in personality disorders, some recent pharmacotherapy trials have been conducted, though efficacy is often unclear. Findings with respect to psychotherapy, particularly dialectical behavior therapy, a form of cognitive behavioral treatment, are promising.