Mental disorders and suicide in Japan: a nation-wide psychological autopsy case-control study

Identifying latent subtypes of symptom trajectories in major depressive disorder patients and their predictors

This study aimed to identify different symptom trajectories based on the severity of depression symptoms within a 2-month follow-up, and to explore predictive factors for different symptom trajectories. Three hundred and ninety-two adults diagnosed with major depressive disorder (MDD) were recruited from two longitudinal cohorts. Patients received antidepressant treatment as usual, and the depression symptoms were evaluated by the 17-item Hamilton depression rating scale (HAMD-17) at baseline, two weeks, and eight weeks. Based on the HAMD-17 scores, different trajectories of symptom change were distinguished by applying Growth Mixture Modeling (GMM). Furthermore, the baseline sociodemographic, clinical, and cognitive characteristics were compared to identify potential predictors for different trajectories. Through GMM, three unique depressive symptom trajectories of MDD patients were identified: (1) mild-severity class with significant improvement (Mild, n = 255); (2) high-severity class with significant improvement (High, n = 39); (3) moderate-severity class with limited improvement (Limited, n = 98). Among the three trajectories, the Mild class had a relatively low level of anxiety symptoms at baseline, whereas the High class had the lowest education level and the worst cognitive performance. Additionally, participants in the Limited class exhibited an early age of onset and experienced a higher level of emotional abuse. MDD patients could be categorised into three distinct latent subtypes through different symptom trajectories in this study, and the characteristics of these subtype patients may inform identifications for trajectory-specific intervention targets.

The clinical perspective on late-onset depression in European real-world treatment settings

The clinical phenotype of the so-called late-onset depression (LOD) affecting up to 30% of older adults and yielding heterogeneous manifestations concerning symptoms, severity and course has not been fully elucidated yet. This European, cross-sectional, non-interventional, naturalistic multicenter study systematically investigated socio-demographic and clinical correlates of early-onset depression (EOD) and LOD (age of onset ≥ 50 years) in 1410 adult in- and outpatients of both sexes receiving adequate psychopharmacotherapy. In a total of 1329 patients (94.3%) with known age of disease onset, LOD was identified in 23.2% and was associated with unemployment, an ongoing relationship, single major depressive episodes, lower current suicidal risk and higher occurrence of comorbid hypertension. In contrast, EOD was related to higher rates of comorbid migraine and additional psychotherapy. Although the applied study design does not allow to draw any causal conclusions, the present results reflect broad clinical settings and emphasize easily obtainable features which might be characteristic for EOD and LOD. A thoughtful consideration of age of onset might, hence, contribute to optimized diagnostic and therapeutic processes in terms of the globally intended precision medicine, ideally enabling early and adequate treatment allocations and implementation of respective prevention programs.

Changes in suicidal ideation during treatment among patients with major depressive disorder: A 6-month naturalistic follow-up study

AIM

There is limited evidence regarding predictors of changes in suicidal ideation (SI) in patients with major depressive disorder (MDD). The objective of this study was to describe changes in SI over a 6-month period and identify their predictors from naturalistic observations of MDD patients.

METHODS

In the cross-sectional analysis, we examined 257 patients with MDD at the first-visit assessment. Among the patients, 119 who completed the 6-month assessment (completers) were included in the longitudinal analysis. For the evaluation of depressive symptoms, including SI, the Quick Inventory of Depressive Symptomatology-Japanese version was administered at both the first-visit and follow-up assessments. At baseline, we also administered the Japanese version of the Ten Item Personality Inventory to assess personality traits and the PRIME Screen-Revised to assess psychotic symptoms.

RESULTS

In the cross-sectional analysis of first-visit patients, 36.2% (93/257) exhibited SI. Among completers, 14.3% (17/119) had prolonged SI. Among the completers with SI at the first-visit assessment, 38.6% (17/44) had SI at the follow-up assessment (prolonged SI). In linear regression models including all completers, prolonged SI was positively associated with endorsement of suspiciousness/persecutory ideas and negatively associated with higher age.

CONCLUSION

More than one-third of completers who had SI at the first-visit assessment experienced prolonged SI (SI at follow-up). Our findings can help clinicians predict the course of MDD by identifying associated demographic and clinical characteristics.

Suicide and prevalence of mental disorders: A systematic review and meta-analysis of world data on case-control psychological autopsy studies

INTRODUCTION

Suicide is a multifaceted event precipitated by underlying biopsychosocial risk factors. Evidence for various psychiatric morbidities underlying suicidality through Psychological Autopsy (PA) is established in case-control studies. However, considering the possible geographical variations and the limited number of studies from developing countries, the estimates of such risk factors across the world could provide great insight into their comparative prevalence and assist in targeting the prevention of suicide.

METHODS

A systematic review of the literature from 1991 to 2020 in the English language was conducted with the protocol registration on PROSPERO ID (CRD 42021249216) to identify the pooled odds ratio of any psychiatric morbidity as a risk factor for suicide.

RESULTS

Out of 1144 articles, 43 studies were included in this review. The pooled odds ratio for any psychiatric morbidity measured across 31 studies was 16.71 (95% CI: 12.29 - 22.70, Tau2 = 0.58, I2 = 80.4%, Cochran's Q = 153.36, df = 30, p-value <0.001). The subgroup analysis for affective disorder, previous suicide attempt, WHO region-wise risk distribution, and publication year of study were not significant.

CONCLUSIONS

There is a sixteen-fold increased risk of suicide in persons with mental disorders compared to healthy controls, and the risk is similar across the geographical region and publication time. The international efforts to reduce the common risk factors for suicide would equally be helpful for all countries despite cultural variations. Early identification and treatment of sleep disorders, physical illnesses, anxiety, and personality disorders should be prioritized along with the established mental disorders to reduce suicide rates across the world.

Depression and Suicidal Ideation in Patients with Mental Illness in South Korea: The Mediating Effect of Alcohol Drinking

This study aimed to investigate the mediating effect of alcohol drinking on the relationship between depression and suicidal ideation inpatients with mental illness. A survey was conducted among 163 individuals with various major mental disorders using a self-reported questionnaire. Data were collected from July to September 2020. Subsequently, the data were analyzed using a t-test, one-way analysis of variance, Pearson's correlation coefficients, hierarchical multiple linear regression, and a Sobel test. Significant relationships were found between alcohol depression and drinking (r = 0.26, p < 0.001), depression and suicidal ideation (r = 0.63, p < 0.001), and alcohol use and suicidal ideation (r = 0.36, p < 0.001). In addition, alcohol drinking was found to partially mediate the association between depression and suicidal ideation (Z = 3.63, p < 0.001). These results indicated that patients with mental illness who are concerned about drinking alcohol might be able to reduce suicidal thoughts by consulting with a healthcare professional or taking informed actions with the support of a counselor or support group.

Chrysin Attenuates Chronic Unpredictable Mild Stress Induced Changes in Behavior, Inflammation and Improves Adrenergic, Serotonergic Function: An <i>In-vivo</i> and Biochemical Study

Chrysin (5,7-dihydroxyflavone) is a flavonoid with a vast number of pharmacological properties because of its antioxidant potential. Chronic stress is one of the predominant etiological factors which evoke molecular alterations in the brain leading to the development of depressive disorder. In the present study, we investigated the effect of Chrysin on Chronic Unpredictable Mild Stress (CUMS) induced alterations in behavior, noradrenergic as well as serotonergic function, and inflammation in brain. Randomly, mice were divided into four groups of six animals in each group. On 28th day after assessing behavioral parameters, brain biochemical markers were assessed. From the results, it is concluded that the chrysin protects the brain cells from CUMS induced molecular changes by attenuation of inflammation and oxidative stress.

Suicide Risk Assessments: A Scientific and Ethical Critique

There are widely held premises that suicide is almost exclusively the result of mental illness and there is "strong evidence for successfully detecting and managing suicidality in healthcare" (Hogan and Grumet, 2016). In this context, 'zero-suicide' policies have emerged, and suicide risk assessment tools have become a normative component of psychiatric practice. This essay discusses how suicide evolved from a moral to a medical problem and how, in an effort to reduce suicide, a paternalistic healthcare response emerged to predict those at high risk. The evidence for the premises is critiqued and shown to be problematic; and it is found that strong paternalistic interventions are being used more often than acknowledged. Using a Principles approach, the ethics of overriding autonomy in suicide prevention is considered. Ethical concerns are identified with the current approach which are potentially amplified by the use of these risk assessments. Furthermore, it is identified that the widespread use of risk assessments in health settings is equivalent to screening without regard to the ethical principles of screening. The essay concludes that this is unethical; that we should abandon the use of standardized suicide risk assessments and 'zero-suicide' policy; and that this may improve outcomes.

Predictive factors for recurrent suicide attempts: Evidence from the ACTION-J study

Aim

Risk factors for attempted suicide have been widely studied. However, there is limited evidence on predictive factors for suicide reattempts. We aimed to identify these in suicide attempters admitted to emergency departments.

Methods

This is the second analysis from a randomized controlled multicenter trial, ACTION-J. Patient characteristics were extracted from baseline demographic data and clinical data of participants. Predictive factors for a recurrent suicide attempt in each gender were examined using Cox proportional hazards regression analysis. Dependent variables were months from trial entry to the first reattempt. Independent variables were characteristics regarded as potential predictive factors.

Results

The study included 914 adults (400 men and 514 women). A visit to a psychiatrist within a month of the suicide attempt was significantly associated with reattempts in men (hazard ratio [HR] 2.49, 95% confidence interval [CI] 1.21-5.25). Substance-related disorders (HR 3.65, 95% CI 1.16-7.9.60), drinking alcohol less than once per month (HR 0.42, 95% CI 0.17-0.88), previous suicide attempts (HR 2.28, 95% CI 1.40-3.87), and taking a drug overdose for the first suicide attempt (HR 1.82, 95% CI 1.14-3.01) were significantly associated with reattempts in women.

Conclusion

Our data highlight the importance of visits to a psychiatrist a short time before the first suicide attempt in men and substance-related disorder, previous suicide attempts, and drug overdose in the first suicide attempt in women as predictive factors for future suicide reattempts.

Mental Disorders and Beyond in the Quest to Understand Suicide: A Reply to Joiner and Robison

We reply to the thoughtful commentary by Joiner and Robison (this issue) about the documentary Robin's Wish. Joiner and Robison suggest that a major depressive episode may have been a proximal cause of Robin Williams' suicide, but that stigma surrounding mental illness led the documentary to eschew a role for depression. We find this perspective compelling and important. Mental illness can be an important cause of suicide, and stigma can harm our ability to understand and treat mental illness and suicide risk. As a complementary perspective, we discuss research and theory suggesting that mental illness does not explain all deaths by suicide. We present research and theory suggesting that suicide is motivated by pain and hopelessness, and that pain and hopelessness can be caused not only by mental illness but by other factors such as overwhelming interpersonal struggles or loss, seemingly insurmountable financial problems, chronic medical conditions, and systematic discrimination and persecution. Finally, we reaffirm Joiner and Robison's belief that understanding and preventing suicide requires the pursuit of accurate knowledge, unburdened by stigma that can harm progress and people.

Suicide cases in developed and emerging countries: an analysis using wavelets

ABSTRACT Objective The aim of this study was to use a wavelet technique to determine whether the number of suicides is similar between developed and emerging countries. Methods Annual data were obtained from World Health Organization (WHO) reports from 1986 to 2015. Discrete nondecimated wavelet transform was used for the analysis, and the Daubechies wavelet function was applied with five-level decomposition. Regarding clustering, energy (variance) was used to analyze the clusters and visualize the clustering process. We constructed a dendrogram using the Mahalanobis distance. The number of groups was set using a specific function in the R program. Results The cluster analysis verified the formation of four groups as follows: Japan, the United States and Brazil were distinct and isolated groups, and other countries (Austria, Belgium, Chile, Israel, Mexico, Italy and the Netherlands) constituted a single group. Conclusion The methods utilized in this paper enabled a detailed verification of countries with similar behaviors despite very distinct socioeconomic, geographic and climate characteristics.

Estimating the risk of suicide associated with mental disorders: A systematic review and meta-regression analysis

BACKGROUND

Mental disorders (MDs) are known risk factors for suicide. This systematic review updates the evidence base for this association and improves upon analytic approaches by incorporating study-level and methodological variables to account for measurement error in pooled suicide risk estimates.

METHODS

A systematic review was conducted to review studies on MDs as risk factors for suicide. Relevant studies were searched using PubMed, Embase, PsychINFO, and existing reviews from 2010 to 19. Studies were eligible if they were longitudinal/case-control studies, representative of the general population, used diagnostic instruments, and quantified suicide risk. The outcome assessed was relative risks (RRs) for suicide due to MDs. A multi-level meta-regression approach was used to obtain pooled RRs adjusted for covariates and between-study effects.

FINDINGS

We identified 20 eligible studies yielding 69 RRs. Disorder type, age, sex, use of psychological autopsy, study design, and adjustment for confounders were tested as predictors of pooled suicide risk. Overall, all disorders were significant predictors of suicide with predicted adjusted RRs ranging from 4·11 [2·09, 8·09] for dysthymia to 7·64 [4·3, 13·58] for major depressive disorder.

INTERPRETATION

Our results indicate that MDs are important risk factors for suicide. This systematic review provides pooled RRs that have been adjusted for methodological sources of bias. Findings from our paper may inform suicide prevention strategies as part of national health agendas.

Monoamino Oxidase A Gene Single-Nucleotide Polymorphisms and Methylation Status and the Risk of Violent Suicide Attempts in Affective Disorder Patients

Background: When investigating the neurobiology of suicidal behavior, Monoamino Oxidase A (MAOA) is one of the prime suspects to consider. Interestingly, MAOA dysregulation has also been associated with violent behavior in previous publications. In the present study, we aimed to establish an association between polymorphisms of the MAOA gene and methylation status of the MAOA gene Exon I, and suicide attempts with violent methods in a sample of affective disorder patients. Methods: Eight hundred fourteen Caucasian affective disorder patients were assessed at the Department of Psychiatry and Psychotherapy of the Medical University Vienna, the Karl Landsteiner University for Health and Science and Zentren für seelische Gesundheit, BBRZ-Med Leopoldau. An assemblage of psychiatric interviews was performed (e.g., SCAN, HAMD, SBQ-R, CTQ) and DNA samples of peripheral blood cells were collected for Sequenom MassARRAY® iPLEX Gold genotyping and Multiplexed and Sensitive DNA Methylation Testing. Results: Female affective disorder patients with a history of violent suicide attempt were found to have a significantly increased frequency of the AA genotype in the rs5906957 single nucleotide polymorphism (p = 0.003). Furthermore, the MAOA gene exon I promoter region showed significantly decreased methylation in female violent suicide attempter(s) as opposed to female affective disorder patients who had no history of suicide attempt or no history of suicide attempt with violent method. Limitations: The small sample size hampers to reveal small genetic effects as to be expected in psychiatric disorders. Conclusions: This study offers promising findings about associations between the MAOA gene and violent suicide especially in women.

Depressive Tendency and the Risk of Death from Pneumonia: The JACC Study

Objective The burden of death from pneumonia is expected to increase with the aging of the population, as has been observed in Japan. Depressive tendency, a common psychosocial sign, may be a risk factor for pneumonia due to its possible association with some immune dysfunction. This study aimed to clarify the association between depressive tendency and the risk of death from pneumonia. Methods A population-based cohort that consisted of 75,174 Japanese men and women was followed for a median of 19.1 years. Four psychological and behavioral symptoms (depressive symptoms) were used to evaluate depressive tendency. Results A total of 1,329 deaths from pneumonia were observed. Depressive symptoms were positively and dose-dependently associated with the risk of death from pneumonia (p<0.001 for trend), and subjects with ≥2 depressive symptoms showed a significantly elevated risk compared to those without any symptoms [multivariable hazard ratio (HR), 1.66; 95% confidence interval (CI), 1.39-1.99]. This association was not significantly affected by sex or age at baseline. The elevated risk was still significant even when subjects were limited to those without any medical histories. The excess risk was observed not only for death occurring within the first 10 years of follow-up (multivariable HR, 2.05; 95% CI, 1.51-2.78) but also for that occurring in the longer follow-up period (multivariable HR, 1.48; 95% CI, 1.18-1.85). Conclusion Depressive tendency may be a risk factor for death from pneumonia. Further studies using a more reliable tool for the evaluation of depressive state are necessary to confirm this relationship.

Relationship between Beck Hopelessness Scale and suicidal ideation: A short-term longitudinal study

We aimed to clarify if the Beck Hopelessness Scale (BHS) predicted change in suicidal ideation in the general population. This study used a prospective cohort design (4-week survey interval) (N = 3,295). The online survey covered the BHS, suicidal ideation, depression/anxiety tendencies, and demographic details. Hierarchical multiple regression analysis showed hopelessness was a significant predictor of change in suicidal ideation from T1 to T2 (B = 0.07, 95% confidence interval: 0.05-0.09). Although high hopelessness was related to a short-term rise in suicidal ideation, the risk for suicide cannot be judged adequately by hopelessness from a clinical perspective.

Fluoxetine and Risk of Bleeding in Patients Aged 60 Years and Older Using the Korea Adverse Event Reporting System Database: A Case/Noncase Study

BACKGROUND

Depression, the leading cause of nonfatal disease burden, has a strong correlation with suicide and affects approximately 7% of the general elderly population. Adverse drug reactions in older patients are particularly important because of reduced drug metabolism, polypharmacy, drug-drug interactions, and drug-disease interactions. Fluoxetine is the first representative selective serotonin reuptake inhibitor but is associated with the possibility of hemorrhage based on its mechanism of action. Serious cases of gastrointestinal bleeding and cerebral hemorrhage have been reported, raising concerns about the safety of this drug.

METHODS

We detected signals of bleeding risk associated with fluoxetine in an elderly population using the Korea Adverse Event Reporting System database. Reporting odds ratios and 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 16,517 adverse events related to antidepressants were reported. The reporting odds ratios for fluoxetine were 2.34 (95% CI, 1.03-5.34) for total bleeding, 4.41 (95% CI, 1.60-12.15) for major bleeding, 2.06 (95% CI, 0.28-15.03) for gastrointestinal bleeding, and 6.12 (95% CI, 2.14-22.60) for brain hemorrhage compared with those of all other antidepressants.

CONCLUSIONS

We detected safety signals with total bleeding, major bleeding, and brain hemorrhage related to fluoxetine. For patients with a high risk of bleeding, such as the elderly population, prescribing antidepressants other than fluoxetine can be considered. The results of this study provide preliminary evidence of a relationship between fluoxetine and hemorrhage but have wide 95% CIs. Further pharmacoepidemiological studies will be needed to confirm the risk of bleeding associated with fluoxetine.

Impact of Age at Childbirth on Maternal Mental Health among Premenopausal Women: The 2010-2012 Korean National Health and Nutrition Examination Survey

OBJECTIVE

No reports have investigated the influence of age at first or last childbirth on maternal mental health. The aim of this study was to determine whether there is an association between age at first or last childbirth and the mental health of premenopausal women.

METHODS

The data used in this study were collected from the 2010 to 2012 Korea National Health and Nutrition Examination Surveys. A total of 3,370 premenopausal women were considered. The association between childbirth age and maternal mental health factors, including stress, depressed mood, and suicidal ideations were analyzed using multiple logistic regression analyses adjusted for confounding factors.

RESULTS

After adjusting confounding factors, younger maternal age at first childbirth was found to be associated with an increase in the prevalence of maternal depressed mood and suicidal ideations. Also, older maternal age at last childbirth was related to an increase in maternal stress, depressed mood and suicidal ideations.

CONCLUSION

Both younger first childbirth and older last childbirth maternal age may be risk factors for poor outcomes of premenopausal women's mental health. These data support the need for comprehensive mental health assessment for premenopausal women who either gave birth at an age too young or too old.

Psychological autopsy review on mental health crises and suicide among youth in Pakistan

INTRODUCTION

Ascertaining putative sociodemographic and clinical causes for death by probable suicide can potentially help implement region-specific strategies to reduce suicide rates. In this study, we wanted to investigate methods utilized and the psychosocial and mental health characteristics of youths (aged 12-26 y) who died by probable suicide.

METHOD

We examined data from mental health clinical files and forensic reports and performed qualitative psychological autopsy interview from more than multiple sources for each youth who died by probable suicide between 1 May and 31 December 2015 in the Khyber Pakhtunkhwa Province of Pakistan.

RESULTS

The two most common methods of probable suicide were by firearm use and self-poisoning utilizing pesticides that were significantly associated with male and female gender, respectively. The most common mental health difficulties were major depressive disorder and harmful use of psychoactive substances. Other clinical features particularly evident included thoughts of self-harm, irritability and aggression, low self-esteem, treatment nonadherence, family dispute, and financial distress.

CONCLUSION

Efforts to reduce the ease of access to firearms and pesticides may potentially have a beneficial effect in reducing the suicide rate in this region of Pakistan.

Preferences for suicide prevention strategies among university students in Japan: a cross-sectional study using full-profile conjoint analysis

In Japan, implementation of suicide prevention policies is mainly supported by public funds. However, it is unclear what kinds of suicide prevention strategies people prefer. We conducted a survey to clarify people's preferences regarding suicide prevention strategies adopted in Japan. This was a cross-sectional self-administered questionnaire survey. Participants were recruited through a lecture held by the first author at their university. We distributed questionnaires to 324 people present at the lecture; 249 completed questionnaires were included in the final analysis. We estimated suicide prevention strategy preferences using full profile conjoint analysis. For all six prevention strategies, the inclusion of each strategy in the policy profile was statistically significantly related to the positive evaluation of the overall policy profile. Marginal Willingness to Pay (MWTP) for restriction of access to means showed the highest value of the six suicide prevention strategies. MWTP was the lowest for public awareness activities. Preferred suicide prevention strategies in Japan are restriction of access to means and enhancement of psychiatric services. The results of this study indicate the strategies that are preferred have a high level of evidence of suicide prevention and do not directly intervene in a person's free will to die by suicide.

Influence of CRHR1 Polymorphisms and Childhood Abuse on Suicide Attempts in Affective Disorders: A GxE Approach

Background: Previous studies have shown that the hypothalamus-pituitary-adrenal-axis (HPA-axis) is closely involved in the development of affective disorders. Given that early life events are also linked to dysregulation of the same system, there might be an association between childhood adversities and suicidal behavior in affective disorders, moderated by HPA-axis genes. We aimed to investigate a potential association between childhood trauma and previous suicide attempts in affective disorder patients, moderated by variants of the corticotropin-releasing hormone receptor 1 (CRHR1) gene. Methods: The current pilot study is part of an ongoing study on suicidal behavior in affective disorders (VieSAD). Two hundred fifty eight Caucasian affective disorder patients were assessed at the Department of Psychiatry and Psychotherapy of the Medical University Vienna and the Karl Landsteiner University for Health and Science. An assemblage of psychiatric interviews was performed (e.g., SCAN, HAMD, SBQ-R, CTQ) and DNA samples of peripheral blood cells were genotyped with TaqMan® SNP Genotyping Assays (rs7209436, rs4792887, rs110402, rs242924, and rs242939). Results: Neither genetic, nor haplotypic associations between CRHR1 polymorphisms and previous suicide attempts could be established for the present sample. Using a binary logistic regression model, significant gene-environment-interactions were found for the single nucleotide polymorphisms (SNPs) rs7209436 and rs110402, reflecting the impact of childhood trauma and CRHR1 polymorphisms on previous suicide attempts. Limitations: A larger sample size will be required to ultimately elucidate the link between childhood trauma and the HPA axis in suicidal behavior. Conclusion: This pilot study presents promising gene-environment-interaction findings in affective disorder patients with a history of suicide attempts.

Association between habitual tryptophan intake and depressive symptoms in young and middle-aged women

BACKGROUND

The intake of tryptophan, the precursor of serotonin, is assumed to affect serotonin availability and depression onset. Nevertheless, a definitive relationship between dietary tryptophan intake and depressive symptoms has not been established. We examined the association between tryptophan intake and depressive symptoms screened in a group of 4272 first-year female dietetic students and 3651 their mothers.

METHODS

Dietary tryptophan intake during the preceding month was assessed with a validated, self-administered diet history questionnaire. Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale (CES-D) using two cutoff scores: CES-D score ≥ 16 and CES-D score ≥ 19 (the optimal cutoff score for Japanese people). The multivariate adjusted prevalence ratio (PR) and 95% confidence interval (CI) for depressive symptoms were calculated using Poisson regression analysis.

RESULTS

The prevalence of depressive symptoms (CES-D score ≥ 16) was 50.0% for young women and 26.5% for middle-aged women. The adjusted PR (95% CI) for depressive symptoms in the highest versus lowest quintile of tryptophan intake was 0.84 (0.75, 0.93) in young women (P for trend < 0.0001) and 0.83 (0.64, 1.01) in middle-aged women (P for trend < 0.0001). These associations were stable even when depressive symptoms were defined as a CES-D score ≥ 19.

LIMITATIONS

This is a cross-sectional study. Depressive symptoms were assessed using a self-reported questionnaire.

CONCLUSIONS

This cross-sectional study showed that a higher tryptophan intake was independently associated with a lower prevalence of depressive symptoms in young Japanese women.

Harnessing Reddit to Understand the Written-Communication Challenges Experienced by Individuals With Mental Health Disorders: Analysis of Texts From Mental Health Communities

BACKGROUND

Mental disorders such as depression, bipolar disorder, and schizophrenia are common, incapacitating, and have the potential to be fatal. Despite the prevalence and gravity of mental disorders, our knowledge concerning everyday challenges associated with them is relatively limited. One of the most studied deficits related to everyday challenges is language impairment, yet we do not know how mental disorders can impact common forms of written communication, for example, social media.

OBJECTIVE

The aims of this study were to investigate written communication challenges manifest in online mental health communities focusing on depression, bipolar disorder, and schizophrenia, as well as the impact of participating in these online mental health communities on written communication. As the control, we selected three online health communities focusing on positive emotion, exercising, and weight management.

METHODS

We examined lexical diversity and readability, both important features for measuring the quality of writing. We used four well-established readability metrics that consider word frequencies and syntactic complexity to measure writers' written communication ability. We then measured the lexical diversity by calculating the percentage of unique words in posts. To compare lexical diversity and readability among communities, we first applied pairwise independent sample t tests, followed by P value adjustments using the prespecified Hommel procedure to adjust for multiple comparison. To measure the changes, we applied linear least squares regression to the readability and lexical diversity scores against the interaction sequence for each member, followed by pairwise independent sample t tests and P value adjustments. Given the large sample of members, we also report effect sizes and 95% CIs for the pairwise comparisons.

RESULTS

On average, members of depression, bipolar disorder, and schizophrenia communities showed indications of difficulty expressing their ideas compared with three other online health communities. Our results also suggest that participating in these platforms has the potential to improve members' written communication. For example, members of all three mental health communities showed statistically significant improvement in both lexical diversity and readability compared with members of the OHC focusing on positive emotion.

CONCLUSIONS

We provide new insights into the written communication challenges faced by individuals suffering from depression, bipolar disorder, and schizophrenia. A comparison with three other online health communities suggests that written communication in mental health communities is significantly more difficult to read, while also consisting of a significantly less diverse lexicon. We contribute practical suggestions for utilizing our findings in Web-based communication settings to enhance members' communicative experience. We consider these findings to be an important step toward understanding and addressing everyday written communication challenges among individuals suffering from mental disorders.

Prevalence of psychiatric diagnoses in individuals who die by suicide or attempt suicide in China based on independent structured diagnostic interviews with different informants

Many individuals who die by suicide or attempt suicide have no pre-existing psychiatric record. In these cases determination of the presence of mental illness at the time of the suicidal act depends on diagnostic interviews with different informants, but the reliability of such interviews is unknown. To address this issue, the current study from northern China conducted independent diagnostic interviews (by different psychiatrists) with a co-resident family member and another associate of 151 suicide decedents, with 120 individuals who attempted suicide, and with two proxy informants for each suicide attempter. In the suicide decedent group, 56% of interviews with family members and 50% with other associates resulted in one or more psychiatric diagnosis; the concordance (kappa) of these two respondents for the presence of any current psychiatric disorder, any mood disorder and any other psychiatric disorder were 0.35, 0.32 and 0.41, respectively. In the suicide attempt group, 47% of interviewers with suicide attempters, 31% with family members, and 15% with other associates resulted in a psychiatric diagnosis; the concordance for any current psychiatric disorder, any mood disorder and any other psychiatric disorder between the interview with the suicide attempter and the combined result of the two separate proxy informant interviews were 0.31, 0.34 and 0.39, respectively. We conclude that the concordance of the presence and type of psychiatric diagnosis of individuals with suicidal behavior based on independent structured interviews by psychiatrists with different informants is low to fair and that using multiple informants will increase the identification of psychiatric disorders.

The depressive-like behaviors of chronic unpredictable mild stress-treated mice, ameliorated by Tibetan medicine Zuotai: involvement in the hypothalamic-pituitary-adrenal (HPA) axis pathway

BACKGROUND

Zuotai, a famous Tibetan medicinal mixture containing metacinnabar, is traditionally used for the purpose of tranquilizing minds and soothing nerves. However, it still lacks substantial experimental data for it to be approved for use.

AIM

This study was designed to assess the effects of Zuotai on depressive-like symptoms in a chronic unpredictable mild stress (CUMS) mouse model, and to explore its potential mechanism, particularly the hypothalamic-pituitary-adrenal (HPA) axis pathway.

MATERIALS AND METHODS

First, Kunming mice were exposed to the CUMS procedure and simultaneously administered Zuotai or imipramine (positive control) by gavage continuously for 6 weeks. Then, depressive-like behaviors of mice in each group were tested with the sucrose preference test, forced swimming test, tail suspension test, and open field test. Meanwhile, the three key neuroendocrine hormones (corticotropin releasing hormone, adrenocorticotropic hormone and corticosterone) in HPA axis pathway, and the level of the emotion-related monoamine neurotransmitters (5-hydroxytryptamine and norepinephrine) were measured using enzyme-linked immunosorbent assay. Furthermore, total mercury in the hypothalamus and hippocampus were determined using an automatic, direct mercury analyzer.

RESULTS

Zuotai or imipramine significantly increased the body weight and the sucrose preference ratio in sucrose preference test, and dramatically improved motor activity in forced swimming test, tail suspension test, and open field test in CUMS mice. Zuotai or imipramine remarkably decreased levels of corticotropin-releasing hormone, adrenocorticotropic hormone, and corticosterone in the HPA axis, and increased levels of 5-hydroxytryptamine and norepinephrine in the serum in CUMS mice. However, a small amount of mercury was deposited in the hypothalamus and hippocampus in Zuotai-treated mice, which may pose a potential risk to the central nervous system.

CONCLUSION

Zuotai has a strong ability to ameliorate depressive-like behaviors in CUMS-treated mice through inhibition of the HPA axis and upregulation of monoamine neurotransmitters. These findings provide new insight into the pharmacological effect of Zuotai on depression.

Alcohol-use disorders and suicide: Results from a psychological autopsy study in Australia

INTRODUCTION

People who die by suicide have a higher risk of an alcohol-use disorder (AUD) at the time of death. The present study aims to compare 1) suicide cases with and without AUD, and 2) suicide and sudden-death controls with AUD.

METHODS

The psychological autopsy method was utilized to investigate suicide and sudden death in Australia (QLD and NSW). Initial information was gathered from coroners' offices. Potential informants were approached and semi-structured interviews were conducted. Univariate and multivariate logistic regression were applied.

RESULTS

People with AUD who died by suicide were significantly more likely to have another substance-use disorder, history of suicide attempt, recent serious arguments with spouse/partner and other family members, been unfaithful to partner/spouse, be victims of a crime, and were less likely to be from a non-English speaking background. They were also younger and had higher levels of aggression compared to non-AUD suicides. AUD suicides were more likely to have mood disorders, previous suicide attempt, expressing hopelessness, higher scores in aggression towards self, romantic relationship breakup, and serious arguments with other family members than AUD sudden deaths. Aggressive behavior, having another substance-use disorder, and history of serious arguments with family members remained significant in the final model comparing suicides with and without AUD.

CONCLUSION

Our findings support that aggressive behavior, comorbidity with other psychiatric disorders as predisposing factors, and recent interpersonal conflicts such as breakup and family conflicts can trigger suicide in people with AUD. There is a need for proper diagnosis, risk assessment, and treatment in suicidal people with AUD.

Exploring suicide risk factors among Japanese individuals: The largest case-control psychological autopsy study in Japan

This case-control psychological autopsy study explored suicide risk factors among Japanese individuals. We targeted 102 suicide completers over 20 years of age and 334 living controls matched to suicide cases by gender, age, and residential municipality in Japan. After controlling for other factors, we found significant associations between suicide and mental disorders, sleeping problems, and verbal communication of one's own death. We discuss the importance of sensitive responses to verbal expressions of suicidal ideation.

Community-based screening intervention for depression affects suicide rates among middle-aged Japanese adults

BACKGROUND

It has been suggested that screening interventions may be effective for suicide prevention. Few studies, however, have reported their effects on outcome measures, including death by suicide among middle-aged adults.

METHOD

We used a quasi-experimental parallel cluster design with matched community-based intervention and control municipalities (total eligible population: 90 000) in Japan. At-risk residents within the intervention area were invited for universal depression screening and subsequent care/support. We compared changes in suicide incidence of adults aged 40-64 years for the 4-year pre- and post-implementation periods in the intervention group with the control group and the whole country. Incidence rate ratios (IRRs) of the outcomes were adjusted for age group, gender and interaction terms, using mixed-effects negative binomial regression models. Suicide rates among intervention and control subgroups were compared.

RESULTS

The screening procedure was offered to 52% of the intervention group, and 61% of those contacted responded over the implementation period. Suicide rates decreased more in the intervention group [IRR 0.57, 95% (CI) 0.41-0.78; F 1,36 = 12.52, p = 0.001] than the control group (IRR proportion 1.63, 95% CI 1.06-2.48; F 1,82 = 5.20, p = 0.025) or the whole country (IRR proportion 1.64, 95% CI 1.16-2.34; F 1,42 = 8.21, p = 0.006). Sensitivity analyses confirmed the results from the primary analysis. There were lower suicide rates among both respondents and non-respondents to the screening than in the control group during the implementation period.

CONCLUSIONS

Prevention efforts involved in the depression screening intervention were probably successful in reducing suicide rates.

Long-Term Suicide Risk in Anxiety-The Lundby Study 1947-2011

The objective of this study was to calculate the long-term risk of accomplished suicide in anxiety disorders, and to compare this with a healthy population. The Lundby Study is a prospective, longitudinal cohort study on a population of 3,563 subjects. Between 1947 and 1997, anxiety disorders were diagnosed in 300 subjects. Up to 2011 there were 68 suicides in all. The suicide risk was 3.3% for anxiety. For only anxiety, risk was increased (p = 0.008), but other diagnoses had a higher risk (p = 0.0001) compared with no diagnosis. Mean time from onset to suicide was 27 years. Risk of suicide in anxiety disorders seems elevated at an intermediate level. Suicide often occurs many years after onset of the disorder.

Utilizing a medical questionnaire to predict anxiety and depression in outpatients

Introduction

Anxiety and depressive symptoms are seen in patients with anxiety and mood disorders but are also common in those with organic disorders. However, since physical symptoms are predominant complaints from patients who visit nonpsychiatric outpatient clinics, anxiety and depressive symptoms are often unrecognized. It is important for physicians to be aware of these issues concurrent with the physical symptoms. We therefore examined whether a self-administered medical questionnaire could identify anxiety and depressive symptoms.

Patients and methods

A total of 453 patients on their first visit to the Department of General Medicine, Chiba University Hospital, Chiba, Japan, participated in this study. They were asked to complete a medical questionnaire and the Hospital Anxiety and Depression Scale questionnaire before examination. Data on age, sex, number of complaints, symptom duration, and number of previous physicians were extracted from the medical questionnaire. These data were used as independent variables in logistic regression analysis to develop a predictive model for the presence of anxiety and depressive symptoms.

Results

Data from 358 (79.0%) patients were included in the analyses. Logistic regression analysis identified the following predictors: “three or more complaints” (odds ratio [OR] 2.39; 95% confidence interval [CI] 1.48–3.88) and “four or more previous physicians” (OR 1.72; 95% CI 1.10–2.69). In the predictive model for the presence of symptoms of anxiety and depression, the likelihood ratio was 2.40 (95% CI 1.33–4.34) in patients reporting both conditions and 1.35 (95% CI 1.04–1.77) in those reporting either condition.

Conclusion

The presence of anxiety and depressive symptoms can be predicted from the items of a medical questionnaire in outpatients visiting a general medicine department of a university hospital. When patients report three or more complaints or four or more previous physicians on a medical questionnaire, physicians should consider the presence of anxiety or depression or both in differential diagnosis.

Educational Levels and Risk of Suicide in Japan: The Japan Public Health Center Study (JPHC) Cohort I

BACKGROUND

Suicide rates have been related to educational level and other socioeconomic statuses. However, no prospective study has examined the association between educational level and the risk of suicide in Japan.

METHODS

We examined the association of education level and suicide risk in a population-based cohort of Japanese men and women aged 40-59 years in the Japan Public Health Center-based Prospective Study Cohort I. In the baseline survey initiated in 1990, a total of 46 156 subjects (21 829 men and 24 327 women) completed a self-administered questionnaire, which included a query of educational level, and were followed up until the end of December 2011. Educational levels were categorized into four groups (junior high school, high school, junior or career college, and university or higher education). During a median follow-up of 21.6 years, the hazard ratios (HRs) and 95% confidence intervals (CIs) of suicide according to educational level were estimated using the Cox proportional hazards regression model adjusted for age; study area; previous history of stroke, ischemic heart disease, or cancer; self-reported stress; alcohol consumption; smoking; living with spouse; and employment status. A total of 299 deaths attributed to suicide occurred.

RESULTS

The HR for university graduates or those with higher education versus junior high school graduates was 0.47 (95% CI, 0.24-0.94) in men, and that for high school graduates versus junior high school graduates was 0.44 (95% CI, 0.24-0.79) in women.

CONCLUSIONS

High educational levels were associated with a reduced risk of suicide for both Japanese men and women.

Factors associated with suicide completion: A comparison between suicide attempters and completers

INTRODUCTION

The objective of this study was to compare the sociodemographic and clinical variables of suicide attempters and completers and to identify risk and protective factors for suicide completion.

METHODS

Subjects (n = 320) visiting to the emergency room were classified into two groups: suicide attempters (n = 222) and suicide completers (n = 98). Univariate analyses and logistic regression models were used to explore the differences between suicide attempters and completers and to identify risk factors for suicide completion.

RESULTS

The results showed that compared with suicide attempters, suicide completers were older, male, having alcohol use disorders, having comorbid health problems, having severe suicide ideation, and using severe suicide methods such as hanging and jumping from a height. Using multiple logistic regression model, risk factors predicting suicide completion were comorbid medical illness, and intense suicide ideation. Factor that served as protective factors against suicide completion was female.

DISCUSSION

This study demonstrated that suicide completers have more severe clinical profile than suicide attempters. Decreasing intensity of suicide ideation and treating comorbid medical illness of suicide attempters might be important in preventing them from suicide completion. It is important that the implementation of suicide preventive programs focused on alcoholism is useful in decreasing suicide rates further. Moreover, suicide completers used highly lethal methods, our results indicate that our country should make greater efforts to decrease hanging and jumping from a height.

Geographical and temporal variations in the prevalence of mental disorders in suicide: Systematic review and meta-analysis

BACKGROUND

In contrast to the previous studies reporting that most suicides occur among people with mental disorders, recent studies have reported various rates of mental disorders in suicide in different geographical regions. We aimed to comprehensively investigate the factors influencing the variation in the prevalence of mental disorders reported among suicide victims.

METHOD

The authors searched Embase, Medline, Web of Science, and the Cochrane Library to identify psychological autopsy studies reporting the prevalence of any mental disorders among suicide victims. A meta-regression analysis was conducted to identify the potential effects of geographical regions, the year of publication, measurements of personality disorder, measurements of comorbidity, and the ratio of females on the prevalence of mental disorders in addition to examining the heterogeneity across studies.

RESULTS

From 4475 potentially relevant studies, 48 studies met eligibility criteria, with 6626 suicide victims. The studies from East Asia had a significantly lower mean prevalence (69.6% [95% CI=56.8 to 80.0]) than those in North America (88.2% [95% CI=79.7-93.5]) and South Asia (90.4% [95% CI=71.8-97.2]). The prevalence of any mental disorder decreased according to the year of publication (coefficients=-0.0715, p<0.001).

LIMITATIONS

Substantial heterogeneities were identified within all subgroup analyses.

CONCLUSIONS

The prevalence of mental disorders among suicide cases seemed relatively low in the East Asia region, and recently published studies tended to report a lower prevalence of mental disorders. The link between the risk factors and suicide in the absence of a mental disorder should be examined in different geographical and sociocultural contexts.

Personality and suicide risk: the impact of economic crisis in Japan

BACKGROUND

The interactive effect of personal factors and social factors upon suicide risk is unclear. We conducted prospective cohort study to investigate whether the impact of the economic crisis in 1997-1998 upon suicide risk differed according to Neuroticism and Psychoticism personality traits.

METHODS

The Miyagi Cohort Study in Japan with a follow-up for 19 years from 1990 to 2008 has 29,432 subjects aged 40-64 years at baseline who completed a questionnaire about various health habits and the Japanese version of the Eysenck Personality Questionnaire - Revised Short Form in 1990.

RESULTS

The suicide mortality rate increased from 4.6 per 100,000 person-years before 1998 to 27.8 after 1998. Although both Neuroticism and Psychoticism were significantly associated with an increased risk of mortality during the whole period from 1990 to 2008, the impact of the economic crisis upon suicide risk differed between the Neuroticism and Psychoticism personality traits. Compared with the lowest category, the hazard ratios (HRs) for the highest Neuroticism increased from 0.66 before 1998 to 2.45 after 1998. On the other hand, the HRs for the highest Psychoticism decreased from 7.85 before 1998 to 2.05 after 1998.

CONCLUSIONS

The impact of the 1997-1998 economic crisis upon suicide risk differed according to personality. Suicide risk increased among these with higher Neuroticism after the economic crisis, but this was not the case for other personality subscales.

Attribution of mental disorders in suicide occurrence

The present study aimed to determine attribution of mental disorders in suicide occurrence. By a cross-sectional study, all suicide records (n = 5188), between 1993 and 2009 in Ilam province, were investigated. Multiple logistic regression analysis was adopted. Totally, 27.5% of the suicides occurred due to mental disorders. This was significantly higher in males (29.3%), individuals born in 1996 (44%) and 1990s (30.3%), those aged 30 years and above (33.2%) and suicide attempters (28.3%), respectively and separately. The risk of suicide due to mental disorders was observed for females (OR = 0.85, CI = 0.74-0.97), those born in 1994 (OR = 2.82, CI = 1.27-6.24), completed suicides (OR = 0.81, CI = 0.68-0.97) and the age group 25 to 29 years old (OR = 0.82, CI = 0.66-1.01). Suicide due to mental disorders was higher among males compared to females, the rate of which was directly proportional to attempted suicide and age. It is therefore recommended that health educations be seriously carried on targeted groups.

A comparison of the characteristics of suicide attempters with and without psychiatric consultation before their suicidal behaviours: a cross-sectional study

BACKGROUND

Because psychiatric disorders are risk factors for suicide, psychiatric consultation should be an essential element of suicide prevention among individuals with a high risk of suicide. The aim of the present study was to compare the characteristics of individuals who had or had not received psychiatric consultation before they attempted suicide in Japan.

METHODS

Clinical records were used to identify 300 consecutive persons who were admitted to the hospital for attempting suicide between April 2006 and March 2013. We divided the patients into two groups. One group consisted of patients who consulted a psychiatrist before their suicidal behaviours (the consultation group), and the other group consisted of patients who had not consulted a psychiatrist before their suicidal behaviours (the non-consultation group). Group differences were analysed with respect to gender, age, method of suicide attempts, psychiatric diagnosis (ICD-10), and duration of hospitalisation in the emergency unit.

RESULTS

Females tended to be over-represented in the consultation group (73.0%), and males tended to be over-represented in the non-consultation group (59.8%). Poisoning by prescription drugs was used more frequently as a method of suicide in the consultation group than in the non-consultation group. Neuroticism and related disorders were higher in the non-consultation group (33.7%) than in the consultation group (18.9%). Mood disorders (32.6%) were nearly as common as neuroticism in the non-consultation group, and together they accounted for almost two-thirds of all diagnoses. Mood disorders were comparable between the consultation group (30.9%) and the non-consultation group (32.6%). Adult personality disorders (13.3%) and schizophrenia and related disorders (26.0%) were higher in the consultation group than in the non-consultation group.

CONCLUSIONS

Measures have to be taken to encourage people with these diverse characteristics to consult psychiatrists, and psychiatrists have to regularly evaluate patients for suicide risk. Furthermore, we need further research on the relationship between psychiatric consultation and poisoning by prescribed drugs.

Association of socioeconomic status in childhood with major depression and generalized anxiety disorder: results from the World Mental Health Japan survey 2002-2006

BACKGROUND

Low socioeconomic status (SES) in childhood is known to be a significant risk factor for mental disorders in Western societies. The purpose of this study was to investigate whether a similar association exists in Japan.

METHODS

We used data from the World Mental Health Japan Survey conducted from 2002-2006 (weighted N=1,682). Respondents completed diagnostic interviews that assessed lifetime prevalence of major depression (MD) and generalized anxiety disorder (GAD), as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Associations between parental education (a proxy of SES in childhood) and lifetime onset of both disorders were estimated and stratified by gender using discrete-time survival analysis.

RESULTS

Among women, high parental education was positively associated with MD (odds ratio [OR]: 1.81, 95% confidence interval [CI]: 1.03-3.18) in comparison with low parental education, even after adjustment for age, childhood characteristics, and SES in adulthood. This same effect was not found for men. In contrast, higher parental education was associated with GAD (OR: 6.84, 95% CI: 1.62-28.94) in comparison with low parental education among men, but this association was not found among the women, in the fully adjusted model.

CONCLUSIONS

In Japan, childhood SES is likely to be positively associated with the lifetime onset of mental disorders, regardless of family history of mental disorders, childhood physical illness, or SES in adulthood. Further study is required to replicate the current findings and elucidate the mechanism of the positive association between mental disorders and childhood SES.

Network analysis for motives in suicide cases: a cross-sectional study

AIM

Suicide victims have various distresses or motives. There are few studies on how these motives toward suicide relate with each other. We used network analyses to extract the structures of correlations among the motives for suicide.

METHODS

We obtained datasets of suicide victims from 2007-2009 in Japan in cooperation with Ibaraki Prefectural Police Headquarters. The data were analyzed by network centrality measures and a structural analysis by block modeling.

RESULTS

Among the motives, depression and physical illness showed relatively high scores of 'degree centrality', whereas depression and unemployment showed relatively high scores of 'betweenness centrality'. Structural analysis by block modeling resulted in eight blocks. The most important block comprised eight motives, including conflict between parent and child, marital conflict, economic hardship, and overloaded with debt.

CONCLUSION

Depression and physical illness were important and priority areas for completed suicides, although these two motives had different influences on suicide behaviors. Furthermore, structural analysis revealed the important role of a block, including some familial and financial motives, which induced hopelessness. Our results suggest that it might be useful to consider the common ways in which motivations for suicide are tied together when suicide intervention is launched from a social model point of view.

Suicide risk among individuals with sleep disturbances in Japan: a case-control psychological autopsy study

OBJECTIVE

This case-control psychological autopsy study aimed to explore a relationship between sleep disturbances and suicide among Japanese, as well as determine the importance and usability of screening for sleep disturbances in suicide prevention.

METHODS

A semi-structured interview was conducted with the close family members of 49 adult suicide completers and 145 gender-, age-, and residential municipality-matched living controls. The survey included sections on demographics, sleep disturbances, and mental disorders. Conditional logistic regression analyses were performed to compare sleep disturbance prevalence between the two groups.

RESULTS

A significantly higher prevalence of sleep disturbances was found among the suicide group (75.5%) compared to the controls (11.0%) (odds ratio [OR]=21.6, p<0.001). The association remained significant after adjusting for mental disorders (OR=12.7, p<0.001). The population attributable risk percent of suicide associated with sleep disturbances and mental disorders was estimated to be 56.4% and 35.3%, respectively.

CONCLUSIONS

The study confirmed that sleep disturbances are an important risk factor of suicide, independent of mental disorders. Sleep disturbances accounted for a greater proportion of suicide cases than did mental disorders in the Japanese population given the higher prevalence, and could thus be considered an important target in suicide prevention in Japan.

Suicide risk in major affective disorder: results from a national survey in China

BACKGROUND

This study investigated suicide risk and its correlates among major affective disorder patients in China and examined possible risk factors for future suicide among individuals with major affective disorder to inform appropriate interventions and management approaches to minimize and prevent suicide.

METHODS

A total of 1478 major affective disorder patients were consecutively examined in 13 mental health centers in China. The patients' socio-demographic and clinical characteristics were recorded using a standardized protocol and data collection procedure. DSM-IV diagnoses were established using the Mini International Neuropsychiatric Interview (MINI), and suicide risk was assessed by the suicide risk module of the MINI.

RESULTS

Of the patients, 963 (65.2%) were in the nonsuicidal risk group and 515 (34.8%) were in the suicidal risk group. Compared to major depressive disorder patients, bipolar disorder patients had higher suicide risk levels (χ2=10.0, df=1, P=0.002); however, there were no statistically significant differences (χ2=2.6, df=1, P=0.1) between bipolar disorder-I and bipolar disorder-II patients. Suicide risk factors were associated with 6 variables in major affective disorder patients, as follows: male gender, unemployed, more frequent depressive episodes (>4 in the past year), depressive episodes with suicidal ideation and attempts, depressive episodes with psychotic symptoms, and no current antidepressant use.

LIMITATIONS

Most of the data were retrospectively collected and, therefore, subject to recall bias.

CONCLUSIONS

This study suggested that bipolar disorder patients have a higher suicide risk than major depressive disorder patients. The factors that were significantly associated with suicide risk may aid in identifying major affective disorder patients who are at risk for future suicidal behavior.

Screening for major and minor depression in a multiethnic sample of Asian primary care patients: a comparison of the nine-item Patient Health Questionnaire (PHQ-9) and the 16-item Quick Inventory of Depressive Symptomatology - Self-Report (QIDS-SR16 )

INTRODUCTION

Depression is common, disabling, and the single most important factor leading to suicide, yet it is underdiagnosed in busy primary care settings. A key challenge facing primary care clinicians in Asia is the selection of instruments to facilitate depression screening. Although the nine-item Patient Health Questionnaire (PHQ-9) and 16-item Quick Inventory of Depressive Symptomatology - Self-Report (QIDS-SR16 ) are used internationally, they have not been directly compared or widely validated in Asian primary care populations. This study aimed to validate the PHQ-9 and QIDS-SR16 against a structured interview diagnosis of Diagnostic and Statistical Manual, 4th Edition, depression based on the Mini-International Neuropsychiatric Interview in a multiethnic Asian sample.

METHODS

From April through August 2011, we enrolled 400 English-speaking Singaporean primary care patients. Participants completed a demographic data form, the PHQ-9, and the QIDS-SR16 . They were assessed independently for major and minor depression using the Mini-International Neuropsychiatric Interview.

RESULTS

Sensitivity and specificity for diagnosing major depression were 91.7% and 72.2%, respectively, for the PHQ-9 (optimal cutoff score of 6), and 83.3% and 84.7%, respectively, for the QIDS-SR16 (optimal cutoff score of 9). The QIDS-SR16 also detected minor depression at an optimal cutoff score of 7, with a sensitivity of 94.4% and specificity of 77.9%. The PHQ-9 and QIDS-SR16 showed good internal consistency (Cronbach's α: 0.87 and 0.79, respectively) and good convergent validity (correlation coefficient: r = 0.73, P < 0.001). The overall prevalence of major and minor depressive disorders was 9%.

DISCUSSION

The PHQ-9 and QIDS-SR16 appear to be valid and reliable for depression screening in Asian primary care settings.

Comparison of the clinical features of suicide attempters by jumping from a height and those by self-stabbing in Japan

BACKGROUND

A history of psychiatric disorders is a high risk for suicide. The present study compared the clinical features of psychiatric patients in Japan who attempted suicide by jumping from a height and those who attempted suicide by self-stabbing.

METHODS

We compared two groups of suicide attempters who were hospitalized for both physical and psychiatric treatment (n=202). We compared the psychiatric diagnoses and clinical features between those who attempted suicide by jumping from a height (N=147) and those who did so by self-stabbing (N=55).

RESULTS

The self-stabbing group (mean age 52.3 years) was significantly older compared to the jumping group (mean age 37.9 years). A significantly higher proportion of females were found in the jumping group. Jumping from a height was significantly associated with schizophrenia spectrum disorders, whereas self-stabbing was significantly associated with mood disorders.

LIMITATIONS

The results were drawn from data from a single hospital in a large urban city, and the study population did not include subjects who completed their suicide attempts.

CONCLUSIONS

Our findings show that differences in suicide methods (here, between jumping from a height and self-stabbing) may be related to suicide attempters' psychiatric diagnosis, gender and age. It is thus important to obtain a more detailed background information about a patient's suicide attempt and to create suicide prevention plans in accord with individuals' psychiatric diagnosis, age and gender, especially among those who have attempted suicide by jumping from a height or self-stabbing.

Melancholic features and hostility are associated with suicidality risk in Asian patients with major depressive disorder

BACKGROUND

Suicide rates are higher in East-Asians than other populations, and especially high in Koreans. However, little is known about suicidality risk and melancholic features in Asian patients with major depressive disorder (MDD).

METHOD

Drug-free MDD outpatients were included from 13 centers across five ethnicities consisting of Chinese (n=290), Korean (n=101), Thai (n=102), Indian (n=27), and Malay (n=27). All were interviewed using the Mini-International Neuropsychiatric Interview (M.I.N.I.), the Montgomery-Åsberg Depression Rating Scale (MADRS), and the Symptoms Checklist 90-Revised (SCL-90-R).

RESULTS

Of 547 subjects, 177 MDD patients showed melancholic features (32.4%). These melancholic MDD patients revealed significantly higher suicidality risk (p<0.0001), hostility (p=0.037), and severity of depression (p<0.0001) than those MDD patients without melancholic features. Suicidality risk was significantly higher in MDD with melancholic features than those without in subjects with lower hostility, whereas it showed no difference in higher hostility. Adjusted odds ratios of melancholic features and hostility for moderate to high suicidality risk were 1.79 (95% CI=1.15-2.79) and 2.45 (95% CI=1.37-4.38), after adjusting for age, sex, education years, and depression severity. Post-hoc analyses showed that suicidality risk was higher in Korean and Chinese than that of Thai, Indian and Malay in MDD subjects with melancholic features, although depression severity showed no significant differences among the ethnicities.

CONCLUSIONS

Suicidality risk is associated with both melancholic features and hostility and it shows cross-ethnic differences in Asian MDD patients, independent of depression severity.

Recurrence of sickness absence due to depression after returning to work at a Japanese IT company

There have been few epidemiological studies on recurrent sickness absence due to depression after returning to work (RTW). The objective of this study was to investigate the prognosis of workers who are RTW with depression in a Japanese company. This study employed a descriptive epidemiology study design. Subjects of this study were 540 employees who worked full-time and were registered in the Health Data System and returned to work from April 2002 to March 2008 after their first leave of absence due to depression. We investigated the recurrence of sickness absence due to depression after returning to work using the Kaplan-Meier survival curve method. During the 8.5 yr follow-up period, almost half of the RTW employees experienced recurrent sickness absence. There was a steep increase in recurrent rates the first two years after RTW, and 85.2% of total recurrence of sickness absence had occurred within three years after the index episode.