Concordance of DSM-IV Axis I and II diagnoses by personal and informant's interview

Reliability of pediatric Rome IV criteria for the diagnosis of disorders of gut-brain interaction

BACKGROUND

The diagnosis of disorders of gut-brain interaction (DGBI) in children is exclusively based on clinical criteria called the Rome criteria. The inter-rater reliability (IRR) measures how well two raters agree with a diagnosis using the same diagnostic tool. Previous versions of the Rome criteria showed only fair to moderate IRR. There have been no studies assessing the IRR of the current edition of the pediatric Rome criteria (Rome IV). This study sought to investigate the IRR of the pediatric Rome IV criteria and compare its reliability with the previous versions of the Rome criteria. We hypothesized that changes made to Rome IV would result in higher IRR than previous versions.

METHODS

This study used the same methodology as the previous studies on Rome II and III, including identical clinical vignettes, number of raters, and levels of expertise. Participants included 10 pediatric gastroenterology fellows and 10 pediatric gastroenterology specialists. IRR was assessed using the percentage of agreement and Cohen's kappa coefficient to account for possible agreement by chance.

RESULTS

The average IRR percentage of agreement using the Rome IV criteria was 55% for pediatric gastroenterologists and 48.5% for fellows, indicating moderate agreement (k = 0.54 for specialists, k = 0.47 for fellows). The results demonstrated higher percentages of agreement and kappa coefficients compared to the Rome II and III criteria.

CONCLUSIONS

The findings demonstrate improved reliability in Rome IV compared to Rome II and III, suggesting that the changes incorporated into the Rome IV criteria have enhanced diagnostic consistency. Despite the advancements, the reliability is still moderate, indicating the need for further refinement of future versions of the Rome criteria.

Lifetime Suicide Attempts in Otherwise Psychiatrically Healthy Individuals

Importance

Not all people who die by suicide have a psychiatric diagnosis; yet, little is known about the percentage and demographics of individuals with lifetime suicide attempts who are apparently psychiatrically healthy. If such suicide attempts are common, there are implications for suicide risk screening, research, policy, and nosology.

Objective

To estimate the percentage of people with lifetime suicide attempts whose first attempt occurred prior to onset of any psychiatric disorder.

Design, Setting, and Participants

This cross-sectional study used data from the US National Epidemiologic Study of Addictions and Related Conditions III (NESARC-III), a cross-sectional face-to-face survey conducted with a nationally representative sample of the US civilian noninstitutionalized population, and included persons with lifetime suicide attempts who were aged 20 to 65 years at survey administration (April 2012 to June 2013). Data from the NESARC, Wave 2 survey from August 2004 to September 2005 were used for replication. Analyses were performed from April to August 2023.

Exposure

Lifetime suicide attempts.

Main Outcomes and Measures

The main outcome was presence or absence of a psychiatric disorder before the first lifetime suicide attempt. Among persons with lifetime suicide attempts, the percentage and 95% CI of those whose first suicide attempt occurred before the onset of any apparent psychiatric disorders was calculated, weighted by NESARC sampling and nonresponse weights. Separate analyses were performed for males, females, and 3 age groups (20 to <35, 35-50, and >50 to 65 years).

Results

In the total sample of 36 309 respondents, 1948 persons had lifetime suicide attempts; 66.8% (95% CI, 64.1%-69.4%) were female, and 6.2% (95% CI, 4.9%-7.4%) had no apparent lifetime psychiatric diagnoses when surveyed. In addition, 13.4% (95% CI, 11.6%-15.2%) made their first suicide attempt prior to psychiatric disorder onset. Thus, an estimated 19.6% of respondents first attempted suicide without an antecedent psychiatric disorder. No significant age or sex differences were detected in the percentage of those with lifetime suicide attempts absent psychiatric disorders, although females were more likely than males to attempt suicide in the year of psychiatric disorder onset (14.9% [95% CI, 12.5%-17.3%] vs 8.6% [95% CI, 6.0%-11.2%]; P < .001), and attempts were less frequent among those older than 50 to 65 years (3.9% [95% CI, 3.5%-4.4%] vs 6.1% [95% CI, 5.4%-6.8%] for 35-50 years and 6.2% [95% CI, 5.6%-6.9%] for 20 to <35 years; P < .001).

Conclusions and Relevance

In this study, an estimated 19.6% of individuals who attempted suicide did so despite not meeting criteria for an antecedent psychiatric disorder. This finding challenges clinical notions of who is at risk for suicidal behavior and raises questions about the safety of limiting suicide risk screening to psychiatric populations.

Occurrence and characteristics of suicidal ideation in psychiatrically healthy individuals based on ecological momentary assessment

Decedents with no known mental disorder comprise 5-40% of suicides, suggesting that suicide ideation (SI) and behavior may occur in the psychiatrically healthy with important implications for suicide risk screening. Healthy Volunteers (HV) and patients with Major Depressive Disorder (MDD) provided 7 days of Ecological Momentary Assessment (EMA) data about SI and stressors. Longitudinal mixed effects logistic regression models compared HV and patient SI and stressors. Mixed effects linear regression models compared HVs' and patients' SI score change from the previous epoch's SI score when each stressor occurred. HVs (n = 42) reported less frequent (p < 0.001) and less intense SI (p < 0.003) than patients (n = 80), yet did endorse SI and/or SI-related items in 44% of EMA epochs, endorsing SI items in 25% of epochs with non-zero SI scores. For 7 of 8 stressors, patients reported stressors more often than HVs (all p < 0.001) responding to them with increased SI (0.0001 < p < 0.0472). HVs were relatively resilient to stressors, reporting SI increases only in response to neglect (p < 0.0147). Although SI and SAs are documented among psychiatrically healthy individuals, scientific attention to these observations has been scant. Real-time SI measurement showed that HVs' SI was less pronounced than MDD patients', but was endorsed, nonetheless. Patients were more likely to report stressors than HVs, perhaps due to greater sensitivity to the environment, and reported SI in response to stressors, which was less common in HVs. Both MDD patients and HVs most often manifested passive SI (viz, "decreased wish to live"). However, passive SI (viz, "desire for death"), may predict suicide, even absent SI per se (thinking about killing yourself). This study validates the utility of real-time SI assessment, showing that HVs endorse SI items in 11% of epochs, which implies that suicide risk screening focused on those with mental disorders may be too narrow an approach.

The path not taken: Distinguishing individuals who die by suicide from those who die by natural causes despite a shared history of suicide attempt

OBJECTIVES

This study aimed to identify variables that distinguish suicide risk among individuals with previous suicide attempts.

METHOD

Using psychological autopsy procedures, we evaluated 86 decedents who had at least one lifetime suicide attempt before eventual death by suicide (n = 65) or natural causes (n = 21).

RESULTS

The Suicide Death group was more likely to be male, to have alcohol in the toxicology report at time of death, and to have a depression diagnosis, while the Natural Cause Death group was more likely to have personality disorder traits, a polysubstance use disorder, higher reported health stress, and an antidepressant in the toxicology report at time of death. Hopelessness and ambivalence were found to distinguish between groups during the 6 months before death.

CONCLUSIONS

These findings suggest important differences between individuals with a shared history of a suicide attempt who die by suicide versus natural causes.

Comparing Childhood Characteristics of Adopted and Non-adopted Individuals Deceased by Suicide

OBJECTIVE

Across the globe more than 35,000 children a year are adopted by non-relatives, and some studies suggest that adopted individuals may be more vulnerable to developing mental disorders. To map the differences in suicide risk factors in adopted and non-adopted individuals, this study will compare the development of mental disorders as well as life events occurring before the age of 18 for both adopted and non-adopted individuals deceased by suicide.

METHODS

This study included 13 adopted and 26 non-adopted individuals deceased by suicide as well as 26 non-adopted living control individuals. Cases were taken from a data bank created over the last decade by researchers of [our institution] comprising a mixture of 700 suicide cases and living control individuals aged from 14 to 84. Adopted and non-adopted individuals deceased by suicide; adopted individuals deceased by suicide and non-adopted living control individuals were each compared on Axis I and II disorders, early life events, and burdens of adversity.

RESULTS

Results show significant differences, with a higher rate of Attention Deficit Hyperactivity Disorder, mental health comorbidity and Cluster C personality disorders among adopted individuals. Furthermore, adopted individuals have higher adversity scores prior to the age of 15.

CONCLUSION

This study underlines the fact that adoptive families need to be supported throughout adoption. Health care professionals need specialized training on this matter, and the psychological challenges adopted individuals face need to be treated at the earliest juncture.

Adversity Over the Life Course: A Comparison Between Women and Men Who Died by Suicide

Purpose: This study sets out to compare the presence of life events across different domains throughout the life course which may contribute to the burden of adversity experienced differently among men and women who died by suicide. Method: In a sample of 303 individuals (213 men and 90 women), data was derived from extensive clinical interviews conducted with informants. Models allowed the identification of patterns of life trajectories. Results: Overall, the burden of adversity was similar across the life course except for the 5-9, 25-29, and 30-34 age ranges, where a significant difference appeared between genders [t-test = 2.13 (p < 0.05), 2.16 (p < 0.05) and 3.08 (p < 0.005), respectively] that seems to disadvantage women. The early adversities of violence and neglect, between 0 and 19 years old, are important for both groups. During the life course, women were more exposed to interpersonal adverse events such as being victims of negligence and violence, relational difficulties or abuse from their spouse, as well as tension with their own children. Men encountered more academic difficulties, legal entanglements and financial difficulties, and were more than three times more likely to develop an alcohol/drug abuse problem than women. Conclusions: The data suggests some gender differences in exposure to longstanding and severe life problems contributing to suicide vulnerability. For women, the continuing burden emerges from chronic interpersonal adversities, whereas, for men, the adverse events are to a larger degree socially exposed, compounded with alcohol misuse. The adversities, especially those of a public or social nature, may be witnessed by others, which should favor the detection of vulnerability over the life course, and psychosocial or mental health services should be offered and provided earlier during the life course. Yet more men die by suicide than women. Resiliency and protective factors may benefit women to a greater degree. Future research should tackle the challenge of investigating these important elements. Meanwhile, from a public health perspective, access to psychosocial and mental health services and social acceptability of seeking services should be part of an ongoing effort in all institutional structures as a way of decreasing downstream mental health problems and vulnerability to suicide.

The Role of Adolescence in Development Paths Toward Suicide: Specificities and Shaping of Adversity Trajectories

Purpose: Adolescence is a key period of transitions in the psychological, cognitive, neurobiological and relational domains, which is associated to high susceptibility to adverse life experiences. However, the way adolescent development alters life paths toward suicide remains unclear. Thereby, we aimed at testing whether and how adolescence interfered with the adversity trajectories of individuals who died by suicide. Methods: In a sample of 303 individuals who died by suicide, longitudinal Burden of Adversity ratings were derived from extensive psychological autopsies and life trajectory narrative interviews conducted with informants. Piecewise Joint Latent Class Models allowed the identification of patterns of adversity trajectories and tested the introduction of breakpoints in life-paths. Classes inferred from the optimal model were compared in terms of socio-demographics, psychopathology, and rate of different adverse life events. Results: The most accurate model derived 2 trajectory patterns with a breakpoint in early adolescence. In the first class (n = 39), the burden of adversity increased steadily from birth to death, which occurred at 23 (SE = 1.29). In the second class (n = 264), where individuals died at 43 years of age (SE = 0.96), the burden of adversity followed a similar trajectory during infancy but stabilized between 10 and 14 years and started to increase again at about 25. Childhood family instability, dependent events, exposure to suicide, intra-family sexual victimization and affective disorders at death were more frequent in class 1. Conclusions: A bifurcation in trajectories between early and late suicides occurs during adolescence. The dynamic pattern of adversity during this period is a key issue to understand the developmental heterogeneity in suicide risk.

Depression and alcohol use disorders as precursors to death by suicide

The combined presence of depression with alcohol abuse can increase suicide risk. We used psychological autopsy to evaluate 101 individuals who died by suicide, to understand relationships between stressful life events, alcohol abuse, and depression. As compared to suicidal adults with depression only, individuals meeting criteria for both a depressive disorder and alcohol use disorder tended to be younger and experienced higher rates of stressful life events during the six months prior to death. Alcohol abuse likely influences interpersonal conflict, financial distress, and legal problems. Interventions focusing on managing life problems may help to reduce suicide risk.

Acute stressors and clinical characteristics differentiate death by suicide, accident, or natural causes among illicit and prescription opiate users

BACKGROUND

Opiate misuse has reached epidemic levels. Prevention efforts depend on distinguishing opiate users from abusers. The current study compared opioid users who died by natural cases, accidents, and suicide using psychological autopsy methods. Groups were compared on substance use characteristics, treatment history, experiences of negative life events, and circumstances at the time of death.

METHODS

Substance use and suicide risk were evaluated using psychological autopsy methods in 63 decedents with positive toxicology for opiates at death divided into three groups: adults dying by suicide (n = 19), accident (n = 19), and natural causes (n = 25). Groups were compared on several dependent measures, using chi-square analyses to examine categorical variables and one-way analyses of variance (ANOVA) to examine continuous variables.

RESULTS

Individuals who died by suicide were similar in many ways to adults who died by an accidental overdose. However, suicide completers were more likely to have struggled with severe depression, and previously attempted suicide, whereas the accidental overdose sample was more likely to display a chronic pattern of severe drug abuse.

CONCLUSIONS

The current study helps to distinguish between opiate users who are at risk for death by an accidental or intentional overdose. In the ongoing opiate crisis, clinicians must understand the risk of overdose and the nuances of accidental behaviors compared to purposeful ones. Signs of suicidal planning, relevant psychopathology, and ongoing life stress may be useful points of intervention for stopping the increasing number of deaths among opiate users.

Are school difficulties an early sign for mental disorder diagnosis and suicide prevention? A comparative study of individuals who died by suicide and control group

BACKGROUND

Suicide is the third leading cause of death worldwide among youth aged 10- to 19, and mental disorders are often associated in the etiology of suicidal behavior. Mental disorders are often under-diagnosed and under-treated in young people, a situation likely to increase the severity of the disorder and suicide risk. Presence of school difficulties may, in some cases, be a consequence of mental disorder, and theses difficulties are observable. Therefore, early detection and early intervention of school difficulties may alleviate the development of mental disorders and suicide vulnerability. The aim of this study is to understand the link between school difficulties and suicide risk.

METHODS

We used the data bank gathered by the McGill Group on Suicide Studies over the past two decades through interviews with the relatives of individuals who died by suicide and with individuals from the community as a control group. We included data on common sociodemographic characteristics, life events and mental health characteristics identified before age 18, among individuals who died before the age of 35 or were interviewed before the age of 35. We identified 200 individuals who died by suicide and 97 living controls. We compared groups according to gender and characteristics.

RESULTS

Within the total sample, 74% were male, 13% had met with academic failure, 18% had engaged in inappropriate behavior at school, and 18% presented combined school difficulties. Combined school difficulties (academic failure and inappropriate behavior) for both sexes and academic failure alone for males were associated with higher suicide risk before the age of 35. School difficulties generally began in early childhood and were linked to mental disorders/difficulties and substance abuse before age 18.

CONCLUSIONS

This study underlines the importance for parents, teachers, and educators to identify children with school difficulties-academic failure and behavioral difficulties at school-as early as possible in order to be able to propose adapted interventions. Early identification and proper diagnosis may prevent chronicity of some disorders, accumulation of adverse events, and even suicide.

Risk-taking behaviors and stressors differentially predict suicidal preparation, non-fatal suicide attempts, and suicide deaths

Negative life events are elevated in suicidal populations. Diathesis-stress and kindling effects models suggest different mechanisms by which negative life events increase suicide risk. Different forms of negative life events - risk-taking behaviors and stressors - may have different effects on non-fatal suicide attempts and suicide. We assessed the effects of risk-taking behaviors and stressors on suicide, history of non-fatal suicide attempts, and active preparation for suicide in a sample of adults who died by suicide or other causes (N = 377). Psychological autopsy procedures using family member interviews and collateral record review were used to complete a risk-taking behaviors composite measure from the Structured Interview for DSM-IV Personality Disorders, the Modified Life Experiences Scale, and the planning subscale of the Suicide Intent Scale. Stressors were significantly associated with death by suicide, even when accounting for demographic and diagnostic characteristics. Risk-taking behaviors were significantly associated with non-fatal suicide attempts, even when accounting for demographic and diagnostic characteristics. Suicide decedents who did not actively prepare for suicide showed significantly higher risk-taking scores than suicide decedents who actively planned for suicide. Our results suggest that risk-taking behaviors and stressors impact suicide risk through separate mechanisms. Risk-taking behaviors may represent a longstanding vulnerability to act impulsively on suicidal thoughts. Stressors may impact risk for fatal suicidal behaviors in mood disordered populations.

Individual versus group female-specific cognitive behavior therapy for alcohol use disorder

OBJECTIVES

To test group-based Female-Specific Cognitive Behavioral Therapy (G-FS-CBT) for women with Alcohol Use Disorder (AUD) against an individual Female-Specific Cognitive Behavioral Therapy (I-FS-CBT). This aims of this paper are to describe G-FS-CBT development, content, feasibility, acceptability, group process, engagement in treatment, and within- and post-treatment outcomes.

METHODS

Women with AUD (n=155) were randomly assigned to 12 manual-guided sessions of G-FS-CBT or I-FS-CBT; 138 women attended at least one treatment session.

RESULTS

Women in G-FS-CBT attended fewer sessions (M=7.6) than women in I-FS-CBT (M=9.7; p<.001). Women in both conditions reported high satisfaction with the treatments. Independent coders rated high fidelity of delivery of both G-FS-CBT and I-FS-CBT. Therapeutic alliance with the therapist was high in both conditions, with I-FS-CBT being slightly but significantly higher than G-FS-CBT. In the first six weeks of treatment, women in both treatment conditions significantly reduced their percent drinking days (PDD) and percent heavy days drinking (PHD) by equivalent amounts, maintained through the rest of treatment and the 12month follow up with no treatment condition effects. Women reported significant improvement in all but one of the secondary outcomes during treatment; gains made during treatment in depression, anxiety, autonomy, and interpersonal problems were maintained during the follow-up period, while gains made during treatment in use of coping skills, self-efficacy for abstinence, self-care, and sociotropy deteriorated over follow up but remained improved compared to baseline.

CONCLUSIONS

Findings support the feasibility, acceptability, and efficacy of a group format for female-specific CBT for AUD, a new 12-session, single gender, community friendly, group therapy with programming specifically for women. Similar, positive outcomes for individual and group treatment formats were found for drinking, mood, coping skills, self-confidence, interpersonal functioning, and self-care.

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 Role of Perceived Burden and Social Support in Suicide and Depression

In a sample of 114 military veterans with depression histories, perceived burden was related to depression symptoms and suicide attempt history. After accounting for perceived burden, sense of belonging was negatively related to depression. Among the areas of social support, family support was inversely related to both depression and suicide history. After accounting for family support, personal meaning from relationships and friend support were related to depression. The results of this study suggest that perceived burdensomeness may be a stronger determinant of suicidality than sense of belonging or social support. This study highlights the contribution of perceived burdensomeness to suicide and 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.

Temperament and Character Profiles of Group-Based Suicide Cases

Abstract. Background: Personality and character traits may be a key predisposing factor to consider in the life course of people who are vulnerable to suicide. Aims: The aim of this study is first to explore the possible presence of different subgroups of suicide decedents based on developmental profiles of adversity, and secondly to examine the association of personality and character dimensions (covariates) with the trajectory outcome. Method: A total of 90 cases of suicide decedents were analyzed using growth mixture modeling (GMM). Results: Results generated two different life trajectories and identified specific temperament profiles. Subjects assigned to the trajectory of high burden of adversity demonstrated a greater predisposition for harm avoidance and those in the trajectory characterized by low burden of adversity displayed greater predisposition for self-directedness. Conclusion: Our results add to the literature by suggesting that different subgroups of suicide completers show a predisposition for either harm avoidance or self-directedness.

Pathways to Suicide in Australian Farmers: A Life Chart Analysis

Farmers have been found to be at increased risk of suicide in Australia. The Interpersonal-Psychological Theory of Suicidal Behaviour suggests that the proximal factors leading to the suicidal desire or ideation include an individual’s experiences of both perceived burdensomeness and thwarted belongingness. Suicidal desire with acquired capability to engage in lethal self-injury is predictive of suicidal behaviour. This study investigates the pathways to suicide of 18 Australian male farmers in order to understand the suicidal process and antecedents to suicide in Australian male farmers. The psychological autopsy (PA) method was used to generate life charts. Two pathways with distinct suicidal processes were identified: acute situational (romantic relationship problems and financial concerns/pending retirement) and protracted (long-term psychiatric disorder). Long working hours, interpersonal conflicts, physical illnesses and pain, alcohol abuse, access to firearms, and exposure to drought were additional common factors identified. An understanding of the interrelatedness of diverse distal and proximal risk factors on suicidal pathways in the wider environmental context for male farmers is required when developing and implementing rural suicide prevention activities.

Factors Related to Suicide in LGBT Populations

Abstract. Background: There is evidence of heightened vulnerability to nonfatal suicidal behaviors among LGBT populations yet a paucity of studies into fatal behaviors. Aim: The specific aim of this article was to identify factors related to suicide in LGBT individuals in Australia. Method: The psychological autopsy (PA) method with a matched case-control study design was used. PA interviews were conducted with 27 next-of-kin of an LGBT person that had died by suicide. Three living LGBT controls per suicide case, matched by age and gender, were also interviewed. Results: The key factors relating to suicide in LGBT people were a lack of acceptance by family and self (reflected in higher internalized homophobia and shame), negative feelings about own sexuality/gender, and dissatisfaction with appearance. LGBT people who died by suicide also tended to go through coming out milestones 2 years earlier than controls. There was a higher prevalence of aggressive behaviors and a more predominant history of physical and sexual abuse. Additionally, there was greater incidence of depression and anxiety and alcohol and substance use disorders. Conclusion: Specific predictive factors for suicide in LGBT populations in Australia were identified, including significantly poorer mental health outcomes and more violence across an array of measures.

Too Much to Bear: Psychometric Evidence Supporting the Perceived Burdensomeness Scale

BACKGROUND

People who feel they have become a burden on others may become susceptible to suicidal ideation. When people no longer feel capable or productive, they may assume that friends and family members would be better off without them.

AIM

The present study was designed to assess preliminary psychometric properties of a new measure, the Perceived Burdensomeness (PBS) Scale.

METHOD

Depressed psychiatric patients (N = 173) were recruited from a veterans affairs medical center. Patients were assessed with a structured diagnostic interview and self-report measures assessing perceived burdensomeness, depression severity, hopelessness, and suicidal ideation.

RESULTS

The present study supported preliminary evidence of reliability and concurrent validity of the PBS. Additionally, perceived burdensomeness was significantly associated with higher levels of hopelessness and suicidal ideation.

CONCLUSION

It is hoped that with the aid of the PBS clinicians may be able to intervene more specifically in the treatment of suicidality.

Suicide Among Inuit: Results From a Large, Epidemiologically Representative Follow-Back Study in Nunavut

OBJECTIVE

The Inuit population in Canada's North has suffered from high rates of death by suicide. We report on the first large-scale, controlled, epidemiologically representative study of deaths by suicide in an Indigenous population, which investigates risk factors for suicide among all Inuit across Nunavut who died by suicide during a 4-year period.

METHODS

We identified all suicides by Inuit (n = 120) that occurred between January 1, 2003, and December 31, 2006, in Nunavut. For each subject, we selected a community-matched control subject. We used proxy-based procedures and conducted structured interviews with informants to obtain life histories, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I and II diagnoses, and measures of impulsive and (or) aggressive traits.

RESULTS

Compared with control subjects, subjects who died by suicide were more likely to have experienced childhood abuse (OR 2.38; 95% CI 1.39 to 4.08), have family histories of major depressive disorder (P = 0.002) and suicide completion (P = 0.02), and have been affected by major depressive disorder (OR 13.00; 95% CI 6.20 to 27.25), alcohol dependence (OR 2.90; 95% CI 1.59 to 5.24), or cannabis dependence (OR 3.96; 95% CI 2.29 to 6.8) in the last 6 months. In addition, subjects who died by suicide were more likely to have been affected with cluster B personality disorders (OR 10.18; 95% CI 3.34 to 30.80) and had higher scores of impulsive and aggressive traits (P < 0.001).

CONCLUSIONS

At the individual level, clinical risk factors for suicide among Inuit are similar to those observed in studies with the general population, and indicate a need for improved access to mental health services. The high rate of mental health problems among control subjects suggests the need for population-level mental health promotion.

The enzymatic activities of brain catechol-O-methyltransferase (COMT) and methionine sulphoxide reductase are correlated in a COMT Val/Met allele-dependent fashion

AIMS

The enzyme catechol-O-methyltransferase (COMT) plays a primary role in the metabolism of catecholamine neurotransmitters and is implicated in the modulation of cognitive and emotional responses. The best characterized single nucleotide polymorphism (SNP) of the COMT gene consists of a valine (Val)-to-methionine (Met) substitution at codon 108/158. The Met-containing variant confers a marked reduction in COMT catalytic activity. We recently showed that the activity of recombinant COMT is positively regulated by the enzyme Met sulphoxide reductase (MSR), which counters the oxidation of Met residues of proteins. The current study was designed to assess whether brain COMT activity may be correlated to MSR in an allele-dependent fashion.

METHODS

COMT and MSR activities were measured from post-mortem samples of prefrontal cortices, striata and cerebella of 32 subjects by using catechol and dabsyl-Met sulphoxide as substrates, respectively. Allelic discrimination of COMT Val(108/185) Met SNP was performed using the Taqman 5'nuclease assay.

RESULTS

Our studies revealed that, in homozygous carriers of Met, but not Val alleles, the activity of COMT and MSR was significantly correlated throughout all tested brain regions.

CONCLUSION

These results suggest that the reduced enzymatic activity of Met-containing COMT may be secondary to Met sulphoxidation and point to MSR as a key molecular determinant for the modulation of COMT activity.

Reliability of ADDIS for diagnoses of substance use disorders according to ICD-10, DSM-IV and DSM-5: test-retest and inter-item consistency

Background

This study investigates test-retest and inter-item consistency of Alcohol Drog Diagnos InStrument (ADDIS), a structured interview to diagnose substance use disorders according to ICD-10, DSM-IV and DSM-5. ADDIS, the Swedish version of SUDDS, is the only instrument in Swedish that produces diagnostic proposals specific to all drug categories, and for all three diagnostic systems. Screening of stressful life events, anxiety, and depression is also included.

Methods

Thirty patients at addiction treatment facilities were interviewed for diagnostic assessment and re-interviewed after one week.

Results

ADDIS has excellent internal consistency. There is also very high test-retest correlation on number of fulfilled criteria for all diagnostic systems. Agreement of diagnostic proposals is substantial, mean absolute agreement is excellent, and mean systematic correlation is almost perfect.

Conclusion

ADDIS is a reliable tool for specific diagnostic assessment of SUDs.

Service use and unmet needs in youth suicide: a study of trajectories

OBJECTIVE

While 90% of suicide victims have suffered from mental health disorders, less than one-half are in contact with a mental health professional in the year preceding their death. Service use in the last year of life of young suicide victims and control subjects was studied in Quebec. We wanted to determine what kinds of health care services were needed and if they were actually received by suicide victims.

METHOD

We recruited 67 consecutive suicide victims and 56 matched living control subjects (aged 25 years and younger). We evaluated subjects' psychopathological profile and determined which services would have been indicated by conducting a needs assessment. We then compared this with what services were actually received.

RESULTS

Suicide victims were more likely than living control subjects to have a psychiatric diagnosis. They were most in need of services to address substance use disorder, depression, interpersonal distress, and suicide-related problems. There were significant deficits in the domains of coordination and continuity of care, mental health promotion and training, and governance.

CONCLUSIONS

Our results show that we need to urgently take action to address these identified deficits to prevent further loss of life in our young people.

Developmental model of suicide trajectories

BACKGROUND

Most developmental studies on suicide do not take into account individual variations in suicide trajectories.

AIMS

Using a life course approach, this study explores developmental models of suicide trajectories.

METHOD

Two hundred and fourteen suicides were assessed with mixed methods. Statistical analysis using combined discrete-time survival (DTS) and growth mixture modelling (GMM) generated various trajectories, and path analysis (Mplus) identified exogenous and mediating variables associated with these trajectories.

RESULTS

Two groups share common risk factors, and independently of these major risk factors, they have different developmental trajectories: the first group experienced a high burden of adversity and died by suicide in their early 20s; and the second group experienced a somewhat moderate or low burden of adversity before they took their own life. Structural equation modelling identified variables specific to the early suicide trajectory: conduct and behavioural difficulties, social isolation/conflicts mediated by school-related difficulties, the end of a love relationship, and previous suicide attempts.

CONCLUSIONS

Psychosocial adversity between 10 and 20 years of age may warrant key periods of intervention.

PERSONALITY DISORDERS AND THE PREDICTION OF ALCOHOL USE OUTCOMES FOR WOMEN: DIMENSIONAL VERSUS CATEGORICAL CLASSIFICATION

The impending shift in DSM-5 from categorical to a hybrid categorical-dimensional diagnosis scheme has generated considerable interest in the relative merits of these respective approaches. This is particularly true for the diagnostically complex category of personality disorders (PDs). The present study assessed whether categorical or dimensional measures better predicted alcohol consumption in a sample of 102 women enrolled in a clinical trial comparing individual Cognitive Behavioral Therapy (CBT) to conjoint CBT for alcohol use disorders (AUD). Linear regression was used to evaluate whether each PD diagnosis (categorical), or the number of PD symptoms endorsed per PD (dimensional) better predicted percent days drinking over the course of six months of treatment. PD criteria (dimensional) better predicted drinking for Paranoid, Borderline, and Obsessive-Compulsive PDs, while diagnosis (categorical) was a better predictor only for Passive-Aggressive PD. Both schemes predicted drinking outcomes for Avoidant, Dependent, and Depressive PDs, and neither was predictive for Narcissistic PD. These findings suggest that the addition of a dimensional approach for PDs potentially enhances the prediction of alcohol use outcomes.

Neither too much, nor too little. The dilemma of identifying personality disorders in adolescents patients with self-reports

The study aimed to compare methods of identification of Personality Disorders (PD) in adolescent patients with psychiatric disorders. A sample of 120 Spanish adolescents with clinical disorders was assessed using the International Personality Disorder Examination (IPDE) interview, its Screening Questionnaires (IPDE-SQ) comprising the ICD-10 and DSM-IV modules, and also the Temperament Character Inventory (TCI) to identify risk of PD. The IPDE-SQ identified a risk of PD around 92-97% of the sample; 61.7% when adjusting the stricter cut-off points. The TCI showed a PD risk of 20%, whereas the prevalence of PD identified by the IPDE clinical interview was around 36-38%. The differences between the IPDE, IPDE-SQ and TCI were significant, and a low agreement among instruments was obtained. Large discrepancy between self-report instruments in identifying PD with regard to the clinical interview raises several questions concerning the use of these instruments in clinical settings on adolescents with psychiatric disorders.

Contacts with health professionals before suicide: missed opportunities for prevention?

AIM

This study aims to examine contacts with different health professionals in the three months prior to death in suicide cases compared to sudden death controls; and, to analyse contacts with health professionals among people who died by suicide having a diagnosable mental health disorder at the time of suicide compared to those who did not have such a diagnosis within four major groups of conditions.

METHODS

The psychological autopsy method was utilised to investigate suicides of individuals over the age of 35years. A case-control study design was applied using sudden death cases as controls. Odds ratios with a 95% confidence interval were calculated.

RESULTS

In total, 261 suicides and 182 sudden deaths were involved. In terms of contacts during the last three months prior to death, 76.9% of suicides and 81.9% of sudden deaths visited a general practitioner (GP). Persons who died by suicide had significantly more frequently contacts with mental health professionals than sudden death controls did. People with a diagnosable mental health disorder at the time of suicide attended GP surgeries with approximately the same frequency of people without a diagnosis at GP level.

CONCLUSION

Similarly, approximately 90% of people who die by suicide and by sudden death seek for help from health care system, mainly from GPs in three months prior to their death. With reference to health care contacts, people who had or did not have a diagnosable psychiatric disorder are not distinguishable at the GP surgery level.

Suicides in older adults: a case-control psychological autopsy study in Australia

AIM

The present study aims to analyse predicting factors of suicide among older adults compared to sudden death controls and middle-aged suicides.

METHODS

During the period 2006-2008, at two Australian sites, the psychological autopsy method was utilised to investigate suicides of individuals over the age of 35 by interviewing next-of-kin and healthcare professionals. A case-control study design was applied using sudden death cases as controls. Initial information was gathered from coroner's offices. Potential informants were approached and interviews were conducted using a semi-structured format.

RESULTS

In total, 261 suicides (73 aged 60+) and 182 sudden deaths (79 aged 60+) were involved. Older adult suicides showed a significantly lower prevalence of psychiatric diagnoses (62%) when compared to middle-aged suicide cases (80%). In both age groups, subjects who died by suicide were significantly more likely to present a psychiatric diagnosis, compared to controls; however, diagnosis did not remain in the final prediction model for older adults. Hopelessness and past suicide attempts remained in the final model for both age groups. In addition, living alone was an important predictor of suicide in older adults.

CONCLUSION

Although mood disorders represent an important target for suicide prevention in old age, there should be increased attention for other risk factors including psychosocial, environmental, and general health aspects of late life.

Women's motivators for seeking treatment for alcohol use disorders

This study examined types of internal and external motivations for seeking treatment and the predictive utility of different types of motivation among 180 women with an alcohol use disorder (AUD) participating in a two-armed trial testing different individual and couple therapies for AUDs. Reasons for seeking treatment were coded for type of internal or external motivation. Most women (97%) cited internal reasons for seeking help, including: concern about progression of AUD (61.1%), health (43.3%), mental health (38.9%), and family (38.3%). Occupational concerns, an internal motivator cited by 6% of women, were associated with better drinking outcomes; interpersonal-family concerns were associated with poorer outcomes. Some motivators for seeking treatment may not be related to sustained changes in drinking, suggesting that understanding motivators for treatment may be inadequate to maintain change. Reasons for help-seeking may need to be addressed in treatment to produce long-lasting change.

A psychological autopsy study of suicide among Inuit in Nunavut: methodological and ethical considerations, feasibility and acceptability

INTRODUCTION

The increasing global prevalence of suicide has made it a major public health concern. Research designed to retrospectively study suicide cases is now being conducted in populations around the world. This field of research is especially crucial in Aboriginal populations, as they often have higher suicide rates than the rest of the country.

OBJECTIVE

This article presents the methodological aspects of the first psychological autopsy study on suicide among Inuit in Nunavut. Qaujivallianiq Inuusirijauvalauqtunik (Learning from lives that have been lived) is a large case-control study, including all 120 cases of suicide by Inuit that occurred in Nunavut between 1 January 2003 and 31 December 2006. The article describes the research design, ethical considerations and strategies used to adapt the psychological autopsy method to Nunavut Inuit. Specifically, we present local social and cultural issues; data collection procedures; and the acceptability, reliability and validity of the method.

METHOD

A retrospective case-control study using the psychological autopsy approach was carried out in 22 communities in Nunavut. A total of 498 individuals were directly interviewed, and medical and correctional charts were also reviewed.

RESULTS

The psychological autopsy method was well received by participants as they appreciated the opportunity to discuss the loss of a family member or friend by suicide. During interviews, informants readily identified symptoms of psychiatric disorders, although culture-specific rather than clinical explanations were sometimes provided. Results suggest that the psychological autopsy method can be effectively used in Inuit populations.

Concordance of psychiatric symptom ratings between a subject and informant, relevancy to post-mortem research

Investigators are interested in determining whether lifetime behavioral traits and specific mood states experienced close to death affect brain gene and protein expression as assessed in post-mortem human brains. Major obstacles to conducting this type of research are the uncertain reliability of the post-mortem psychiatric diagnoses and clinical information because of the retrospective nature of the information. In this study, we addressed the concordance of clinical information obtained through an informant compared with information obtained through a clinician interview of the subject. To test this, we measured both lifetime and within the week psychiatric symptoms of subjects (n=20) and an informant, their next-of-kin (n=20) who were asked identical questions. We found Diagnostic and Statistical Manual (DSM)-IV axis 1 diagnoses by Mini-International Neuropsychiatric Interview proportion of positive agreement for major depression was 0.97, bipolar disorder was 0.81, whereas proportion of negative agreement was 0.97 for schizophrenia. Symptom scale intra-class correlation coefficients and 95% confidence interval were: Bipolar Inventory of Signs and Symptoms=0.59 (0.23, 0.81), Brief Psychiatric Rating Scale=0.58 (0.19, 0.81), Hamilton Depression Rating Scale=0.44 (0.03, 0.72), Montgomery Asberg Depression Rating Scale=0.44 (0.03, 0.72), Young Mania Rating Scale=0.61 (0.30, 0.82), Barratt Impulsiveness Score=0.36 (-0.11, 0.70) and Childhood Trauma Questionnaire=0.48 (-0.15, 0.83). We show that DSM-IV diagnoses; lifetime impulsivity severity, childhood trauma score and symptom scores were significantly consistent between the subjects and their informants. These data suggest, with some limitations, that both retrospective and informant obtained information can provide useful clinical information in post-mortem research.

Psychological autopsy studies as diagnostic tools: are they methodologically flawed?

One of the most established "truths" in suicidology is that almost all (90% or more) of those who kill themselves suffer from one or more mental disorders, and a causal link between the two is implied. Psychological autopsy (PA) studies constitute one main evidence base for this conclusion. However, there has been little reflection on the reliability and validity of this method. For example, psychiatric diagnoses are assigned to people who have died by suicide by interviewing a few of the relatives and/or friends, often many years after the suicide. In this article, we scrutinize PA studies with particular focus on the diagnostic process and demonstrate that they cannot constitute a valid evidence base for a strong relationship between mental disorders and suicide. We show that most questions asked to assign a diagnosis are impossible to answer reliably by proxies, and thus, one cannot validly make conclusions. Thus, as a diagnostic tool psychological autopsies should now be abandoned. Instead, we recommend qualitative approaches focusing on the understanding of suicide beyond mental disorders, where narratives from a relatively high number of informants around each suicide are systematically analyzed in terms of the informants' relationships with the deceased.

What do women want? Alcohol treatment choices, treatment entry and retention

Study aims were to assess preferences for individual or conjoint treatment, differences between women with alcohol use disorders (AUDs) selecting each modality, and the impact on treatment entry and retention of providing a choice of treatments. During initial screening, women with AUDs in an intimate relationship with a male partner were given the choice of individual or conjoint treatment. After choosing a treatment modality and completing all assessments they entered one of two randomized trials testing different approaches to each treatment modality. Standardized measures were used to assess drinking quantity, frequency, and problems; motivation to change; and relationship satisfaction. Women's reasons for choice of treatment modality were coded using an iterative coding process. Results showed that women were more likely to select and follow through with individual than conjoint treatment. Women cited a desire to work on individual problems, lack of perceived support from their partner, and logistical issues as reasons for preferring individual treatment. Women in the two choice groups did not differ significantly on individual, partner, or relationship characteristics, but small to medium effect sizes suggested that women choosing individual treatment were more educated and less satisfied with their relationship, had fewer pretreatment heavy drinking days, and heavier drinking partners. Offering women a choice of treatment modality increased the probability of entering treatment, but not treatment attendance. Results suggest that barriers to couple therapy for women with AUDs need to be addressed to facilitate more widespread dissemination. Given women's preferences, it also is important to offer a range of treatments.

Impact of employment status and work-related factors on risk of completed suicide. A case-control psychological autopsy study

The objective of this study was to determine the impact of work-related factors on risk for completed suicide. Psychiatric disorders and socio-demographic factors including work-related factors were assessed by a semi-structured interview using the psychological autopsy method in 163 completed suicide cases and by personal interview in 396 living population-based control persons. Unemployment (in particular, for more than six months), (early) retirement, or homemaker status were associated with highly significantly increased suicide risk, independently of categorized psychiatric diagnosis. In addition, adverse psychosocial working conditions, such as monotonous work, increased responsibility and pronounced mental strain due to contact with work clients, significantly increased suicide risk as well, again independently of categorized psychiatric diagnosis. These findings demonstrate that negative consequences of unemployment, homemaker status with no outside occupation, or (early) retirement, as well as adverse psychosocial working conditions, present relevant risk factors contributing to suicidal behavior, independently of diagnosed psychiatric disorders. Employment and a positive modification of working conditions, may possibly be preventive to important adverse mental health outcomes, including suicidality.

The European Psychiatric Association (EPA) guidance on suicide treatment and prevention

Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. SUICIDAL CRISIS: Acute intervention should start immediately in order to keep the patient alive.

DIAGNOSIS

An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential.

TREATMENT

Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. Treatment with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. Treatment with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. TREATMENT TEAM: Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. FAMILY: The suicidal person independently of age should always be motivated to involve family in the treatment. SOCIAL SUPPORT: Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks.

SAFETY

A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. TRAINING OF PERSONNEL: Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.

The next generation of psychological autopsy studies. Part I. Interview content

The psychological autopsy (PA) is a systematic method to understand the psychological and contextual circumstances preceding suicide. The method requires interviews with one or more proxy respondents (i.e., informants) of decedents. The methodological challenges that need to be addressed when determining the content of these research interviews for PA studies are described and recommendations are made for meeting these challenges in future PA investigations. Ways to improve the data collected about mental disorders and life events--domains that are assessed in almost all PA studies--are discussed at length. Other understudied content areas considered include the role of personality traits, medical illness and functional limitations, availability of lethal agents, medications, and select distal variables including child maltreatment and family history of mental disorders and suicide. The benefits and challenges to using common protocols across studies are also discussed.

Youth and young adult suicide: a study of life trajectory

OBJECTIVES

Explore the unique developmental challenges and early adversity faced by youth and young adult who died of suicide.

METHOD

Sixty-seven suicide victims (SG) were compared with 56 living control with no suicidal ideations in the last year, matched for age, gender, and geographical region. Mixed methods were used: consensus DSM-IV diagnoses were formulated based on Structured Clinical Interview for DSM-IV (SCID)-I and -II interviews complemented by medical charts. Life calendar method was conducted with closest third party informant. Life-history calendar served to measure life events and adversity throughout the life course and were analyzed by attributing burden of adversity score per five-year segment, which was then cluster-analyzed to define suicide victim profiles.

RESULTS

During the last year, mood disorders, abuse and dependence disorders, and anxiety disorder were between 8 and 63 times more likely to be present in the suicide group. Between 0 and 4 years old, 50% of children in the SG were exposed to abuse, physical and/or sexual violence; 60% between 5 and 9 years old; and by the time they were 10-14 years old, 77% were exposed to these forms of violence. In the control group, the respective figures were 14%, 18% and 34%. In the suicide group, the trajectories leading to suicide are different as we observe two different subgroups, one with early-onset and one with later-onset of adversity. To a large extent, people in the suicide group were exposed to major adversity and they were more likely to present cumulative comorbid disorders.

Relationships of suicide ideation with cause-specific mortality in a longitudinal study of South Koreans

Using 7-year mortality follow-up data (n = 341) from the 1998 National Health and Nutrition Examination Surveys of South Korean individuals (N = 5,414), the authors found that survey participants with suicide ideation were at increased risk of suicide mortality during the follow-up period compared with those without suicide ideation. The cause-specific analyses showed that, in men, suicide ideation was significantly associated with mortality due to cardiovascular disease, external causes, and other causes. However, there was no significant association between suicide ideation and cause-specific mortality in women. The relationship between suicide ideation and cause-specific mortality in men was not fully explained by baseline health status, socioeconomic status, health behavior, or psychosocial factors.

Development of the Screener for Assessing Depression Scale: Why do we need another depression scale?*

Abstract Depression is a significant problem which affects the lives of a substantial number of people. Improved recognition of depression is an important step towards the treatment and prevention of depression. Objective. The present study examined the reliability and validity of the Screener for Assessing Depression (SAD) Scale as a measure of depression severity and as a confirmation of a major depressive episode. Method. The sample included 100 adults who were receiving inpatient psychiatric treatment (60 met criteria for a major depressive disorder and 40 met criteria for other psychological disorders without depression as a main feature). Results. Different cut-off scores were proposed in order to score the SAD Scale as a screening measure or to confirm a depressive episode. Scoring the SAD Scale according to the criteria for a major depressive episode correctly classified 87% of the sample. Conclusion. Overall, the results indicated that the SAD Scale is a reliable and valid measure for detecting a depressive episode and for assessing depression severity.

Validity of Proxy-Based Reports of Impulsivity and Aggression in Chinese Research on Suicidal Behavior

Background: In studies about the risk factors for suicidal behavior, the assessment of impulsiveness and aggression often depend on information from proxy informants. Aims: To assess the validity of proxy informants’ reports on impulsiveness and aggression in China. Methods: Modified Chinese versions of the Barratt Impulsiveness Scale (BIS-CV) and the Buss-Perry Aggression Questionnaire (AQ-CV) were administered to 131 suicide attempters treated at a hospital in rural China, to coresident relatives about the attempters, to 131 matched community controls, and to coresident relatives about the controls. Results: BIS-CV and AQ-CV total scores and subscale scores were all significantly higher for suicide attempters than for matched controls. Proxy informants considered subjects slightly more impulsive and aggressive than the subjects reported themselves. Subject-proxy concordance for total BIS-CV and AQ-CV scores were excellent for both attempters and controls (ICCs = 0.76–0.83). Concordance for the three BIS-CV subscales was 0.74–0.81 for attempters and 0.74–0.83 for controls. Concordance for the five AQ-CV subscales was 0.66–0.85 for attempters and 0.56–0.82 for controls. Limitations: Results are based on respondents from a single location in rural China. Conclusions: The results support the validity of the BIS-CV and AQ-CV and of research on suicidal behavior in China that uses proxy-based reports of impulsiveness and aggression.

A randomized trial of individual and couple behavioral alcohol treatment for women

Although alcohol use disorders (AUDs) adversely affect women, research on efficacious treatments for women is limited. In this randomized efficacy trial of 102 heterosexual women with AUDs, the authors compared alcohol behavioral couple therapy (ABCT) and alcohol behavioral individual therapy (ABIT) on percentage of days abstinent (PDA) and percentage of days of heavy drinking (PDH) over 6 months of treatment and 12 months of posttreatment follow-up. Baseline relationship functioning and comorbid disorders were tested as moderators of outcome. Piecewise linear growth models were used to model outcomes. During treatment, women increased their PDA and decreased their PDH, with significantly greater improvements in ABCT than in ABIT (d = 0.59 for PDA; d = 0.79 for PDH). Differences favoring ABCT were maintained during follow-up. Women with poorer baseline relationship functioning improved more on PDA during treatment with ABCT than with ABIT. For PDH, results during treatment and follow-up favored ABCT for women with better baseline relationship functioning. ABCT resulted in better outcomes than ABIT for women with Axis I disorders at the end of follow-up (PDA), and for women with Axis II disorders at the end of treatment (PDA) and at the end of follow-up (PDH).

Substance use disorders as risk factors for suicide in an Eastern and a Central European city (Tallinn and Frankfurt/Main)

Cultural and regional differences on the well-known elevated suicide risk in substance use disorders have not been clarified yet. Therefore, the suicide risk associated with substance use disorders in a society of transition and in a socially and economically stable society should be identified and compared. Data from two population-based matched case-control studies were used to analyse the association between alcohol and other substance consumption and the risk of suicide. Data in Frankfurt were obtained by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) in 163 suicides that occurred in 1999 and 2000, and data from Tallinn were collected according to DSM-IV criteria on 156 deceased persons who committed suicide in 1999 by using the psychological autopsy method and in each city in matched population-based control persons by personal interview. In both cities, substance use disorders were significantly associated with suicide. Odds ratios for suicide were higher in Tallinn than in Frankfurt. The highest risk was observed in Tallinn among men with alcohol use disorders, aged 35 to 59 years. Although substance use and, in particular, alcohol use disorders were confirmed as risk factors for suicide in Tallinn and in Frankfurt, the much higher suicide risk associated with alcoholism in Tallinn than in Frankfurt indicates the importance of cultural, socio-political, and regional impact of suicide risk in alcoholism.

Smoking differently modifies suicide risk of affective disorders, substance use disorders, and social factors

BACKGROUND

Although an association between smoking and suicide has repeatedly been shown, information about a modifying influence of smoking on other risk factors for suicide is lacking.

METHODS

Axis I and Axis II disorders, sociodemographic factors, and tobacco use were assessed by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) and Personality Disorders (SCID-II) in 163 suicides (mean age 49.6+/-19.3 years; 64.4% men;) by psychological autopsy method and by personal interview in 396 living population-based control persons (mean age 51.6+/-17.0 years; 55.8% men).

RESULTS

Smoking status (current smokers, lifetime non-smokers, and former smokers) differently modifies the effects of psychiatric disorders and sociodemographic variables on suicide risk. Former and current smoking modified suicide risk associated with affective disorders, but only current smoking increased suicide risk for substance use disorders. Ex-smokers with affective disorders, particularly with major depression, had less increased suicide risk than current smokers and non-smokers with affective disorders. Estimated suicide risks for personality disorders and 'no professional training' were strongly increased by smoking.

LIMITATIONS

Due to the small size of some of the subgroups, confidence intervals are wide. Therefore, precise risk estimation is not possible.

CONCLUSIONS

Clinicians should interpret smoking as an indicator of increased risk of suicide for individuals with substance use disorders, personality disorders, and adverse social factors. Further studies are needed to investigate the effects of smoking cessation on suicide risk of patients with psychiatric disorders such as major depression and substance use disorders.

Life trajectories and burden of adversity: mapping the developmental profiles of suicide mortality

BACKGROUND

Little is known about differential suicide profiles across the life trajectory. This study introduces the life-course method in suicide research with the aim of refining the longitudinal and cumulative assessment of psychosocial factors by quantifying accumulation of burden over time in order to delineate distinctive pathways of completed suicide.

METHOD

The psychological autopsy method was used to obtain third-party information on consecutive suicides. Life-history calendar analysis served to arrive at an adversity score per 5-year segment that was then cluster-analysed and correlated to define victim profiles.

RESULTS

Two distinct life trajectories emerged: (1) individuals who experienced childhood traumas, developmental adversity and little protection were more likely to present concurrent psychiatric and Axis II disorders; and (2) individuals who experienced less adversity but seemed more reactive to later major difficulties.

CONCLUSIONS

The life calendar approach presented here in suicide research adds to the identification of life events, distal and recent, previously associated with suicide. It also quantifies the burden of adversity over the life course, defining two distinct profiles that could benefit from distinct targeted preventive intervention.

Effect of tryptophan hydroxylase-2 gene variants on suicide risk in major depression

BACKGROUND

Suicide and depressive disorders are strongly associated, yet not all depressed patients commit suicide. Genetic factors may partly explain this difference. We investigated whether variation at the tryptophan hydroxylase-2 (TPH2) gene and its 5' upstream region may predispose to suicide in major depressive disorder (MDD) and whether this predisposition is mediated by impulsive-aggressive behaviors (IABs).

METHODS

We genotyped 14 single nucleotide polymorphisms (SNPs) in 259 depressed subjects, 114 of which committed suicide while depressed. Phenotypic assessments were carried out by means of proxy-based interviews. Single-marker and haplotype association analyses were conducted. Differences in behavioral and personality traits according to genotypic variation were investigated, as well as genetic and clinical predictors of suicide.

RESULTS

We found two upstream and two intronic SNPs associated with suicide. No direct effect of these variants was observed on IABs. However, a slight association with reward dependence scores was found. Controlling for suicide risk factors, two SNPs (rs4448731 and rs4641527) significantly predicted suicide, along with cluster B personality disorders and family history of suicide.

CONCLUSIONS

The TPH2 gene and its 5' upstream region variants may be involved in the predisposition to suicide in MDD; however, our findings do not support the role of IABs as mediators.

Critical issues in psychological autopsy studies

This paper reviews research based on the psychological autopsy (PA) method applied to the study of suicide. It evidences the presence of a number of methodological problems. Shortcomings concern sampling biases in the selection of control subjects, confounding influences of extraneous variables, and reliability of the assessment instruments. The absence of homogeneity among studies in the procedure employed, as well as the lack of defined guidelines for performing this type of inquiry are emphasized. Questions needing empirical investigation in the future are pointed out. It is concluded that the validity and reliability of findings emerging from the use of this method of investigation would benefit from a standardization of its application.

Suicide cases in New Brunswick from April 2002 to May 2003: the importance of better recognizing substance and mood disorder comorbidity

OBJECTIVE

To investigate all suicide cases that occurred in New Brunswick in the 14 months spanning April 1, 2002, to May 31, 2003, to determine 6-month and lifetime prevalence rates of psychopathology in the deceased.

METHOD

We used 2 psychological autopsy methods: direct proxy-based interviews and medical chart reviews, together with telephone contacts with informants. Consensus DSM-IV diagnoses were formulated by clinical panels on the basis of the Structured Clinical Interviews I and II for DSM-IV complemented by medical charts.

RESULTS

Of the 109 suicide deaths identified by the coroner at the time of the study, we were able to investigate 102. At time of death, 65% of the suicide victims had a mood disorder, 59% had a substance-related disorder, and 42% had concurrent mood and substance-related disorders. The lifetime prevalence of substance-related disorders among these suicide victims was 66%. Finally, 52% of the suicide victims presented with a personality disorder; one-half of these were of the cluster B type.

CONCLUSIONS

Although treatment of depression has frequently been recognized as the focal point of clinically based suicide-prevention efforts, our results underscore substance-related disorders as a key dimension of completed suicide. Suicide-prevention programs should be designed to address this problem more directly.

Axis I disorders and personality disorders as risk factors for suicide

There is a lack of psychological autopsy studies assessing the influence of axis I disorders on axis II disorders as risk factors for suicide. Therefore, we investigated the association between personality disorders, axis I disorders, and suicide. Psychiatric disorders were evaluated by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) and Personality Disorders (SCID-II) in 163 completed suicides (mean age 49.6 +/- 19.3 years; 64.4% men) and by personal interview in 396 population-based control persons (mean age 51.6 +/- 17.0 years; 55.8% men). In both genders, suicides significantly more often had personality disorders of all clusters than controls, also after adjustment for axis I disorders (p < 0.001, each). In addition, alcohol-related disorders, major depression, and co-occurrence of personality disorders of more than one cluster (men: OR = 16.13; women: OR = 20.43) remained independent predictors for suicide in both genders, "pure" cluster B personality disorders only in women and "pure" cluster C personality disorders only in men. In both genders, co-occurrence of personality disorders of more than one cluster contributed to risk of completed suicide after control for axis I psychiatric disorders and has to be considered as an independent risk factor for suicide.

Recent life events and suicide: a case-control study in Tallinn and Frankfurt

The purpose of this study was to analyze the differences in the disposition and frequency of recent life events preceding suicide in two cities with different socio-political backgrounds: Tallinn in Estonia and Frankfurt/Main in Germany. The information about 156 suicidents in Tallinn and 163 suicidents in Frankfurt was compiled using the psychological autopsy technique [Shneidman, E. S. (1981). The psychological autopsy. Suicide and Life-Threatening Behavior, 11, 325-340; Jacobs, D., & Klein-Benheim, M. (1995). The psychological autopsy: A useful tool for determining proximate causation in suicide cases. Bulletin of American Academy of Psychiatry Law, 23(2), 165-182]. General population controls were matched by age and sex. The occurrence of recent life events was similar among suicidents in Tallinn (81%) and Frankfurt (77%). However, in both sites only male suicides had higher risk of occurrence of any life event than controls (Tallinn: OR'=1.9; 95% CI=1.1-3.7; Frankfurt: OR'=2.0; 95% CI=1.0-4.1) and the mean number of life events was significantly higher among male suicidents in Tallinn in comparison with controls. This may indicate that males are more sensitive to the rapid changes in a society undergoing transition. It seems that it is not the number of life events, but rather their meaning and disposition that creates the risk of suicide. Family discord (weighted OR=4.5; 95% CI=2.5-8.1), loss of job (weighted OR=2.6; 95% CI=1.0-6.4) and financial deterioration (weighted OR=2.2; 95% CI=1.3-3.8) were more prevalent among suicides in Tallinn in comparison with those in Frankfurt. The most significant differences between suicides and controls were family discord, separation and loss of job in Tallinn and somatic illness in Frankfurt. These differences between the two societies, post-Soviet Estonia and Germany, could be explained by the different positions of Estonia and Germany on the survival/self-expression dimensions recorded by the World Value Survey. People in Estonia tend to emphasize economic and physical security above all other goals, and feel threatened by the changes taking place in society. In Germany, good health is considered a necessity for a consumer and self-expressive style of life, and poor health is perceived as a serious threat to the quality of life in a post-materialistic value system.

STin2 variant and family history of suicide as significant predictors of suicide completion in major depression

BACKGROUND

Suicide is the most serious outcome of major depression, yet not all depressed patients will commit suicide. Genes, along with other factors, might account for this difference. Serotonergic alterations have been observed in suicide and depression and impulsive-aggressive behaviors. Therefore, we aimed to identify predictors of suicide, considering genetic variation at the serotonin transporter (5-HTT) gene.

METHODS

We investigated the 5-HTT gene-linked polymorphic region (5-HTTLPR) and intron 2 (STin2) variants of this gene and their relationship to behavioral and clinical risk factors for suicide in a sample of depressed suicides (n =106) and depressed control subjects (n =152), diagnosed by means of proxy-based interviews.

RESULTS

We found a significant association of suicide completion with having at least one copy of the STin2 10 allele [chi(2)(1) = 10.833, p = .002]. No differences were found for the 5-HTTLPR variable number of tandem repeats. After controlling for behavioral and clinical risk factors for suicide, the STin2 variant remained a significant predictor of suicide in major depression when jointly considered with a family history of suicide (odds ratio 5.560, 95% confidence interval 1.057-29.247).

CONCLUSIONS

The STin2 locus might account, at least in part, for the observed familial aggregation of suicidal behavior. These results should be further explored in families where clustering of suicidal behavior is observed.