The Iowa 500: suicide in mania , depression, and schizophrenia

Association of HOMER1 rs2290639 with suicide attempts in Hong Kong Chinese and the potentially functional role of this polymorphism

OBJECTIVE

Animal evidence and genetic studies suggest that HOMER1 (homer homolog 1) is involved in the etiology of suicidal behavior and major depression disorder (MDD). However, most of genetic studies were performed in Caucasians and the potentially functional role of associated polymorphisms in HOMER1 was seldom reported. The purpose of this study was to investigate the association of a HOMER1 polymorphism rs2290639 with suicide attempts (SA) and MDD in Hong Kong Chinese, and then briefly elucidate the potentially functional role of the associated polymorphism.

METHODS

NEO personality inventory, impulsiveness and depression rating scales were completed by the subjects. The association studies of HOMER1 rs2290639 with SA or MDD were performed by case-control association studies. The bioinformatics analyses were adapted to predict potential transcription factors binding sites for the associated polymorphism.

RESULTS

The association studies and meta-analysis suggested that the HOMER1 rs2290639 was significantly associated with susceptibility to SA but seemed not to be associated with MDD in Hong Kong Chinese. This polymorphism might affect the transcription of the HOMER1 gene through interacting with a reliable transcription factor as found by three of four bioinformatics tools. In addition, close correlations between impulsiveness and NEO personality five factors were found in SA and MDD patients, which provide a possible way to assess the impulsiveness of patients through subjects' personality profiles for Hong Kong Chinese.

CONCLUSIONS

The HOMER1 rs2290639 polymorphism was significantly associated with susceptibility to SA in Hong Kong Chinese affected by psychiatric disorders, which might be explained by the potentially functional role of this polymorphism.

A comparison of correlates of suicidal ideation prior to initial hospitalization for first-episode psychosis with prior research on correlates of suicide attempts prior to initial treatment seeking

AIM

Individuals with first-episode psychosis, like those with chronic psychotic disorders, are at elevated risk for suicidal ideation and suicide attempts. However, relatively little is known about suicidality among first-episode patients prior to their initial presentation for treatment. This analysis was designed as a US-based examination of recent findings on prior suicide attempts from Dublin, Ireland, here focusing on prevalence and correlates of suicidal ideation during the weeks prior to initial treatment-seeking.

METHODS

Participants included 109 first-episode inpatients with primary psychotic disorders in public-sector settings that serve an urban, low-income, socially disadvantaged, predominantly African American population. Eligible patients had received <3 months of prior antipsychotic treatment and had not been hospitalized for psychosis >3 months prior to the index admission, though most were completely treatment naïve. Assessments included the Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, Birchwood Insight Scale, and a rigorous method for determining age at onset of first psychotic symptoms and duration of untreated psychosis.

RESULTS

Disconcertingly, nearly one quarter of patients (23%) endorsed a history of suicidal ideation in the 2 weeks prior to first admission. In the model designed to replicate the prior study in Ireland, Calgary Depression score (calculated omitting hopelessness and suicidal ideation as these were separate variables in the analysis) was a predictor of suicidal ideation (P < 0.01). In separate bivariate analyses analogous to the original study, two domains of insight were associated with suicidal ideation.

CONCLUSIONS

Findings suggest that depression, insight, and suicidality should be carefully monitored among first-episode patients initiating treatment and during the early course of illness. As insight improves, coping strategies should be enhanced with a goal of minimizing depression and preventing suicidality.

Risk and protective genetic variants in suicidal behaviour: association with SLC1A2, SLC1A3, 5-HTR1B &NTRK2 polymorphisms

Background

Suicidal behaviour is known to aggregate in families. Patients with psychiatric disorders are at higher risk for suicide attempts (SA), however protective and risk genetic variants for suicide appear to be independent of underlying psychiatric disorders. Here we investigate genetic variants in genes important for neurobiological pathways linked to suicidal behaviour and/or associated endophenotypes, for association with SA among patients with co-existing psychiatric illness. Selected gene-gene and gene-environment interactions were also tested.

Methods

DNA was obtained from bloods of 159 patients (76 suicide attempters and 83 non-attempters), who were profiled for DSM-IV Axis I psychiatric diagnosis. Twenty-eight single nucleotide polymorphisms (SNPs) from 18 candidate genes (COMT, 5-HT2A, 5-HT1A, 5-HTR1B, TPH1, MAO-A, TPH2, DBH, CNR1, BDNF, ABCG1, GABRA5, GABRG2, GABRB2, SLC1A2, SLC1A3, NTRK2, CRHR1) were genotyped. Genotyping was performed by KBioscience. Tests of association between genetic variants and SA were conducted using Chi squared and Armitage Trend tests. Binary logistical regression analyses were performed to evaluate the contribution of individual genetic variants to the prediction of SA, and to examine SNPs for potential gene-gene and gene-environment interactions.

Results

Our analysis identified 4 SNPs (rs4755404, rs2269272, rs6296 and rs1659400), which showed evidence of association with SA compared to a non-attempter control group. We provide evidence of a 3-locus gene-gene interaction, and a putative gene-environment interaction, whereby genetic variation at the NTRK2 locus may moderate the risk associated with history of childhood abuse.

Conclusion

Preliminary findings suggest that allelic variability in SLC1A2/3, 5-HTR1B and NTRK2 may be relevant to the underlying diathesis for suicidal acts.

Elucidating biological risk factors in suicide: role of protein kinase A

Suicide is a major public health concern. Although there have been several studies of suicidal behavior that focused on the roles of psychosocial and sociocultural factors, these factors are of too little predictive value to be clinically useful. Therefore, research on the biological perspective of suicide has gained a stronghold and appears to provide a promising approach to identify biological risk factors associated with suicidal behavior. Recent studies demonstrate that an alteration in synaptic and structural plasticity is key to affective illnesses and suicide. Signal transduction molecules play an important role in such plastic events. Protein kinase A (PKA) is a crucial enzyme in the adenylyl cyclase signal transduction pathway and is involved in regulating gene transcription, cell survival, and plasticity. In this review, we critically and comprehensively discuss the role of PKA in suicidal behavior. Because stress is an important component of suicide, we also discuss whether stress affects PKA and how this may be associated with suicidal behavior. In addition, we also discuss the functional significance of the findings regarding PKA by describing the role of important PKA substrates (i.e., Rap1, cyclic adenosine monophosphate response element binding protein, and target gene brain-derived neurotrophic factor). These studies suggest the interesting possibility that PKA and related signaling molecules may serve as important neurobiological factors in suicide and may be relevant in target-specific therapeutic interventions for these disorders.

Suicidal behavior in the older patient with schizophrenia

Little is known about treating elderly suicidal patients with schizophrenia. The purpose of this article is to review the literature dealing with this population and to discuss what is required to advance this field. Most available studies from middle-aged and older individuals suggest that risk factors include hopelessness, lower quality of life, past traumatic events, depressive symptoms, lifetime suicidal ideation and past attempts; it is not clear whether these findings are generalizable to geriatric populations. Although little treatment research has been performed in older suicidal patients with schizophrenia, an integrated psychosocial and pharmacologic approach is recommended. In addition, one recent study augmented antipsychotic treatment with an SSRI (i.e., citalopram) in a sample of middle-aged and older individuals with schizophrenia with subsyndromal depression; in that study, serotonin selective reuptake inhibitor augmentation reduced depressive symptoms and suicidal ideation. More research is required to better understand suicidal behavior in older patients with schizophrenia.

The role of psychopharmacology in suicide prevention

The potential role of psychopharmacology in suicide prevention is often minimised. This may to some extent reflect that few medication trials have specifically focussed on prevention of suicidal behaviour – indeed this outcome is often not reported in trials. However, there is reasonably strong evidence that lithium may reduce risk of suicide, the postulated mechanism being a specific effect on aggression. Evidence is lacking with regard to any protective effect of other mood stabilizers. Clozapine may reduce suicidal behaviour in patients with schizophrenia, with reduction of affective symptoms being a possible explanation. The role of antidepressants in relation to suicide risk is highly controversial, especially in children and adolescents. It is unclear whether minor tranquillizers or hypnotics can assist in suicide prevention, although they can reduce the anxiety symptoms that may occur during initial treatment with SSRI antidepressants. Itis also uncertain whether psychopharmacology has a role in preventing suicidal behaviour in people with personality disorders. Despite the limitations of the evidence we contend that suicide risk should be an important factor in deciding when and what to prescribe.

Declaration of Interest: We have no interests to declare.

Managing suicide risk in patients with schizophrenia

The management of suicide risk in patients with schizophrenia poses many challenges for clinicians. Compared with the general population, these patients have an 8.5-fold greater risk of suicide. This article reviews the literature dealing with the treatment of at-risk patients with schizophrenia. An integrated psychosocial and pharmacological approach to managing this population of patients is recommended. Although there is at least modest evidence suggesting that antipsychotic medications protect against suicidal risk, the evidence appears to be most favourable for second-generation antipsychotics, particularly clozapine, which is the only medication approved by the US FDA for preventing suicide in patients with schizophrenia. In addition, treating depressive symptoms in patients with schizophrenia is an important component of suicide risk reduction. While selective serotonin receptor inhibitors (SSRIs) ameliorate depressive symptoms in patients with schizophrenia, they also appear to attenuate suicidal thoughts. Further research is needed to more effectively personalize the treatment of suicidal thoughts and behaviours and the prevention of suicide in patients with schizophrenia.

Factors affecting outcome in schizophrenia and their relevance for psychopharmacological treatment

A major focus of current treatment research in schizophrenia is the determinants of long-term outcome, including functional outcome and general medical well being, rather than just specific domains of psychopathology such as positive and negative symptoms, mood symptoms, and cognitive impairment. This focus does not negate the importance of the latter issues but sees them as factors contributing to long-term outcome to variable extents. A long-term treatment focus facilitates a more clinically relevant assessment of benefits versus risks of available treatments. For instance, atypical antipsychotic drugs as a group have clear advantages for several important domains of efficacy that may influence long-term outcome, but are also more expensive over the long term. Use of some agents may also result in deleterious physical health consequences as well as large additional costs over the long term owing to metabolic adverse effects. The present paper focuses on several key issues in schizophrenia which are important determinants of long-term outcome in schizophrenia, or influence choice of antipsychotic drugs, or both, including: (i) duration of untreated psychosis; (ii) impact of relapse on long-term outcome; (iii) limited efficacy for specific domains of psychopathology of current treatments; (iv) mortality owing to suicide; and (v) mortality owing to other causes (e.g. cardiovascular disease).

Functional impairment in patients with mania: baseline results of the EMBLEM study

OBJECTIVES

The European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) is a large-scale prospective observational multicentre study to evaluate the longitudinal course of bipolar disorder and its associations with pharmacological treatment following an acute manic or mixed episode. We present an overview of the study design and patient characteristics at baseline while focusing on factors influencing work performance in the year prior to enrollment.

METHODS

A total of 530 investigators across 14 European countries enrolled 3,681 patients with acute mania between December 2002 and June 2004. Longitudinal observations are ongoing until July 2006. Socio-demographic variables, psychiatric history, clinical status and information on pharmacological treatment for bipolar disorder were recorded. Items from the SLICE of LIFE were applied, including a measure of work impairment during the previous year. The distribution of the baseline characteristics was analysed with descriptive statistics. Eighteen variables were investigated as hypothesized risk factors for work impairment applying logistic regression models.

RESULTS

In the previous year, 28 and 68% of patients were classified as having 'low' and 'high' work impairment, respectively. Clinical Global Impression - Bipolar Disorder (CGI-BP) overall, CGI-BP depression at baseline, rapid cycling during the previous 12 months, age between 35 and 64 years, substance abuse other than alcohol and cannabis and living without a partner or as dependent household member were significantly associated with work impairment during the previous year.

CONCLUSIONS

EMBLEM is to our knowledge the largest prospective observational study assessing patients during and after an acute episode of mania. Work impairment is significant in the year prior to an acute episode of mania.

Clinical predictors of suicidal acts after major depression in bipolar disorder: a prospective study

OBJECTIVE

This study determined the clinical predictors of suicidal behavior during a 2-year follow-up of patients with bipolar disorder presenting with a major depressive episode (MDE).

METHOD

Sixty four patients with DSM-III-R bipolar disorder were assessed at presentation for treatment of an MDE. Correlates of past suicidal behavior were determined by comparing patients with and without a history of suicide attempts using a t-test, Wilcoxon test or chi-squared test of independence on individual explanatory variables. Putative predictors of attempts during the follow-up period were tested separately using Cox proportional hazards regression analysis.

RESULTS

Twelve of 64 patients had at least one suicide attempt in the follow-up period, five of them attempted in the first 2 months and seven around or shortly after the 1-year follow-up visit. All attempters had a history of past suicide attempts. Most predictors of future suicidal behavior were correlates of past suicidal behavior. Family history of suicide acts and comorbid borderline personality disorder predicted early attempts, while younger age, high hostility scores, number of past attempts, subjective pessimism as reflected in depression and suicidal ideation, and few reported reasons for living predicted suicidal acts during the whole period.

CONCLUSION

In this data set of bipolar patients we noted an intriguing picture of two clusters of suicide attempts. Hostility was the strongest risk factor. These findings may have implications in both the identification of at-risk patients and the timing of clinical interventions including aggressive pharmacotherapeutic prophylaxis to prevent relapse or recurrence of depressive symptomatology.

Psychiatric diagnoses and suicide: revisiting the evidence

BACKGROUND

The key role of prevention and treatment of mental disorders in the prevention of suicide is widely acknowledged. Which specific disorders need to be targeted remains to be conclusively demonstrated.

AIMS

To re-examine the presence of psychiatric diagnosis in cases of completed suicide from a global perspective.

METHOD

A review of studies reporting diagnoses of mental disorders in cases of completed suicide with or without history of admission to mental hospitals.

RESULTS

Most cases were from Europe and North America (82.2%). The majority (98%) of these had a diagnosis of at least one mental disorder. Among all diagnoses, mood disorders accounted for 30.2%, followed by substance-use related disorders (17.6%), schizophrenia (14.1%), and personality disorders (13.0%).

CONCLUSIONS

The mental health paradigm in suicide prevention covers just a part of the problem. Antisuicide strategies focusing exclusively on the identification and treatment of depression need to be reconsidered. In addition to this, other mental disorders should be targeted, in particular alcohol-use disorders and schizophrenia. More emphasis should also be placed on psychosocial and environmental interventions diminishing and counteracting stress.

Suicide in 406 mood-disorder patients with and without long-term medication: a 40 to 44 years' follow-up

There is no data on the variation in the suicide risk over lifetime and on the suicide-preventive effect of the long-term treatment of mood-disorder patients with antidepressants and neuroleptics. Our research focused on 186 unipolar (D), 60 bipolar II (Dm), 130 nuclear bipolar I (MD), and 30 preponderantly manic patients (M/Md); that were followed-up from 1963 to 2003. By 2003, 45 (11.1%) of the 406 patients had committed suicide. Suicide rates were highest among D patients (Standardized Mortality Ratio, SMR = 26.4), MD (SMR = 13.6), Dm (SMR = 10.6) and lowest among M/Md patients (SMR = 4.7). Prospectively, the suicide rate decreased over the 44 years' follow-up; Lithium, neuroleptics and antidepressants reduced suicides significantly. Long-term treatment also reduced overall mortality, and combined treatments proved more effective than mono-therapy.

Suicidal behaviors and drug abuse: impulsivity and its assessment

Impulsivity appears to play an important role in suicidal behaviors and drug abuse, which are two psychiatric problems that may interact with one another. Interpretation of the literature on impulsivity in these behaviors may be complicated by the variety of measurement techniques for the assessment of impulsivity. There are three general types of impulsivity assessment: self-report, biological, and laboratory behavioral. Because laboratory behavioral measures both meet an operational definition of impulsivity and are sensitive to state-dependent changes in impulsivity, this paper presents data that focuses on laboratory behavioral performance among samples emitting suicidal behaviors or substance abuse. To better account for influence of impulsivity in these psychiatric disturbances, no single source of measurement should be used without the consideration of other types of instruments.

Suicidal behavior in schizophrenia and schizoaffective disorder: examining the role of depression

Understanding the relationship between depression and suicidal behavior among individuals with schizophrenia and schizoaffective disorder can aid assessment and treatment. In this study, 86 individuals with schizophrenia and schizoaffective disorder were assessed for past and current suicidal behavior, depression, hopelessness, and reasons for living. Thirty-four percent reported a history of suicide attempts. Suicidal behavior typically occurred 4.5 years after the onset of psychosis and 7.5 years after the onset of the first major depressive episode for those who had a history of major depression. Depression was frequent among both attempters and non-attempters, but only half of the attempters reported a suicide attempt during an episode of major depression. And almost half of those with depression never made a suicide attempt despite a long history of illness. Although depression is a potential stressor for triggering suicidal behavior in a vulnerable subset of individuals with schizophrenia, schizophrenia research must identify other risk factors for suicidal behavior. Clinicians should remember that even without a depressive episode there is still a significant risk for suicidal behavior in schizophrenia.

Atypical antipsychotics and suicide in mood and anxiety disorders

Globally, a million people commit suicide every year, and 10-20 million attempt it. Mood disorders, especially major depressive disorder (MDD) and bipolar disorder, are the most common psychiatric conditions associated with suicide. Primary (psychiatric and physical illness), secondary (psychosocial), and tertiary (demographic) risk factors for suicide have been identified. Comorbid psychiatric illness, particularly anxiety symptoms or disorders, significantly increase the risk of suicidal behavior. Current standard risk assessments and precautions may be of limited value, while assessing the severity of anxiety and agitation may be more effective in identifying patients at risk. Lithium is the medication that has most consistently demonstrated an antisuicidal effect. The effects of antidepressants and conventional antipsychotics on suicide risk are uncertain, but atypical antipsychotics appear promising. Atypical antipsychotics have beneficial effects on depressed mood both in patients with MDD and in patients with bipolar disorder. In addition, data in patients with schizophrenia have demonstrated a significant improvement in the incidence of suicidal behavior with clozapine compared with olanzapine. Electroconvulsive therapy appears to have an acute benefit on suicidality.

Antisuicide properties of psychotropic drugs: a critical review

The authors consider the extent to which psychotropic medications demonstrate benefits in the prevention of suicidal behavior in psychiatric patients. Results of a MedLine search are critically reviewed for lithium, divalproex and other anticonvulsants, conventional and atypical antipsychotics, and antidepressants. The existing literature is almost entirely limited to noncontrolled, often retrospective studies that do not control for potential biases in treatment selection, the use of multiple medications, the impact of medication nonadherence, and nonrandomized treatment discontinuations. Nevertheless, an extensive literature has arisen regarding observed reductions in suicidal behavior with lithium for mood disorders and, to a lesser extent, with clozapine for schizophrenia. A substantially smaller literature suggests more negative than positive data with divalproex or carbamazepine in bipolar disorder, while minimal information exists regarding suicidality with atypical antipsychotics other than clozapine. Studies of antidepressants have mostly been short-term and have focused more on whether they induce (rather than ameliorate) suicidal thoughts or behaviors. The sum of existing studies is generally inconclusive about whether antidepressants appreciably reduce risk for suicide completions. Relatively little is known about pharmacotherapy effects on suicidal ideation as distinct from behaviors. Possible mechanistic considerations for understanding antisuicide properties include a therapeutic impact on depression, impulsivity, or aggression, potentially mediated through serotonergic or other neuromodulatory systems. Recommendations are provided to guide future research as well as clinical practice.

Suicidality in schizophrenia: a review of the evidence for risk factors and treatment options

Suicide is a major contributor to the morbidity and mortality of schizophrenia, accounting for approximately 10% of deaths in these patients. The known risk factors for suicide in schizophrenia include prior suicide attempts, substance abuse, male sex, onset during first decade of illness, social isolation, depression, and feelings of hopelessness. There is significant evidence suggesting that clozapine reduces the suicide rate in patients with schizophrenia and schizoaffective disorder. Possible factors that lead to a decrease in suicidality with clozapine include the following: a direct antidepressant action, improved cognitive function and insight, diminished negative symptoms, reduced substance abuse, and improved compliance. These effects may converge or lessen feelings of hopelessness and more of its converse optimism. The International Suicide Prevention Trial (InterSePT) is a large prospective, 2-year randomized trial of the comparative effects of clozapine and olanzapine involving 980 patients at high risk for suicide in 11 countries in 56 sites. The study included complete freedom to augment these treatments if needed, blinded ratings, a blinded Suicide Monitoring Board, and equivalent clinical contact. The results support the superiority of clozapine over olanzapine to reduce the risk of suicidality and suggest its use should be considered for all patients with schizophrenia with high risk for suicide.

Postpsychotic depression in schizophrenia patients

Depression is a frequent comorbidity in the course of schizophrenia and is associated with increased mortality from suicide. Postpsychotic depression is defined as the syndrome of major depression occurring following remission of psychotic symptoms in a person with schizophrenia. Various proposed causes, differential diagnosis, and issues regarding management of postpsychotic depression are discussed.

Mortality of patients with mood disorders: follow-up over 34-38 years

BACKGROUND

All follow-up studies of causes of death in affective disordered patients have found they have markedly elevated suicide rates and a less reproducible increased mortality from other causes. The reported rates by gender, disorder type and treatment are more variable.

METHODS

Hospitalised affective disordered patients (n=406) were followed prospectively for 22 years or more. Later, mortality was assessed for 99% of them at which time 76% had died.

RESULTS

Standardised Mortality Rates (observed deaths/expected deaths) for patients were elevated especially for suicide and circulatory disorders in both men and women. Women actually had higher suicide rates but that did not take into account the twofold increase in general population rates for men. Unipolar patients had significantly higher rates of suicide than bipolar Is or IIs. In all groups long term medication treatment with antidepressants alone or with a neuroleptic, or with lithium in combination with antidepressants and/or neuroleptics significantly lowered suicide rates even though the treated were more severely ill. Although at the age of onset the suicide rates were most elevated, from ages 30 to 70 the rates were remarkably constant despite the different courses of illness.

LIMITATIONS

The patients were identified as inpatients and followed prospectively. The treatments were uncontrolled and are not quantifiable but were documented during the follow-up.

CONCLUSIONS

Men and women hospitalised for affective disorders have elevated mortality rates from suicide and circulatory disorders. Unipolars have higher suicide rates than bipolar Is or IIs. Long term medication treatment lowers the suicide rates, despite the fact that it was the more severely ill who were treated.

Suicidal behavior: is there a genetic predisposition?

OBJECTIVES

To review the data that support the role of genetic factors in the predisposition to suicidal behavior and to examine whether or not these factors are part of the genetic liability to mood disorders. To review molecular genetic studies carried out in suicidal behavior.

METHODS

A review of the literature was carried out by means of systematic bibliographic database searches and complemented by searches in the references of relevant publications.

RESULTS

There is consistent evidence suggesting that genetic factors play an important role in the predisposition to suicide and suicidal behaviors. Although there is important overlap between suicide and mood disorders, a common genetic liability seems unlikely. It is possible that part of the predisposition to suicide may be transmitted via the presence of impulsive and impulsive-aggressive behaviors. An increasing number of molecular genetic studies have been carried out in subjects with suicidal behavior. There is some support for a role of some genes that code for components of the serotonergic pathway in the etiology of suicidal behavior, but these studies are still preliminary.

CONCLUSIONS

Further studies are needed at the epidemiological, clinical and molecular level to better characterize the genetics of suicide. These should control for the presence of behaviors that are considered as part of the phenotypic spectrum of suicide.

Cognitive-behavioral therapy in schizophrenia

The authors review the literature on cognitive-behavioral approaches to the treatment of schizophrenia. They begin by providing a historical context to explain the recent resurgence of interest in this area. Next, they provide an overview of studies of cognitive-behavioral interventions that target poor insight, medication nonadherence, and refractory symptoms. Insight and nonadherence are emphasized because these are particularly common and problematic areas that present major stumbling blocks in the treatment of patients suffering from schizophrenia that are not yet sufficiently addressed by the interventions clinicians currently have in their treatment arsenal. The authors conclude that support exists for the efficacy of interventions derived from cognitive-behavioral approaches in improving some aspects of insight into illness, increasing adherence to medication, ameliorating the severity of symptoms, and mitigating other negative consequences of schizophrenia. Finally, the authors offer guidelines for future work in this area and emphasize the importance of identifying patients who are most likely to benefit from the use of cognitive-behavioral approaches.

Treatment of suicidality in schizophrenia

Between 4 and 13% of people with schizophrenia commit suicide and between 25 and 50% make a suicide attempt, a reflection of the devastating toll this syndrome takes on the quality of life, that is, the subjective and objective sense of well-being. Many risk factors for suicide in schizophrenia have been identified, the most important of which are previous suicide attempts, depression, hopelessness, substance abuse, and male gender. Insight into having a serious mental illness and less severe cognitive impairment are also associated with increased risk for suicide in schizophrenia, most likely when accompanied by feelings of hopelessness. Typical neuroleptic drugs have not been shown to reduce the risk of suicide. However, several types of evidence suggest that clozapine, an atypical antipsychotic drug, appreciably reduces the suicide attempt and completion rates in schizophrenia and schizoaffective disorder, perhaps by as much as 75-85%. Other atypical antipsychotic drugs may have a similar effect, but direct evidence is lacking. Improvement in positive and negative symptoms, reduced extrapyramidal side effects (EPS), a direct antidepressant action, improved cognitive function, and improved compliance may contribute to reduced suicidality. The International Suicide Prevention Trial (InterSePT) is a large prospective, randomized study intended to compare the effectiveness of clozapine with that of olanzapine in reducing suicide and suicide-related events in schizophrenic and schizoaffective patients. Some information about suicidality in the patient sample is reported here.

The Schizophrenia Suicide Risk Scale (SSRS): development and initial validation

BACKGROUND

Estimations about the lifetime risk of suicide in schizophrenia vary between 4 and 10%. At present, there does not exist a suicide risk scale developed particularly for schizophrenic patients. The aims of the present study were to: (1) develop a clinically useful semi-structured scale for the estimation of short-term suicide risk among schizophrenic patients, and (2) to carry out an initial validation of the scale.

METHODS

A 25-item Schizophrenia Suicide Risk Scale (SSRS) was constructed on the base of the literature. The SSRS scores of 69 living schizophrenic patients (LS group) were compared with the scores of 69 schizophrenic suicides (SS group) whose data had been collected previously from The Finnish nationwide and representative psychological autopsy study. Internal consistency of the SSRS was evaluated with Cronbach alpha. The most important SSRS items predicting suicide were identified with a logistic regression analysis. Sensitivity, specificity, positive predictive value, and negative predictive value of the SSRS in predicting suicide with various cut-off scores were calculated.

RESULTS

In the final logistic regression model, the following SSRS items significantly predicted suicide: suicide plans communicated to someone during the past 3 months; one or more previous suicide attempts; loss of professional skills demanding job; depression observed during an interview; and suicide plans communicated during an interview. With high cut-off scores the specificity of the SSRS became satisfactory, but the sensitivity dropped below 32%. Internal consistency of the anamnestic history of the SSRS was low, which suggests that anamnestic risk factors for suicide in schizophrenia are multifactorial. Internal consistency of the interview-based items was high, and present state risk factors seemed to consist of two separate factors, depression-anxiety and irritability.

CONCLUSIONS

The SSRS may be clinically useful in identifying schizophrenic patients with a particularly high risk for suicide. However, the SSRS seems not to be a practical screening instrument for suicide risk in schizophrenia, and it is probably impossible to construct a suicide risk scale with both high sensitivity and high specificity in this disorder.

Completed suicide: an update for the general psychiatrist

Objectives: To review the most recent information on completed suicide for the general adult psychiatrist.

Methods: Literature review.

Results: Suicide is the result of a complex interaction of multiple variables. Prediction is highly dependent on clinical evaluation. Predictive factors identify groups better than individuals. Prevention has both clinical and political implications.

Conclusions: Reduced access to lethal methods (historically, from barbiturates to modified vehicle exhaust systems and paracetamol), attention to social factors (such as alcohol availability and employment levels) and clinical vigilance, coupled with adequate treatment of psychiatric disorders and close follow-up, should help to reduce suicide rates. Wider cultural issues (eg. religion) are poorly understood and require further research.

Suicide risk assessment: a review of risk factors for suicide in 100 patients who made severe suicide attempts. Evaluation of suicide risk in a time of managed care

A study of 100 patients who made a severe suicide attempt suggested that the managed care criteria often applied for approving admission to hospitals for potentially suicidal patients were not, in fact, predictive of features seen in patients who actually made such attempts. Severe anxiety, panic attacks, a depressed mood, a diagnosis of major affective disorder, recent loss of an interpersonal relationship, recent abuse of alcohol or illicit substances coupled with feelings of hopelessness, helplessness, worthlessness, global or partial insomnia, anhedonia, inability to maintain a job, and the recent onset of impulsive behavior were excellent predictors of suicidal behavior. The presence of a specific suicide plan or suicide note were not. Patients with managed care were overrepresented by 245% in the study.

Suicide in patients hospitalized for schizophrenia: 1913-1940

From a sample of 1357 schizophrenic patients hospitalized between 1913 and 1940 at the Phipps Clinic, we have follow-up data on 1212 (89%) cases, with a mean length of follow-up of 11 years. Of these 1212 patients, 28 (2%) are known to have committed suicide. Suicide was significantly correlated with 1) previous suicide attempts, 2) depressive symptoms, 3) preoccupation with suicide, 4) affective illness in close relatives, 5) poor premorbid social and work history, 6) sexual worries, and 7) psychomotor agitation. Marital status, gender, age at onset, age at admission, number of previous admissions, condition at discharge from Phipps, length of hospitalization, the presence of any type of delusions or hallucinations, alcohol problems, paranoid or catatonic features, and utilization of shock therapies were not significantly correlated with subsequent suicide. The seven variables significantly correlated with suicide enumerated above were chosen to construct a scale suggesting which patients were at high risk for suicide.

Management of the suicidal patient with schizophrenia

No matter what the course of treatment determined to be most appropriate, suicidal behavior must be considered thoroughly, and it must be conveyed to the patient that the clinician can assist him or her through this period of increased distress. Hopelessness must be viewed as a symptom with the assumption that a more meaningful sense of purpose will emerge despite the chronic and potentially limiting nature of schizophrenia. Most people with schizophrenia are not suicidal, and most who are suicidal can be offered interventions that will reduce their symptomatology and thereby dissipate their suicidal behavior.

Assessment and intervention for the suicidal patient with schizophrenia

The risk for suicidal behavior in schizophrenia is high with 10-15% committing suicide and 20-40% making suicide attempts. Due to the chronicity and complexity of schizophrenia and the multi-determined nature of suicidal behavior, the clinician must utilize a biopsychosocial approach to assessment and intervention. Clinical factors such as psychosis, depression and substance abuse increase the risk for suicidal behavior in schizophrenia. Social factors such as social adjustment and social supports also play a critical role. Ongoing assessment and intervention of suicidal behavior, clinical symptomatology, social environment and treatment issues are essential. Prediction and prevention of suicidal behavior are not always possible however. Treatment focused on the reduction of symptomatology and maintenance of an effective social environment may attenuate the risk for suicidal behavior in schizophrenia.

Euthanasia and physician-assisted suicide: attitudes and experiences of oncology patients, oncologists, and the public

BACKGROUND

Euthanasia and physician-assisted suicide are pressing public issues. We aimed to collect empirical data on these controversial interventions, particularly on the attitudes and experiences of oncology patients.

METHODS

We interviewed, by telephone with vignette-style questions, 155 oncology patients, 355 oncologists, and 193 members of the public to assess their attitudes and experiences in relation to euthanasia and physician-assisted suicide.

FINDINGS

About two thirds of oncology patients and the public found euthanasia and physician-assisted suicide acceptable for patients with unremitting pain. Oncology patients and the public found euthanasia and physician-assisted suicide least acceptable in vignettes involving "burden on the family" and "life viewed as meaningless". In no vignette--even for patients with unremitting pain--did a majority of oncologists find euthanasia or physician-assisted suicide ethically acceptable. Patients actually experiencing pain were more likely to find euthanasia or physician-assisted suicide unacceptable. More than a quarter of oncology patients had seriously thought about euthanasia or physician-assisted suicide and nearly 12 percent had seriously discussed these interventions with physicians or others. Patients with depression and psychological distress were significantly more likely to have seriously discussed euthanasia, hoarded drugs, or read Final Exit. More than half of oncologists had received requests for euthanasia or physician-assisted suicide. Nearly one in seven oncologists had carried out euthanasia or physician-assisted suicide.

INTERPRETATION

Euthanasia and physician-assisted suicide are important issues in the care of terminally ill patients and while oncology patients experiencing pain are unlikely to desire these interventions patients with depression are more likely to request assistance in committing suicide. Patients who request such an intervention should be evaluated and, where appropriate, treated for depression before euthanasia can be discussed seriously.

Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other Axis I disorders

The lifetime rate of suicide attempts among subjects in the Epidemiologic Catchment Area database with bipolar disorder, unipolar disorder, and any other DSM-III-defined Axis I disorder were determined. The latter constituted a control or reference group. The lifetime rates of suicide attempts of persons in these diagnostic groups were 29.2%, 15.9%, and 4.2%, respectively. Multivariate logistic regression analysis was used to calculate the odds ratio of subjects within a diagnostic group having a history of a suicide attempt relative to subjects in a second group. The odds ratio of subjects with bipolar disorder having a history of a suicide attempt relative to subjects in the control group was 6.2 (df 1, x(2) = 5347.2, p < .0001). The odds ratio of subjects with unipolar disorder having a history of a suicide attempt relative to subjects in the control group was 3.1 (df = 1, x(2) = 4785.2, p < .0001). The odds ratio of subjects with bipolar disorder having a history of a suicide attempt relative to unipolar subjects was 2.0 (df = 1, x(2) = 697.9, p < .0001). Bipolar disorder has a strong relationship to a history of suicide attempts relative to unipolar disorder and other Axis I disorders.

Pharmacologic Treatment of Bipolar Disorder Through the Life Cycle

Bipolar disorder is a long-term illness associated with multiple relapses and recurrences throughout the life cycle. Lithium, carbamazepine, and valproate are the mainstays of treatment for this illness. Each of these agents will be reviewed as well as alternatives for patients who fail treatment with lithium, have manic agitation, psychosis, depression, rapid cycling, and mixed mania. Compliance issues will also be dis cussed. Copyright © 1996 by W.B. Saunders Company

The long-term management of depression

The long-term outlook for patients with unipolar depression is often poor. As few as one-fifth will remain well and a similar number will suffer chronic depression. It is now standard practice to extend acute treatment into a 4-6 month period of continuation therapy, and the value of prophylactic treatment over longer periods is becoming more widely recognised. Care must, however, be exercised in choosing suitable long-term treatment. Relatively little work on the prophylactic efficacy of the tricyclic antidepressants has been carried out, although imipramine has been shown to be effective. The selective serotonin re-uptake inhibitors (SSRIs) have been studied extensively and may be the most suitable long-term treatment for depression. Sertraline is effective in preventing both relapse and recurrence of depression and was the first agent specifically indicated for the long-term treatment of depression in the UK. In addition to clinical efficacy, many other factors favour SSRIs in the long-term management of depression. The tolerability of a drug is of major importance in long-term therapy since it affects compliance. Other important considerations include toxicity, safety in overdose, drug interaction potential, psychomotor effects and accident liability.

Adult criminality among formerly hospitalized child psychiatric patients

Among 170 preadolescent children (138 males, 32 females) admitted to the University of Iowa Psychiatric Hospital between 1970 and 1983, 23 males (17%), had adult prison records at follow-up in 1990. Assaultive behavior in childhood predicted adult imprisonment (odds ratio = 4.96, 95% confidence interval 1.8-13.8, p = 0.002), as did criminality in a biological parent (odds ratio = 4.0, 95% confidence interval 1.3-12.4, p = 0.015). Diagnosis, including conduct disorder, was not correlated with outcome. Among these young children, male gender, violence, and parental criminality identified persons at high risk for adult imprisonment. Psychiatric hospitalization in childhood is a risk for adult disturbance, including sociopathy.

Mianserin-induced up-regulation of serotonin receptors on normal human platelets in vivo

The antidepressant, mianserin, is a serotonin receptor (5-HT2) antagonist and produces down-regulation of 5-HT2 and 5-HT1c receptors in the cerebral cortex of rats. In preparation for testing the validity of platelets as a model system for changes in 5-HT2 receptors during antidepressant drug treatment, mianserin (40 mg daily), was given to five human volunteers for five days, and platelets were collected on days 0, 1, 6, and 8. 5-HT2 receptor affinity and density were measured by specific binding of 125I-LSD, with and without an excess of spiperone. 5-HT uptake site affinity and density were determined by 3H-paroxetine binding, with and without an excess of fluoxetine. Platelet serotonin content was measured using high pressure liquid chromatography and electrochemical detention. Platelet 5-HT2 receptor density was increased and the ligand affinity was decreased during mianserin administration. In contrast, platelet 5-HT content was not altered significantly by mianserin administration, nor was platelet uptake site density and ligand affinity.

Alpha 2-adrenoceptors in the brain of suicide victims: increased receptor density associated with major depression

To examine directly in the brain the status of the alpha 2-adrenoceptor in major depression, the specific binding of the agonists [3H]clonidine and [3H]UK 14304 was quantitated in various brain regions of suicide victims with a retrospective diagnosis of depression or other psychiatric disorders. In depressed suicides, the binding capacity of [3H]clonidine was found to be increased in the hypothalamus (Bmax 35%-55% greater), and to a lesser extent in the frontal cortex, as compared with that in matched controls, schizophrenic suicides, or suicides with various diagnosis. The binding capacity of [3H]UK 14304 also was found increased in the frontal cortex (Bmax 30% greater), and to a lesser extent in the hypothalamus, of depressed suicides. In other brain regions such as the amygdala, hippocampus, and cerebellum there also was a tendency for an increased receptor density associated with suicide. Moreover, in the frontal cortex of suicides, the potency of norepinephrine in displacing the binding of the antagonist [3H]idazoxan also was found increased (Ki decreased eight-fold). The results indicate that the density and affinity of alpha 2A-adrenoceptors in the high-affinity state are increased in the brain of depressed suicides.

Increased [3H] raclopride binding sites in postmortem brains from schizophrenic violent suicide victims

The specific binding of the D2-dopamine receptor antagonist radioligand [3H] raclopride was quantitated in the postmortem caudate and frontal cortex from schizophrenic suicide victims and control subjects. In schizophrenic suicides the density of binding sites (Bmax) was higher (40%, P < 0.05) in the caudate, whereas it did not change in the cortex as compared to those in controls. The apparent dissociation constants (KD) were also found increased both in caudate (24%) and cortex (75%) from schizophrenics, but these apparent decreases in receptor affinity did not reach statistical significance. The mean Bmax value in drug-free schizophrenic suicides (n = 3) did not differ from the Bmax value in neuroleptic drug-treated schizophrenics (n = 7) but it was found increased in respect to control subjects (n = 9). No differences in [3H] raclopride binding were observed between non-schizophrenic suicide victims (n = 4) and matched controls (n = 4), suggesting that the modifications of D2-dopamine receptors in schizophrenia are not related to suicide.

Modulation of [3H]paroxetine binding to the 5-hydroxytryptamine uptake site in an animal model of depression

The effects of learned helplessness on the 5-hydroxytryptamine (5-HT) uptake site were studied in rats using [3H]paroxetine binding. This ligand was chosen because it was demonstrated to label directly the 5-HT uptake site whereas the [3H]imipramine binding site has been demonstrated to be heterogeneous in nature. Moreover, [3H]imipramine appears to bind to a presynaptic recognition site different from the uptake site. Exposure to uncontrollable shock training and testing resulted in an overall increase in [3H]paroxetine binding in all the groups studied [nonhelpless (NLH), learned helpless (LH), spontaneously helpless (SPLH)] as compared to naive controls (NC). However, the increase in [3H]paroxetine binding was significantly higher in the LH and SPLH groups. The maximum number of [3H]paroxetine binding sites in the rat hippocampus was increased significantly in learned helpless rats (LH and SPLH) at day 4 and day 30 after the shock escape test as compared to NC and NLH rats. By contrast, in the rat hypothalamus the maximum number of [3H]paroxetine binding sites was reduced significantly in the LH rats as compared to naive controls and NLH rats during the same time course. There was no change in [3H]paroxetine binding sites in any other brain regions examined in LH, NLH, and NC rats. The results suggest that a hippocampal hypothalamic connection might play a role in the serotonergic mediation of learned helpless behavior.

Concurrent medical illness in the schizophrenic patient. Epidemiology, diagnosis, and management

The management of the medically ill schizophrenic patient presents a dual dilemma for the physician. The patient may have a serious medical illness that must be diagnosed and effectively treated, yet the patient's psychiatric disorder may interfere with effective management. Thus, undiagnosed and untreated medical illness can result in significant morbidity for schizophrenic patients. Because schizophrenic patients may appear to be less cooperative than medical patients without concurrent psychiatric illness, they can cause countertransference reactions on the part of physicians and nursing staff that can interfere with treatment. Schizophrenic patients also have deficits in the processing of sensory information. These deficits require the staff to make changes in management in order to facilitate the patient's ability to cooperate with treatment and to give reliable informed consent. A host of other factors complicate the medical management and treatment of schizophrenic patients. Such factors include medication side effects of psychotropic medication, the potential interactions between medications used to treat the patient's physical illness with psychotropics, pregnancy in the female patient, and the strength of the patient's support system. The ability to successfully diagnose and treat concurrent medical illness in the schizophrenic patient will depend on the physician's ability to be flexible and to understand the implications of the patient's underlying disorder for his relationship to hospital staff. This paper reviews some of the relevant literature and describes possible treatment strategies integrating what we know about schizophrenia with medical management.

Does platelet serotonin receptor supersensitivity accompany endogenous depression?

In a population of drug-free bipolar and unipolar depressed women, it was found that the concentration of serotonin sufficient to induce half-maximal shape change velocity in platelets is significantly (p less than 0.001) lower (0.13 +/- 0.0.04 microM) than that of closely matched controls (0.532 +/- 0.1 microM). This platelet concentration becomes higher after 1-3 months of antidepressant treatment (0.47 +/- 0.16 microM). Possible mechanisms for this up- or down-regulation of platelet serotonin receptor responsiveness are discussed.