Clinical assessment versus research methods in the assessment of suicidal behavior

Effects of selective serotonin reuptake inhibitors (SSRIs) on suicide: A network meta-analysis of double-blind randomized trials

The relationship between the use of selective serotonin reuptake inhibitors (SSRIs) and suicide risk in patients with mental disorders remains controversial. We conducted a network meta-analysis to examine the effects of SSRIs on suicide risk in patients with mental disorders. A comprehensive search was conducted across PubMed, Web of Science, PsycINFO, CENTRAL, Wanfang Database, and China National Knowledge Infrastructure for articles published until December 19, 2023. The main outcomes were suicidal ideation and instances of suicidal behavior. We included 29 double-blind randomized trials in our analysis. The findings suggest that SSRIs primarily offer short-term protection against suicidal ideation. By week 2, paroxetine, fluoxetine, escitalopram, and non-SSRI treatments were linked to a decreased suicide risk compared with a placebo, with the exception of sertraline. This protective effect was diminished by week 8. In contrast, studies on instances of suicidal behavior from weeks 1 to 10 found no significant difference in efficacy between SSRIs, non-SSRIs, and placebo. These results indicate that SSRIs may offer short-term protection against suicidal ideation. However, their long-term effectiveness in mitigating suicidal ideation and preventing suicidal behaviors is limited.

Suicidal behavior across a broad range of psychiatric disorders

Suicide is a leading cause of death worldwide. In 2020, some 12.2 million Americans seriously contemplated suicide, 3.2 million planned suicide attempts, and 1.2 million attempted suicide. Traditionally, the approach to treating suicidal behavior (SB) has been to treat the "underlying" psychiatric disorder. However, the number of diagnoses associated with SB is considerable. We could find no studies describing the range of disorders reported to be comorbid with SB. This narrative review summarizes literature documenting the occurrence of SB across the lifespan and the full range of psychiatric diagnoses, not only BPD and those that comprise MDE, It also describes the relevance of these observations to clinical practice, research, and nosology. The literature searches contained the terms "suicid*" and each individual psychiatric diagnosis and identified 587 studies. We did not include case reports, case series, studies only addressing suicidal ideation or non-suicidal self-injury (NSSI), studies on self-harm, not distinguishing between SB and NSSI and studies that did not include any individuals that met criteria for a specific DSM-5 diagnosis (n = 366). We found that SB (suicide and/or suicide attempt) was reported to be associated with 72 out of 145 diagnoses, although data quality varied. Thus, SB is not exclusively germane to Major Depressive Episode (MDE) and Borderline Personality Disorder (BPD), the only conditions for which it is a diagnostic criterion. That SB co-occurs with so many diagnoses reinforces the need to assess current and past SB regardless of diagnosis, and supports the addition of charting codes to the DSM-5 to indicate current or past SB. It also comports with new data that specific genes are associated with SB independent of psychiatric diagnoses, and suggests that SB should be managed with specific suicide prevention interventions in addition to treatments indicated for co-occurring diagnoses. SB diagnostic codes would help researchers and clinicians document and measure SB's trajectory and response to treatment over time, and, ultimately, help develop secondary and tertiary prevention strategies. As a separate diagnosis, SB would preclude situations in which a potentially life-threatening behavior is not accounted for by a diagnosis, a problem that is particularly salient when no mental disorder is present, as is sometimes the case.

The necessity, validity, and clinical utility of a new diagnostic entity: Acute suicidal affective disturbance

OBJECTIVE

Here we argue for the necessity, validity, and clinical utility of a new diagnostic entity, acute suicidal affective disturbance (ASAD).

METHOD

We expand on the conceptual, clinical, and practical rationale for ASAD, propose its defining features, describe research results to date, and suggest avenues for future research.

RESULTS

There is accruing evidence for the existence of a previously unclassified, rapid-onset mood disturbance that geometrically escalates and regularly results in life-threatening behavior.

CONCLUSIONS

ASAD research may not only improve the field's understanding of suicidal behavior but also enhance clinical effectiveness and save lives.

Risk Factors for Suicidal Behavior Depend on Age for Veterans in the Pacific Islands

We examined whether risk factors for suicidal behavior depend on age among military veterans in the Pacific Islands (N = 29,595). For veterans under 54 years old, having a diagnosis of posttraumatic stress disorder, borderline personality disorder, a drug use disorder, and having a service-related disability predicted suicidal behavior. For veterans 54 years old or older, having a mood disorder predicted suicidal behavior. Having a history of suicidal behavior and a high number of VA health care visits were associated with suicidal behavior for both age groups. Our findings suggest that the predictive value of certain risk factors in veterans in the Pacific Islands may depend on age.

Disagreement between self-reported and clinician-ascertained suicidal ideation and its correlation with depression and anxiety severity in patients with major depressive disorder or bipolar disorder

OBJECTIVES

To study the disagreement between self-reported suicidal ideation (SR-SI) and clinician-ascertained suicidal ideation (CA-SI) and its correlation with depression and anxiety severity in patients with major depressive disorder (MDD) or bipolar disorder (BPD).

METHODS

Routine clinical outpatients were diagnosed with the MINI-STEP-BD version. SR-SI was extracted from the 16 Item Quick Inventory of Depression Symptomatology Self-Report (QIDS-SR-16) item 12. CA-SI was extracted from a modified Suicide Assessment module of the MINI. Depression and anxiety severity were measured with the QIDS-SR-16 and Zung Self-Rating Anxiety Scale. Chi-square, Fisher exact, and bivariate linear logistic regression were used for analyses.

RESULTS

Of 103 patients with MDD, 5.8% endorsed any CA-SI and 22.4% endorsed any SR-SI. Of the 147 patients with BPD, 18.4% endorsed any CA-SI and 35.9% endorsed any SR-SI. The agreement between any SR-SI and any CA-SI was 83.5% for MDD and 83.1% for BPD, with weighted Kappa of 0.30 and 0.43, respectively. QIDS-SR-16 score, female gender, and ≥4 year college education were associated with increased risk for disagreement, 15.44 ± 4.52 versus 18.39 ± 3.49 points (p = 0.0026), 67% versus 46% (p = 0.0783), and 61% versus 29% (p = 0.0096). The disagreement was positively correlated to depression severity in both MDD and BPD with a correlation coefficient R(2) = 0.40 and 0.79, respectively, but was only positively correlated to anxiety severity in BPD with a R(2) = 0.46.

CONCLUSION

Self-reported questionnaire was more likely to reveal higher frequency and severity of SI than clinician-ascertained, suggesting that a combination of self-reported and clinical-ascertained suicidal risk assessment with measuring depression and anxiety severity may be necessary for suicide prevention.

Suicidal behaviours during treatment for first-episode psychosis: towards a comprehensive approach to service-based prevention

AIM

Suicidal behaviours (suicide attempts and suicides) are common among individuals experiencing, or having recently experienced, a first-episode psychosis (FEP). Current interventions for suicidal behaviours are crisis driven and focused on hospital admission of patients at imminent risk of ending their lives. This paper aims to describe ideas for universal, selective and indicated strategies that may complement existing practices to suicide risk management in first-episode patients.

METHODS

Key findings from the Suicidal Behaviours in FEP Project were used to develop suggested interventions. The project examined the temporal course of suicide risk, common characteristics of suicidal behaviours and predictors of suicidal behaviours in 699 patients with FEP.

RESULTS

Key findings included: (i) 12% of FEP cohort engaged in suicidal behaviours during treatment (up to 3 years); (ii) first month of treatment conferred the highest suicide risk; (iii) 64% of suicidal behaviours were overdoses, usually on antipsychotics; (iv) 20% of suicidal behaviours occurred on psychiatric units and all involved hanging/strangulation; (v) most suicidal behaviours were impulsive, precipitated by psychosocial stressors and with serious intent; and (vi) proximal non-suicidal self-injurious behaviour and proximal negative life events were the strongest predictors.

CONCLUSION

Comprehensive approach by mental health services to prevention of suicidal behaviours among first-episode patients could be facilitated by: delineating safe quantities of prescribed medications available to outpatients; regular audits of fixtures on inpatient units; enhancing risk recognition by family members; routinely monitoring suicide risk levels; developing crisis cards with all new FEP patients to facilitate help seeking during distress; and skills training programs targeting distress tolerance, interpersonal effectiveness and problem-solving.

Assessment and Management of Suicide Risk in Primary Care

Background: Risk assessment and management of suicidal patients is emphasized as a key component of care in specialist mental health services, but these issues are relatively unexplored in primary care services. Aims: To examine risk assessment and management in primary and secondary care in a clinical sample of individuals who were in contact with mental health services and died by suicide. Method: Data collection from clinical proformas, case records, and semistructured face-to-face interviews with general practitioners. Results: Primary and secondary care data were available for 198 of the 336 cases (59%). The overall agreement in the rating of risk between services was poor (overall κ = .127, p = .10). Depression, care setting (after discharge), suicidal ideation at last contact, and a history of self-harm were associated with a rating of higher risk. Suicide prevention policies were available in 25% of primary care practices, and 33% of staff received training in suicide risk assessments. Conclusion: Risk is difficult to predict, but the variation in risk assessment between professional groups may reflect poor communication. Further research is required to understand this. There appears to be a relative lack of suicide risk assessment training in primary care.

Assessment following deliberate self-harm: who are we seeing and are we following the guidelines?

Objectives: To determine whether assessments of patients admitted to a general hospital following deliberate self-harm (DSH) were in line with the Royal College of Psychiatrists guidelines. To examine the profile of cases and presentations and to make recommendations for improvements to the service.

Method: Clinical and demographic data recorded on 70 admissions after DSH during 1997-98 were analysed retrospectively. A checklist was also developed, using factors shown by previous research to be associated with future risk of suicide, to determine the quality of assessments.

Results: The majority (70%) of assessments took place within 24 hours of admission thereby meeting College recommendations. Medical personnel performed all adult assessments. Circumstances of the overdose, recent stresses, psychiatric diagnosis, immediate risk and follow-up arrangements were documented in the majority of cases. Family psychiatric history, past suicidal behaviour, alcohol and drug abuse history, and previous violence, were frequently not documented. A copy of a discharge summary to the GP was found in 41% of charts. Overdoses accounted for 93% of cases of DSH. The most frequently recorded problem (37.5%) was adjustment disorder.

Conclusions: Despite evidence showing that non-psychiatric medical staff are competent in assessing DSH and guidelines encouraging multidisciplinary involvement, DSH assessments remain the preserve of the medical psychiatric team. Closer attention should be paid to all the risk factors associated with suicide by assessors; a checklist could prove helpful. There is room for improved communication between psychiatric services and GPs following DSH. The setting up of a self-harm service planning group could improve the co-ordination and efficiency of delivery of general hospital services to this patient group.

Past suicide attempts in depressed inpatients: clinical versus research assessment

The objective of this study was to compare structured clinical assessment versus research measurement of suicidal risk among inpatients with major depression. Fifty depressed inpatients underwent a structured clinical and an independent research assessment of suicidal risk. Agreement between both assessments and its impact upon time to first readmission was tested. A false negative rate of 25% in the clinical screening of past suicide attempts was associated with older age, concealment, and reported lower frequency of suicidal thoughts. Mean times to first readmission (2.5 years follow-up) were 74 weeks (discordant responders) and 118 weeks (concordant responders). A failure to detect 25% of patients with past suicide attempt history in the clinical assessment was associated with older age and concealment of suicidal thoughts.

Evidence for the management of adolescent depression

Adolescent depression is a prevalent and disabling condition resulting in emotional suffering and social and educational dysfunction. Care for adolescent depression is suboptimal and could be improved through the development and use of quality indicators (QIs). This article reports on the development of a care pathway and QIs for the primary and specialty care management of adolescent depression from case identification through symptom remission. It presents evidence from a review of adolescent clinical practice guidelines and research literature to support QIs at critical nodes in the pathway, and describes implications for practice based on existing evidence. Barriers to measure development are identified, including gaps in empirical evidence, and a research agenda is suggested.

Suicidal ideation and the subjective aspects of depression

BACKGROUND

Suicidal ideation is common in depression, but only moderately related to depression severity - in part because certain clusters of symptoms, such as those related to core mood disturbance, have a differential relationship to suicidal thinking.

METHODS

400 medication free participants with current major depression were assessed with either or both the Hamilton Depression Rating Scale (HDRS, n=396) and Beck Depression Inventory (BDI, n=366), and the Scale for Suicide Ideation (SSI). Depression rating scales were decomposed into symptoms clusters previously reported (Grunebaum et al., 2005), in order to evaluate their association to suicidal thinking.

RESULTS

Correlations between overall depression severity ratings and the measure of suicidal ideation were modest, and reduced when specific items assessing suicidal thinking on these depression scales were removed. Symptom clusters assessing Psychic Depression (HDRS), Subjective Depression (BDI), and Self-Blame (BDI) were the strongest correlates of suicidal ideation; other somatic and vegetative symptoms had little or no association to suicidal ideation. Severity of these symptom clusters effectively discriminated those with (SSI>0) and without (SSI=0) ideation; severity of these symptom clusters was less strongly associated with the severity of ideation once ideation was present.

LIMITATIONS

This is a cross-sectional study, and the dynamic relationship between changes in the severity of various depressive symptoms and change in suicidal thinking remains to be explored.

CONCLUSIONS

Depression severity is moderately associated with suicidal ideation, and accounted for primarily by core mood disturbance symptoms and self-punitive thinking. These associations may explain why suicide risk might remain high during treatment even though somatic and vegetative symptoms improve.

Do we miss depressive disorders and suicidal behaviours in clinical practice?

This study involved a detailed standardized initial research assessment which was carried out with 100 young people aged 12-15 years newly referred to a child and adolescent mental health service. The assessment involved the K-SADS interview with the young person and their parent, the Strengths and Difficulties Questionnaire, the Clinical Global Impression Scale, and the Children's Global Assessment Scale. Diagnoses resulting from these 'research assessments' were compared with clinical diagnoses, which were determined by case note analysis and discussion with the key clinician. Results showed that a clinical diagnosis of depressive disorder was made in only one-third of those who received a 'research assessment' diagnosis of depressive disorder, and suicidality was missed in a significant proportion of cases. Those with a diagnosis of depressive disorder had significantly more problems, more comorbidity, more suicidality and greater functional impairment than those without. It is important to keep depression and suicidality in mind when assessing young people with complex mental health difficulties. Unless specific pointers are sought, it is easy to miss these, which may mean that vulnerable young people do not benefit from potentially effective treatments.

Prospective study of risk factors for increased suicide ideation and behavior following recent discharge

OBJECTIVE

The purpose of this study is to prospectively examine the association between predictors from the three thematic areas - suicidality, personal risk factors and patient care factors - and the occurrence of postdischarge suicide ideation and behavior in recently discharged patients.

METHODS

The design is a prospective cohort study of all patients admitted to an inner city inpatient psychiatric service with a lifetime history of suicidal behavior and current suicidal ideation. Predictors of suicide ideation at 1, 3 and 6 months following discharge and suicide behavior over the 6 months of follow-up were examined.

RESULTS

The incidence of death by suicide during the study period was 3.3% [95% confidence interval (CI)=0.9%-8.3%], and 39.4% (95% CI=30.0%-49.5%) of the surviving participants reported self-injury or suicide attempts within 6 months of hospital discharge. Risk factors such as recent suicide attempts, levels of depression, hopelessness and impulsivity were predictive of increased suicide ideation or behavior after discharge from the inpatient service.

CONCLUSIONS

The high risk of suicide ideation, suicide attempts and suicide demonstrated in these recently discharged patients supports the need to develop selective prevention strategies.

The p4 screener: evaluation of a brief measure for assessing potential suicide risk in 2 randomized effectiveness trials of primary care and oncology patients

BACKGROUND

Depression is the most common mental disorder, and suicide is its most serious consequence. The primary objective of this study was to evaluate preliminary evidence for the P4 screener as a brief measure to assess potential suicide risk.

METHOD

The P4 screener was prospectively evaluated in 2 randomized effectiveness trials of primary care (January 2005-June 2008; N = 250) and oncology patients (March 2006-August 2009; N = 309). Potential suicide ideation was assessed at 5 time points in both trials: baseline and 1, 3, 6, and 12 months. The P4 screener asks about the "4 P's": past suicide attempts, suicide plan, probability of completing suicide, and preventive factors. Patients were classified as minimal, lower, and higher risk based upon responses to these 4 items.

RESULTS

A suicide assessment was triggered 1 or more times by 17.6% (44 of 250) of Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) participants and 16.5% (51 of 309) of Indiana Cancer Pain and Depression (INCPAD) participants at some point in the trial. Of the patients who triggered a suicide assessment, the majority (29 of 44 in SCAMP and 27 of 51 in INCPAD) were classified as minimal risk by the algorithm. Only 1 (0.4%) of the SCAMP participants and 5 (1.6%) of the INCPAD participants were classified as higher risk. Among the latter, the most common factors preventing patients from attempting suicide were the "4 F's": faith, family, future hope, and fear of failing in their attempt.

CONCLUSIONS

Preliminary findings suggest that the P4 screener may be useful in assessing potential suicide risk in the clinical care of depressed patients as well as in clinical research.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00118430 (SCAMP) and NCT00313573 (INCPAD).

Identifying adolescents at risk through voluntary school-based mental health screening

This study compares referrals for mental health services among high school students randomized to two means of referral to mental health services: referral via systematic identification through a brief mental health screening procedure (n = 365) or referral via the usual process of identification by school personnel, parents, or students themselves (n = 291). Screened students were significantly more likely than control students (AOR: 21.64 95%CI 6.66-70.36) to receive a referral for mental health services, whether it be to school-based services (AOR: 11.68 95%CI 3.52-8.73) or community-based services (AOR: 20.02 95%CI 2.66-150.41). Post-study, for those screened, 95.5% of school-based mental health services referrals, and 39.3% of community-based referrals were accessed. School based mental health screening identified a significantly greater proportion of youth to be in clinical need of mental health services than would have likely been identified without screening, and increased rates of referral resulted in greater access to mental health services.

Association of polymorphisms of the tryptophan hydroxylase 2 gene with risk for bipolar disorder or suicidal behavior

Bipolar disorder (BD) is a severe psychiatric illness characterized by the occurrence of elevated mood alternating with depressive episodes, having a estimated lifetime prevalence of 0.4-1.6% using DSM-IV criteria. Disturbances of the central serotonergic system has been associated with the pathophysiology of affective disorders and suicidal behavior. Tryptophan hydroxylase 2 (TPH2) which is a rate limiting enzyme in the serotonin synthesis is considered an important candidate gene associated with psychiatric disorders. Our sample consisted of 527 subjects (303 diagnosed with bipolar disorder and 224 healthy controls) which were genotyped for eight tagSNPs (rs4448731, rs4565946, rs11179000, rs7955501, rs10506645, rs4760820, rs1487275 and rs10879357) covering the whole gene of the human TPH2. Statistical analyses were performed using UNPHASED version 3.0.12 and Haploview((R)). Single markers, genotype and haplotype association analysis did not show significant genetic association with bipolar disorder or suicidal behavior. Our findings do not support the association between diagnosis of BD or suicidal behavior and TPH2 polymorphisms.

Study of the outcome of suicide attempts: characteristics of hospitalization in a psychiatric ward group, critical care center group, and non-hospitalized group

BACKGROUND

The allocation of outcome of suicide attempters is extremely important in emergency situations. Following categorization of suicidal attempters who visited the emergency room by outcome, we aimed to identify the characteristics and potential needs of each group.

METHODS

The outcomes of 1348 individuals who attempted suicide and visited the critical care center or the psychiatry emergency department of the hospital were categorized into 3 groups, "hospitalization in the critical care center (HICCC)", "hospitalization in the psychiatry ward (HIPW)", or "non-hospitalization (NH)", and the physical, mental, and social characteristics of these groups were compared. In addition, multiple logistic analysis was used to extract factors related to outcome.

RESULTS

The male-to-female ratio was 1:2. The hospitalized groups, particularly the HICCC group, were found to have biopsychosocially serious findings with regard to disturbance of consciousness (JCS), general health performance (GAS), psychiatric symptoms (BPRS), and life events (LCU), while most subjects in the NH group were women who tended to repeat suicide-related behaviors induced by relatively light stress. The HIPW group had the highest number of cases, and their symptoms were psychologically serious but physically mild. On multiple logistic analysis, outcome was found to be closely correlated with physical severity, risk factor of suicide, assessment of emergent medical intervention, and overall care.

CONCLUSION

There are different potential needs for each group. The HICCC group needs psychiatrists on a full-time basis and also social workers and clinical psychotherapists to immediately initiate comprehensive care by a medical team composed of multiple professionals. The HIPW group needs psychological education to prevent repetition of suicide attempts, and high-quality physical treatment and management skill of the staff in the psychiatric ward. The NH group subjects need a support system to convince them of the risks of attempting suicide and to take a problem-solving approach to specific issues.

Comparison of clinical and research assessments of diagnosis, suicide attempt history and suicidal ideation in major depression

A number of studies have compared clinical diagnostic and suicide assessments to standardized schedules to determine the level of agreement. At best there is only moderate diagnostic agreement, but most often it is fair. There are only a few reports comparing clinical assessments for suicidal behavior with standardized schedules. We present the data from 201 inpatient admissions for major depression that had both clinical diagnostic and suicide evaluations by PGYII resident physicians under supervision from an attending psychiatrist and research evaluations using standardized schedules for diagnosis and suicide by at least masters' level clinicians. There was moderate agreement for diagnosis and suicide attempt history but only fair agreement for the presence of suicidal ideation using Cohen's kappa statistic. In regards to suicide attempt history a cross-tabulation demonstrated that 18.7% of those patients identified by a research schedule as having a past suicide attempt were not identified as such by the clinicians. A cross-tabulation demonstrated that 29.7% of those patients identified by structured interview as having suicidal ideation were not identified as such by the clinician. There was a statistically significant difference in the level of agreement for suicide attempt history between clinical and research assessments for attempts within a year of admission and those beyond a year. These findings suggest the importance of adding a structured diagnostic and suicide assessment to routine clinical care to improve the reliability and validity of clinical evaluations and to inform treatment planning to benefit our patients.

Suicide behavior and neuropsychological assessment of type I bipolar patients

BACKGROUND

Neuropsychological deficits are often described in patients with bipolar disorder (BD). Some symptoms and/or associated characteristics of BD can be more closely associated to those cognitive impairments. We aimed to explore cognitive neuropsychological characteristics of type I bipolar patients (BPI) in terms of lifetime suicide attempt history.

METHOD

We studied 39 BPI outpatients compared with 53 healthy controls (HC) matched by age, educational and intellectual level. All subjects were submitted to a neuropsychological assessment of executive functions, decision-making and declarative episodic memory.

RESULTS

When comparing BDI patients, regardless of suicide attempt history or HC, we observed that bipolar patients performed worse than controls on measures of memory, attention, executive functions and decision-making. Patients with a history of suicide attempt performed worse than non-attempters on measures of decision-making and there were a significant negative correlation between the number of suicide attempts and decision-making results (block 3 and net score). We also found significant positive correlation between the number of suicide attempts and amount of errors in Stroop Color Word Test (part 3).

LIMITATIONS

The sample studied can be considered small and a potentially confounding variable - medication status - were not controlled.

CONCLUSION

Our results show the presence of neuropsychological deficits in memory, executive functions, attention and decision-making in BPI patients. Suicide attempts BPI scored worse than non-suicide attempt BPI on measures of decision-making. More suicide attempts were associated with a worse decision-making process. Future research should explore the relationship between the association between this specific cognitive deficits in BPIs, serotonergic function and suicide behavior in bipolar patients as well other diagnostic groups.

Detecting suicidality among adolescent outpatients: evaluation of trained clinicians' suicidality assessment against a structured diagnostic assessment made by trained raters

BACKGROUND

Accurate assessment of suicidality is of major importance. We aimed to evaluate trained clinicians' ability to assess suicidality against a structured assessment made by trained raters.

METHOD

Treating clinicians classified 218 adolescent psychiatric outpatients suffering from a depressive mood disorder into three classes: 1-no suicidal ideation, 2-suicidal ideation, no suicidal acts, 3-suicidal or self-harming acts. This classification was compared with a classification with identical content derived from the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS-PL) made by trained raters. The convergence was assessed by kappa- and weighted kappa tests.

RESULTS

The clinicians' classification to class 1 (no suicidal ideation) was 85%, class 2 (suicidal ideation) 50%, and class 3 (suicidal acts) 10% concurrent with the K-SADS evaluation (gamma2 = 37.1, df 4, p = 0.000). Weighted kappa for the agreement of the measures was 0.335 (CI = 0.198-0.471, p < 0.0001). The clinicians under-detected suicidal and self-harm acts, but over-detected suicidal ideation.

CONCLUSION

There was only a modest agreement between the trained clinicians' suicidality evaluation and the K-SADS evaluation, especially concerning suicidal or self-harming acts. We suggest a wider use of structured scales in clinical and research settings to improve reliable detection of adolescents with suicidality.

Is the 5-HTTLPR polymorphism associated with bipolar disorder or with suicidal behavior of bipolar disorder patients?

The serotonin transporter gene has a 44 bp insertion/deletion polymorphism within the promoter region (5-HTTLPR) with two allelic forms, the long (L) and the short (S) variants. Association between the low-activity S variant and bipolar disorder (BPD) has been shown but its replication has not been consistent. It has also been described as an association between the S allele and suicidal behavior. Since suicidal behavior is a rather frequent event in BPD, an important question is whether suicidality, instead of bipolarity itself, could be related to S allele. We assessed 351 subjects (167 bipolar inpatients and 184 healthy controls). Diagnosis was conducted by a psychiatrist using a structured interview (MINI-PLUS), according to DSM-IV criteria. Suicidal behavior was assessed using a semi-structured instrument and a review of medical records. Genotyping of the 5-HTTLPR was performed using PCR. There were 77 patients with a history of previous suicide attempts. Bipolar patients and healthy controls showed comparable genotypic and allelic frequencies. Patients carrying the S allele made violent suicide attempts more frequently (chi(2) = 20.2; P = 0.0001) and made more suicide attempts (t = 2.6; P = 0.01). We were able to show an association between the S allele and suicidal behavior but not with BPD. Our data suggest that a phenotypic stratification, taking into account the suicidal behavior history, is of pivotal importance when performing association studies between BPD and 5-HTTLPR genotypes, which could explain previous contradictory results.

Meta-analysis of aggression and/or hostility-related events in children and adolescents treated with fluoxetine compared with placebo

This meta-analysis assessed aggression and/or hostility-related events in children and adolescents treated with fluoxetine (n = 376) compared with placebo (n = 255). Aggression and/or hostility-related events were identified in 2.1% of fluoxetine versus 3.1% of placebo-treated patients (p = 0.588). This analysis fails to support an association between fluoxetine treatment and increased risk of aggression and/or hostility-related events in children and adolescents compared with placebo.

Positive affect and suicide ideation in older adult primary care patients

Suicide is a significant public health problem for older adults. Identification of protective factors associated with reduced risk is important. The authors examined the association of positive affect and suicide ideation in 462 primary care patients ages 65 and older. Positive affect distinguished suicide ideators from nonideators, after controlling for age, gender, depression, negative affect, illness burden, activity, sociability, cognitive functioning, and physical functioning. There was a trend toward age moderation of this relationship. Clinical and theoretical formulations of late-life suicide should consider the role of positive affect, including the possibility that its protective effects grow more pronounced with age.

Association study of T102C 5-HT(2A) polymorphism in schizophrenic patients: diagnosis, psychopathology, and suicidal behavior

The objective of this study was to examine the association between the serotonin (5-HT)2A gene polymorphism (102T/C) and suicidal behavior in schizophrenic inpatients. We studied 129 subjects who met the diagnostic criteria for schizophrenia according to a structured clinical interview (MINI-PLUS). Patients underwent a semistructured interview to assess suicide attempt history and its characteristics. In addition, at least one close relative of the patient was interviewed to assess proband and family suicidal behavior. Healthy controls were students and hospital staff members free of psychiatric and medical illness. Genotypes were determined after polymerase chain reaction amplification of the region of 5-HT(2A)/T102C containing the polymorphic site and digestion with the restriction enzyme Hpall. We found no association between suicidal attempt history and suicide attempt characteristics and genotypic or allele frequencies. Suicidal behavior was also not associated with demographic or psychopathological characteristics. These results suggest that the 5-HT(2A) gene polymorphism (102T/C) is not involved in genetic susceptibility to suicidal behavior, but further studies in a larger sample are needed.

Accuracy of diagnosis at routine psychiatric assessment in patients presenting to an accident and emergency department

OBJECTIVE

This study aimed to compare diagnoses obtained from routine psychiatric assessment in accident and emergency (A&E) settings with those from a standardized diagnostic interview.

METHODS

Using Cohen's kappa, the agreement between diagnoses from routine psychiatric assessment and structured interview was calculated. Further statistical analysis was used to investigate differences between some of the main diagnostic subgroups.

RESULTS

The overall kappa value for all diagnoses was .47. Adjustment disorder, major depressive disorder and alcohol misuse/dependence were commonly identified, both at routine assessment and on structured interview. There was a disparity between the two diagnostic systems in the extent to which major depressive disorder and adjustment disorder were identified. Further analysis between these two groups was inconclusive as to the reasons for this difference.

CONCLUSIONS

There was moderate agreement between clinical and standardized diagnoses. Anxiety disorders were poorly identified at routine assessment. There is difficulty distinguishing between adjustment disorder and depressive episode in the A&E setting.

Investigation of A218C tryptophan hydroxylase polymorphism: association with familial suicide behavior and proband's suicide attempt characteristics

According to WHO, suicide accounts for about 1,000,000 deaths worldwide every year. In view of these dramatic data, several studies have tried to identify possible biological mechanisms and markers of suicide. Genes encoding for proteins involved in the serotonergic transmission are major candidates in association studies of suicidal behavior. The gene that codes for tryptophan hydroxylase (TPH), the rate-limiting enzyme in the biosynthesis of serotonin, is one of these candidates. Two polymorphisms in intron 7 of this gene (A218C and A779C) have been described, but their role in suicidal behavior remains uncertain. TPH A218C polymorphism was analyzed in a sample of 248 psychiatric patients and 63 healthy controls. In addition, at least one close relative member was interviewed to assess family suicidal behavior history. Our research confirmed that a positive history of suicide attempts in a family member is associated with the chance of an individual to attempt suicide. Furthermore, we demonstrated that familial suicide attempts are more lethal and frequently more violent. We were not able to find significant differences of the TPH genotype frequencies between patients and controls. The TPH A218C genotypes were not associated with a history of suicide attempt and the lethality of the most lethal lifetime suicide attempt and suicide attempt method. The authors conclude that the A218C polymorphism of the TPH gene may not be a susceptibility factor for suicidal behavior in this group of psychiatric patients but confirm that a family suicidal behavior history increases the proband's suicide attempt risk.

ACNP Task Force report on SSRIs and suicidal behavior in youth

This Task Force report by the American College of Neuropsychopharmacology evaluates the safety and efficacy of selective serotonin reuptake inhibitor (SSRIs) antidepressants for depressed youth under 18 years. The report was undertaken after regulatory agencies in the United States and United Kingdom raised concerns in 2003 about the possibility that treatment of depression in children and adolescents with SSRIs may increase the risk of suicidal thinking or suicide attempts.

Suicidal behavior among inpatients with schizophrenia and mood disorders in Chengdu, China

This study evaluated the characteristics of suicidal behavior (suicide attempt or suicidal ideation) among 230 consecutively admitted inpatients with schizophrenia and mood disorders in a university hospital in China. The rate of lifetime suicidal behavior was found to be significantly higher in patients with mood disorders (62.4%) than in patients with schizophrenia (38.6%). The rate of suicidal behavior was significantly higher in patients with major depressive disorder (86.8%) than those with bipolar disorders (42.6%). Patients with schizophrenia attempted suicide for the first time earlier in life than the patients with mood disorders. Mood disorder patients, especially those with major depressive disorder, had more and more serious suicide attempts than the patients with schizophrenia.

The safe treatment of the suicidal patient in an adult inpatient setting: a proactive preventive approach

This paper focuses on the work of an inpatient service in an acute care safety net hospital in the prevention of suicide on its inpatient service and during the high-risk period post discharge. The strategy utilized a comprehensive proactive systems approach to the suicidal patient including: a formalized suicide assessment jointly done by medical and nursing staff, accurate diagnosis and best practice treatment, a flexible nursing observation policy, groups on inpatient units focused on suicide and key risk factors and triggers, and a communication tool to the next level of care that describes the strategies learned by the patient to deal with his or her suicidality. Incidents of self-injurious behaviors and special observation hours were monitored.

Familial suicide behaviour: association with probands suicide attempt characteristics and 5-HTTLPR polymorphism

OBJECTIVE

There is compelling evidence that a serotonergic dysfunction may play a major role in suicide behaviour and it has also been demonstrated that suicide is, at least partially, genetically determined. Thus, the serotonin-related genes are the major candidates. Previously a functional polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) was identified and the presence of the short allele (S) was found to be associated with a lower level of expression of the gene and lower levels of 5-HT uptake when compared with the long allele (L). The purpose of this study was to evaluate the association between family suicide behaviour history and probands' suicide attempt (SA) history, SA characteristics and 5-HTTLPR genotype.

METHOD

We genotyped 237 probands (major depressed or schizophrenic patients) and used a semistructured interview to determine probands' SA characteristics and first- and second-degree family suicidal behaviour.

RESULTS

An association between suicidal family history and proband's SA but not with SA characteristics and probands genotype was found.

CONCLUSION

Our results suggest that multiple biological and environmental factors underlie familial transmission of suicidal behaviour.

The LSARS-II: Lethality of Suicide Attempt Rating Scale-Updated

The concept of lethality is essential to the assessment of suicide risk; yet operational definitions of lethality for purposes of its measurement have been loose and varied. A number of scaling measures have been published in the literature, with no relative consensus on the best of these. In addition, only a few of these scales have published data on their psychometric properties. Of these, we argue that the best is the Lethality of Suicide Attempt Rating Scale (LSARS; Smith, Conroy, & Ehler, 1984). Presented here is a significantly revised and redesigned listing of drugs and chemicals and lethal ranges of ingestion (in caps, tabs, or ounces) by body weight to update that scale.

Understanding impulsivity in severe depression? A psychometrical contribution

BACKGROUND

Depression, especially severe depression, is strongly associated with suicidality. Impulsivity is one of the main dimensions of suicidality. The objective of this study was to assess the structure of impulsivity in severe depression and its relationships to suicide attempts.

METHODS

127 depressed in-patients were assessed at admission and after 4 weeks of treatment for depression and impulsivity with the Impulsivity Rating Scale (IRS) and the Impulse Control Scale (ICS) or the Baratt Impulsivity Scale (BIS).

RESULTS

Three dimensions of impulsivity were evidenced in these severely depressed patients, i.e., behavioral loss of control, nonplanning and cognitive. These three dimensions are state dependent. Recent suicide attempts in severe depression are related to loss of control and cognitive impulsivity but not to nonplanning. IRS ad ICS may assess primarily behavioral impulsivity, i.e., loss of control and nonplanning, whereas BIS may assess primarily cognitive impulsivity.

CONCLUSIONS

In the future, these three dimensions should be correlated to biological and genetic markers of impulsivity [serotonergic (5-HT) system] and prospective studies should assess the predictive value of the three dimensions of impulsivity in the occurrence of suicide attempts in depressed patients.

Staff perceptions of care for deliberate self-harm patients in rural Western Australia: a qualitative study

Suicide has been a major community concern in Esperance, a geographically isolated port on the south coast of Western Australia. This study explores the views of regional health staff on barriers to the effective management of deliberate self-harm (DSH) and ways in which those barriers could be addressed. Semi-structured interviews were tape-recorded, transcribed and subjected to qualitative content analysis. Interviewees included 77% of general practitioners (n = 7), 18% of nurses (n = 13) and 55% of mental health professionals (n = 5). The most important barrier was a lack of structure to treating DSH, resulting in deficiencies and inconsistencies in its management. Suggestions to improve the management of DSH included better communication between services, support for nurses in raising the issue of suicide, use of a simple risk assessment tool, the development of a nurse liaison position, and a multidisciplinary planning group. The higher rates of DSH and completed suicide in rural and remote regions compared with metropolitan areas make secondary prevention particularly important.

Clinical Evaluation of Prior Suicide Attempts and Suicide Risk in Psychiatric Inpatients

Summary: Background: In practice psychiatrists rely on their own experience and intuition to evaluate the suicide potential of individual patients, but the algorithms for the decision-making process remain unclear. Objectives: (1) to establish models for the decision making process for evaluating suicide risk; (2) to simulate the impact of information concerning the number of previous suicide attempts on the clinician's ability to detect patients who performed medically serious suicide attempts (MSSAs). Methods: Four decision models (linear, dichotomized, hyperbolic, and undifferentiated) depicting the influence of the number of previous suicide attempts on the clinician's recognition of MSSAs in 250 psychiatric inpatients were elicited and tested by a series of discriminant analyses. Results: The dichotomized model (“all or none”) was found to be the most efficient in detecting medically serious suicide attempts. Conclusion: The “all or none” paradigm seems to be the most appropriate way to evaluate the weight of previous suicide attempts in the decision-making process identifying medically serious suicide attempt patients.

Stressful life events and impulsiveness in failed suicide

The relationship of recent stressful life events with impulsiveness in triggering suicide attempts and how impulsiveness changes from one suicide attempt to another is unclear. This study used structured-interview tools and standardized measurements to examine the relationship between life stress and impulsiveness in a sample of patients who required hospitalization for a medically serious suicide attempt. After controlling for potentially confounding variables, the number of disrupted interpersonal relationships in the preceding year was a significant predictor of the impulsiveness of the suicide attempt, with three or more losses (but not other life stresses) associated with less impulsive attempts (T = 2.4, p = .02). Female gender (T = -1.98, p = .05) and lifetime DMS-III-R diagnoses (T = -2.45, p = .02) were significantly associated with more impulsive attempts. In 55 patients with at least two suicide attempts, impulsiveness, lethal intent, and communication of intent were significantly greater for the present compared to the prior attempt (p = 0.000). Certain stressful life events, gender, and total lifetime DSM-III-R diagnoses are associated with impulsiveness of failed suicide attempts; yet, impulsiveness is not necessarily consistent from one suicide attempt to another. This evidence supports and amplifies a stress-diathesis model of suicide behavior. Accordingly, efforts to increase personal resilience in individuals who have "failed suicide" may be more effective at preventing suicide morbidity than simple stress-reduction measures alone.

Development and initial validation of the Self-harm Behavior Questionnaire

Evaluation of suicide-related behaviors and thoughts about suicide with a newly developed self-report instrument is described. The Self-Harm Behavior Questionnaire (SHBQ; Gutierrez, 1998) generates detailed clinical information from an easy to administer and score self-report form. A sample of 342 participants were drawn from university undergraduate students enrolled in various psychology courses. Participants were then divided into a severe suicidal ideation group (n = 20) and a nonsuicidal control group (n = 20) to conduct subgroup and criterion-related validity analyses. Preliminary analyses indicate this new questionnaire is both valid and reliable when used with young adults drawn from a nonclinical population. The questionnaire should be of use to both clinicians and researchers due to the flexibility of the data generated.

Multimethod assessment of suicidality in adolescent psychiatric inpatients: preliminary results

OBJECTIVE

To examine agreement among multiple assessments of adolescent suicidal ideation and suicidal behavior for adolescent psychiatric inpatients, including pencil/paper checklists; structured and unstructured interviews; and adolescent, clinician, and parent reports, and to provide suggestions for the accurate and reliable assessment of suicidality in adolescence.

METHOD

Participants included 153 adolescent psychiatric inpatients (54 boys, 99 girls) between the ages of 12 and 17 years. Measurement of suicidal ideation and behavior included common assessment instruments and standard clinical practices, including the Suicidal Ideation Questionnaire, NIMH Diagnostic Interview Schedule for Children, clinician interview, and parent report (Behavior Assessment Scale for Children).

RESULTS

Results revealed significantly different rates of suicidality across each instrument and poor to moderate agreement between similar measures of adolescent suicidal ideation and suicidal behavior. Agreement between measures was generally best for boys, for older adolescents, and for assessments relying on a single informant. Reporters were most likely to agree on the presence of suicidality for more severely suicidal adolescents; this finding suggests that agreement in itself may be a useful marker for adolescent suicide.

CONCLUSIONS

Results of this preliminary study supported the use of multiple measurement approaches when examining adolescent suicidality, particularly those that rely on clinician judgment and adolescents' own reports. Implications for future research and for clinical practice are also discussed.

The depressed suicidal patient. Assessment and treatment

Depressive disorders are associated with significant psychosocial impairment and disability. Depression should be thoroughly evaluated, as should current and past suicidality and potential risk factors for suicide. Mortality by suicide characterizes the course of major affective disorders in approximately 15% of those suffering from these illnesses. Several neurobiological correlates of suicidality have been discovered. Treatment of depression with suicidality may involve hospitalization, pharmacotherapy, electroconvulsive therapy, and psychotherapy. Special populations include children and adolescents, the elderly, medically ill patients, patients with comorbid personality disorders, and patients with comorbid substance abuse disorders. Clinicians encountering patients with depressive disorders should be proficient in the assessment and treatment of depression with suicidality.

Gate questions in psychiatric interviewing: the case of suicide assessment

Gate questions are commonly used to shorten structured interviews, by not probing negative responses with more detailed questions. This study quantified cases of aborted suicide attempts that would have been missed, if we had skipped detailed questions following a gate. To accomplish this, we interviewed a random sample of 135 adult psychiatric inpatients concerning their past suicidal behavior. Using our structured interview, subjects were asked a general question about aborted suicide attempts, and then asked method-specific questions regardless of their response to the general "gate" question. Of the seventy subjects who were found to have histories of aborted attempts, 44.3% answered "no" to the gate question. Comparing these "false negative" subjects to "true positives," who had answered "yes" to the gate question and reported bona fide aborted attempts yielded no significant associations with demographics, psychiatric diagnoses, or reported histories of actual suicide attempts. Thus, a large number of subjects with aborted attempts would have been missed if a negative response to the gate question had not been probed. Clinical and reasearch implications generally, as well as implications for suicide assessment, are discussed.