Suicides in Mood Disorders in Psychiatric Settings in Nordic National Register-Based Studies

The relationship between a comprehensive index of prosperity and suicide rates in former Soviet countries, including a comparison with European and Asian countries: Discussion from a new perspective

Investigations of suicide in countries of the former Soviet Union, which broke into 15 different countries in the early 1990s, require examinations of a combination of economic, social, and health factors. It is important to address these factors individually and to examine the various composite indicators for each. Moreover, it would be worthwhile to explore the potential applicability of a comprehensive worldwide index. We analyzed data from nine of the former Soviet countries for which both the annual suicide rate and the Global Competitiveness Index (GCI) were available for the years 2006-2017. We determined the precise relationships between the suicide rate and the GCI during this period in these nine countries as well as in nine countries with high suicide rates in Europe and Asia. The results indicated the following: (i) In six of the nine former Soviet countries with complete data, the suicide rate showed a relationship with the GCI. Notably, this relationship was inverse in all but one country. (ii) Among the nine European and Asian countries with high suicide rates, three exhibited a correlation between the suicide rate and the GCI. Measures to prevent suicide should be devised especially in countries of the former Soviet Union through collaboration among multiple fields and organizations, as necessary, with particular attention paid to countries with worse or worsening GCI values.

Variations in Suicide Risk and Risk Factors After Hospitalization for Depression in Finland, 1996-2017

Importance

Although incidence of suicide in depression varies remarkably temporally, risk factors have been modeled as constant and remain uncharted in the short term. How effectively factors measured at one point in time predict risk at different time points is unknown.

Objective

To examine the absolute risk and risk factors for suicide in hospitalized patients with depression starting from the first days after discharge up to 2 years and to evaluate whether the size of relative risk by factor displays temporal patterns over consecutive phases of follow-up.

Design, Setting, and Participants

This population-based study using Finnish registers (hospital discharge, population, and cause of death registers) included all hospitalizations for depression as the principal diagnosis in Finland from 1996 to 2017, with a maximum follow-up of 2 years. Data were analyzed from January 2022 to November 2023.

Main Outcomes and Measures

Incidence rate (IR), IR ratios, hazard functions, and hazard ratios for suicide by consecutive time periods (0 to 3 days, 4 to 7 days, 7 to 30 days, 31 to 90 days, 91 to 365 days, and 1 to 2 years) since discharge.

Results

This study included 193 197 hospitalizations among 91 161 individuals, of whom 51 197 (56.2%) were female, and the mean (SD) age was 44.0 (17.3) years. Altogether, patients were followed up to 226 615 person-years. A total of 1219 men and 757 women died of suicide. Incidence of suicide was extremely high during the first days after discharge (IR of 6062 [95% CI, 4963-7404] per 100 000 on days 0 to 3; IR of 3884 [95% CI, 3119-4835] per 100 000 on days 4 to 7) and declined thereafter. Several factors were associated with risk of suicide over the first days after discharge. Current suicide attempt by hanging or firearms increased the risk of suicide most on days 0 to 3 (IR ratio, 18.9; 95% CI, 3.1-59.8) and on days 0 to 7 (IR ratio, 10.1; 95% CI, 1.7-31.5). Temporal patterns of the size of the relative risk diverged over time, being constant, declining, or increasing. Clinical factors had the strongest association immediately. Relative risk remained constant among men and even increased among those with alcohol or substance use disorder.

Conclusions and Relevance

In this study, patients hospitalized for depression had extremely high risk of suicide during the first days after discharge. Thereafter, incidence declined steeply but remained high. Within the periods of the highest risk of suicide, several factors increased overall risk manyfold. Risk factors' observed potencies varied over time and had characteristic temporal patterns.

Predicting a short-term change of suicidal ideation in inpatients with depression: An ecological momentary assessment

INTRODUCTION

Patients with depression often require inpatient treatment due to their high suicide risk. Ecological momentary assessment (EMA) studies have shown that suicidal ideation (SI) fluctuates over time. As affective instability and psychological pain (PP) are common experiences in borderline personality disorder (BPD), often comorbid with depression, we examined factors predicting short-term changes of SI in depressive inpatients with or without BPD.

METHODS

Psychiatric inpatients with depression with (N = 30) or without (N = 37) comorbid BPD assessed their anxiety, PP, severity of depression, SI, and hopelessness three times daily using visual analogue scales. Multilevel regression models were estimated.

RESULTS

Altogether 4320 EMA observations, spanning on average 3.4 successive days, were collected. Only severity of depression (β = 0.19; [95 % CI = 0.06, 0.32]) and previous SI (β = 0.32; [95 % CI = 0.23, 0.41]) predicted near-future SI within several hours. PP predicted near-future SI in inpatients with depression and BPD (β = 0.28; [95 % CI = 0.11, 0.46]), but not in patients without BPD.

LIMITATIONS

The follow-up data represents only the first days of hospitalization. The context of the EMA is the acute psychiatric ward, affecting generalizability to outpatients.

CONCLUSIONS

Short-terms changes in SI are predicted by changes in severity of depression and previous SI in depressed inpatients without BPD, and also by changes in PP in depressed inpatients with BPD. As SI and its risk factors may oscillate within a time scale of hours, frequent monitoring of momentary severity of depression, PP, and SI may be warranted in inpatient settings.

Risk of suicidal behavior in patients with major depression and bipolar disorder - A systematic review and meta-analysis of registry-based studies

Suicide is a health priority and one of the most common causes of death in mood disorders. One of the limitations of this type of research is that studies often establish rates of suicide behaviors in mood disorders by using diverse comparison groups or simply monitoring cohort of patients over a time period. In this registry-based systematic review, national registers were identified through searches in six academic databases, and information about the occurrence of suicide behaviors in mood disorders was systematically extracted. Odds ratios were subsequently calculated comparing rates of death by suicide in mood disorders in comparison with age and period matched rates of death by suicide in the general population obtained from country-wide national registers. The aim was to provide the most recent summary of epidemiological and clinical factors associated to suicide in mood disorders whilst calculating the likelihood of death by suicide in mood disorders in comparison with non-affected individuals according to national databases. The study follows the Preferred Reporting Guidelines for Systematic Reviews and Meta-analyses and was prespecify registered on Prospero (CRD42020186857). Results suggest that patients with mood disorders are at substantially increased risk of attempting and dying by suicide. Several epidemiological, clinical and social factors are reported to be associated with clinical populations at risk of suicide. Meta-analyses of completed deaths by suicide suggest that the likelihood for dying by suicide in mood disorders is 8.62 times higher in major depression and 8.66 times higher in bipolar disorder with higher number of untoward events in women compared to men in both conditions. The likelihood of dying by suicide in major depressive disorders is higher in the first year following discharge. Clinical guidelines might consider longer periods of monitoring following discharge from hospital. Overall, due to the higher risk of suicide in mood disorders, efforts should be made to increase detection and prevention whilst focusing on reducing risk in the most severe forms of illness with appropriate treatment to promote response and remission at the earliest convenience.

Borderline personality disorder and depression severity predict suicidal outcomes: A six-month prospective cohort study of depression, bipolar depression, and borderline personality disorder

BACKGROUND

Suicide risk is high in patients with major depressive disorder (MDD), bipolar disorder (BD) and borderline personality disorder (BPD). Whether risk levels of and risk factors for suicidal ideation (SI) and suicide attempts (SA) are similar or different in these disorders remains unclear, as few directly comparative studies exist. The relationship of short-term changes in depression severity and SI is underinvestigated, and might differ across groups, for example, between BPD and non-BPD patients.

METHODS

We followed, for 6 months, a cohort of treatment-seeking, major depressive episode (MDE) patients in psychiatric care (original n = 124), stratified into MDE/MDD, MDE/BD and MDE/BPD subcohorts. We examined risks of suicide-related outcomes and their risk factors prospectively. We examined the covariation of SI and depression over time with biweekly online modified Patient Health Questionnaire 9 surveys and analysed this relationship through multi-level modelling.

RESULTS

Risk of SA in BPD (22.2%) was higher than non-BPD (4.23%) patients. In regression models, BPD severity was correlated with risk of SA and clinically significant SI. During follow-up, mean depression severity and changes in depression symptoms were associated with SI risk regardless of diagnosis.

CONCLUSIONS

Concurrent BPD in depression seems predictive for high risk of SA. Severity of BPD features is relevant for assessing risk of SA and SI in MDE. Changes in depressive symptoms indicate concurrent changes in risk of SI. BPD status at intake can index risk for future SA, whereas depressive symptoms appear a useful continuously monitored risk index.

Cause-specific excess mortality after first diagnosis of bipolar disorder: population-based cohort study

BACKGROUND

Bipolar disorder (BD) is associated with increased mortality, but evidence on cause-specific mortality is limited.

OBJECTIVE

To investigate cause-specific premature excess mortality in BD.

METHODS

Finnish nationwide cohort study of individuals with and without a diagnosis of BD who were aged 15-64 years during 2004-2018. Standardised mortality ratios (SMRs) with 95% CIs were calculated for BD using the mortality rates in the Finnish general population without BD as weights. Causes of death were defined by the International Classification of Diseases, 10th revision codes.

FINDINGS

Of the included 47 018 individuals with BD, 3300 (7%) died during follow-up. Individuals with BD had sixfold higher mortality due to external causes (SMR: 6.01, 95% CI: 5.68, 6.34) and twofold higher mortality due to somatic causes (SMR: 2.06, 95% CI: 1.97, 2.15). Of the deaths due to external causes, 83% (1061/1273) were excess deaths, whereas 51% (1043/2027) of the deaths due to somatic causes were excess. About twice the number of potential years of life were lost in excess due to external causes than due to somatic causes. Alcohol-related causes contributed more to excess mortality than deaths due to cardiovascular disease.

CONCLUSION

External causes of death contributed more to the mortality gap than somatic causes after controlling for age-specific background general population mortality.

CLINICAL IMPLICATION

A balanced consideration between therapeutic response, different treatment options and risk of cause-specific mortality is needed to prevent premature mortality in BD and to reduce the mortality gap.

Assessment of lethality and its clinical correlates in suicide attempters with mood disorders

BACKGROUND

Relatively limited literature is available on lethality assessment for suicide attempts in affective disorders from the Indian subcontinent.

AIMS

To assess the lethality and its clinical correlates in lifetime suicide attempters with mood disorders.

METHODS

A total of 100 lifetime suicide attempters, aged ≥18 years, with a DSM-5 diagnosis of bipolar disorder (BD) or major depressive disorder-recurrent (MDD-R) were recruited. Current euthymia was ascertained (Hamilton Depression Rating Scale (HAM-D) ≤7; Young Mania Rating Scale (YMRS) ≤4). Assessments were conducted using clinical pro forma, Risk-Rescue Rating Scale (RRRS), Columbia Suicide Severity Rating Scale (C-SSRS) and Barratt's Impulsiveness Scale (BIS).

RESULTS

Average age of the sample was 36.32 ± 11.76 years (48% males, 52% females). The mean duration of affective illness was 10.59 ± 8.32 years. Risk-rescue scores for lethality were significantly higher in males (vs females), bipolar disorder (vs unipolar), multiple attempters (vs single) and planned (vs unplanned) attempters. Risk-rescue score also showed a significant positive correlation with lifetime total and depressive episodes, and intensity of ideations, and a significant negative correlation with BIS-attention impulsiveness. Regression analysis [F (3,96) = 12.196, P < 0.001, adjusted R² = 0.253] found that lifetime lithium prescription, intensity of suicidal ideations and attention impulsiveness explained 25.3% variance in lethality.

CONCLUSION

Absence of lifetime lithium, higher intensity of suicidal ideations and lower attentional impulsiveness predicted higher lethality of suicide attempts. Lethality of suicide attempts was found to be associated with a multitude of clinical factors, notably male gender, bipolarity, multiple attempts, planned attempts and number of total and depressive episodes. Assessment of lethality and its correlates can help to plan strategies towards risk prevention in mood disorders.

Psychological pain and suicidal behavior: A review

Despite accumulation of clinical research on risk factors for suicidal process, understanding of the mechanisms and pathways underlying the emergence of suicidal thoughts and their progression to acts is insufficient. The suicidal process has been conceptualized in multiple psychological theories that have aimed to shed light on the interplay of contributing factors. One of the central concepts included in both the cubic model of suicide and the three-step theory of suicide is psychological pain (mental pain or psychache). Over the two last decades, interest in psychological pain has increased considerably, particularly since the discovery of the complex link between the pain processing system and the neurobiology of suicide, and the putative antisuicidal effect of buprenorphine. Growing evidence supports the association between experiencing psychological pain and suicidal ideation and acts in both clinical and non-clinical samples. However, many questions related to the concept of psychological pain and its role in prediction of suicidal behavior remain to be answered in future research. In this narrative review, we have outlined the history of the concept, the definition of psychological pain, and the tools developed for its measurement, summarized the empirical research on psychological pain in relation to suicidal behavior, and suggested future directions for clinical research on psychological pain and suicidal behavior.

New frontiers in suicide vulnerability: immune system and sex hormones

Suicide is one of the leading causes of death worldwide and men have a higher risk of attempting and completing suicide than women. Accumulating evidence leads to a possible key role of the immune system and sex hormones in psychiatric conditions associated with suicide vulnerability (e.g., major depressive disorder). Moreover, the literature highlights a dysregulation of the immune system and altered sex hormone levels in suicidal patients. Sex hormones and the immune system may have a role in suicide risk and sex differences in suicide vulnerability. This brief review emphasises a research area focused on a possible interplay between the immune system and sex hormones that may help develop a better understanding of suicide vulnerability in the perspective of sex-specific therapeutic approaches.

Risk factors for suicide in psychiatric emergency patients in Beijing, China: A large cross-sectional study

Psychiatric emergency patients constitute a population at high risk of suicidal thoughts and behaviors (STB). However, the risk factors for STB in this population have not been clearly defined. This study aimed to explore the risk factors for STB in psychiatric emergency patients in China. A cross-sectional analysis was conducted at the emergency department of psychiatry, Anding Hospital, Capital Medical University from 2015 to 2017. The Chinese suicide risk factors scale was used to test the STB of the patients. Multivariable logistic regression analysis was used to determine the risk factors of STB. A total of 12,345 patients were included. Their average age was 36 years. According to the suicide risk scale, 3436 cases (27.83%) were at risk of STB, mainly young adults. The multivariable analysis showed that urban residence, years of education, living in Beijing, ethnic Han, living alone, unemployment, poor relationship with parents, one or more siblings, visit time in the night, family history, disease course, total duration, the total number of psychiatric hospitalizations, a clear diagnosis, Brief Psychiatric Rating Scale total score ≥28.5, Hamilton Depression Rating Scale total score ≥20, and Young Mania Rating Scale total score ≥12 were independent risk factors for STB.

The renin-angiotensin system, mood, and suicide: Are there associations?

Available evidence points to a possible role of the renin-angiotensin system (RAS) in the pathophysiology of mood disorders and suicide. We carried out a critical analysis of literature data regarding this role, with a focus on the proposed association between RAS dysfunction and suicidal behavior. Epidemiological, genetic, and biochemical findings are described, and the pathophysiological hypothesis aiming at explaining the possible relationship between RAS and suicide are discussed. Available findings do support the involvement of the RAS in the neurobiology of suicide, although the exact mechanisms underlying this involvement are still unknown.