A prospective study of the paradoxical relationship between impulsivity and lethality of suicide attempts

BACKGROUND

Biological studies suggest that lower serotonergic activity is associated with both greater suicide lethality and impulsive personality traits. These results may lead to the conclusion that impulsivity in the attempt should be associated with greater lethality. However, Klerman's review of epidemiologic suicide studies suggests an inverse relationship between impulsivity and lethality. This seemingly paradoxical relationship between impulsivity and lethality has not been explored in large representative clinical samples of suicide attempts.

METHOD

During 1996 to 1998, 478 individuals who attempted suicide were studied in a general hospital in Madrid, Spain. Impulsivity was measured as described in the literature by combining 2 items of Beck's Suicidal Intent Scale (active preparation for attempt and degree of premeditation). Lethality of the attempt was assigned 1 of 4 levels according to the need for medical and/or psychiatric treatment.

RESULTS

More than half of the attempts were impulsive (55%; 95% confidence interval [CI], 51% to 59%), approximately one fourth of the attempts had an intermediate level of impulsivity (28%; 95% CI, 24% to 32%), and approximately one sixth of the attempts were not impulsive (17%, 95% CI, 13% to 21%). There was an inverse association between the impulsivity and lethality of the suicide attempt (chi2 = 62.639, df = 6, p < .0001). The most impulsive attempts tended to result in less morbidity, while the less impulsive attempts tended to be more lethal.

CONCLUSION

If the inverse relationship between impulsivity and lethality is replicated in other large and representative samples, new studies will be needed to clarify the complex interactions between the clinical dimensions (lethality, impulsivity as a state, and impulsivity as a personality trait) and the biological correlates (particularly serotonergic function) of suicidal behavior.

Dysregulation of emotional response in current and abstinent heroin users: negative heightening and positive blunting

OBJECTIVE

Evidence suggests that abstinent opioid users have abnormal emotional response to natural reinforcing stimuli, but little is known about the emotional response of subjects currently using heroin. Abnormal emotional experience could underlie poor sensitivity to negative events related to heroin use and reduced ability to consider alternative reinforcers to help overcome addiction. In this paper, we will assess the subjective response of current and abstinent heroin users exposed to emotionally competent positive and negative stimuli.

MATERIALS AND METHODS

We administered the "Clinical Instrument for Emotional Response Evaluation" (including neutral, pleasant, and unpleasant images from the International Affective Picture System) to 22 current opioid users enrolled in a clinical trial using controlled prescribed heroin and 41 abstinent opioid users enrolled in residential treatment. The dependent variable was their subjective response to the images measured with the Self-Assessment Manikin, a scale designed to rate the International Affective Picture System (IAPS) images in the three dimensions of emotion: valence, arousal, and dominance. We compared these ratings with IAPS normative values for healthy participants.

RESULTS

Significant group x emotional condition interactions were found in the arousal dimension. Post-hoc tests showed that compared to healthy participants, both current and abstinent heroin users had greater emotional response to neutral images and lower response to pleasant images. Furthermore, current opioid users had higher emotional response to unpleasant images when compared to healthy participants and lower response to pleasant images when compared to abstinent users.

CONCLUSIONS

Current opioid users have abnormal emotional experience, characterized by heightened response to unpleasant stimuli and blunted response to pleasant stimuli.

Suicide attempts among women during low estradiol/low progesterone states

The relationship between the menstrual cycle and risk for suicidal behaviors is not clear. The aim of this study is to determine whether perimenstrual phases in fertile women are associated with acute risk for suicide attempt and explore whether risk is elevated during low estradiol/low progesterone states. Women (N=431) recruited within 24h of a suicide attempt were assessed for psychopathology, suicidal behavior and LH, FSH, estradiol and progesterone blood levels. Among fertile women (N=281/431), suicide attempts were more likely to occur during menses (26%, 72/281 observed vs. 15%, 43/281 expected attempts; p<0.001). Compared to women whose attempts occurred during other phases, women who attempted suicide during low estradiol/low progesterone states (menstrual phase, amenorrhea and menopause) reported severe suicide intent, a measure that may be predictive of eventual suicide death. Suicide attempts among women are more likely when estrogen and progesterone levels are low and attempts made under these conditions are associated with greater severity. Low gonadal hormone levels may constitute a key factor in the neurobiological basis of suicidal behavior among women, suggesting a novel, testable hypothesis regarding the underpinnings of suicidal acts.

Low plasma cholesterol levels in suicidal males: a gender- and body mass index-matched case-control study of suicide attempters and nonattempters

Findings from animal and human studies suggest an association between low cholesterol levels and suicidal behaviors. The purpose of this case-control study was to test whether cholesterol levels in suicide attempters are lower than in controls without suicide attempt history matched by gender, age, and body mass index (BMI). Suicide attempters (n=177: 68 men and 109 women) and controls (177 blood donors) were assessed. Serum cholesterol levels were significantly lower in suicide attempters than in controls. After gender stratification, the difference remained significant in men, but not in women.

Association between obsessive-compulsive disorder and a variable number of tandem repeats polymorphism in intron 2 of the serotonin transporter gene

BACKGROUND

Pharmacological studies indicate a dysregulation of the serotonergic system in obsessive-compulsive disorder (OCD). A variable number tandem repeats (VNTR) polymorphism with three alleles (Stin2.9, Stin2.10, Stin2.12) has been described in intron 2 of the serotonin transporter (5-HTT) gene. This polymorphism has been associated with unipolar depression, bipolar disorder, schizophrenia, and anxiety disorders including OCD.

METHODS

The association between OCD and the polymorphism is examined in 97 OCD patients, 578 psychiatric controls and 406 healthy controls, all Spanish Caucasians.

RESULTS

Genotype frequencies for the polymorphism were significantly different in OCD patients, psychiatric patients and controls. There was a significant excess of 12/12 and 12/10 genotypes in OCD patients compared to psychiatric patients and controls.

CONCLUSIONS

Our results indicate a possible association between the Stin2.12 allele of the VNTR polymorphism and OCD.

Low serum cholesterol may be associated with suicide attempt history

OBJECTIVE

This case-control study used both healthy blood donors and psychiatric inpatients as controls and controlled for gender, age, low body mass index, alcohol and nicotine use, and aggressive and impulsive behaviors to examine the association between low serum cholesterol levels and suicide attempts.

METHOD

At a Spanish general hospital, the recruitment included 417 patients with suicide attempt history (138 men and 279 women), 155 psychiatric inpatient controls without suicide history (68 men and 87 women), and 358 healthy controls (220 men and 138 women). All participants were aged 18 years or older. To study the association between low serum cholesterol levels (fasting < 160 mg/dL) and suicide attempts, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated in univariate analyses. Logistic regression models adjusted ORs for confounding variables in male, female, and total samples. The study was conducted from January 1996 to December 1997.

RESULTS

The ORs in the total sample (for psychiatric and healthy controls respectively) were 1.8 (95% CI = 1.2 to 2.9, p = .007) and 1.9 (95% CI = 1.4 to 2.6, p < .001) for the univariate analyses, and 1.6 (95% CI = 0.95 to 2.6, p = .08) and 1.6 (95% CI = 1.0 to 2.4, p = .04) after variable adjustment. In women, the adjusted OR was 1.8 (95% CI = 0.90 to 3.5, p = .09) for psychiatric controls. In men, the adjusted OR was 2.0 (95% CI = 0.99 to 4.1, p = .05) for healthy controls. All ORs were in the hypothesized direction but some subsamples appeared too small to reach significance.

CONCLUSION

This study, somewhat limited by the small sample size, suggests that low cholesterol may be associated with suicide attempts. Low cholesterol level in suicide attempts may be more important from a pathophysiologic than from a diagnostic point of view.

Lack of association between testosterone and suicide attempts

OBJECTIVE

To determine whether testosterone levels differ in male suicide attempters versus healthy controls and to explore the associations between testosterone levels and time of blood collection, and between testosterone levels and characteristics of suicide attempts.

METHOD

A sample of 112 male suicide attempters was studied. Thirty-seven male blood donors were recruited as controls.

RESULTS

The mean testosterone levels were 5.1 ± 2.9 ng/ml in male attempters and 4.6 ± 1.6 ng/ml in controls. Group differences in testosterone levels were not significant when we studied the interaction with time of extraction (F = 0.37; d.f. = 2; p = 0.70) or when matched by age and time of extraction (t = -0.74; d.f. = 26; p = 0.47). When partial correlations were performed correcting for the effect of time of extraction, significant partial correlations were found in testosterone levels with history of aggressive behavior and lethality of the attempt.

CONCLUSIONS

When circadian variation and age were considered, we found no support for the putative role of testosterone as a biological marker of suicidal behavior. Further research should consider: (1) testosterone and neurosteroids; (2) serial determinations with a minimal time gap between the attempt and the blood extraction; (3) controls within the same time periods, and (4) other variables that may affect testosterone levels, such as body mass index, physical activity and sleep disturbances.

Association between the menses and suicide attempts: a replication study

OBJECTIVE

In our prior (first) study, suicide attempts were associated with the menses. The main hypothesis of this replication (second) study is that the proportion of suicide attempters during the menses is significantly higher than the expected probability in the general population.

METHODS

Using the same methodology and setting, this replication naturalistic study included 120 fertile female suicide attempters with regular menstrual cycles during a 1-year period in the emergency room of a general hospital in Madrid, Spain, serving a catchment area of 500,000 people.

RESULTS

The significant increase in probability of attempting suicide during the menses for the first study was 1.61; for the second study, 1.72; and for both studies combined, 1.68 (95% confidence interval, 1.27-2.09). Thus, using the combined results, the probability of attempting suicide during the menses was 1.68 times higher than the overall probability of attempting suicide for any fertile women. In the catchment area, the population rate of fertile women arriving at the hospital after a suicide attempt was 166 per 100,000. The probability for women during the menses arriving at the hospital after a suicide attempt was significantly higher, 279 per 100,000 (1.68 x 166 per 100,000). The 95% confidence interval was 211 to 347 per 100,000.

CONCLUSIONS

Despite inherent limitations, this naturalistic study replicates a small but significant increase of suicide attempts during the menses.

Premenstrual symptoms and luteal suicide attempts

OBJECTIVE

If premenstrual symptoms (PMS) are temporally and specifically associated with suicidal attempts, suicide attempts in women with PMS should occur more frequently in the luteal phase.

METHOD

In a general hospital, 125 fertile female suicide attempters (and 83 blood donors as controls) with regular menstrual cycles were prospectively studied. A retrospective DSM-IV diagnosis of Premenstrual Dysphoric Disorder (PMDD) was made.

RESULTS

Attempts during the luteal phase were not more frequent in females with PMDD (34%,23/68) than in those without PMDD (35%, 20/57). The sample had enough power to detect medium and large effect sizes. As expected, there was a significantly higher frequency of PMDD in suicide attempters than in the controls (54% vs 6%; Fisher's exact test, p < or = 0.001).

CONCLUSION

This study was limited by the use of retrospective PMDD diagnosis but suggests that PMDD may not be associated with suicidal acts during the luteal phase,when PMS are present.

Life cycle and suicidal behavior among women

It is nowadays accepted that, independently of methodological issues, women commit fewer suicides than men but make more frequent attempts. Yet, female suicidal risk varies greatly along the lifetime and is linked to the most significant moments in it. A wide analysis of the existing literature was performed to provide a narrative description on the evolution of female suicidal rates from childhood to old age, considering the milestones in their life history. A detailed analysis of gender differences in suicidal behavior is key to establish preventive measures and priorities. More specific studies are needed to adapt future interventions on female suicide.

A pilot study on a gene-hormone interaction in female suicide attempts

This one-year naturalistic study included all suicide attempters in a catchment area. In the first published set of analyses, an association between menses and suicide attempts was replicated. According to the polymorphism of the serotonin transporter promoter area, the subjects can be classified as S individuals (s/s or s/l) or L individuals (l/l). In the second published set of analyses, L females appeared protected from suicide attempts since they were underrepresented among female (and not male) attempters. This new, unpublished third set of analyses tested for an interaction between the same polymorphism and low hormonal activity (during menses and menopause). In fertile female attempters, the proportion of L women in the menses (41%, 7/17) was significantly higher than expected in the population (15.5 %) and almost significantly higher than in S female attempters (22%,19/87). L females were also overrepresented in postmenopausal attempters. Despite sample size limitations, this gene-hormone interaction needs to be further investigated in female suicide attempters.

Nucleotide variation in central nervous system genes among male suicide attempters

Despite marked morbidity and mortality associated with suicidal behavior, accurate identification of individuals at risk remains elusive. The goal of this study is to identify a model based on single nucleotide polymorphisms (SNPs) that discriminates between suicide attempters and non-attempters using data mining strategies. We examined functional SNPs (n = 840) of 312 brain function and development genes using data mining techniques. Two hundred seventy-seven male psychiatric patients aged 18 years or older were recruited at a University hospital psychiatric emergency room or psychiatric short stay unit. The main outcome measure was history of suicide attempts. Three SNPs of three genes (rs10944288, HTR1E; hCV8953491, GABRP; and rs707216, ACTN2) correctly classified 67% of male suicide attempters and non-attempters (0.50 sensitivity, 0.82 specificity, positive likelihood ratio = 2.80, negative likelihood ratio = 1.64). The OR for the combined three SNPs was 4.60 (95% CI: 1.31-16.10). The model's accuracy suggests that in the future similar methodologies may generate simple genetic tests with diagnostic utility in identification of suicide attempters. This strategy may uncover new pathophysiological pathways regarding the neurobiology of suicidal acts.

Fibromyalgia and psychopathology

Introduction

Fibromyalgia seems to be associated with various forms of psychopathology, particularly major affective disorders.

Objective

To evaluate associated psychopathology in a series of women with diagnosis of fibromyalgia.

Methods

Patient inclusion from 1st March to 30th June 2010. Symptom Checklist (SCL-90-R) was used for evaluation. SPSS was used for statistical analysis of data and results.

Results

A total of 34 women voluntarily joined our study. Mean age was 52.2 years (standard deviation (SD) 7.17). 11.4% were singled, 74.3% married or unmarried couples, 8.6% were divorced, and 5.7% were widowers. 74.3% of women lived with their couple and/or children whereas 8.6% lived by their own, and 8.6% with their parents. Results obtained with SCL-90-R showed:

Global Severity Index (GSI) 1.86 (Standard Deviation (SD) 0.54); Positive Symptom Distress Index (PSDI) 2.58 (SD 0.36); Positive Symptom Total (PST) 167.85 (SD 49.30); Somatization (SOM) 2.62 (SD 0.53); Obsessive-Compulsive (O-C) 2.59 (SD 0.78); Interpersonal Sensitivity (I-S) 1.50 (SD 0.86); Depression (DEP) 2.5 (SD 0.75); Anxiety (ANX) 1.75 (SD 0.74); Hostility (HOS) 1.11 (SD 0.82); Phobic Anxiety (PHOB) 1.09 (SD 0.84); Paranoid Ideation (PAR) 1.11 (SD 0.85); Psychoticism (PSY) 1.05 (SD 0.62), and other vague symptoms 2.15 (SD 0.70).

Conclusion

Our patients with fibromyalgia scored higher in somatization, obsession-compulsion, depression, and anxiety. In view of the results, there is an important association between fibromyalgia and various forms of psychopathology.

[Attempted suicide and previous contact with health system]

INTRODUCTION

Suicide behavior is an important health problem. Several works found have reported that the majority of completed suicides visited to the general practitioner in previous days.

METHOD

219 suicide attempts attended in a General Hospital were asked about their previous contact with health system.

RESULTS

The third part of the patients have visited the general practitioner in the previous month. 60% of the patients with personal antecedents of psychiatric diseases have visited to mental services in the previous month.

CONCLUSIONS

It is necessary to find risk suicide markers that allow identifying these patients in primary attention. The increment of the consultation periodicity is proposed as efficient risk suicide marker.

[Familiar history of suicidal behavior]

Suicide is such a serious public health problem that it has been proposed as an indicator of mental health of a society. Self-harm, a behavior related with suicide, is also a public health problem with a prevalence 8 to 15 times higher than suicide. Suicide behavior is the result of different social, cultural, biological and psychopathological factors and affects all the cultures. This clinical case of 4 brothers from a family of 8 siblings seen repeatedly due to suicide attempts make it possible to discuss these factors. The family and social report describes a low economical and cultural level. The family climate is marked by aggressive environment and inappropriate care of the children. Different members of the siblings initiated drug consumption as a teenager. It is interesting to point out the high frequency of suicide attempts in this family and the health resources used as well as the deterioration in the quality of life associated. The elevated weight of the fa m i ly factors in the development of the suicide behavioris observed and offers the opportunity of questioning if whether it is the environmental factors, genetic vulnerability to mental disorder or specific predisposition to suicidal behavior that is transmitted in the family.