Mapping caregivers’ distress: a network analysis of burden, meaning in life, and mental health in families facing suicidal behavior

A Suicide-Specific Diagnosis – The Case For

After completing this article, readers should be able to: Most youth occasionally experience the blues, feel sad, or become irritable. Nevertheless, it is important to consider the possibility of a depressive disorder when a depressed or irritable mood is more than temporary, occurs in conjunction with other symptoms, or interferes with daily functioning. Major depressive disorder (MDD) is manifested by a depressed or irritable mood or diminished interest or pleasure that lasts for at least 2 weeks. This is accompanied by changes in cognitive and physical functioning. Dysthymic disorder (DD) is a less severe type of depression that involves chronic symptoms and lasts for at least 1 year. These specific types of depressive disorders are the focus of this article.Depressive disorders can be identified in children of all ages, but they become increasingly prevalent during adolescence. In fact, the peak ages of depressive symptom onset in lifespan studies are 15 to 19 years and 25 to 29 years. The sharpest rise in prevalence occurs among girls during adolescence and early adulthood. Approximately 2% of school-age children and 4% to 6% of adolescents struggle with MDD at any one point in time. Lifetime prevalence rates by late adolescence range between 20% and 25%.Prior to puberty, there is about a 1:1 gender ratio for depressive disorders. After puberty, this shifts to a 2:1 ratio of females to males, which continues throughout adulthood. A combination of hormonal and social changes during puberty may explain the differing rates of depression among males and females.Depression has a complex genetic and environmental basis. Adoption, twin, and family studies all point to the impact of genetic factors, which seem to establish a young person's biologic vulnerability for depression. The onset of a depressive episode, however, often is precipitated by difficult life events or stressful experiences such as a parental divorce, school change, or relationship breakup. Other environmental risk factors include maltreatment (sexual abuse, physical abuse, or neglect). The pathways to depression are complex and variable. Some depressive disorders are more biologic; others are more situational.The symptoms of MDD and DD, as outlined in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV; American Psychiatric Association, 1994), include changes in physical, cognitive, and emotional domains (Tables 1 and 2).In 1996, the World Health Organization ranked depression among the most disabling of all diseases in the world, leading all other disorders in "years lived with disabilities." The reasons for this are apparent when one considers the course of depressive illness. Approximately 70% of youth who have MDD experience another depressive episode within 5 years, and youth who have depressive disorders have a fourfold risk of an adult depressive disorder. Approximately 50% of children and adolescents who have MDD can be expected to have adult recurrences. Early onset and recurrences also have been described as a cause of treatment-resistant depression in later life, leading to multiple episodes that last longer, become more severe, and become more difficult to treat. These tend to be associated with more hospitalizations, job absenteeism, and impaired work performance.Depressive disorders in youth are associated with impaired functioning in several areas of daily living. These include strained family and peer relationships, school attendance difficulties, and academic performance problems. Affected youth often experience suicidal thoughts and are at increased risk for attempted and completed suicide.Early-onset bipolar disorder (BD) often presents as depressive symptoms, which can make it difficult to distinguish between bipolar and unipolar depression. BD is characterized by alternating periods of mania and depression. The inflated self-esteem, excess energy, and poor judgment that characterize a manic phase often result in dangerous activity and substantial social problems. Rapid cycling and mixed symptom states occur in subtypes of BD. Approximately 20% to 40% of children who have MDD eventually develop BD. Some clues to the risk for developing a manic or hypomanic episode include psychosis, psychomotor retardation, or a family history of BD.Another potential diagnostic dilemma occurs when a child or adolescent is abusing alcohol or drugs. Youth are not always forthcoming about such abuse, which may be associated with declining school performance, withdrawal from usual social activities, sleep disturbance, and negative moods. Careful questioning of the youth and parent/guardian is necessary to identify a substance use disorder in youth presenting with depressive symptoms. It can be equally challenging to identify a depressive disorder in youth initially identified for services because of problems related to alcohol or substance abuse.Most children and adolescents who are depressed also have a history of some other psychiatric or alcohol/drug use disorder. For example, 25% to 75% of depressed youth have one or more anxiety disorders, such as separation anxiety disorder or social phobia. Disruptive behavior disorders, such as attention-deficit disorder or oppositional defiant disorder, are also common, and substance abuse or dependence characterizes a significant minority of youth who are depressed. A gender difference exists in patterns of comorbidity. Girls more commonly have comorbid anxiety conditions; boys are more likely to have comorbid conduct disorders or substance use disorders.Children and adolescents rarely seek professional treatment. Thus, parents, teachers, pediatricians, and others who have regular contact with youth play critical roles in recognizing youth who are depressed. Few youth use the word "depressed"; even fewer report to someone that they may be experiencing a clinical depression. Therefore, it is helpful to ask youth about experiences of feeling down, "bad," miserable, bored, or irritated. Signs of clinical depression that often initially are visible to others include withdrawal from activities, decline in school performance, change in sleep patterns, and sadness or irritability.The United States Preventive Services Task Force recently recommended the use of two questions in screening for depression among adults: "Over the past 2 weeks, have you ever felt down, depressed, or hopeless?" and "Have you felt little interest or pleasure in doing things?" The Task Force concluded that evidence is inconclusive regarding the effectiveness of routine screening of children and adolescents, but these two questions may help clinicians detect primary symptoms of depression. More comprehensive screening instruments and diagnostic tools or a referral to a mental health professional should be considered if indicated. The Reynolds Adolescent Depression Inventory (RADS) and the Children's Depression Inventory (CDI) are screening tools used in some school and mental health clinics.Clinical interviews are the cornerstone of a comprehensive assessment and should include, at a minimum, interviews with the youth as well as the parent or guardian. In addition to gathering a complete history of presenting problems (onset, chronicity, severity, prior history of symptoms, and treatment), a full psychiatric interview is conducted to obtain information about possible comorbid conditions. For example, it is critical to ascertain whether psychotic features, disruptive behavior disorders, anxiety disorders, or substance abuse problems are present. Information also is gathered about the youth's medical, developmental, social, and educational histories as well as the family psychiatric history.Important sources of information may include school academic and attendance records; teacher reports; and appropriate biomedical, psychological, or other test findings. Standardized self-report questionnaires may permit youths to answer questions about current symptoms without directly verbalizing the extent of their emotional distress to an adult. This approach sometimes can facilitate honest reporting of the number and severity of depressive symptoms. If noted in a self-report questionnaire, critical items always should be followed up with direct inquiry by the clinician (eg, if a youth reports suicidal ideation).The initial goals of treatment are to ensure the youth's safety and develop an effective therapeutic alliance with the youth and parents. This alliance will facilitate ongoing communication and continuation of care. Consultation with teachers and other caregivers also is important. A focus on patient and family education and a collaborative approach to treatment planning can enhance the youth's adherence to treatment recommendations.Psychoeducation is a key component of the treatment. Beyond this, perspectives on the first line of treatment vary. The choice of whether to begin with psychotherapeutic or psychopharmacologic interventions or a combination depends on depression severity and chronicity, prior history of depressive episodes, likelihood of adherence, previous response to treatment, patient and family motivation for treatment, and availability of resources. Because of the psychological, environmental, and social problems associated with depression and its treatment, pharmacotherapy usually is not sufficient as the sole treatment. Attention to parental mental health and family stress as well as to strategies for helping parents manage the youth's irritability, isolation, or other problems should be included in psychotherapeutic interventions. These systemic concerns affect treatment adherence and ultimate outcomes.Psychoeducation addresses the signs and symptoms of depression; the importance of psychotherapy and psychiatric medication; and common misconceptions about the illness, therapy, or medications. It also is helpful to address the impact that depression has on school, social, and family functioning and the ways in which parents and teachers may aid in recovery. Parent and family education may increase adherence and reduce self-blame. Education of parents can help them identify their own mood disorders and potential treatment needs as well. Education also can reduce blame for symptoms such as irritability and anhedonia that may affect others.Controlled studies have documented the short-term effectiveness of cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) for depressed youth. Both generally are time-limited therapies that involve collaboration or guided discovery between the therapist and adolescent. CBT focuses on self-understanding of negative mood states and on the identification and modification of negative, distorted thought patterns. It also emphasizes problem-solving skills, communication skills, and the development of more adaptive behavior patterns. IPT strives to improve the youth's interpersonal functioning by improving self-understanding, problem-solving, communication, and coping in the realm of relationships. It focuses on a chosen interpersonal problem such as grief, a difficult role transition, an interpersonal conflict or role dispute, social skill deficits, or issues in step-parent families. Although randomized, controlled clinical trials have not been conducted for psychodynamic therapy with depressed youth, this approach may be useful. Family therapy is an important supplement to any of these approaches if difficulties in family communication and support are identified. Goals of family therapy may include improving family affective communication, increasing adaptive behaviors, and changing both interpersonal and family functioning.Selective serotonin reuptake inhibitors (SSRIs) are the antidepressants of choice for youth who require pharmacotherapy (American Academy of Child and Adolescent Psychiatry, 1998). The efficacy of the SSRI fluoxetine in reducing depressive symptom severity in children and adolescents has been demonstrated in two double-blind, randomized, placebo-controlled trials. Paroxetine also has demonstrated efficacy compared with imipramine and placebo in a double-blind, placebo-controlled comparison. Other antidepressant medications are not well studied. Dosing guidelines recommend starting with 10 mg fluoxetine and increasing to 20 mg. The maximum dose is 40 mg to 80 mg. When treating a child younger than 8 years of age, clinicians may want to start with 4 to 8 mg elixir of fluoxetine. However, the efficacy and safety data have been demonstrated only down to age 8 years. If there are problems with insomnia, appetite loss, or restlessness, paroxetine is a more sedating SSRI, and dosing guidelines are identical to those for fluoxetine. SSRIs should be discontinued if symptoms of mania appear. However, youth may benefit from treatment with an SSRI for an extended period before BD develops.An adequate trial of SSRIs is at least 4 to 6 weeks. If no or only minimal improvement is observed, a dose increase should be considered and medication continued for at least 4 to 6 additional weeks. If no improvement has been observed, alternative strategies should be considered, including a referral to a psychiatrist in cases of treatment-resistant depression. Additionally, if the pediatrician is not comfortable in the prescriber role, a psychiatric consultation or referral to a physician experienced in the use of medication is recommended. Frequent medication adjustments are ill-advised, and tapering of medications that have shorter half-lives (eg, paroxetine) is recommended. Obtaining serum levels rarely is necessary unless concerns arise about toxicity or compliance. Studies among adults suggest that the same doses used to treat MDD are efficacious for DD.Tricyclic antidepressants (TCAs) are not considered a first-line treatment for children and adolescents who are depressed, but they may be helpful in treating youth who have comorbid attention-deficit/hyperactivity disorder, enuresis, and narcolepsy as well as for augmentation purposes.In contrast to TCAs and monoamine oxidase inhibitors, SSRIs have a relatively safe adverse effects profile, are easily used (once daily), are suitable for long-term maintenance, and have a low lethality after overdose. Additional information on adverse effects, medication interactions, and the treatment of comorbid conditions is available in reviews of practice recommendations published by the American Academy of Child and Adolescent Psychiatry.ECT can be a useful adjunct for individuals whose depression is severe or life-threatening, who have not responded to other treatments, who cannot take antidepressant medications, and who may have psychotic depression. The decision to use ECT must be made carefully and usually requires the recommendation of more than one psychiatrist as well as a substantial discussion with the child's parent or guardian.Unless there are significant adverse effects, medication should be continued for 6 to 12 months if it is believed to help in the remission of depressive symptoms. The pharmacotherapy should be monitored monthly during this continuation phase. Psychotherapy is helpful during this phase to bolster coping skills and to address antecedents, stressors, and interpersonal conflicts that may have contributed to the onset of depression. Medication adherence also may be improved by psychotherapy.Once the patient's symptoms have remitted for 6 to 12 months, the maintenance phase of treatment may last from 1 year to indefinitely. The goals are to facilitate healthy development and to prevent relapse or recurrence. These may be accomplished through monthly or quarterly visits, depending on the severity and chronicity of the present episode, frequency of previous episodes, comorbid disorders, the patient's motivation, and contextual factors (eg, support systems, family stress, and psychopathology).The presence of comorbid conditions often predicts a poorer response to psychopharmacologic and psychosocial treatments. These conditions, such as anxiety, disruptive behavior, and substance use disorders, often persist after remission of the depressive symptoms and require targeted treatments. Because of time, cost, or the incompatibility of treatments, addressing all conditions simultaneously may be impossible. Hence, the clinician often must prioritize treatment goals and the sequence of interventions.A depressive disorder may be "treatment-resistant" because of an inadequate dosage or duration of medication trial, inadequate duration or "fit" with a particular psychotherapy, poor treatment adherence, complicating comorbidity, undetected BD, chronic or severe life events, misdiagnosis, or mistreatment. Psychopharmacologic strategies to address treatment-resistant depression should be applied systematically in conjunction with family education and support and include optimization, switching, augmentation, or combination. Consultation with a psychiatrist always is advised with treatment-resistant cases.If BD is present or is a possibility, a mood-stabilizing agent (eg, lithium carbonate, valproate, or carbamazepine) may be warranted, especially because antidepressants may induce mania in youths at risk for BD. Approximately 30% to 50% of adults experience modest antidepressant effects with mood stabilizers alone. Antidepressants may be useful adjuncts in such treatments. Psychotic depression may require a combination of antidepressants with antipsychotics or ECT. Neuroleptics should be tapered after psychotic symptoms remit due to the risk of tardive dyskinesia. Atypical antipsychotic medications may be preferred. However, the long-term effects of these medications have not been studied in youth.Suicide is the third leading cause of death among children and adolescents (National Center for Health Statistics, CDC, 2000). The suicide rate for ages 15 to 24 years is 11.1 per 100,000, which is much higher than the rate for youth between the ages of 5 and 14 years (0.8 per 100,000). The suicide rate for males in the 15- to 19-year age group is markedly higher than that for females (Table 3). Rates differ by racial and ethnic group. African-American youth have lower suicide rates than Caucasian youth, with the lowest adolescent suicide rate being that of African-American females. The highest suicide rate is that of Native American males.Although many youth who report suicidal thoughts or attempt suicide do not become suicide victims, these categories overlap substantially. For instance, having frequent thoughts of suicide is the best predictor of suicide attempts, and most youth who attempt suicide report a history of suicidal ideation. Furthermore, greater severity of reported suicidal thoughts increases the likelihood of a suicide attempt within the next year. Approximately 35% to 45% of adolescents who complete suicide have a positive history of suicide attempt. The prevalences of both self-reported suicidal ideation and suicide attempts are higher for adolescent females than for adolescent males (Table 3).Risk factors for completed suicide and suicidal behavior are similar in most respects. There are a few exceptions, however, such as the more specific relationship between availability of firearms and completed suicide. In this section, we review the primary risk factors for completed suicide (Table 4).A history of prior suicidal behavior is the strongest predictor of future suicidal behavior. Nonlethal suicidal gestures or self-inflicted harm, which sometimes are thought to be manipulative or attention-seeking, should not be taken lightly. Youth often can be poor judges of lethality, and what is believed to be a gesture actually may be accompanied by significant suicidal intent. It also may result in substantial physical harm or even suicide because of an error in knowledge or judgment (eg, potential lethality of acetaminophen overdose).Approximately 80% of youth who attempt suicide and 90% of youth suicide victims have histories of identifiable psychiatric or mental disorders. The most common types of psychopathology in these youth are depressive disorders, alcohol or substance abuse, conduct disorder or patterns of aggressive behavior, and anxiety disorders. Increased suicide risk is associated with conditions that often are refractory to treatment or present management problems. These include BD, a chronic depressive disorder comorbid with alcohol or substance abuse, and psychotic presentations.Depressive disorders are linked with increased risk for suicidal ideation, suicide attempts, and completed suicides (Table 5). In fact, suicidal ideation and behavior are common and often unrelenting problems among youth who have depressive disorders. Eighty-five percent of depressed youth report significant suicidal ideation, and 32% of depressed youth report one or more suicide attempts prior to adulthood. Retrospective studies have found that about 50% of adolescent suicides involve the consumption of alcohol, which increases impulsivity, impaired judgment, and mood changes.Environmental or family stress, especially a history of neglect or physical, emotional, or sexual abuse, are considered significant risk factors for suicidal behavior. Interpersonal conflict and loss (eg, fights, break-ups, deaths) also are risk factors. Additionally, hopelessness, impulsivity, aggressive behavior, and agitation are psychological characteristics associated with increased risk for suicidal behavior.Gay, lesbian, and bisexual adolescents are at increased risk for suicidal behavior. Recent general population surveys indicate that of these youth experience suicidal ideation, and have made one or more suicide attempts during the past year. of the risk factors in these youth are the same as those for youth. such as comorbid substance abuse and however, are more common among youth who have a In risk factors such as and are specific to those who negative within risk for anxiety, and suicide increases when a youth someone who suicide. In these at and and and social as well as at identification with the suicidal behavior are recommended. of suicide may suicide are to possible to reduce and to parents and to of youth to such are found more commonly in the of suicide victims than in the of other youth, including those of suicidal youth. The importance of suicidal youth's to firearms is by documented between more and in suicide as or should be from the of suicidal youth or monitored by parents and that if adolescents will suicidal and previous suicidal behavior. questions should address whether children or adolescents they not if they ever have thought about or to if they ever have thought about or to and if they have or such a in It is important to that an adolescent about suicidal thoughts or will not such or or increase the risk for suicidal behavior. inquiry regarding the chronicity, and of such thoughts is Standardized self-report such as the may permit the youth to answer without direct which can facilitate If critical items related to or planning and items significant of chronicity, severity, or always should be followed up with direct Other sources of information include reports from parents, teachers, or others who may have suicidal or such as with the assessment of depressive disorders, a comprehensive that from the youth and parent or is psychiatric or may be necessary for found to be at suicide generally are and and attempts that have significant lethality and that include taken to indicate as well as knowledge and planning and should be taken Furthermore, to safety requires of the child's and caregivers should be advised to especially firearms and medications, from the by young children should not be as For example, when a child it may not be behavior should be carefully for associated mood or other or are used in many The patient is to not to attempt suicide. Furthermore, the patient is to to contact the or other adult if or a suicidal or experiences suicidal intent. on these have the past with an increasing on the as an assessment The may current suicidal intent. It also information about the patient's to and to helpful It is useful to review what positive coping the youth and parent take in the of a suicidal This an for problem-solving and can the of some youth and to or the risk of suicidal behavior. It should be however, that not support the that such prevent they are not for comprehensive for a suicidal youth, suicide risk factors, including suicidal and behaviors, are monitored at of when with suicidal youth next at up on and information to the youth and parent or about easily management and regular patient with guidelines for to in population of suicidal youth is in of primary psychiatric comorbid conditions, the presence of complicating psychosocial and Therefore, the treatment should be on a comprehensive of psychopathology more suicide risk and factors.

Ed Shneidman reports on his 1971 analysis of the suicides that had occurred in the Terman Gifted Children Study. Begun in the 1920s at Stanford University, Professor Lewis Terman identified 1,528 high-IQ California students and, over the years, they have been continuously followed. Today, the remaining subjects (about 100) have a mean age of 93. In his uniquely Shneiderian manner, Ed relates how, in 1971, he utilized a psychological autopsy approach to accurately predict the suicides of a small subsample of the 20 suicides that had occurred to date among the 857 male participants. Almost 35 years later, he shares with us his slightly revised view of those factors that he believes play significant predictable roles in the eventuality of suicide. Jeremy Kisch et al. report on analyses from the Spring 2000 National College Health Assessment Survey (NCHA), sponsored by the American College Health Association. This is the largest and most comprehensive survey to date (15,977 college students) that provides a replication of the CDC's 1995 National College Health Risk Behavior Survey (NCHRBS). This study investigates the relationship between suicidal behavior and depressed mood, as well as other risk factors which increase vulnerability to suicidal behavior. Of particular note is that less than 20% of college students reporting suicidal ideation or attempts were receiving treatment (psychotherapy and/or medications). Adolescent suicide continues to be a major focus of much research as evidenced by the number and range of studies published in SLTB over the years. Researchers have appropriately focused on identifying critical risk factors associated with suicidal behaviors. Thompson et al. explored the roles of anxiety, depression, and hopelessness as mediators between known risk factors and suicidal behaviors among 1,287 potential high school dropouts. As a step toward theory development, a model was tested that posited the relationships among these variables and their effects on suicidal behaviors. The results showed direct effects of depression and hopelessness on suicidal behaviors for males, and direct effects of hopelessness, but not depression, for females. For both males and females, anxiety was directly linked to depression and hopelessness; drug involvement had both direct and indirect effects on suicidal behavior. Lack of family support showed indirect influences on suicidal behaviors through anxiety for both males and females as hypothesized. As the authors point out, for mental health professionals, school personnel, and prevention scientists working with at-risk or suicidal youth, the findings make evident the need to address multiple co-occurring problem behaviors such as drug involvement, emotional distress, and suicidal behaviors. Over the years, SLTB has published data emanating from the CDC's Youth Risk Behavior Survey (YRBS), which is conducted biannually. (see SLTB 30: 304–312; 32: 321–323). The four questions that measure suicidal ideation and attempts are ordered along an implicit continuum of development and severity from seriously considering suicide, to planning, to actually attempting suicide, and, finally, to requiring medical attention for a suicide attempt. As presented by Victor Perez, this process assumes a straightforward sequence of suicidal thought and action and is the underpinning of the content and order of the YRBS questions. However, the assumed ordinal properties of the four questions had never been empirically tested. Brener, Krug, and Simon (SLTB 30: 304–312) found discrepancies in the trends of responses to the questions measuring suicidal activity in their analysis of the YRBS from 1991–1997. Specifically, they showed that although the percentage of students who reported having seriously considered or attempted suicide in the past 12 months had declined steadily since 1991, the percentage of students requiring medical attention for an injurious suicide attempt had increased. They concluded that injurious suicide attempts might not be linked to seriously considering or planning a suicide attempt. Perez examines the assumed ordinal relationship in the 1999 Youth Risk Behavior Survey by constructing a trajectory that identifies all possible response patterns among the four questions measuring suicidal activity. Significant differences between means of dependent variables at each level of the normative trajectory supported the hypothesis that frequency of risk behaviors increases monotonically with successive suicidal thought and behavior. Research on the relationship between schizophrenia and suicidal behaviors has languished until recently (see SLTB 30: 34–49; 34: 66–76; 34: 76–86; 34: 311–319). Camilla Haw et al. identify the risk factors for deliberate self-harm (DSH) in schizophrenia. They provide an explanation and reference to their use of the broader (European) term DSH, rather than attempted suicide. Although there are several published review articles on risk factors for suicide and suicidal behavior in schizophrenia, there are few reviews which make any mention of risk factors for DSH, and there is an assumption that the risk factors for DSH and suicide are the same. Haw et al. examined cohort and case-control studies of patients with schizophrenia or related diagnoses that reported DSH as an outcome. Five variables (past or recent suicidal ideation, previous DSH, past depressive episode, drug abuse or dependence, and higher mean number of psychiatric admissions) were associated with an increased risk of DSH, while one (unemployment) was associated with a reduced risk. In a continuing series of studies (see SLTB 27: 153–163), Eric Blaauw et al. focus on the prevention of suicide in jails and prisons. This current study aims to identify combinations of characteristics (demographic, psychiatric, and criminal) that are capable of identifying potential suicide victims. Characteristics of 95 suicide victims in the Dutch prison system were compared with those of a random sample of 247 inmates in ten jails. Combinations of indicators for suicide risk were also tested for their capability of identifying 209 suicides in U.S. jails and 279 prison suicides in England and Wales. A combination of two demographic characteristics (age over 40, homelessness), two criminal characteristics (one prior incarceration, violent offense), and two indicators of psychiatric problems (history of psychiatric care, history of hard drug abuse) proved capable of identifying 82 percent of the suicide victims in the Netherlands at a specificity of .82 in the general inmate population. Less powerful combinations correctly classified 53% of the U.S. suicides and 47% of the U.K. suicides. Blaauw and colleagues conclude that a small set of demographic and criminal characteristics and indicators of psychiatric problems is useful for the identification of suicide risk in jails and prisons. They point out that the characteristics can easily be incorporated in a screening device that can be administered during the intake process for new inmates. Some risk factors for suicidal behavior are similar to those often studied in the field of criminology. The link between suicide and crime is most apparent when there is a homicide followed by suicide. People who kill others rarely kill themselves afterward. When they do, they are more likely to have killed someone with whom they are intimately involved—an intimate partner or a child. A review of the literature on this phenomenon in Australia, Canada, and the United States showed that, in all three countries, the majority of those who commit suicide after a homicide are male partners or ex-partners of female victims. Using data on over 700 intimate femicides, Myrna Dawson examined the role of premeditation in cases of intimate femicide-suicide compared to killings that do not culminate in a suicide. Her results show that premeditation is more likely to occur in cases involving the offenders' suicide, but that evidence of premeditation varies depending on the type of suicidal killer. Michel Préville et al. present the results of a psychological autopsy investigation of 101 adults aged 60 years and older who died by suicide in Quebec in 1998–1999. The study looks at a number of variables from proxy survivor interview data, including health- and mental health-related behaviors, mental health diagnoses, and social and demographic variables. In this study, 42.6% of the suicide cases presented with mental disorders at the time of their death (mainly depression), and nearly 44% of the suicide cases had no current or pre-existing psychiatric condition. Only 27.7% of the cases did not express any idea of death during the 6-month period preceding their suicidal death. Interestingly, 53.5% of the suicide cases consulted a general practitioner or specialist during the 2-week period preceding their death. The authors suggest that family members and friends could play an important role in preventing elderly suicide attempts by encouraging their parents to discuss their suicidal thoughts with their general practitioner. The results show some similar and some disparate results compared to other studies of elderly suicides, indicating the need for research that examines the complex causal nature of the relationship between mental disorders and suicide among the elderly. Adding to his studies of homeless veterans who abuse substances (SLTB 33:430–432), Brent Benda studied 315 male and 310 female homeless military veterans in a V.A. inpatient program designed to treat substance abusers, many of whom also suffer psychiatric disorders. The study examined gender differences in factors associated with the odds of having suicidal thoughts, and of attempting suicide, in comparison to being nonsuicidal. Childhood and current sexual and physical abuses, depression, fearfulness, relationship problems, limited social support, and low self-esteem were more strongly associated with suicidal thoughts and attempts for women than for men veterans. Extent of alcohol and other drug abuse, aggression, resilience, self-efficacy, combat exposure, combat-related PTSD, and work problems were more strongly associated with suicidal thoughts and attempts for men than for women. While anticipating the release of the CDC's final 2002 national suicide death numbers and rates, there have been different explanations offered for the apparent slow, but steady decline in national suicide rates over the last years. In 1996 the rate was 11.52/100,000; 11.23 in 1997; 11.13 in 1998; 10.47 in 1999; 10.43 in 2000, and 10.69 in 2001. By the time you receive this issue, we will know whether the trend is heading downward or beginning to climb back up. Recently, my attention was drawn to an Editorial originally published on July 30, 1904, in the Journal of the American Medical Association, entitled, “The Increase in Suicide.” I have excerpted portions as follows: The increase of suicide has come to be such a marked feature of social statistics in this country that physicians must be made to realize the possibilities there may be of bringing about a decrease in this unfortunate matter by more care and prevision. Suicides are somewhat more than twice as frequent now as they were ten years ago. … Carefully collected statistics show that there was a constant increase from 3,531 suicides in 1891 to 6,600 in 1897, then a drop in 1898 to 5,920, and in 1899 to 5,340. In 1900 there were 6,755 suicides, an increase of over 150 above the figures for 1897, the highest previous number, and there has been a constant increase since, in 1903 the number of suicides being very close to 8,600. During the last thirteen years—that is, since 1891, there have been altogether 77,617 cases of suicide reported in the newspapers of this country. The decrease in the number of suicides during 1898 and 1899 is not surprising, if we remember the conditions that prevailed in the commercial world at that time. After a period of hard times there was the wave of prosperity and a decided reaction in men's feelings that made the future look bright enough for everyone. Curiously enough, the statistics, however, do not show that city life is so much harder on the people than country life. During the last ten years, the suicide rate in fifty cities of this country has about doubled. That is, however, only in proportion to the suicide rate throughout all the rest of the country and does not especially condemn the high pressure of large city life as a disturbing factor of mentality. The most serious thing about the statistics is the fact that, though suicides are more common among men than women in all countries, the difference is gradually growing less, and in recent years, this has been quite marked. (43: 333–334) The 1890 census data from some states was partially destroyed by a fire in 1921; however, the federal records indicate an 1890 U.S. census of 62,116,811. Using this number, the rates are as follows: 5.68/100,000 in 1891, 10.63 in 1897, 9.53 in 1898, and 8.60 in 1899. The official U.S. census in 1900 was 74,607,225. In 1900, there were 6,755 suicides, yielding a rate of 9.05/100,000. In 1903, there was a significant increase in the number of suicides to approximately 8,600. Using the 1900 census, the suicide rate rose to 11.53/100,000. During the 13-year period between 1891–1903 there were 77,617 suicides, or approximately 5,971/year. This yields a roughly estimated rate of 9.61/100,000 for this 13-year period. Taken as a whole for the years surrounding the turn of the 20th century, the rate hovered around 9–10/100,000. One hundred years later, we continue to grapple with similar rates and similar risk factors.

Suicide is a major public health concern accounting for 800 000 deaths globally each year. Although there have been many advances in understanding suicide risk in recent decades, our ability to predict suicide is no better now than it was 50 years ago. There are many potential explanations for this lack of progress, but the absence, until recently, of comprehensive theoretical models that predict the emergence of suicidal ideation distinct from the transition between suicidal ideation and suicide attempts/suicide is key to this lack of progress. The current article presents the integrated motivational–volitional (IMV) model of suicidal behaviour, one such theoretical model. We propose that defeat and entrapment drive the emergence of suicidal ideation and that a group of factors, entitled volitional moderators (VMs), govern the transition from suicidal ideation to suicidal behaviour. According to the IMV model, VMs include access to the means of suicide, exposure to suicidal behaviour, capability for suicide (fearlessness about death and increased physical pain tolerance), planning, impulsivity, mental imagery and past suicidal behaviour. In this article, we describe the theoretical origins of the IMV model, the key premises underpinning the model, empirical tests of the model and future research directions.

The Promise and Limits of Suicide Genetics.

A Suicide-Specific Diagnosis – The Case Against

Background: Suicidal behaviour (SB) refers to behaviours, ranging from non-fatal suicidal behaviour, such as suicidal ideation and attempt, to completed suicide. Despite recent advancements in genomic technology and statistical methods, it is unclear to what extent the spectrum of suicidal behaviour is explained by shared genetic aetiology.Methods: We identified nine genome-wide association statistics of suicidal behaviour (sample sizes, n, ranging from 62,648 to 125,844), ten psychiatric traits [n up to 386,533] and collectively, nine summary datasets of anthropometric, behavioural and socioeconomic-related traits [n ranging from 58,610 to 941,280]. We calculated the genetic correlation among these traits and modelled this using genomic structural equation modelling, identified shared biological processes and pathways between suicidal behaviour and psychiatric disorders and evaluated potential causal associations using Mendelian randomisation.Results: Among populations of European ancestry, we observed strong positive genetic correlations between suicide ideation, attempt and self-harm (rg range, 0.71–1.09) and moderate to strong genetic correlations between suicidal behaviour traits and a range of psychiatric disorders, most notably, major depression disorder (rg = 0.86, p = 1.62 × 10−36). Multivariate analysis revealed a common factor structure for suicidal behaviour traits, major depression, attention deficit hyperactivity disorder (ADHD) and alcohol use disorder. The derived common factor explained 38.7% of the shared variance across the traits. We identified 2,951 genes and 98 sub-network hub genes associated with the common factor, including pathways associated with developmental biology, signal transduction and RNA degradation. We found suggestive evidence for the protective effects of higher household income level on suicide attempt [OR = 0.55 (0.44–0.70), p = 1.29 × 10−5] and while further investigation is needed, a nominal significant effect of smoking on suicide attempt [OR = 1.24 (1.04–1.44), p = 0.026].Conclusion: Our findings provide evidence of shared aetiology between suicidal behaviour and psychiatric disorders and indicate potential common molecular mechanisms contributing to the overlapping pathophysiology. These findings provide a better understanding of the complex genetic architecture of suicidal behaviour and have implications for the prevention and treatment of suicidal behaviour.

P02-113 - Mental health and coping strategies in families caring for patient with epilepsy in Iran

BackgroundFamily carers are an important source of care for older people. Although several studies have reported that subjective caregiver burden is related to depressive symptoms there are no systematic reviews quantifying this association.ObjectiveTo establish the extent to which subjective caregiver burden is associated with depressive symptoms and whether this association would vary by study or care characteristics.MethodsWe searched major databases such as PubMed, CINAHL, PsycINFO, Scopus and ISI Proceedings up to March 2018, and conducted a meta-analysis of included studies. Summary estimates of the association were obtained using a random-effects model to improve generalisation of findings.ResultsAfter screening of 4,688 articles, 55 studies were included providing a total of 56 independent comparisons with a total of 9,847 carers from data across 20 countries. There was a large, positive association between subjective caregiver burden and depressive symptoms ( = 0.514; 95% CI = 0.486, 0.541), with very low heterogeneity amongst individual studies (I2 = 8.6%). Sensitivity analyses showed no differences between cross-sectional or repeated measures ( = 0.521; 95% CI = 0.491, 0.550; 51 samples) and longitudinal studies ( = 0.454; 95% CI = 0.398, 0.508; 6 samples). We found a higher effect size for those caring for people living with dementia compared to those caring for frail older people, and stroke survivors. Carer sex, age and kinship did not change the estimate of the effect.ConclusionsSubjective caregiver burden is a significant risk factor for depressive symptoms in carers of older people and may precipitate clinical depression. Those caring for people with dementia experience greater burden. There is a need for longitudinal evaluations examining the effects of potential mediators of the association of subjective burden and depressive symptoms. Future interventions should test whether minimizing subjective burden may modify the risk of developing depression in carers of older relatives.

To compare clinical traits of suicidal vulnerability among in-patients with suicidal behavior disorder (SBD) with and without borderline personality disorder (BPD). we recruited adult patients with SBD, consecutively and voluntarily hospitalized in a specialized unit for affective disorders and suicidal behavior between July and October 2016. Ninety-two inpatients having attempted suicide within the past 2 years were divided into two subgroups according to the presence or absence of BPD. Clinical vulnerability traits for suicidal behavior were assessed. Half of the patients with SBD also had BPD. Patients with BPD were nine times more likely to be major suicide repeaters compared to those without. They were also more likely to display clinical and psychological vulnerability traits for suicidal behavior, even after considering potential confounders. Emotional dysregulation, shame-proneness, impulsiveness, preoccupied attachment pattern, and childhood trauma were high in both groups, but significantly increased in those with (vs. without) BPD status. Psychological traits remained stable in SBD-BPD patients, regardless of the time since the last suicide attempt (i.e. SBD in recent vs. early remission). Clinical and psychological traits associated with suicidal vulnerability are present in all SBD patients compared to non-suicidal populations, but comorbidity with BPD is associated with particularly high scores. BPD could be considered as a specifier for SBD diagnoses.

Suicide among members of the military is a topic of current national importance.Historically, active-dutyU.S. Army soldiers had a lower rate of completed suicide than demographicallymatchedcivilians.However, as therate forcivilians has remained consistent, that for soldiers has escalated in the past decade. As a result, since 2008, the military rate has exceeded the civilian rate (1). This phenomenon has understandably led to a greatly increased emphasis on understanding suicide risk and protective factors among soldiers and to the search foreffectivepreventionprogramsandtreatmentmodels. For example, the Department of the Army and the National Institute of Mental Health have funded the large-scale Army Study To Assess Risk and Resilience in Servicemembers (Army STARRS) (2), which is beginning to yield valuable informationonrisk factors. Simultaneously, treatment researchers are investigating psychotherapeutic methods to reduce suicide ideationandattempts inbothactive-dutyandveteranhealthcare settings (3, 4). In the context of the need for effective treatment of suicidal military members, Rudd et al. (5), in their article published in this issue of the Journal, report on results of an intervention tailored to the demands of an active military setting that is based on the elements of treatment shown to be effectivewith other populations, brief cognitive-behavioral therapy (CBT). They randomly assigned 152 active-dutyArmy soldiers at high risk for suicide to treatment as usual or to treatment as usual plus brief CBT. Participating soldiers were recruited from inpatient and emergency department clinical settings; all of themhadeithera suicideattempt in thepastmonthor suicidal ideationwith intent todie in thepastweek.Treatment asusual could consist of psychotherapy, psychiatric medication, substance abuse treatment, or other support groups. Brief CBT consisted of 12 planned sessions on aweekly or biweekly basis, although there was flexibility in the actual duration of treatment depending on how well the participants mastered the skills that were covered. Assessments were conducted at baseline, and then at 3, 6, 12, 18, and 24 months after baseline, with the primary outcome consisting of the occurrence of suicide attempts over this 2-yearperiod.Results showedthat across all participants, there were 31 suicide attempts by 26 soldiers in the 2 years. Strikingly, those who received brief CBT along with treatment as usual were 60% less likely to make a suicide attempt than thosewho received treatment as usual alone (N58/76 in CBT [13.8%] compared with N518/76 in treatment as usual [40.2%]). The difference could not be attributed to group differences in dropout or in such baseline characteristics as previous suicide attempts or severity of depression. Soldiers participating inCBT also had fewer hospitalization days than those in treatment as usual alone. Despite the dramatic treatment differences for suicide attempts, there were no treatment group differences at any assessment point in current or worstpoint suicidal ideation, hopelessness, depression, anxiety, or posttraumatic symptoms. In other words, the treatment was highly specific in its impact on suicide attempts. The authors acknowledge limitations of the study, above all, the amount of missing data on self-reported hopelessness, depression, anxiety, and posttraumatic stress symptoms over time. However, suicide attempts were assessed by in-person or telephone interviews and therefore were less affected by missing data. A second limitation is that the sample was 88%male, indicating the need for further study of suicide prevention among female soldiers. This limitation has taken on more significance since the recent publication of initial findings from the Army STARRS project, showing that active-duty women had higher odds of making a suicide attempt than men (6). These findings are extremely good news in the search for solutions to what has been appropriately designated as the “vexing challenge” of increasedmilitary suicide rates (7). Are the results credible in the context of related research, and what can we learn from them about effective psychotherapy more generally? First, is it credible that a treatment can have major and specific impact on suicidal behavior without having differential impact on associated symptoms? This type of specificity of skills-based treatment models that address suicide risk is not without precedent. Dialectical-behavior therapy, which includes group-based skills training and individual psychotherapy, initially proved effective in comparison to treatment as usual in decreasing suicidal behavior without

This study compares demographic and clinical characteristics of 52 individuals with schizophrenia or schizoaffective disorder who had attempted suicide with those of 104 individuals with schizophrenia or schizoaffective disorder who had not made a suicide attempt. Participants were interviewed with the Diagnostic Interview for Genetic Studies. Most suicide attempts were of moderate to severe lethality, required medical attention, and involved significant suicidal intent. Individuals who had and had not attempted suicide did not differ with respect to demographic variables, duration of illness, rate of depression, or substance abuse. The two groups are affected differentially when depressed. Biopsychosocial assessments and interventions are essential for reducing the risk for suicidal behavior in individuals with schizophrenia.

Men's Depression, Externalizing, and DSM-5-TR: Primary Signs and Symptoms or Co-occurring Symptoms?

Suicidal behavior is a leading cause of injury and death worldwide, and previous cross-sectional studies have demonstrated that nonmedical use of prescription drugs (NMUPD) was associated with suicidality. However, there is not any study in China having examined the longitudinal relationships between NMUPD, suicidal ideation, and suicidal attempts, as well as explored the potential mediating effects of depressive symptoms. To determine whether baseline NMUPD was associated with subsequent suicidal ideation and attempts while controlling for depressive symptoms and to determine whether the increased risks were mediated by depressive symptoms. In this longitudinal study, a total of 3273 students in randomly selected schools in Guangzhou were surveyed from 2009 to 2010 (response rate, 96.8%) and followed up at 1 year (2011-2012; retention rate, 96.1%). The dates of data analysis were October 9, 2015, to October 15, 2015; additional data analysis occurred March 23, 2016, to March 29, 2016. Suicidal ideation, suicidal attempts, NMUPD, depressive symptoms, and alcohol-related problems. Overall, 3273 adolescents (mean [SD] age, 13.7 [1.0] years) were recruited for this study. The final results showed that after controlling for sociodemographic information (including sex, age, household socioeconomic status, and living arrangements), baseline depressive symptoms, baseline alcohol-related problems, baseline suicidal ideation, and baseline suicidal attempts, baseline opioids misuse (adjusted odds ratio [AOR], 2.31; 95% CI, 1.30-4.11), sedatives misuse (AOR, 4.46; 95% CI, 1.54-7.94), and nonmedical use of any prescription drug (AOR, 1.97; 95% CI, 1.21-3.23) were positively associated with suicidal ideation at follow-up. Additionally, baseline opioid misuse (AOR, 3.39; 95% CI, 1.33-5.63) and nonmedical use of any prescription drug (AOR, 2.91; 95% CI, 1.26-3.71) were also associated with subsequent suicidal attempts after controlling for sex, age, household socioeconomic status, living arrangements, depressive symptoms, alcohol-related problems, suicidal ideation, and suicidal attempts at baseline. There were significant standardized indirect effects of baseline opioids misuse on subsequent suicidal ideation (standardized β estimate = 0.020; 95% CI, 0.010-0.030) and suicidal attempts (standardized β estimate = 0.009; 95% CI, 0.004-0.015) through depressive symptoms; the standardized indirect effect of baseline sedatives misuse on subsequent suicidal ideation through depressive symptoms was also significant (standardized β estimate = 0.016; 95% CI, 0.005-0.026). In this study, NMUPD at baseline was associated with subsequent suicidal ideation and attempts. These findings support that proper surveillance systems with the potential to reduce adolescent suicidality should be established to control and supervise suicidality and NMUPD among Chinese adolescents.

ABSTRACTBackground and ObjectivesAlthough a substantial amount of research has focused on negative aspects of caregiving, less research has been conducted investigating positive aspects of providing informal care. The aim of this study was to investigate the longitudinal association between caregiving satisfaction and psychological distress in informal carers of dependent older people, and whether this relationship is mediated by caregiver burden.Research Design and MethodsProspective longitudinal study with a probabilistic sample of 332 caregivers of older relatives, with data collected at baseline and at 1‐year follow‐up. We measured caregiving satisfaction, psychological distress, subjective caregiver burden and several covariates (caregivers' sex, age and objective caregiver burden). Data were analysed using generalised estimation equations with multiple imputation. The STROBE checklist was used to support the writing of this document.ResultsAfter controlling for covariates, caregiving satisfaction was significantly negatively associated with lower levels of subjective caregiver burden (B = −0.17, 95% CI: −0.23, −0.11) and emotional distress (B = −0.23, 95% CI: −0.36, −0.11). When subjective burden was included in the model, the relationship between caregiving satisfaction and psychological distress was no longer significant (B = −0.11, 95% CI: −0.23, 0.02), whereas the association between subjective burden and psychological distress remained (B = 0.75, 95% CI: 0.57, 0.92). The Sobel test confirmed these results (p < 0.001), indicating that subjective caregiver burden mediates the relationship between caregiving satisfaction and psychological distress (complete mediation) over time.Discussion and ImplicationsCaregiving satisfaction exerts a longitudinal protective effect on carers' psychological distress via subjective burden. Our findings indicate that interventions aimed at strengthening caregiving satisfaction may play a significant role in maintaining positive mental health outcomes for informal caregivers.