Depressed Suicide Attempters Research Articles

Age and Suicidal Ideation in Older Depressed Inpatients

Age-related patterns of symptom presentation may complicate the recognition of suicide risk. The authors sought to determine whether there is a relationship between age and reported suicidal ideation in depressed suicide attempters (DSAs) and depressed nonattempters (DNs) 50 years of age and over. Regression analyses revealed that increasing age is significantly associated with the absence of suicidal ideation in both DSAs and DNs. Because of their lower rates of depressed mood and suicidal ideation, the depressions of older adults may more readily escape detection. Preventive or treatment measures initiated after the onset of the suicidal state may be insufficient, and other preventive strategies ought to be considered.

Attempted Suicide in Older Depressed Patients: Effect of Cognitive Functioning

The authors explored cognitive functioning and suicidal behavior in older depressed patients. Inpatients age 50 years or older (N=103) with major depression, 45 of whom had attempted suicide, were evaluated within 1 week of their hospital admission. Measures of suicidal behavior included suicide attempter status, the Suicide Intent Scale (SIS), ratings of method used (violent/nonviolent), and seriousness of injuries sustained (lethality). The Mini-Mental State Exam (MMSE) score measured cognitive impairment; covariates were age, gender, and living arrangement. The MMSE score was not associated with suicide attempter status, but for attempters, MMSE score showed a positive association with SIS score, but not method or lethality. Findings suggest that although cognitive disturbance may be associated with less-deliberate acts among older depressed suicide attempters, it does not appear to influence the potential lethality of their behavior.

A protracted case

Patients with severe manic and depressive episodes often become part of a particular social pattern in which spouse, children, friends and associates each play a role in a combined effort to mitigate the consequences of the incessant mood changes. In protracted cases the family hardly knows an existence that is not dominated by fear of imminent disaster, depressive suicidal attempts or manic deeds of misjudgement

Arginine Vasopressin Is Associated with Hypercortisolemia and Suicide Attempts in Depression

Activation of the hypothalamic–pituitary–adrenal (HPA) axis is commonly seen in patients suffering from depression (Charlton and Ferrier 1989). Raised plasma concentrations of cortisol may be present (Butler and Besser 1968; Deuschle et al 1997), along with increased 24-hour urinary free cortisol levels (Carroll et al 1976). Detailed analysis of plasma adrenocorticotropic hormone (ACTH) reveals an increase in pulse frequency (Mortola et al 1987; Deuschle et al 1997). In approximately 40–50% of all patients with depression, plasma cortisol is not normally suppressed by dexamethasone (Arana et al 1985). The mechanism of the hypercortisolemia is believed to be related to increased hypothalamic secretion of corticotropinreleasing hormone (CRH) (Charlton and Ferrier 1989; Licinio and Gold 1991), and increased adrenal sensitivity to ACTH (Charlton and Ferrier 1989). Since most studies of the HPA axis in depression concentrate on CRH as the predominant ACTH secretagogue, there are relatively few data concerning the role of arginine vasopressin (AVP), which is also a potent stimulus to ACTH secretion (Gillies et al 1982). The aim of this study was to determine whether there was any relationship between afternoon plasma levels of cortisol, ACTH, and AVP in depressed subjects, particularly in those displaying biochemical hypercortisolemia. We also sought to determine if any relationship existed between severity of depression and suicidal behavior and activation of the HPA axis.

Cerebrospinal fluid amines and higher-lethality suicide attempts in depressed inpatients

Previous studies have found that not all suicide attempters with major depression have reduced serotonergic activity based on low cerebrospinal fluid 5-hydroxyindoleacetic acid (CSF- 5-HIAA) levels. In this study we hypothesized that serotonergic function is lower in depressed patients who have carried out high-lethality suicide attempts resulting in more medical damage, which might explain differences in serotonergic activity among depressed suicide attempters. We assessed the relationship of CSF 5-HIAA and other amine metabolites to the most lethal lifetime suicide attempt in 22 drug-free inpatients with major depression. CSF 5-HIAA levels were lower in depressed patients with a history of a high-lethality or well-planned suicide attempt compared to depressed patients with a history of only low-lethality suicide attempt(s). Other CSF monoamine metabolites did not correlate with suicidal behavior. Low serotonergic activity may correlate with a predisposition to more lethal suicide attempts in major depression.

S-64-1 - Changes in immune function in a rodent model of depression and its relevance to major depression

Previous reports have shown a significant relationship between suicide ideation and mixed depression. The aim of this study was to explore the prevalence and clinical characteristics of mixed depression among non-violent suicide attempters.Using a structured interview (modified Mini International Neuropsychiatric Interview) and assessing all the symptoms of 16 psychiatric diagnoses, the authors examined 100 consecutive nonviolent suicide attempters (aged 18–65) within 24 h after their attempts. Mixed depression was defined as a major depressive episode (MDE)/dysthymic disorder plus 3 or more co-occurring hypomanic symptoms, according to the definition validated by Akiskal and Benazzi [Akiskal, H.S., Benazzi, F., 2003a. Delineating depressive mixed states: Their therapeutic significance. Clin. Approaches Bipolar Disord. 2, 41–47, Akiskal, H.S., Benazzi, F., 2003b. Family history validation of the bipolar nature of depressive mixed states. J. Affect. Disord. 73, 113–122.].Current mixed depression was present in 63.0% in the total sample, and in 70.8% among the 89 depressive suicide attempters. Irritability, distractibility and psychomotor agitation were present in more than 90% of the subjects with mixed depression. The rate of mixed depression was significantly higher among bipolar than non-bipolar depressive suicide attempters (90% vs. 62%). Patients with mixed depression had the following concurrent disorders: bipolar disorders 41.0%, panic disorder 30.0%, generalized anxiety disorder 89.0%, alcohol abuse/dependence 56.0%, and substance abuse 27.0%. Mixed depression versus non-mixed depression had the following significant associations (odds ratio = OR): females 2.4, bipolar II disorder 9.3, generalized anxiety disorder 41.3, irritability 101.6 and psychomotor agitation 61.1.The study didn't include suicide attempters with very high risk of fatality.The important new finding of this study is the very high prevalence of mixed depression among depressed suicide attempters. The rates of mixed depression among bipolar and non-bipolar depressive suicide attempters were much higher than previously reported among nonsuicidal bipolar II and unipolar depressive outpatients, suggesting that suicide attempters come mainly from mixed depressives with predominantly bipolar II base. Irritability and psychomotor agitation were the strongest predictors of suicide attempt. From a public health standpoint, our data highlight the necessity of detecting and treating mixed (bipolar) depression in the prevention of suicidal behaviour.

S-63-3 - Complex presentations of bipolar disorder

Previous reports have shown a significant relationship between suicide ideation and mixed depression. The aim of this study was to explore the prevalence and clinical characteristics of mixed depression among non-violent suicide attempters.Using a structured interview (modified Mini International Neuropsychiatric Interview) and assessing all the symptoms of 16 psychiatric diagnoses, the authors examined 100 consecutive nonviolent suicide attempters (aged 18–65) within 24 h after their attempts. Mixed depression was defined as a major depressive episode (MDE)/dysthymic disorder plus 3 or more co-occurring hypomanic symptoms, according to the definition validated by Akiskal and Benazzi [Akiskal, H.S., Benazzi, F., 2003a. Delineating depressive mixed states: Their therapeutic significance. Clin. Approaches Bipolar Disord. 2, 41–47, Akiskal, H.S., Benazzi, F., 2003b. Family history validation of the bipolar nature of depressive mixed states. J. Affect. Disord. 73, 113–122.].Current mixed depression was present in 63.0% in the total sample, and in 70.8% among the 89 depressive suicide attempters. Irritability, distractibility and psychomotor agitation were present in more than 90% of the subjects with mixed depression. The rate of mixed depression was significantly higher among bipolar than non-bipolar depressive suicide attempters (90% vs. 62%). Patients with mixed depression had the following concurrent disorders: bipolar disorders 41.0%, panic disorder 30.0%, generalized anxiety disorder 89.0%, alcohol abuse/dependence 56.0%, and substance abuse 27.0%. Mixed depression versus non-mixed depression had the following significant associations (odds ratio = OR): females 2.4, bipolar II disorder 9.3, generalized anxiety disorder 41.3, irritability 101.6 and psychomotor agitation 61.1.The study didn't include suicide attempters with very high risk of fatality.The important new finding of this study is the very high prevalence of mixed depression among depressed suicide attempters. The rates of mixed depression among bipolar and non-bipolar depressive suicide attempters were much higher than previously reported among nonsuicidal bipolar II and unipolar depressive outpatients, suggesting that suicide attempters come mainly from mixed depressives with predominantly bipolar II base. Irritability and psychomotor agitation were the strongest predictors of suicide attempt. From a public health standpoint, our data highlight the necessity of detecting and treating mixed (bipolar) depression in the prevention of suicidal behaviour.

Prolactin response to fenfluramine and suicide attempt lethality in major depression.

This study employed an alternative method for assessing serotonergic function to further evaluate our finding that cerebrospinal fluid (CSF) 5-hydroxyindole acetic acid (5-HIAA) in depressed suicide attempters with a lifetime history of higher lethality suicide attempts is significantly lower compared to depressed patients who have a history of low lethality suicide attempts. We used dl-fenfluramine (60 mg) as a neuroendocrine probe to examine the serotonin system in 41 in-patients with a DSM-III-R major depressive episode, divided into two groups on the basis of a lifetime history of high or low lethality suicide attempts. Fenfluramine challenge test outcome was defined as the maximum prolactin response in the five hours following fenfluramine. Patients with a history of a higher lethality suicide attempt had a significantly lower prolactin response to fenfluramine, even when controlling for cortisol, age, sex, weight, comorbid cluster B personality disorder, pharmacokinetic and menstrual cycle effects. The data provide further support for the hypothesis that serotonin dysfunction is associated with more lethal suicide attempts, and suggests that higher lethality suicide attempters or failed suicides resemble completed suicides both behaviourally and biochemically.

Are cerebrospinal fluid or urinary monoamine metabolite measures stronger correlates of suicidal behavior in depression?

A series of depressed patients had monoamine metabolites measured in cerebrospinal fluid (CSF) and urine. We wished to see if CSF or urinary measures were more strongly associated with suicidal behavior in depression. Using a variety of graphical and analytic statistical approaches we found that the urinary measures of dopamine metabolism had the strongest association with suicide attempts in depression. These surprising results suggest that selected peripheral correlates of monoaminergic neurotransmission deserve further study in suicidal behavior.

Features associated with suicide attempts in depression: A partial replication

Clinical and symptomatic features were examined in relation to suicide attempts in a hetorogenous group of depressed patients. Depressed patients who had attempted suicide had had their first episode of affective disorder at a significantly earlier age, had had significantly more episodes of affective disorder, and more of them had bipolar disorder. However, there was only one significant difference for baseline symptoms scores on four affective symptom rating scales. A family history of suicide was associated with a history of a violent suicide attempt.

Cognitive style and pleasant activities among female adolescent suicide attempters.

Cognitive style and pleasant activities of 77 suicide-attempting female minority adolescents were compared with those of 2 groups of non-suicide-attempting female minority adolescents, 39 who were psychiatrically disturbed and 23 who were nondisturbed. Suicide attempters differed from other groups, even when depression and IQ were statistically controlled. They reported significantly fewer alternatives for solving interpersonal problems, were significantly more focused on problems, and were more likely to report a wishful thinking style of coping in stressful situations than were members of the nondisturbed comparison group. Across groups, depression was associated with significantly more dysfunctional attributions. Interpersonal problem-solving ability and attributional style best distinguished the suicide attempters. Results suggest using different cognitive-behavioral interventions with depressed and nondepressed minority female adolescent suicide attempters.

Risk factors of suicide among schizophrenics

This case control study included 74 Chinese schizophrenics (DSM-III criteria) who died of suicide and 74 age- and sex-matched nonsuicide schizophrenics. Sociodemographic variables were unrelated with suicide. Associations were found between suicide and severity of illness (more frequent admissions, higher dose of medication and earlier appointments), history of major depressive episodes and suicidal attempts, last admission for reasons other than schizophrenic symptoms alone, and suicidal ideas on mental state examination. The last 2 factors, together with the maintenance dose of medication, were identified as the most important risk factors by logistic regression analysis.

Features associated with suicide attempts in recurrent major depression

Sixty-seven individuals with recurrent major depression and a history of suicide attempts are compared with 163 individuals with recurrent major depression and no history of suicide attempts. The groups are contrasted on demographic features, clinical course, severity of depression, co-morbidity, and acute symptom profiles. Patients with a history of attempts are distinguished from non-attempters by suicidal ideation, marital isolation, neurovegetative signs, feelings of failure, and co-morbid alcoholism or bipolar II disorder. Logistic regression analysis using a model which included a portion of the significant variables correctly classified 77% of the cases. These findings are discussed with reference to prediction of suicide attempts in individuals with major affective disorder.

Cognitive style and pleasant activities among female adolescent suicide attempters.

Cognitive style and pleasant activities of 77 suicide-attempting female minority adolescents were compared with those of 2 groups of non-suicide-attempting female minority adolescents, 39 who were psychiatrically disturbed and 23 who were nondisturbed. Suicide attempters differed from other groups, even when depression and IQ were statistically controlled. They reported significantly fewer alternatives for solving interpersonal problems, were significantly more focused on problems, and were more likely to report a wishful thinking style of coping in stressful situations than were members of the nondisturbed comparison group. Across groups, depression was associated with significantly more dysfunctional attributions. Interpersonal problem-solving ability and attributional style best distinguished the suicide attempters. Results suggest using different cognitive-behavioral interventions with depressed and nondepressed minority female adolescent suicide attempters.