Attempted suicide and suicide in functional psychoses

Clinical predictors of suicidal acts after major depression in bipolar disorder: a prospective study

OBJECTIVE

This study determined the clinical predictors of suicidal behavior during a 2-year follow-up of patients with bipolar disorder presenting with a major depressive episode (MDE).

METHOD

Sixty four patients with DSM-III-R bipolar disorder were assessed at presentation for treatment of an MDE. Correlates of past suicidal behavior were determined by comparing patients with and without a history of suicide attempts using a t-test, Wilcoxon test or chi-squared test of independence on individual explanatory variables. Putative predictors of attempts during the follow-up period were tested separately using Cox proportional hazards regression analysis.

RESULTS

Twelve of 64 patients had at least one suicide attempt in the follow-up period, five of them attempted in the first 2 months and seven around or shortly after the 1-year follow-up visit. All attempters had a history of past suicide attempts. Most predictors of future suicidal behavior were correlates of past suicidal behavior. Family history of suicide acts and comorbid borderline personality disorder predicted early attempts, while younger age, high hostility scores, number of past attempts, subjective pessimism as reflected in depression and suicidal ideation, and few reported reasons for living predicted suicidal acts during the whole period.

CONCLUSION

In this data set of bipolar patients we noted an intriguing picture of two clusters of suicide attempts. Hostility was the strongest risk factor. These findings may have implications in both the identification of at-risk patients and the timing of clinical interventions including aggressive pharmacotherapeutic prophylaxis to prevent relapse or recurrence of depressive symptomatology.

Neurocognitive functioning in dually diagnosed middle aged and elderly patients with alcoholism and schizophrenia

BACKGROUND

Alcohol abuse and dependence have important clinical implications for managing patients with schizophrenia. Alcoholism in schizophrenia patients can interfere with the course and prognosis of the schizophrenic illness.

OBJECTIVE

The purpose of the present study was to compare the cognitive status, symptom profile and quality of life of middle aged and older patients (>44 years old) with schizophrenia and alcohol abuse/dependence vs those without alcohol abuse/dependence. We initially hypothesized that more males in this age group with schizophrenia would exhibit alcoholism. We also examined the characteristics of the 45-54 year age group with those of the > or = 55 year old group and hypothesized that comorbidity with alcohol would be associated with worse cognition and quality of life in later life.

METHODS

Data were obtained from a database from the Center for Services and Interventions research at the University of California, San Diego. Patients had diagnoses of schizophrenia or schizoaffective disorder. Data collected included demographic characteristics, cognitive status (tested with the Mattis Dementia Rating Scale learning, the Figural and Story Memory Test of the Wechsler Memory Scale-Revised and the California Verbal Learning Test [CVLT]). In addition, patients had undergone psychopathologic assessment and were screened for quality of life using the Quality of Well Being scale.

RESULTS

We demonstrated that the older aged patients with alcoholism had worse scores assessing cognition relative to the same aged group without alcoholism. In addition, they had worse cognitive scores relative to the younger group (45-54 year old) with alcoholism. There was no significant difference with regards to quality of life. In addition, more males than females exhibited alcoholism.

CONCLUSION

The results are consistent with the premise that the higher cognitive function in the younger schizophrenia patients with alcoholism appear to mask the effects of alcohol use on cognition at that age. However, for the older group of schizophrenia patients, the effects of alcohol use on neuropsychological functioning appear to be deleterious.

Changes in mental disorder distribution among suicide attempters in mid-west area of Kanagawa

To clarify changes in mental disorder distribution in suicide attempters, a comparison was made between the period when an economic recession started (1992, 1993) and the period when the recession became serious (2000). The subjects were 212 suicide attempters admitted to the Emergency Medical Center of Tokai University Hospital during a 2-year period between 1992 and 1993 (group A) and 255 suicide attempters admitted during a 1-year period between January and December 2000 (group B). Mental disorders were classified according to the International Classification of Diseases (10th revision; ICD-10). Distribution was compared between groups A and B and significant differences were observed in mental disorder distribution (P < 0.001). The percentages of subjects with depression, those with neurotic disorders, and those with other disorders were higher in group B than in group A. Conversely, the percentage of subjects with schizophrenia was lower in group B than in group A. Mental disorder distribution in suicide attempters significantly changed. However, it was not certain that this change was related to the economic recession and increased unemployment in Japan.

Suicidal behaviour in bipolar disorder: risk and prevention

Bipolar (manic-depressive) disorder is a common and severe illness. It is also potentially fatal as a result of accidents and increased mortality associated with comorbid substance use and medical illnesses, but its highest lethality results from suicide. Suicide rates, averaging 0.4% per year in men and women diagnosed with bipolar disorder, are >20-fold higher than in the general population. Suicidal acts often occur early in the illness course and in association with severe depressive and dysphoric-agitated mixed phases of illness, especially following repeated, severe depressions. Systematic consideration of risk and protective factors enhances assessment of potentially suicidal patients. Short-term interventions employed empirically to manage acute suicidality include close clinical supervision, rapid hospitalisation and use of electroconvulsive treatment. Several plausible therapeutic interventions have limited evidence of long-term effectiveness against mortality risks associated with any psychiatric disorder, including antidepressant, antimanic, antipsychotic and electroconvulsive, as well as psychosocial, treatments. However, in bipolar disorder and other major affective disorders, lithium maintenance treatment is a notable exception, with strong and consistent evidence that it reduces suicidal risk. The growing range of drugs being introduced to treat acute and long-term phases of bipolar disorder, including antiepileptic drugs, atypical antipsychotics and relatively safe, modern antidepressants, require research assessment for their ability to limit premature mortality from suicide and other causes. For now, however, more can be done to improve treatment in major affective illnesses by application of current knowledge in a systematic fashion, with close and sustained clinical follow-up of patients at risk, hopefully with a resulting reduction of mortality rates.

Alcohol dependence and hospitalization in schizophrenia

Treatment of schizophrenia is often complicated by substance abuse. We report here findings of a retrospective study evaluating readmission rates of patients meeting DSM IV criteria comorbid for schizophrenia and alcohol or drug dependence treated with depot haloperidol or fluphenazine over a 2-year period. During the study period, 14 of the 26 (54%) male veteran patients were admitted to the VAMC, Charleston; 46% of patients met criteria for alcohol, marijuana or cocaine dependence. Patients with alcohol dependence appeared to be at highest risk for hospital admission (p < 0.05). Moreover, patients with alcohol dependence had longer hospital stays (p < 0.05) than patients without alcohol dependence. Marijuana or cocaine dependence was slightly, but not statistically more common among admitted patients. Marijuana or cocaine dependence did not predict length of stay or number of admissions. Alcohol dependence may be an important factor in schizophrenic exacerbation, and may be an important target for treatment.

Complications of severe mental illness related to alcohol and drug use disorders

In this chapter we review research on the relationships between substance use disorder and 11 domains of adjustment for people with severe mental illness. Studies are divided into correlational research and prospective, longitudinal research, with greater weight given to those in the latter category. The weight of the evidence indicates that substance abuse severely complicates severe mental illness in the following domains: relapse of psychiatric illness, hospitalization, disruptive behavior, familial problems, residential instability, decreased functional status, HIV infection, and medication noncompliance. We discuss the limits of causal inference in these studies and the possible mechanisms that relate substance abuse to various complications.

Determinants of choice of method for suicide and the person/situation debate in psychology

Researchers have not identified personological predictors of choice of method for suicide, whereas an availability hypothesis has received support. Thus, the situational position may be useful as a framework for efforts to prevent suicide.

Suicide as an outcome for mental disorders. A meta-analysis

BACKGROUND

Mental disorders have a strong association with suicide. This meta-analysis, or statistical overview, of the literature gives an estimate of the suicide risk of the common mental disorders.

METHOD

We searched the medical literature to find reports on the mortality of mental disorders. English language reports were located on MEDLINE (1966-1993) with the search terms mental disorders', 'brain injury', 'eating disorders', 'epilepsy', 'suicide attempt', 'psychosurgery', with 'mortality' and 'follow-up studies', and from the reference lists of these reports. We abstracted 249 reports with two years or more follow-up and less than 10% loss of subjects, and compared observed numbers of suicides with those expected. A standardised mortality ratio (SMR) was calculated for each disorder.

RESULTS

Of 44 disorders considered, 36 have a significantly raised SMR for suicide, five have a raised SMR which fails to reach significance, one SMR is not raised and for two entries the SMR could not be calculated.

CONCLUSIONS

If these results can be generalised then virtually all mental disorders have an increased risk of suicide excepting mental retardation and dementia. The suicide risk is highest for functional and lowest for organic disorders with substance misuse disorders lying between. However, within these broad groupings the suicide risk varies widely.

The Significance of the Method Chosen for Suicide in Understanding the Psychodynamics of the Suicidal Individual

The suicide notes of those using active and passive methods for suicide were compared for the presence of fifty classifications regarding such psychodynamics as perturbation, lethality, relations, self-cognitions, etc. The two sets of notes resembled each other closely. The lone difference was that those using active methods more often communicated that rejection by a significant other was a critical factor; however, this finding was not replicated with a different (and larger) sample.

Rates and correlates of suicide attempts in first-admission psychotic patients

The relationship of attempted suicide to demographic characteristics, current and lifetime psychiatric diagnoses, clinical history, and current symptoms was assessed in a sample of 184 recently hospitalized psychotic patients. Forty-three patients (23%) had an attempt history, and 28 (15% of sample; 65% of attempters) made an attempt during the episode for which they were hospitalized. Demographic characteristics did not distinguish attempters from nonattempters. Variables significantly associated with having ever attempted suicide were current diagnosis of unipolar major depressive disorder but not bipolar; lifetime major depressive episode; a history characterized by a less acute onset, lower pre-admission psychosocial functioning, and episodes of physical violence; and a symptom picture characterized by greater depression, hopelessness, negative symptoms, hallucinations and less thought disorder. Those with a current attempt had significantly higher rates of lifetime history of major depression and less physical violence than those with past attempts only. The potential importance of the data for predicting future suicidal acts is discussed.

Schizophrenia and substance abuse

BACKGROUND

Recent research from North America has demonstrated higher than expected rates of drug and alcohol abuse among the seriously mentally ill. Schizophrenics appear to be particularly susceptible to the negative effects of substance abuse. These include psychiatric and social complications, with antisocial behaviour, particularly violence emerging as one of the most worrying features. This review examines the strength of the association and explores the possible explanations for the apparent link between schizophrenia, substance abuse and violence.

METHOD

The literature was searched using Medline, supplemented with a manual literature search.

RESULTS

Very few articles specifically approached the problem of violence among substance abusing schizophrenics, but over 80 papers were identified which were helpful in exploring the link between dangerous behaviour and substance abuse by schizophrenics.

CONCLUSIONS

While there is circumstantial evidence to support the hypothesis that schizophrenics who abuse drugs or alcohol are at an increased risk of behaving violently, longitudinal studies are required to facilitate a better understanding of the mediating mechanisms.

Schizophrenics remanded to the Forensic Psychiatric Institute of British Columbia, 1975-1990

Clinical and legal data were collected on 1265 schizophrenic patients remanded to a maximum security hospital, for psychiatric evaluation of fitness to stand trial. Schizophrenics accounted for over half of the remand population. When compared to the nonschizophrenic group, they had more previous admissions to the Forensic Psychiatric Institute and the Provincial Mental Hospital. They were also more likely to be found unfit to stand trial or to have their charges stayed by the Crown. However, approximately half of the schizophrenics in this study returned to Court, fit to stand trial and with no further psychiatric treatment provided. This study raises major questions about the purpose and value of remanding schizophrenics to a maximum security hospital for in-patient fitness evaluations.

Current cannabis use and tardive dyskinesia

The aim of this study was to examine the relationship between substance abuse and tardive dyskinesia (TD) in 51 chronic, neuroleptic-treated, community outpatients with a DSM-III-R diagnosis of schizophrenia. In the presence of a clinical researcher, subjects completed a questionnaire on past and current alcohol and drug use, and provided information pertaining to variables which have, in the past, been implicated in the development of TD: smoking habits, caffeine consumption, and current neuroleptic dose. Subjects were also administered the Abnormal Involuntary Movement Scale (AIMS) in an interview format with either two or three trained raters present in the room. Consistent with previous reports, our results indicated a trend for females and older patients with a longer duration of illness to show elevated scores on the AIMS. In a hierarchical multiple regression analysis, however, cannabis use was found to correlate best with the presence of TD, out-ranking other putative factors.

Suicide by psychotics

The authors studied 31 cases with psychotic diagnoses from a consecutive series of 204 suicides in San Diego. They were compared to 25 similar cases from 134 suicides gathered in the city of St. Louis and St. Louis county 25 years earlier. The proportion of psychotic subjects (less than 20%) in the two samples was similar. The San Diego psychotics were younger on the average than those from St. Louis and had more polysubstance abuse than alcoholism. Only rarely did psychotics in either sample commit suicide by particularly "crazy" methods. In the San Diego suicides, the psychotics without a depressive syndrome had as many depressive symptoms as those with a depressive syndrome. Schizophrenics in the San Diego sample made suicidal communications just as often as the other psychotics and the nonpsychotics. Fewer schizophrenics than other psychotics or nonpsychotics had stressors identified at the time of death, but over half of all the subjects did have them.

Patterns of self-destructive behaviour in schizophrenia

Of 110 consecutive, young schizophrenic patients, 18 (16.4%) died during a follow-up period of 14-17 years from first admission. Fifteen of them met with a sudden death. Definite suicide was proven in 10 cases (9%). Suicide was associated with chronicity in course, social dependency, and lowered efficiency. Some type of warning was present in all suicide cases. The frequency of suicide thoughts and attempts was high in the whole material. Suicide attempts were associated with protracted non-regressive symptomatology, readmission to hospital, social intervention, and female sex. The disparity of characteristics between attempted suicide and definite suicide cases may partly be explained by the preponderance of women among the former and by the fact that only half of the suicidal deaths occurred when the frequency of attempts was at its peak. In attempted suicide in men their characteristics were compatible with those of the whole group, as well as with those of the suicide cases.

Suicide among psychiatric patients of a district general hospital

Twenty-two psychiatric patients who committed suicide while receiving hospital treatment or within 3 months of discharge from psychiatric care were studied using general population statistics, a random sample of 100 psychiatric patients and a control group matched individually with the hospital suicides. The rate of suicide among psychiatric in-patients was over 50 times that in the general population. A higher vulnerability to suicide was detected among in-patients (v. other patient groups), men (v. women) and middle-aged patients (v. older and younger patients). Suicides were differentiated from controls in having suffered more losses (P less than 0.05), being psychiatrically ill for the first time (P less than 0.05), having a past history of deliberate self-harm (P less than 0.05), and not receiving a schizophrenic diagnosis (P less than 0.02). People with mid-life crises, patients who swing rapidly into depression while receiving treatment, and individuals who are judged to be depressed because of personal problems may carry a particularly high suicide risk during psychiatric treatment.

Suicide in psychiatric in-patients

Suicide risks for psychiatric hospital in-patients may be described by empirical relationships that take account of sex, length of admission and diagnosis. Risks are highest in males, in the first week of admission, and in depressed patients. Hospital suicide rates do not follow the same pattern as those for the general population and it is suggested that this effect may be the result of current selection procedures. The standard mortality ratio, which compares hospital with general population suicides, has remained unchanged over fifty years.

Suicide in chronic schizophrenia

A matched controlled study of 30 chronic schizophrenic suicides is presented. Eighty per cent were male and committed suicide at a mean age of 25.8 years after a mean duration of illness of 4.8 years. Significantly more of the suicides had a chronic relapsing schizophrenic illness; 23.3 per cent committed suicide while in-patients, and 50 per cent of the out-patients committed suicide within three months of discharge from in-patient care. Significantly more of the suicides had a past history of depression (56.6 per cent), were depressed in the last episode of contract (53.3 per cent), had their last admission for depression or suicidal ideation (55.2 per cent) and were unemployed (80 per cent).

[Suicide and endogenous psychosis]

The frequency of suicide among a population of 675 patients with functional psychoses, within a period of observation between 9 and 24 years, was 5.5%. Suicide was the cause of death in 25.6% of all lethal outcomes. The suicide frequency of schizophrenics was 1.4%, of the bipolar cases 2.4% of the monopolar depressives 10.4%. The frequency of suicide of the parents and sibs of schizophrenics was 1.3%, of schizoaffectives 3.8%, monopolar depressives 4.2%, bipolar affective psychotics 4.3%. There was no sex difference in regard to suicide frequency but in regard to the choice of suicide means (strangulation in male, poisoning and submersion in female relatives).