Psychotropics and suicide prevention. Implications from toxicological screening of 5281 suicides in Sweden 1992-1994

The association between self-reported mental health, medication record and suicide risk: A population wide study

Suicide mortality and mental ill health are increasing globally. Mental ill health can be measured in multiple ways. It is unclear which measure is most associated with suicide risk. This study explored the association between self-rated mental health and medication record and death by suicide. The 2011 Northern Ireland Census records of adults aged 18-74 years (n=1,098,967) were linked to a centralised database of dispensed prescription medication and death registrations until the end of 2015. Mental health status was ascertained through both a single-item self-reported question in the Census and receipt of psychotropic medication. Logistic regression models examined the association between indicators of mental ill health and likelihood of suicide mortality. Of the 1,098,967 cohort members, 857 died by suicide during the study period. Just over half of these deaths (n=429, 50.1%) occurred in individuals with neither indicator of mental ill health. Cohort members with both self-reported mental ill health and receipt of psychotropic medication had the highest risk of suicide (OR=6.13, 95%CI: 4.94–7.61), followed by those with psychotropic medication record only (OR=4.00, 95%CI: 3.28–4.88) and self-report only (OR=2.88, 95%CI: 2.16–3.84). Individuals who report mental ill health and have a history of psychotropic medication use are at a high risk of suicide mortality. However, neither measure is particularly sensitive, as both failed to signal over half of subsequent suicides. Some individuals who report poor mental health but are not in receipt of psychotropic medication are at increased risk of suicide, indicating possible unmet treatment need. The combination of the two indicators offers more precision for identifying those most at risk for targeted interventions.

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Mental ill health is associated with an increased risk of suicide, but measuring population mental health is difficult.

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The suicide risk associated with both subjective and objective indicators of mental ill health have not been examined.

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Most individuals who die by suicide have no indicator of mental ill health.

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Having both self-reported poor mental health and psychotropic medication record carried the highest risk of suicide death.

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Increased risk of suicide in individuals who report poor mental health but are not on medication may indicate unmet need.

Predictors of re-attempt in a cohort of suicide attempters: A survival analysis

BACKGROUND

Suicide prevention is one of the greatest challenges in mental health policies. Since a previous suicide attempt is the main predictor of future suicidal behaviour, clinical management of suicide attempters is vital for lowering mortality. Psychopharmacological interventions are still nonspecific, and their effectiveness have often been questioned. In this study, we aim to identify predictors of suicide re-attempt in a cohort of suicide attempters, with particular focus on different aspects of psychopharmacological treatment.

METHODS

This is a prospective study. Adults presenting with a suicide attempt were approached to take part in our study, resulting in a final sample of 371 participants. Participants were followed from inclusion to next suicide attempt, death by other causes, loss of the patient, or after a maximum of two years. We conducted Kaplan-Meier survival analyses and a multivariate Cox regression model for several exposure variables.

RESULTS

During the study period, 70 participants (18,9%) re-attempted. 60% of re-attempts occurred within the first 6 months. Three factors were independently associated with risk of re-attempt in the Multivariate Cox regression model: diagnosis of a Cluster B personality disorder, good treatment compliance, and at least one previous suicide attempt prior to the index event.

LIMITATIONS

Indication bias precludes a clear interpretation of our results regarding psychopharmacological treatment. Poor adherence may also be a consequence of relapse rather than just one of its causes.

CONCLUSIONS

A correct psychopharmacological treatment is insufficient to prevent re-attempts in populations at risk. Strategies to increase compliance should be taken into account as part of prevention programs.

[Antidepressants and Suicidality: A Contradiction?]

Antidepressants and Suicidality: A Contradiction? Abstract. In 2004, the European and American authorities released a black-box warning on antidepressants indicating an association with an increased risk of suicidality (suicidal ideation and behavior) in young people. Until today, this issue remained controversial. The present review gives an overview on the relationship between antidepressant therapy and the risk of suicide and suicidality, respectively: there is no evidence of an increased risk of suicide, but of an increased rate of suicidality during the first period after starting an antidepressant treatment in young patients. Importantly, this risk was not higher than before treatment initiation. However, an intensified supervision is needed especially during the first weeks of treatment. Finally, the risk posed by untreated depression is far greater than a risk associated with antidepressant treatment.

The relationship between the prescription of pyschotropic drugs and suicide rates in adults in England and Wales

BACKGROUND

A few studies have demonstrated an inverse relationship between the general population and suicide rates and antidepressant prescribing rates. Correlations between general population suicide rates and prescribing rates of other psychotropic drugs have also been observed. There have not been any studies during the last decade.

METHODS

The relationship between adult suicide rates and prescription rates of psychotropic drugs by the broad British National Formulary (BNF) categories, for individual psychotropic drug groups within the BNF categories (e.g. selective serotonin reuptake inhibitors) and for individual psychotropic drugs was examined over a 12-year period (1995-2006) was examined using Spearman's rank correlation. All data were ascertained from the archives of the Office for National Statistics.

RESULTS

There was an absence of significant correlations between adult suicides rates and rates of prescriptions of psychotropic drugs in the broad BNF categories, individual psychotropic drug groups and individual psychotropic drugs.

DISCUSSION

The findings may be due to methodological errors. Should the findings be accurate, then the following approaches require consideration to reduce suicide rates further: (i) development of strategies to ensure continued prescription of psychotropic drugs at the current level; (ii) development of strategies to improve non-pharmacological measures, including improved mental health services provision for adults, improved assessment of suicide risk, increased availability of psychosocial interventions and restricting the availability of methods of suicide; and (iii) development of strategies to implement improvement in distal risk (e.g. societal socio-economic status) and protective (e.g. societal educational attainment) factors for suicide at a societal level.

Diagnoses and prescriptions of antidepressants in suicides: Register findings from the Friuli Venezia Giulia Region, Italy, 2002-2008

OBJECTIVE

To explore to what extent and under which diagnoses individuals who committed suicide had received psychiatric in-patient care, and how many had previously committed non-lethal self-harm. To investigate the antidepressant treatment received by these individuals.

METHODS

Case-control study based on a health register.

RESULTS

Psychiatric hospitalisation was found in 31.2% of the cases and 2.3% of the controls, and was a strong predictor for suicide with an odds ratio (OR) = 19.5. This did not differ significantly between diagnostic categories (except anxiety disorders with OR = 5.3). Non-lethal self-harm in the study period was committed by 14.3% of the cases and 0.14% of the controls, and was twice as common in female cases than in male cases. Previous self-harm was a very strong independent predictor for suicide with OR = 53.1 when a single episode of self-harm had occurred, and OR = 98.0 for repeated episodes (adjusted for age, gender and hospitalisation). Only 16.1% of the cases were currently on antidepressant medication at the time of suicide.

CONCLUSIONS

Few of the suicides had previously been psychiatric in-patients. Even fewer had current prescriptions for antidepressants. This suggests that better diagnosis and treatment of psychiatric patients is an important suicide preventive intervention.

A 2-year psychological autopsy study of completed suicides in the athens greater area, Greece

OBJECTIVE

To study the characteristics of a sample of suicide victims from the Athens Greater Area using the psychological autopsy method for the first time in Greece.

METHODS

We studied all recorded cases of completed suicide for the 2-year time period November 2007-October 2009 collecting data from the victims' forensic records as well as from the completion of a psychological autopsy questionnaire.

RESULTS

335 persons were recorded as suicide victims. We contacted relatives of 256 victims interviewing those of 248 of them (96.9%). The differences regarding sex, marital and employment status between our sample and the general population were statistically significant (p<0.001). The male/female ratio was 3:1. Comparatively more victims were divorced, separated or single and a greater proportion were pensioners or unemployed. 26.0% of the victims had history of prior attempts (64.4% once, 20.3% twice and 15.3% more times). 42.6% were taking psychiatric medication-significantly more women than men according to blood tests; 14.2% had been hospitalized in a psychiatric clinic the year prior to their death. 84.8% have deceased at the place of suicide and 15.2% died in the hospital; 80.3% died indoors and 19.7% outdoors. Men died primarily by hanging or shooting by a firearm while women preferred jumping from height instead (p<0.001). As many as 48.8% had expressed their intention to die to their relatives; 26.6% left a suicide note.

CONCLUSION

Our study has shown that the psychological autopsy method is applicable and widely accepted yielding results comparable to the international literature. Specific parameters associated with suicide have been studied for the first time in Greece.

The relationship between the prescription of psychotropic drugs and suicide rates in older people in England and Wales

BACKGROUND

Several studies have reported an inverse correlation between general population and elderly suicide rates and antidepressant prescribing rates. Correlations between general population and elderly suicide rates and prescribing rates of other psychotropic drugs have also been reported. All studies of elderly suicide rates have used data over a decade old.

METHODS

The relationship between elderly suicide rates and prescription rates of psychotropic drugs by the broad British National Formulary (BNF) categories, for individual psychotropic drug groups within the BNF categories (e.g. SSRIs), and for individual psychotropic drugs was examined over a 12-year period (1995-2006) using Spearman's rank correlation. All data were ascertained from the archives of the National Statistics Office.

RESULTS

There was an absence of significant correlations between elderly suicides rates and rates of prescriptions of psychotropic drugs in the broad BNF categories, individual psychotropic drug groups and individual psychotropic drugs.

DISCUSSION

The findings may be due to methodological flaws. However, if they are genuine, then the following approaches require consideration to further reduce suicide rates: (1) development of strategies to ensure continued prescription of psychotropic drugs at the current level; (2) development of strategies to improve non-pharmacological measures, including improved mental health services provision for older people, improved assessment of suicide risk, increased availability of psychosocial interventions and restricting the availability of methods of suicide; and (3) development of strategies to implement improvement in distal risk (e.g. societal socio-economic status) and protective (e.g. societal educational attainment) factors for suicide at a societal level.

Temporal trends in new exposure to antiepileptic drug monotherapy and suicide-related behavior

OBJECTIVE

Because some recent studies suggest increased risk for suicide-related behavior (SRB; ideation, attempts) among those receiving antiepileptic drugs (AEDs), we examined the temporal relationship between new AED exposure and SRB in a cohort of older veterans.

METHODS

We used national Veterans Health Administration databases to identify veterans aged ≥65 years who received a new AED prescription in 2004-2006. All instances of SRB were identified using ICD-9-CM codes 1 year before and after the AED exposure (index) date. We also identified comorbid conditions and medication associated with SRB in prior research. We used generalized estimating equations with a logit link to examine the association between new AED exposure and SRB during 30-day intervals during the year before and after the index date, controlling for potential confounders.

RESULTS

In this cohort of 90,263 older veterans, the likelihood of SRB the month prior to AED exposure was significantly higher than in other time periods even after adjusting for potential confounders. Although there were 87 SRB events (74 individuals) the year before and 106 SRB events (92 individuals) after, approximately 22% (n = 16) of those also had SRB before the index date. Moreover, the rate of SRB after AED start was gradually reduced over time.

CONCLUSIONS

The temporal pattern of AED exposure and SRB suggests that, in clinical practice, the peak in SRB is prior to exposure. While speculative, the rate of gradual reduction in SRB thereafter suggests that symptoms may prompt AED prescription.

Substances used in completed suicide by overdose in Toronto: an observational study of coroner's data

OBJECTIVE

To identify the substances used by people who die from suicide by overdose in Toronto and to determine the correlates of specific categories of substances used.

METHOD

Coroner's records for all cases of suicide by overdose in Toronto, Ontario, during a 10-year period (1998 to 2007) were examined. Data collected included demographic data, all substances detected, and those determined by the coroner to have caused death. Logistic regression analyses were used to examine demographic and clinical factors associated with suicide by different drug types.

RESULTS

There were 397 documented suicides by overdose (mean age 49.1 years, 50% female). Most substances detected were psychotropic prescription medications (n = 245), followed by other prescription medications (n = 143) and over-the-counter (OTC) medications (n = 83). More than one-half of all suicides by overdose were determined to have only one specific substance as the cause of death (n = 206). In suicides where only one class of substance was present in lethal amounts, OTC medication (n = 48), opioid analgesics (n = 44), and tricyclic antidepressants (n = 44) were most common.

CONCLUSIONS

Suicides by overdose involved the use of different classes of substances, including psychotropic prescription medication, other prescription medications, as well as OTC medications. Physicians and pharmacists should be aware of commonly used prescription and OTC medications in overdose and exercise increased vigilance in prescribing or dispensing them to at-risk patients.

Treatment of Veterans with depression who died by suicide: timing and quality of care at last Veterans Health Administration visit

OBJECTIVE

To examine the recency and quality of the last Veterans Health Administration (VHA) visit for patients with depression who died by suicide.

METHOD

We obtained services and pharmacy data for all 1,843 VHA patients with diagnosed depressive disorders (DSM-IV criteria) who died by suicide from April 1999 through September 2004. We ascertained the location and timing of their final VHA visit. For visits occurring within 30 days of suicide, we examined 3 quality indicators: (1) evidence that mental illness was a focus of the final visit, (2) adequacy of antidepressant dosage, and (3) recent receipt of mental health services.

RESULTS

Just over half of the patients (51%) with depression diagnoses had a VHA visit within 30 days of suicide. A minority of these patients (43%) died by suicide within 30 days of a final visit with mental health services, although 64% had received such services within 91 days of their suicide. Among the 57% of patients who died by suicide within 30 days and who were seen in non-mental health settings for their final visit, only 34% had a mental health condition coded at the final visit, and only 41% were receiving adequate dosages of antidepressant (versus 55% for those last seen by mental health services) (P < .0005).

CONCLUSIONS

Veterans Health Administration patients with depression who died by suicide within 30 days of their final visit received relatively high rates of mental health services, but most final visits still occurred in non-mental health settings. Increased referrals to mental health services, attention to mental health issues in non-mental health settings, and focus on antidepressant treatment adequacy by all providers might have reduced suicide risks for these patients.

Changes in the prevalence of major depression in an Australian community sample between 1998 and 2008

OBJECTIVE

To identify changes in the prevalence of major depression between 1998, 2004 and 2008 in South Australia.

METHODS

Face-to-face Health Omnibus surveys were conducted in 1998, 2004 and 2008 with approximately 3000 participants aged 15 years and over, who were random and representative samples of the South Australian population. Each survey used the same methodology. Outcome measures were: major depression as detected by the Mood module of the Primary Care Evaluation of Mental Disorders instrument; mental health literacy by recognition and exposure to classical symptoms of depression; and health status using the SF-36 Physical and Mental Component summaries.

RESULTS

There was a significant increase in the prevalence of major depression from 6.8% (95%CI: 5.9%-7.7%) to 10.3% (95%CI: 9.2%-11.4%; χ² 24.59, p < 0.001) between 1998 and 2008. Significant increases were observed in males aged 15-29 and females aged 30-49 years. There was no significant increase in any other sub-group. The strongest predictor of major depression was health status. Participants with poor/fair mental health literacy were 37% less likely to be classified with major depression.

CONCLUSIONS

The prevalence of major depression increased significantly in South Australia over the last decade and there was a reduction in mental health status and an increase in persons reporting poor health. Unexpectedly, having poor or fair mental health literacy was significantly protective for major depression. Ideally, public health initiatives should result in an improvement in health, but this did not appear to have occurred here.

The treatment of borderline personality disorder: implications of research on diagnosis, etiology, and outcome

The treatment of patients with borderline personality disorder (BPD) is challenging. Making a diagnosis is necessary to plan therapy. But since we do not know the etiology of BPD, treatment cannot be based on a well-established theory. Outcome research shows that most patients recover with time. A series of clinical trials show that a variety of psychotherapies are effective in BPD and that the effects of medication are unimpressive.

Decrease in suicide among the individuals treated with antidepressants: a controlled study of antidepressants in suicide, Sweden 1995-2005

OBJECTIVE

Ecological studies have demonstrated a substantial decrease in suicide in parallel with an increase in the use of antidepressants. Causality cannot, however, be inferred from such studies. The aim of this study was to test on the individual level the hypothesis that treatment with antidepressant medication has been a substantially contributing cause of the decrease in suicide.

METHOD

Time trends in the detection of antidepressants and five 'control medications' in the forensic toxicological screening of 16 937 suicides and 33 426 controls in Sweden 1995-2005.

RESULTS

The expected number of antidepressant-positive suicides in 2005 was 409 if the hypothesis was true and 603 if it was false. The observed number in 2005 was 420. The control medications were detected to the extent that was expected if not preventing suicide.

CONCLUSION

The observed trend in the number of suicides with antidepressants was well predicted by the hypothesis that the increased use of antidepressants has been a substantially contributing cause of the decrease in suicide.

Antidepressant use and suicide prevention: a prescription database study in the region Friuli Venezia Giulia, Italy

OBJECTIVE

To investigate the possible impact of the increased use of antidepressants on suicide rates in the Italian region of Friuli Venezia Giulia (FVG).

METHOD

Individual-based data on antidepressants in FVG from 1997 to 2006 were obtained from the regional prescription database, and linked to data on suicide for the same period obtained from the regional health information system. Age and sex were considered.

RESULTS

The number of users of antidepressants increased almost fivefold during the study period. Selective serotonin reuptake inhibitors accounted for 71% of the individual users in 2006. The number of defined daily doses (DDD) per patient increased almost sevenfold. In parallel, the suicide rate decreased by one-third in men as well as in women, and in subjects under and over the age of 60 years.

CONCLUSION

Suicide rates in FVG have declined in agreement with the hypothesis that the use of antidepressants may prevent suicide.

Adequacy of, attitudes toward, and adherence to treatments by suicidal and nonsuicidal depressed patients

We examined differences in treatments received, and attitudes and adherence to them between suicidal and nonsuicidal patients with major depressive disorder (MDD). Psychiatric MDD patients with no suicidal behavior (N = 92), suicidal ideation (N = 92), or attempts (N = 34) were compared during 6 months of follow-up in the Vantaa Depression Study (VDS). Patients with suicidal behavior received antidepressants or adequate antidepressant treatment significantly more often, had more frequent appointments with psychiatrists, more psychotherapeutic support, and more favorable attitudes toward antidepressant treatment than nonsuicidal patients. However, after adjusting for the confounding severity of depression, the significance of these differences was lost. Adherence to treatment was similar in the patient groups. Overall, among psychiatric patients with MDD, those known to be suicidal have higher suicide risk and should receive more intensive treatment. However, suicidal behavior per se does not seem to markedly influence treatments provided nor should it be associated with negative attitudes or poor adherence to treatments.

Treatment of depression with selective serotonin inhibitors: the role of fluvoxamine

The advent of the selective serotonin reuptake inhibitors (SSRIs) is generally considered to have improved the treatment of depression. Head-to-head trials comparing SSRIs to each other have shown little difference in efficacy among agents. The main differences between the SSRIs relate to safety and tolerability profiles, reflecting the fact that the SSRIs possess significant and variable secondary pharmacological properties. This heterogeneity contributes to clinically relevant differences that clinicians are increasingly using to select antidepressant treatment more closely appropriate to specific patient populations and circumstances. This review assesses the place of fluvoxamine amongst the SSRIs in the context of current issues and concerns with drug therapy. Fluvoxamine has a proven efficacy and safety profile in treating elderly patients with depression. The beneficial effects of fluvoxamine in obsessive-compulsive disorder (OCD) are also well documented. On the other hand, its σ1-receptor binding profile may account for the observed high level of efficacy in psychotic depression and may explain the benefit of fluvoxamine in treating depression comorbid with anxiety/stress. There is no definitive evidence that suicide risk is higher with SSRIs than with other antidepressants or nonpharmacological treatments and postmarketing surveillance indicates that fluvoxamine is not associated with a higher level of suicidality.

Have education and publicity about depression made a difference? Comparison of prevalence, service use and excess costs in South Australia: 1998 and 2004

OBJECTIVE

To identify changes in depression, its management and associated excess costs, between 1998 and 2004 in South Australia.

METHODS

A face-to-face Health Omnibus Survey was conducted in 2004 among 3015 randomly selected participants aged 15 years and over, who were a random and representative sample of the South Australian population, and this was compared with a survey conducted in 1998 that used the same methodology. The main outcome measures were prevalence of depression detected by the Mood Module of the Primary Care Evaluation of Mental Disorders (PRIME-MD); use of health services; health-related quality of life assessed by the Assessment of Quality of Life; estimates of excess costs and demographic data.

RESULTS

There was no significant change in the overall prevalence of depression, although there was a significant decrease in respondents with other depressions, and a non-significant increase in those with major depression. No significant differences in the mean number of PRIME-MD depression symptoms were reported. Greater use of predominantly non-medical treatment services and antidepressants were reported by both those with depression and those without depression. There was a marked increase in the associated excess costs of depression.

CONCLUSIONS

There has been no significant improvement in the prevalence of depression and its associated morbidity and financial burden in the South Australian community between 1998 and 2004, despite a number of professional and community education programmes. It is possible that without these efforts and the increased treatment reported on in this survey, there may have been an increase in the prevalence of depression and an even greater financial burden. However, it is also possible that community services for the provision of treatment for depression have not been able to implement research strategies that have been demonstrated to be effective.

Toxicologic findings in suicide: a 10-year retrospective review of Kentucky medical examiner cases

Toxicologic analysis is an integral component in the investigation of suicide and requires correlation with a detailed scene inspection, with an extensive exploration into the decedent's medical and social background to uncover suicidal ideation or intent and a postmortem examination of the body. In this review, the authors analyzed 2864 cases classified as suicide upon autopsy and toxicologic examinations between 1993 and 2002 in the Kentucky Division of Medical Examiner's Services. Blood and urine were collected in 95.0% and 72.3% of cases, respectively. A total of 32.5% of the victims had negative blood toxicologic results, and 52.7% of urine toxicology screens yielded no drugs. Analysis of the data indicated that 3 times as many women had taken antidepressants and more than twice as many had consumed opioids. Drug toxicity ("overdose") ranked as the third (9.9%) leading cause of suicide after firearm injury (67.5%) and hanging (13.7%). Women succumbed to drug toxicity more than men (27.5% versus 5.9%). Of the overdose deaths, 66.5% had a negative blood alcohol concentration (BAC), while antidepressants, opioids, and benzodiazepines were detected in blood in 54.4%, 37.4%, and 29.2% of the subjects, respectively. The collection of these data serves the goals of public health and clinicians in devising strategies for suicide prevention.

Modeling of the temporal patterns of fluoxetine prescriptions and suicide rates in the United States

BACKGROUND

To study the potential association of antidepressant use and suicide at a population level, we analyzed the associations between suicide rates and dispensing of the prototypic SSRI antidepressant fluoxetine in the United States during the period 1960-2002.

METHODS AND FINDINGS

Sources of data included Centers of Disease Control and US Census Bureau age-adjusted suicide rates since 1960 and numbers of fluoxetine sales in the US, since its introduction in 1988. We conducted statistical analysis of age-adjusted population data and prescription numbers. Suicide rates fluctuated between 12.2 and 13.7 per 100,000 for the entire population from the early 1960s until 1988. Since then, suicide rates have gradually declined, with the lowest value of 10.4 per 100,000 in 2000. This steady decline is significantly associated with increased numbers of fluoxetine prescriptions dispensed from 2,469,000 in 1988 to 33,320,000 in 2002 (r(s) = -0.92; p < 0.001). Mathematical modeling of what suicide rates would have been during the 1988-2002 period based on pre-1988 data indicates that since the introduction of fluoxetine in 1988 through 2002 there has been a cumulative decrease in expected suicide mortality of 33,600 individuals (posterior median, 95% Bayesian credible interval 22,400-45,000).

CONCLUSIONS

The introduction of SSRIs in 1988 has been temporally associated with a substantial reduction in the number of suicides. This effect may have been more apparent in the female population, whom we postulate might have particularly benefited from SSRI treatment. While these types of data cannot lead to conclusions on causality, we suggest here that in the context of untreated depression being the major cause of suicide, antidepressant treatment could have had a contributory role in the reduction of suicide rates in the period 1988-2002.

Tolerability and safety of fluvoxamine and other antidepressants

Selective serotonin [5-hydroxytryptamine (5-HT)] reuptake inhibitors (SSRIs) and the 5-HT noradrenaline reuptake inhibitor, venlafaxine, are mainstays in treatment for depression. The highly specific actions of SSRIs of enhancing serotonergic neurotransmission appears to explain their benefit, while lack of direct actions on other neurotransmitter systems is responsible for their superior safety profile compared with tricyclic antidepressants. Although SSRIs (and venlafaxine) have similar adverse effects, certain differences are emerging. Fluvoxamine may have fewer effects on sexual dysfunction and sleep pattern. SSRIs have a cardiovascular safety profile superior to that of tricyclic antidepressants for patients with cardiovascular disease; fluvoxamine is safe in patients with cardiovascular disease and in the elderly. A discontinuation syndrome may develop upon abrupt SSRI cessation. SSRIs are more tolerable than tricyclic antidepressants in overdose, and there is no conclusive evidence to suggest that they are associated with an increased risk of suicide. Although the literature suggests that there are no clinically significant differences in efficacy amongst SSRIs, treatment decisions need to be based on considerations such as patient acceptability, response history and toxicity.

Utah youth suicide study: psychological autopsy

We conducted a psychological autopsy study to further understand youth suicide in Utah. While traditional psychological autopsy studies primarily focus on the administration of psychometric measures to identify any underlying diagnosis of mental illness for the suicide decedent, we focused our interviews to identify which contacts in the decedent's life recognized risk factors for suicidal behavior, symptoms of mental illness, as well as barriers to mental health treatment for the decedent. Parents and friends recognized most symptoms universally, although friends better recognized symptoms of substance abuse than any other contact. The study results suggest that parents and friends are the most appropriate individuals for gatekeeper training and, in conjunction with other innovative screening programs, may be an effective strategy in reducing adolescent suicide.

Changes in mental health literacy about depression: South Australia, 1998 to 2004

OBJECTIVE

To identify changes in mental health literacy in regard to depression between 1998 and 2004.

DESIGN AND SETTING

Face-to-face interviews with a random and representative sample of the South Australian population in 2004, compared with a similarly conducted survey in 1998 that used the same vignette, questions and methodology.

PARTICIPANTS

3015 randomly selected participants, aged 15 years and over.

MAIN OUTCOME MEASURES

Responses to both open-ended and direct questions about symptoms and treatment options for depression.

RESULTS

The 3015 interviews conducted represented a response rate of 65.9%. Compared with 1998, in 2004 there was a significant increase in the proportion of people recognising depression in the vignette, acknowledging personal experience of depression, and perceiving professional assistance to be more helpful and less harmful. However, although more people nominated psychiatrists or psychologists as therapists of choice, the difference between 1998 and 2004 was not significant.

CONCLUSIONS

There has been a significant increase in mental health literacy, at least as regards depression, in the South Australian community between 1998 and 2004. The lack of significant change in psychiatrists and/or psychologists being perceived as therapists of choice is of concern and suggests that community education about their expertise may be appropriate.

Antidepressant drug use and suicide prevention

Depression has been identified as occurring in the majority of people who commit suicide. Effective antidepressant medications have been available for over half a century. It seems logical to conclude that treatment of depression with antidepressants would have a suicide preventive effect. This has been difficult to demonstrate due to the infrequency of suicide and methodological problems in prospectively testing the hypothesis. Pooled data from controlled clinical trials of antidepressants have not demonstrated a suicide preventive effect, but patient selection and the brief time of most trials limits the power of the data. Some reports from either long-term or very large databases have provided evidence that antidepressants prevent suicide. All but one study using aggregated data from naturalistic settings have shown inverse relationships between use of antidepressants and suicide rates in various populations. Definite conclusions cannot be drawn from naturalistic studies since unknown confounders cannot be excluded. The number of geographically widespread studies reporting positive results with varying methods leads us to conclude, however, that antidepressants do exert a suicide preventive effect.

Suicide Prevention

Abstract. Because of the almost complete absence of randomized controlled trials demonstrating the effectiveness of specific treatments, there is sometimes a degree of pessimism about our ability to prevent suicidal behaviors. However, the methodological challenges to produce such research are formidable and may never be overcome. Therefore, a pragmatic review of evidence-based methods of suicide prevention is required. This review of recent studies using a variety of research strategies, both nonpharmacological and pharmacological, particularly at the community level, provides persuasive data that suicide prevention is possible. This is achievable by the application of broad community and professional education programs, as well as by the optimum management of mental disorders.

Selective serotonin reuptake inhibitor antidepressants and the risk of suicide: a controlled forensic database study of 14,857 suicides

OBJECTIVE

To test the hypothesis that selective serotonin reuptake inhibitor (SSRI) antidepressants may have a suicide emergent effect, particularly in children and adolescents.

METHOD

Detections of different antidepressants in the forensic toxicological screening of 14 857 suicides were compared with those in 26,422 cases of deaths by accident or natural causes in Sweden 1992-2000.

RESULTS

There were 3411 detections of antidepressants in the suicides and 1538 in the controls. SSRIs had lower odds ratios than the other antidepressants. In the 52 suicides under 15 years, no SSRIs were detected. In 15-19-year age group, SSRIs had lower relative risk in suicides compared with non-SSRIs.

CONCLUSION

The hypothesis that treatment of depressed individuals with SSRIs leads to an increased risk of suicide was not supported by this analysis of the total suicidal outcome of the nationwide use of SSRIs in Sweden over a period of 9 years, either in adults or in children or adolescents.

Depression, antidepressants and suicidality: a critical appraisal

Regulatory agencies in the United Kingdom and United States have been critically examining the possible link between suicidality and antidepressant use in children and adults, which has resulted in an FDA directive to the manufacturers of all antidepressant medications to add a 'black box' warning that describes the increased risk of suicidal behaviour in children and adolescents who take antidepressants. A crucial issue in this debate, as we discuss here, is the assessment of the capacity of antidepressants to increase suicidality over and above what is caused by the underlying disorder, major depression, which is itself the principal cause of suicide.

Australian and New Zealand clinical practice guidelines for the treatment of depression

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Ministry of Health.

METHOD

The CPG team reviewed the treatment outcome literature, consulted with practitioners and patients and conducted meta-analyses of outcome research.

TREATMENT RECOMMENDATIONS

Establish an effective therapeutic relationship; provide the patient with information about the condition, the rationale for treatment, the likelihood of a positive response and the expected timeframe; consider the patient's strengths, life stresses and supports. Treatment choice depends on the clinician's skills and the patient's circumstances and preferences, and should be guided but not determined by these guidelines. In moderately severe depression, all recognized antidepressants, cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) are equally effective; clinicians should consider treatment burdens as well as benefits, including side-effects and toxicity. In severe depression, antidepressant treatment should precede psychological therapy. For depression with psychosis, electroconvulsive therapy (ECT) or a tricyclic combined with an antipsychotic are equally helpful. Treatments for other subtypes are discussed. Caution is necessary in people on other medication or with medical conditions. If response to an adequate trial of a first-line treatment is poor, another evidence-based treatment should be used. Second opinions are useful. Depression has a high rate of recurrence and efforts to reduce this are crucial.

The evaluation of suicide prevention activities: state of the art

One million people commit suicide world-wide every year. The need for suicide prevention is obvious, and very different approaches have been investigated to reduce the number of suicides. Some interventions aim at identified high-risk groups (e.g. support for people after suicide attempt), some at the population as a whole (e.g. restricting the access to means for suicide). There is, however, but little evidence for the efficacy of suicide prevention activities. This can mostly be attributed to methodological problems such as the lack of randomised controlled studies and the fact that the sample size is too small to show an effect. Despite these problems, some interventions showed promising results (e.g. long-term lithium treatment). A main problem, however, is that many people at risk do not get in contact with health care institutions. Moreover, no single approach by itself seems to contribute to a substantial decline in the suicide rate. The authors therefore argue that a combination of different strategies in a multi-level approach might prove to be the most effective.

Antisuicide properties of psychotropic drugs: a critical review

The authors consider the extent to which psychotropic medications demonstrate benefits in the prevention of suicidal behavior in psychiatric patients. Results of a MedLine search are critically reviewed for lithium, divalproex and other anticonvulsants, conventional and atypical antipsychotics, and antidepressants. The existing literature is almost entirely limited to noncontrolled, often retrospective studies that do not control for potential biases in treatment selection, the use of multiple medications, the impact of medication nonadherence, and nonrandomized treatment discontinuations. Nevertheless, an extensive literature has arisen regarding observed reductions in suicidal behavior with lithium for mood disorders and, to a lesser extent, with clozapine for schizophrenia. A substantially smaller literature suggests more negative than positive data with divalproex or carbamazepine in bipolar disorder, while minimal information exists regarding suicidality with atypical antipsychotics other than clozapine. Studies of antidepressants have mostly been short-term and have focused more on whether they induce (rather than ameliorate) suicidal thoughts or behaviors. The sum of existing studies is generally inconclusive about whether antidepressants appreciably reduce risk for suicide completions. Relatively little is known about pharmacotherapy effects on suicidal ideation as distinct from behaviors. Possible mechanistic considerations for understanding antisuicide properties include a therapeutic impact on depression, impulsivity, or aggression, potentially mediated through serotonergic or other neuromodulatory systems. Recommendations are provided to guide future research as well as clinical practice.

The role of benzodiazepines in elderly suicides

AIMS

In Sweden, suicides by drug poisoning have decreased in the population at large during the past two decades. However, drug poisoning suicides increased among the elderly during this period. Suicides by benzodiazepine poisoning increased in this age group despite a reduction in prescription sales of these drugs. This study aims therefore to determine the role of benzodiazepines in suicide late in life.

METHODS

Information concerning all definite suicides and deaths due to "undetermined" causes recorded among Swedish citizens aged 65 and above during 1992 - 96 was obtained from the Cause-of-Death Register. Death certificates were scrutinized to determine the type of drug employed in drug-related suicides. Results of the post mortem screening for drugs and alcohol were then examined.

RESULTS

A benzodiazepine was implicated in 216/548 (39%) of the drug poisoning suicides recorded among the elderly. Death certificates revealed that a benzodiazepine was the sole agent in 72% of these cases. Flunitrazepam or nitrazepam were implicated in 90% of the single benzodiazepine suicides. In addition to the suicides classified as drug poisonings, 82 cases were found in which a drug may have contributed to the cause of death. Benzodiazepines predominated. The terminal cause of death was drowning, often in the victim's own bathtub, in three-quarters of these cases. The annual fatality ratios for the newer benzodiazepine-like hypnotics zopiclone and zolpidem appear to be on the rise.

CONCLUSION

Benzodiazepines, especially the hypnotics flunitrazepam and nitrazepam, are common in drug poisoning suicides in the elderly and should be prescribed with caution for this age group.

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.

Mental health literacy of those with major depression and suicidal ideation: an impediment to help seeking

Mental health literacy is the knowledge and beliefs about mental disorders that aid their recognition, management, or prevention, and is an important determinant of help seeking. This has relevance in suicide prevention, particularly for those with major depression, the clinical condition most frequently associated with suicidal behavior. In this study of a random and representative community sample, a vignette depicting classical features of major depression was presented to subjects along with questions related to mental health literacy. The responses of those with major depression, as delineated by the Primary Care Evaluation of Mental Disorders instrument, both with and without suicidal ideation, were compared to those of a third group of respondents. The results demonstrated that despite increased professional contact by those with major depression and suicidal ideation, there were few differences among the three groups on either open-ended or direct questions related to mental health literacy. This indicates that increased professional contact in itself was not related to increased mental health literacy, and suggests that more specific psychoeducational programs are required.

Differences in community mental health literacy in older and younger Australians

BACKGROUND

Depression has been traditionally considered to increase with age, although that may be due to sampling of those who have presented with depressive conditions. It is now recognised that patients' understanding of depression and beliefs about its appropriate treatment, mental health literacy, influences treatment-seeking behaviour.

OBJECTIVES

This study delineates depression, recent use of health services and mental health literacy in a random and representative community sample of younger and older South Australians.

METHODS

Depression, health service utilisation and mental health literacy were assessed in a random and representative sample of 2010 South Australians. Results for those aged between 65 and 74 years (n=300) and those aged 15 to 24 years (n=521) were compared.

RESULTS

Compared with the younger group, older subjects did not report greater levels of current depression although they were more likely to have seen a medical practitioner in the last 12 months and be taking antidepressants. However, their mental health literacy in terms of recognition of a mental health problem in a vignette was somewhat poorer and fewer recommended treatment from a counsellor, telephone service or psychologist and more considered that a psychiatrist would be harmful. They also more often perceived the clergy as helpful.

CONCLUSIONS

Depression was not more common among older than younger members of the community. Despite recognising depression in a vignette less often and perceiving less likelihood of help from several different mental health professionals, those in the older group were more likely to receive antidepressant medication and to have recently consulted a medical practitioner.

Sedative use and misuse in the United States

OBJECTIVE

To determine the prevalence and correlates associated with sedative use and misuse in the general population.

METHOD

Data were drawn from the National Comobidity Survey (n = 8098), a representative sample of adults in the community. Multivariate logistic regression analyses were used to identify correlates of sedative use, non-prescription use and self-perceived dependence.

RESULTS

The life-time prevalence of self-perceived sedative dependence was 0.5%, 7.1% reported non-prescribed sedative use and 17.0% had been prescribed sedatives and denied misuse. Individuals who used sedatives without a prescription were more likely to be male (OR = 0.61 (0.44, 0.86)), have lower income (OR = 0.71 (0.54, 0.94)), more education (OR = 1.51 (1.17, 1.96)), major depression (OR = 1.47 (1.04, 2.08)), agoraphobia (OR = 1.59 (1.09, 2.32)), ASPD (OR = 5.29 (3.42, 8.20)) and suicide ideation (OR = 1.91 (1.23, 2.94)), compared with those who did not use sedatives. Individuals with self-perceived dependence on sedatives were older (OR = 1.05 (1.02, 1.08)), had less education (OR = 0.2 (0.1, 0.7)) and were more likely to have a parent who abused prescription medications (OR = 4.3 (1.03, 18.03)), compared with those without sedative dependence.

CONCLUSIONS

Almost one in 10 adults report misuse of sedatives in their lifetime. Sedative use and misuse are associated with high levels of psychopathology and suicide risk, and show a specific association with parental abuse of prescription medications in the general population. Future work to understand more effectively the nature of these associations may ultimately lead to improved effectiveness of preventive interventions.

Psychopharmacological treatment and psychiatric morbidity in 390 cases of suicide with special focus on affective disorders

OBJECTIVE

The aim of this study was, on the basis of data from health-care registers, to describe the adequacy of psychopharmacological treatment in suicides.

METHOD

Data on consecutive suicides in a Danish County (Funen) in the period of 1 April 1991-31 December 1995 were identified in the Danish Psychiatric Central Register, the National Patient Register, the National Health Insurance and Odense University Pharmacoepidemiological Database.

RESULTS

Twenty-five per cent of the suicides previously hospitalized due to affective disorders and 3% of the suicides without psychiatric hospitalizations at all, received an apparently adequate treatment with antidepressants the month before suicide.

CONCLUSION

The most striking finding was the insufficiency of treatment with antidepressants in the group of suicides without psychiatric hospitalization, in particular in light of the fact that depression is assumed to be present in at least 50% of all suicides.

Antidepressant medication and suicide in Sweden

OBJECTIVE

To explore a possible temporal association between changes in antidepressant sales and suicide rates in different age groups.

METHODS

A time series analysis using a two-slope model to compare suicide rates in Sweden before and after introduction of the selective serotonin reuptake inhibitors, SSRIs.

RESULTS

Antidepressant sales increased between 1977-1979 and 1995-1997 in men from 4.2 defined daily doses per 1000 inhabitants and day (DDD/t.i.d) to 21.8 and in women from 8.8 to 42.4. Antidepressant sales were twice as high in the elderly as in the 25-44-year-olds and eight times that in the 15-24-year-olds. During the same time period suicide rates decreased in men from 48.2 to 33.3 per 10(5) inhabitants/year and in women from 20.3 to 13.4. There was significant change in the slope in suicide rates after the introduction of the SSRI, for both men and women, which corresponds to approximately 348 fewer suicides during 1990-1997. Half of these 'saved lives' occurred among young adults.

CONCLUSION

We demonstrate a statistically significant change in slope in suicide rates in men and women that coincided with the introduction of the SSRI antidepressants in Sweden. This change preceded the exponential increase in antidepressant sales.

Psychoactive substances in suicides. Comparison of toxicologic findings in two samples

The goal in this study was to assess if there is any constancy in detections of psychoactive substances in consecutive suicides. Toxicologic findings in 179 suicides in San Diego County, California, between 1981 and 1982, and 333 suicides in Mobile County, Alabama, between 1990 and 1998, were compared. Alcohol was detected in about 30% of suicides in both samples. Abusable prescription psychoactive substances, i.e., benzodiazepines and opiates, were detected in one fifth of cases in both locations. Nonabusable prescription psychoactive substances, mainly antidepressants, were found in more suicides in Mobile than in San Diego. Detection rates of different classes of psychoactive substances have not changed much in the past decade. Detection of alcohol, cocaine, or cannabis in about 40% of suicides supports the clinical practice of discouraging consumption of these substances in depressed patients. Another challenge is the low rate of detection of antidepressants in suicide, which suggests undertreatment of depression in suicides. Continued reporting of routine, comprehensive, toxicologic findings in suicides is useful to monitor patterns of use of psychoactive substances in this group and to guide suicide prevention in clinical practice and public health policy.

Mental health literacy: an impediment to the optimum treatment of major depression in the community

BACKGROUND

Mental health literacy refers to the knowledge and beliefs about mental disorders which aid their recognition, management and prevention. This study examined the mental health literacy and experience of depression in a random and representative community population.

METHODS

The experience of depression and mental health literacy of 3010 subjects from a random and representative population were determined on the basis of responses to the mood module of the PRIME-MD and questions about a vignette of a person with features of major depression.

RESULTS

Those with major depression had significantly more personal experience of depression than those with other depressions and those who were not depressed, but there were few significant differences between the groups in terms of mental health literacy. Of those with major depression, 40% considered anti-depressants helpful, but 40% also considered they were harmful.

CONCLUSIONS

There is a considerable impediment to the recognition and management of major depression and a need for further community education programs.

Patterns of psychoactive substance detection from routine toxicology of suicides in Mobile, Alabama, between 1990 and 1998

BACKGROUND

Postmortem toxicology can be useful for reconstructing some clinically important events occurring before a suicide. Its utility may be improved by examining patterns of detected substances in a population over time.

METHODS

Toxicology was performed for 333 (96%) of the 346 suicides occurring in Mobile County, Alabama, between October 1990 and September 1998. Detected psychoactive substances were grouped in three categories: alcohol, cocaine, and cannabis; abusable prescription medications; and non-abused psychotropic medications. The overlap between these three categories was assessed.

RESULTS

Psychoactive substances were detected in 227 (68%) of 333 suicides. Of the cases positive for any prescription psychoactive medication, 2/3 were positive for an abusable medication. An abusable substance was found in 56% of cases positive for non-abused psychotropic medication. Alcohol, cocaine and/or cannabis were found in 34% of cases with abusable prescription medications and in 33% with non-abused psychotropics.

LIMITATIONS

Clinicians must be aware of a number of methodological realities when interpreting routine postmortem toxicology results.

CONCLUSIONS

Routine surveillance of psychoactive substances among suicides can provide useful data for directing and monitoring strategies for suicide prevention in clinical practice.