Are comorbid anxiety disorders a risk factor for suicide attempts in patients with mood disorders? A two-year prospective study

BACKGROUND

Comorbid anxiety disorders have been considered a risk factor for suicidal behavior in patients with mood disorders, although results are controversial. The aim of this two-year prospective study was to determine if lifetime and current comorbid anxiety disorders at baseline were risk factors for suicide attempts during the two-year follow-up.

METHODS

We evaluated 667 patients with mood disorders (504 with major depression and 167 with bipolar disorder) divided in two groups: those with lifetime comorbid anxiety disorders (n=229) and those without (n=438). Assessments were performed at baseline and at 3, 12, and 24 months. Kaplan-Meier survival analysis and log-rank test were used to evaluate the relationship between anxiety disorders and suicide attempts. Cox proportional hazard regression was performed to investigate clinical and demographic variables that were associated with suicide attempts during follow-up.

RESULTS

Of the initial sample of 667 patients, 480 had all three follow-up interviews. During the follow-up, 63 patients (13.1%) attempted suicide at least once. There was no significant difference in survival curves for patients with and without comorbid anxiety disorders (log-rank test=0.269; P=0.604). Female gender (HR=3.66, P=0.001), previous suicide attempts (HR=3.27, P=0.001) and higher scores in the Buss-Durkee Hostility Inventory (HR=1.05, P≤0.001) were associated with future suicide attempts.

CONCLUSIONS

Our results suggest that comorbid anxiety disorders were not risk factors for suicide attempts. Further studies were needed to determine the role of anxiety disorders as risk factors for suicide attempts.

The effect of social adjustment and attachment style on suicidal behaviour

OBJECTIVE

Prior studies examining the relationship between social adjustment and suicidal ideation or behaviour have not examined attachment. This study examines the effect of attachment on the association between current social adjustment and suicide attempt risk.

METHOD

Attachment, social adjustment, and history of suicide attempt were assessed in patients participating in research on major depressive disorder (N = 524). Suicide attempters and non-attempters were compared with attachment style and social adjustment using hierarchical logistic regression models. The two factor scoring method of the Adult Attachment Scale (secure vs. avoidant) was utilized as each measures unique aspects of attachment.

RESULTS

Anxious attachment (OR = 1.33; 95% CI = 1.016-1.728; P = 0.038) but not overall social adjustment (P = 0.14) was associated with a history of a past suicide attempt when both attachment and social adjustment were assessed in the same model. Among subtypes of social adjustment, work adjustment was associated with past history of suicide attempt (OR = 1.25; 95%CI = 1.019-1.540; P = 0.033). As impairment in work adjustment increased by 1 unit, the likelihood of reporting a suicide attempt increased by approximately 25%. There was no interaction between anxious attachment and work adjustment (P = 0.81).

CONCLUSION

Anxious attachment and work adjustment warrant further study as potential treatment targets in depressed suicidal patients.

Clinical features of depressed patients with or without a family history of alcoholism

OBJECTIVE

To compare clinical features of depressed subjects without alcoholism but with a family history of alcoholism to a depressed group without alcoholism and without a family history of alcoholism.

METHOD

Clinical and demographic data of 209 depressed subjects without a history of alcoholism in first-degree relatives and 73 depressed individuals with a history of alcoholism in first-degree relatives were compared. Subjects with a personal history of alcoholism were excluded.

RESULTS

Depressed subjects with a family history of alcoholism have a significantly higher prevalence of reported childhood physical and sexual abuse and post-traumatic stress disorder (PTSD), make more suicide attempts, and have greater intent to die at the time of their most lethal suicide attempt, compared to depressed subjects without a family history of alcoholism.

CONCLUSION

Depressed patients with a family history of alcoholism are at greater risk for suicidal behavior and PTSD and may require more careful management.

Lower cortisol levels in depressed patients with comorbid post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is often comorbid with major depressive episodes (MDEs) and both conditions carry a higher rate of suicidal behavior. Hypothalamic-pituitary-adrenal (HPA) axis and serotonin abnormalities are associated with both conditions and suicidal behavior, but their inter-relation is not known. We determined cortisol response to placebo or fenfluramine in MDE, MDE and PTSD (MDE+PTSD), and healthy volunteers (HVs) and examined the relation of cortisol responses to suicidal behavior. A total of 58 medication-free patients with MDE (13 had MDE+PTSD) and 24 HVs were studied. They received placebo on the first day and fenfluramine on the second day. Cortisol levels were drawn before challenge and for 5 h thereafter. The MDE+PTSD group had the lowest plasma cortisol, the MDE group had the highest, and HVs had intermediate levels. There were no group differences in cortisol response to fenfluramine. Suicidal behavior, sex, and childhood history of abuse were not predictors of baseline or postchallenge plasma cortisol. Cortisol levels increased with age. This study finds elevated cortisol levels in MDE and is the first report of lower cortisol levels in MDE+PTSD. The findings underscore the impact of comorbidity of PTSD with MDE and highlight the importance of considering comorbidity in psychobiology.

Medication supervision and adherence of persons with psychotic disorders in residential treatment settings: a pilot study

BACKGROUND

Little is known about risk factors for and predictors of medication nonadherence within residential facilities. This pilot study examined the association between medication adherence and level of supervision and other environmental and clinical variables among patients with schizophrenia and related psychotic disorders living in supported housing.

METHOD

A convenience sample of 74 adult residents with schizophrenia and related psychotic disorders (DSM-IV criteria) living in 4 supported housing facilities in New York City were assessed by their treating psychiatrist for medication cessation during the previous month. Demographic characteristics, medications, supervision, global function as measured by the Global Assessment of Functioning (GAF), and substance abuse were also assessed. A priori hypotheses were that regimen complexity would be directly and medication supervision would be inversely related to medication nonadherence.

RESULTS

In multivariate models, lack of direct medication supervision, negative medication attitude, and lower GAF score were associated with increased medication nonadherence in the recent past.

CONCLUSION

This pilot study suggests that direct supervision of medication is associated with better adherence in residential treatment settings. This finding is relevant for mental health service planners and clinicians working in these settings.

Delusions and suicidality

OBJECTIVE

Delusions have been considered a risk factor for suicidal behavior. To determine whether specific delusion types are related to suicidal behaviors, the authors compared the clinical characteristics of patients with mood disorders and schizophrenia who did and did not have a history of suicide attempts.

METHOD

After admission for inpatient or outpatient psychiatric treatment, 429 patients (ages 14-72 years; 47.1% male; and 73.0% Caucasian) were assessed with a structured clinical interview that generated axis I and II diagnoses. In addition, their psychiatric symptoms, history of suicide attempts, and overall functioning were rated.

RESULTS

Data for three diagnostic subgroups (223 patients with major depression, 150 with schizophrenia, and 56 with bipolar disorder) were analyzed separately. Multivariate analyses did not find evidence of a relationship between delusions and history of suicidal ideation or suicide attempts in any of the diagnostic groups.

CONCLUSIONS

This study did not find evidence that the presence of delusions distinguished persons with or without a history of suicide attempt.