Do Suicidal Females have “Male-type” Depression?

Recent studies suggest an evidence for a “male depressive syndrome” in patients with major depressive disorder.

Because males are markedly overrepresented among suicide victims and the opposite is true for suicide attempters, we investigated the rate and global severity of Gotland Male Depression as measured by the Gotland Male Depression scale in 86 suicide victims (74 males, 12 females), 86 suicide attempters (21 males, 65 females) with current DSM-IV major depressive episode and in 144 normal controls (116 males, 28 females). The rate of Gotland “Male” Depression (total score of 13 or more) was significantly higher in depressed suicide victims (98%) and in depressed suicide attempters (93%) than in normal controls (2%, p=0.00001). Among depressed suicide victims 100% of males and 83% of females have had Gotland “Male” Depression (p=0.02) while the same figures among the depressed suicide attempters were 91% and 94%, respectively (not significant). The total Gotland Male Depression scores were significantly higher in depressive suicide victims (22.26) and depressive suicide attempters (23.23) than in normal controls (4.01, p=0.00001 and p=0.0001, respectively), with significant gender differences only among depressed suicide victims (males: 22.85, females: 18.58, p=0.009) and normal controls (males: 4.33, females: 2.71, p=0.05).

However, since male and female depressed inpatients do not show clinically significant difference in their mean total scores on Gotland scale symptoms (11.99 vs 12.04, Möller-Leimkühler et al, 2004), it would be premature to conclude from our present findings that compared to nonsuicidal female depressives, suicidal female depressives have male-type depression profile.

Social psychiatry and public mental health: present situation and future objectives. Time for rethinking and renaissance?

OBJECTIVE

To describe the social psychiatric challenges of modern psychiatry in European societies in the light of recent psychiatric research evidence and to show how these challenges could be conceptualized.

METHOD

Reviewing aggregate morbidity and mortality data from the WHO European Health for All Database, and summarizing consultations and fact-finding missions to many European countries during the authors engagement as WHO Regional Advisor for Mental health from 1998 to 2004.

RESULTS

Societal change in Europe is leading to stress and mental ill health for its populations. The consequence is a dramatic increase in burden due to mental illness and stress-related morbidity and mortality.

CONCLUSION

A re-thought and re-conceptualized social and societal psychiatry with focus on public mental health must have a renaissance. Innovative efforts are of crucial and imperative importance seeing mental health in the light of recent experience and science as probably the most important public health issue.

Mental health in Europe: problems, advances and challenges

OBJECTIVE

To describe mental health care needs and challenges across the WHO European region of 51 nations.

METHOD

Based on morbidity and mortality data from HFA Statistical Database and Health2l, the policy framework of WHO Europe, major trends in mental health care needs, psychiatric reform and mental health promotion are discussed.

RESULTS

There is a mortality crisis related to mental ill health in Eastern European populations of transition. Destigmatization is required to improve early intervention and humanization of services, and national mental health audits are needed to create the basis for national mental health planning, implementation and monitoring. There are both problems and advances in service restructuring, and comprehensive mental health promotion programmes, preventive and monitoring strategies are required.

CONCLUSION

Partnerships between national and international organizations, especially WHO and the European Union, have to be strengthened to make progress on the way to integrated community mental health services.

Preventing suicide and premature death by education and treatment

Suicide is a leading cause of mortality. It is, in principle, preventable - given the fact that we possess effective treatments for depressive illness, the major contributor to such mortality. Nonetheless, complex logistic problems have prevented the institution of successful suicide prevention programs. The present review summarizes the author's work on the island of Gotland in Sweden, where the small size of the population permitted the institution of an educational and treatment program aimed at the general medical practitioners. The program was successful in reducing suicide rates by 60%. This was accompanied by reduction of different indices measuring depressive morbidity. Prevention was successful for as long as the program was instituted. The author provides his reflections on the public health implications of his data - particularly for Eastern Europe which is experiencing widespread stress in the workplace and in economic situations. More hypothetically, he presents his views on a serotonin-mediated 'male suicide syndrome'.

Improvement of care for people suffering from depression: the need for comprehensive education

In the years 1983-1984, the Swedish Committee for Prevention and Treatment of Depressions (PTD) offered an educational programme to all general practioners (GPs) on the Swedish island of Gotland. This education has led to a significant decrease in inpatient care, morbidity, mortality and costs incurred by depressive illness on the island. Unspecific medication decreased and specific antidepressive medication increased. Recent scrutiny of all suicides on Gotland during the 1980s showed that the overall decrease due to the educational programme was mainly in those committed by females with recognized major depression who had been in contact with GPs. This was expected. However, the number of male suicides was almost unaffected by the educational programme nor by the GPs' improved ability to diagnose and treat depressions. We believe that male depressive suicidants may not be reached by the medical health care system. This might be due to mens' alexithymic incapacity to ask for help and/or their atypical depressive symptoms, manifested by aggressive or abusive behaviour that leads to rejection or mis-diagnosis in the health care system. Consequently, there is underdiagnosis and undertreatment of male depressions which may explain the paradoxical fact that men in Sweden and elsewhere are only half as often depressed but commit suicides up to five times more often than females in Sweden. New sex-specific diagnostical and therapeutical tools as well as sex specific research and comprehensive educational programs concerning depression and suicidality are needed.

[Male depression--stress reaction combined with serotonin deficiency?]

An educational programme on depressive disorders, given to general practitioners on the Swedish island of Gotland, resulted in a statistically significant reduction of the suicide rate among women, though that among men was virtually unaffected. Further analysis showed the profile of depression among men to differ from that among women, the male pattern typically being more characterised by irritability, aggressiveness, acting out, antisocial behaviour and alcohol abuse, and reduced impulse control and stress tolerance. Predisposition to affective disorders, suicide and alcoholism seems to be genetically determined. The syndrome, which is not easily recognised and is seldom properly treated or prevented, seems to be related to central serotonin deficiency and hypercortisolaemia.

Decreasing tendency of seasonality in suicide may indicate lowering rate of depressive suicides in the population

The seasonality of suicide is well known and a repeatedly demonstrated phenomenon. The authors analyzed the seasonality of 148 suicide events on Gotland between 1981 and 1996. A marked and significant seasonality with a spring and summer peak was found between 1981 and 1989, when the prescription of antidepressants was relatively low and stable. However, this seasonality disappeared in the period between 1990 and 1996, when prescription of antidepressants increased dramatically, indicating that more and more depressed patients were pharmacologically treated. As the seasonality of suicide in the population is the reflection of the seasonal nature of depressive suicides, the result suggests that a decreasing tendency of seasonality in suicide may indicate the lowering rate of depressive suicides in the given population.

Prevention of depression and suicide by education and medication: impact on male suicidality. An update from the Gotland study

Depression is an endemic disease with high morbidity, and a high mortality in depression-related suicide. Suicidal tendencies, especially among males, are increasing today in East European countries. General practitioners are considered to have a very important role in the prevention and treatment of depression. Matters of depression are more openly discussed in society. Patients showing up in primary care are nowadays less reluctant to see depression as a causative factor behind their symptoms. Taboos concerning the stigma of depression and suicidality are weaker. In spite of this, important problems still exist regarding poor diagnostic and treatment routines in primary care and the inability of depressive and suicidal men to seek for help or to be recognized. In the years 1983-1984, the Swedish Committee for Prevention and Treatment of Depression (PTD) offered an educational programme to all general practitioners (GPs) on the Swedish island of Gotland. During the 1980s this education was shown to lead to a significant decrease in inpatient care, morbidity, suicide, mortality and costs of depressive illness on the island. The use of anxiolytic and sedative medication decreased and that of antidepressant medication increased. This all showed that an educational programme in primary care on depression and suicide was effective. However, the effects faded and, unexpectedly, the number of male suicides was almost unaffected by the educational programme and by the GPs' ability to diagnose and treat depression. Repeated educational activities during the 1990s again led to a decrease in suicides, mainly in females. Also, the increase in antidepressant prescriptions following GP education in the 1990s was mostly in the treatment of female patients. One of the reasons was that few suicidal males are known to the medical services although many of these people are known to the police and social welfare services. The reasons why depressed and suicidal men do not show up in the medical services are discussed, and found to lie in the differences between the male and the female depressive syndrome, leading to difficulties in reaching, diagnosing and treating these patients. Strategies for finding and treating suicidal depressives are discussed. One conclusion is that males are as often depressed as females, but in different ways, and that one of the reasons behind the dramatic over-representation of males amongst suicide victims may be found in the low rate of diagnosis and treatment of the male depressive syndrome, (hit J Psych Clin Pract 1997; 1: 39-46).

Depression and suicide on Gotland. An intensive study of all suicides before and after a depression-training programme for general practitioners

In 1983 and 1984, the Swedish Committee for the Prevention and Treatment of Depression (PTD) organised a postgraduate training programme on the diagnosis and treatment to all the general practitioners on Gotland, Sweden. In the following years, the frequency of suicide and inpatient care for depression decreased significantly, as well as the frequency of sick leave for depression. The results of the Gotland study have provided evidence for the view that early recognition and adequate treatment of depression is one essential method of suicide prevention (Rutz et al., 1989; Rutz et al., 1992). A detailed retrospective clinical analysis, of all 115 consecutive suicide victims on Gotland between 1981 and 1992 presented in this study, showed that male gender and violent methods were overrepresented. 50 suicides had a DSM-III-R axis I diagnosis and half of them (n = 25) had primary major depression. Bipolar II disorder was relatively overrepresented in this sample. After the PTD programme, the proportion of depressive suicides was significantly lower than before. This finding strongly suggests that the significant decrease in the suicide rate after the PTD programme is a direct result of the robust decrease in depressive suicides of the area served by trained GPs. The practical importance of this finding is briefly discussed.

[Regional distribution of working physicians, diagnosed cases of depression and suicide mortality in Hungary]

Based on the well-known and strong relationship between suicide and depression, the authors investigated the regional distribution of the suicide rates, rates of diagnosed depressions and rates of working physicians in Hungary. It was found a strong significant positive correlation between the of working doctors and rate of diagnosed depressions, and both the mentioned parameters showed a strong significant negative correlation with the suicide rates. The more is the number of doctors/100,000 inhabitants, the better is the recognition of depression and the lower is the suicide rate in the given region. The rate of working doctors was significantly higher in the countries located in the western part of Hungary, which may have a role in the lower suicide mortality of this area of the country.

Suicide rate, prevalence of diagnosed depression and prevalence of working physicians in Hungary

Based on the well-known relationship between depression and suicide, we investigated the regional distribution of the suicide rate, rate of diagnosed depression and prevalence of working physicians in Hungary. A strong significant positive correlation was found between the rate of working physicians and rate of diagnosed depression, and both parameters showed a strong significant negative correlation with the suicide rate. The more physicians per 100,000 inhabitants, the better is the recognition of depression and the lower is the suicide rate in the given region. The rate of working doctors was significantly higher in the counties located in western Hungary, which may have a role in the lower suicide mortality in this area of the country.

Cost-benefit analysis of an educational program for general practitioners by the Swedish Committee for the Prevention and Treatment of Depression

In 1983-1984 the Swedish Committee for the Prevention and Treatment of Depression launched an educational program on the diagnosis and treatment of depressive disorders for all general practitioners on the island of Gotland. The baseline year chosen was 1982 and the immediate effects were evaluated in 1985. In 1988 the long-term effects were evaluated. These two evaluations indicated strictly time-related beneficial effects on the frequency of sick leave and inpatient care for depressive disorders, the pattern of prescription of psychopharmacologic drugs and the frequency of suicide. This article describes a cost-benefit analysis of the program. The cost of the educational program, changes in drug prescription and inpatient care were calculated as well as indirect costs concerning changes in morbidity and mortality. The calculation of the savings to society was subject to a sensitivity analysis. This shows that the educational program resulted in savings to society on the order of about SEK 155 million (USD 26 million). It is concluded that educational programs of this kind should be repeated every second to third year.

Long-term effects of an educational program for general practitioners given by the Swedish Committee for the Prevention and Treatment of Depression

In 1983-1984 the Swedish Committee for the Prevention and Treatment of Depression offered an educational program on diagnosis and treatment of depressive disorders to all general practitioners on the island of Gotland. The program has been carefully evaluated; 1982 was used as the baseline and the main evaluation was carried out in 1985. After the educational programs, the frequency of sick leave for depressive disorders decreased, the frequency of inpatient care for depressive disorders decreased to 30% of that at the baseline; the prescription of antidepressants increased, but prescription of major tranquilizers, sedatives and hypnotics decreased. The frequency of suicide on the island decreased significantly. This study describes the long-term effects. In 1988, 3 years after the project ended, the inpatient care for depressive disorders increased, the suicidal rate returned almost to baseline values and the prescription of antidepressants stabilized. Thus, the effects were strictly related in time to the educational programs, indicating that the effects were real and not only a coincidence with local trends on Gotland. Furthermore, the results indicate that educational programs that can have pronounced effects on the health care system have to be repeated approximately every 2 years if long-term effects are to be expected.

Effect of an educational program for general practitioners on Gotland on the pattern of prescription of psychotropic drugs

During the years 1983-1984, an educational program was given to all general practitioners on the island of Gotland. This report evaluates changes in prescription habits from 1982 to 1985. To correct for general trends that occurred simultaneously, the prescription habits were compared to the habits in the rest of Sweden. Both on Gotland and in Sweden as a whole, the use of antidepressants increased from 1982-1985, but significantly more on Gotland. In 1982, the use of antidepressants was low on Gotland, 54% of that in the rest of Sweden. After the educational programs, Gotland reached 77% of the use in the rest of Sweden. In 1982, the use of lithium was 123% of that in the rest of Sweden. After the educational programs, the use of lithium was unchanged, and a small increase of 5.6% was seen in the rest of Sweden. After the educational programs, the prescription of sedatives on Gotland decreased (-8.2%), and an increase of 4.5% was seen in the rest of Sweden. The use of major tranquilizers also decreased significantly (-23%) on Gotland. Even in the rest of Sweden, a significant but much smaller decrease was seen: -13%. On Gotland the frequency of hypnotics remained stable from 1982-1985, and a significant increase was seen in the rest of Sweden.

Frequency of suicide on Gotland after systematic postgraduate education of general practitioners

In 1983-1984 the Swedish Committee for Prevention and Treatment of Depression (PTD Committee) introduced an educational program for all general practitioners (GPs) on the Swedish island of Gotland. The primary goal was to increase knowledge about diagnosis and treatment of patients with affective disorders. The effects of the educational programs were evaluated in detail; GPs identified more patients with depressive disorders and treated them more accurately. The suicide rate on Gotland was followed, primarily to ensure that the new treatment strategies did not include a risk for the individual patients. However, it was also hoped that increased awareness of patients with affective disorders and better treatment routines could reduce the suicide rate. The suicide rate dropped the year after the educational programs were introduced. This was a statistically significant deviation both from the long-term trend on Gotland and from the trends in Sweden as a whole. Programs aiming at giving GPs increased capacity and responsibility to treat patients with affective disorders do not increase the frequency of suicide. Better primary treatment of patients with depressive disorders may reduce the suicide rate in a given area.

An educational program on depressive disorders for general practitioners on Gotland: background and evaluation

General practitioners are the psychiatrists' most important coworkers in the treatment of depressive disorders. A high degree of knowledge about this illness in this group of doctors is of decisive importance. However, the value of postgraduate educational programs for general practitioners has been questioned. The Swedish Committee for the Prevention and Treatment of Depression (PTD) offered an educational program on symptoms, etiology, diagnosis, prevention and treatment of depression to all general practitioners on the Swedish island of Gotland. Lectures on suicide, depressive illness in childhood and in old age and psychotherapy of depressive states were also given. In several control periods data were collected on suicides, referrals to the local psychiatric department, emergency admissions, the quantity of sick leave used and the quantity of inpatient care due to depression. Even the prescription of psychopharmacological drugs on the island was investigated. Overall, the results indicated that general practitioners gratefully accepted the educational program and achieved increasing competence and stringency in treating and preventing depressive states. The program was associated with decreases in the use of psychiatric inpatient care and the sick leave frequency of depressed patients. The possibility of preventing suicides was positively influenced.

Patients admitted for compulsory treatment to selected psychiatric units in Italy and in Sweden

Eighty-five Italian and forty-nine Swedish patients consecutively admitted for compulsory treatment to either an Italian or a Swedish psychiatric unit in selected areas of the two countries have participated in an exploratory study aimed at assessing the main characteristics of compulsory admitted patients, and in particular, the immediate reason for admission. The two series proved to be quite similar as concerns most sociodemographic variables, and as concerns clinical diagnosis and severity of the morbid condition at admission as measured by means of a rating scale. More Swedish than Italian patients lived alone when admitted to hospital, and for more of them the request for admission was made by other people than relatives, and a larger proportion of them was accompanied to the hospital by medical or social welfare personnel. In both series the largest proportion had a low educational level and belonged to the lower social groups. The same proportion in the two series had previous admissions. The most common reason for admission was "odd or improper behaviour" for the Swedish patients, and "feared or manifest dangerousness" for the Italian patients. The Italian patients remained at hospital on average half the time than the Swedish patients.

Structural changes and their consequences in a "natural" psychiatric sector: Gotland 1976-1981

In recent years discussions about the development of psychiatric care internationally and in Scandinavia have been focused on principles of opening and sectorizing, sometimes at the cost of existing differentiated and effective psychiatric in-patient care-programs. During the last 6 years a process of strengthening and opening psychiatric care was started on the Swedish island of Gotland (55 000 inhabitants), based on an existing mental hospital, utilizing the existing personnel, maintaining existing effective structures of institutional care and developing new ones in out-patient care. The intention was to combine principles of subspecialized psychiatric in-patient are treatment with ideas of sectorization, accessibility and openness. Our results seem to show that it is well possible to reach positive results, optimizing and opening up an existing institution, using a basic psychodynamic, synoptic and eclectic ideology, offering differentiated treatment programs and without the immediate use of sectorizing principles. Sectorization and accessibility without qualified treatment programs of in-patient care may not be a sufficient solution to all the problems we find in psychiatric organisations. On the other hand, our achieved positive results have probably the naturally sectorized character of the island of Gotland as a presupposition. Principles of sectorization and differentiation seem in psychiatry not to be contrary but complementary. However, it seems to be legitimate, possible and effective to start a process of psychiatric evolution transforming an existing old-fashioned mental hospital.

Interdisciplinary cooperation in an integrated psychiatric rehabilitation program

The development of psychiatry is at present stormy with discussions dividing, polarising and partly paralysing. Current experience shows that psychotherapeutic approaches are not alternatives to psychopharmacological ones but necessary complements. An integrated therapy which treats the patient as a social, psychological and organic entity has not yet been spread to the poorly-equipped psychiatric periphery but is mainly restricted to the modern richly-endowed psychiatric centers. Modern psychiatric rehabilitation principles according to this integrated synoptic view seem however to be applicable even to custodial-treated patients at peripheral psychiatric institutions. In this article we present the special psycho-social, epidemiological, administrative and economical structure of the island of Gotland due to its geographical isolation. We describe the construction and forming of a rehabilitation program under greatly limited economical conditions. The program combines communication-oriented group therapy with consequent pharmacotherapy and a structured ergotherapeutic and ADL-therapeutic program and is applied to a primarily unselected sample of patients. We also describe the education and supervision of the staff as well as the components of our program. Positive results in spite of limited resources have been achieved. Problems are discussed.