Skin autofluorescence of advanced glycation end products and mortality in affective disorders in the lifelines cohort study: A mediation analysis

OBJECTIVE

Life expectancy in patients suffering from affective disorders is considerably diminished. We investigated whether skin autofluorescence (SAF), indicating concentration of advanced glycation end products in the skin and oxidative stress, mediates the association between affective disorders and excess mortality.

METHODS

Included were 81,041 participants of the Lifelines cohort study. Presence of major depressive disorder, dysthymia, generalised anxiety disorder, panic disorder or social phobia was assessed with the Mini-International Neuropsychiatric Interview. SAF was assessed as mediator in Cox proportional hazards models for all-cause or natural-cause mortality.

RESULTS

Mortality was increased in cases with major depression compared to controls (36.4 vs. 22.5 per 100,000 person years). Partial mediation by SAF of the association between affective disorders and mortality was shown (9.0-10.5%, P<.001-.002), although attenuated by cardiometabolic parameters and history of physical illness. For major depressive disorder, partial mediation by 5.5-10.3% was shown (crude model: P<.001; fully adjusted model: P=.03).

LIMITATIONS

The relatively short duration of follow-up and the relatively young cohort resulted in a lack of power to detect an association between mortality and dysthymia, social phobia and two or more comorbid disorders.

CONCLUSION

Evidence of partial mediation by SAF of the association between affective disorders and all-cause and natural-cause mortality was demonstrated, although attenuated by health factors. For major depression, mediation by SAF was largest and remained significant after adjustment for sociodemographic and health factors, identifying oxidative stress as possible determinant of premature death.

The impact of psychiatric and medical comorbidity on the risk of mortality: a population-based analysis

BACKGROUND

As life expectancy increases, more people have chronic psychiatric and medical health disorders. Comorbidity may increase the risk of premature mortality, an important challenge for health service delivery.

METHODS

Population-based cohort study in Ontario, Canada of all 11 246 910 residents aged ⩾16 and <105 on 1 April 2012 and alive on 31 March 2014. Secondary analyses included subjects having common medical disorders in 10 separate cohorts. Exposures were psychiatric morbidity categories identified using aggregated diagnosis groups (ADGs) from Johns Hopkins Adjusted Clinical Groups software® (v10.0); ADG 25: Persistent/Recurrent unstable conditions; e.g. acute schizophrenic episode, major depressive disorder (recurrent episode), ADG 24: Persistent/Recurrent stable conditions; e.g. depressive disorder, paranoid personality disorder, ADG 23: Time-limited/minor conditions; e.g. adjustment reaction with brief depressive reaction. The outcome was all-cause mortality (April 2014-March 2016).

RESULTS

Over 2 years' follow-up, there were 188 014 deaths (1.7%). ADG 25 conferred an almost threefold excess mortality after adjustment compared to having no psychiatric morbidity [adjusted hazard ratio 2.94 (95% CI 2.91-2.98, p < 0.0001)]. Adjusted hazard ratios for ADG 24 and ADG 23 were 1.12 (95% CI 1.11-1.14, p < 0.0001) and 1.31 (95% CI 1.26-1.36, p < 0.0001). In all 10 medical disorder cohorts, ADG 25 carried significantly greater mortality risk compared to no psychiatric comorbidity.

CONCLUSIONS

Psychiatric disorders, particularly those graded persistent/recurrent and unstable, were associated with excess mortality in the whole population, and in the medical disorder cohorts examined. Future research should examine whether service design accounting for psychiatric disorder comorbidity improves outcomes across the spectrum of medical disorders.

Depression and cause-specific mortality in an ethnically diverse cohort from the UK: 8-year prospective study

BACKGROUND

Depression is associated with increased mortality, however, little is known about its variation by ethnicity.

METHODS

We conducted a cohort study of individuals with ICD-10 unipolar depression from secondary mental healthcare, from an ethnically diverse location in southeast London, followed for 8 years (2007-2014) linked to death certificates. Age- and sex- standardised mortality ratios (SMRs), with the population of England and Wales as a standard population were derived. Hazard ratios (HRs) for mortality were derived through multivariable regression procedures.

RESULTS

Data from 20 320 individuals contributing 91 635 person-years at risk with 2366 deaths were used for analyses. SMR for all-cause mortality in depression was 2.55(95% CI 2.45-2.65), with similar trends by ethnicity. Within the cohort with unipolar depression, adjusted HR (aHRs) for all-cause mortality in ethnic minority groups relative to the White British group were 0.62(95% CI 0.53-0.74) (Black Caribbean), 0.53(95% CI 0.39-0.72) (Black African) and 0.69(95% CI 0.52-0.90) (South Asian). Male sex and alcohol/substance misuse were associated with an increased all-cause mortality risk [aHR:1.94 (95% CI 1.68-2.24) and aHR:1.18 (95% CI 1.01-1.37) respectively], whereas comorbid anxiety was associated with a decreased risk [aHR: 0.72(95% CI 0.58-0.89)]. Similar associations were noted for natural-cause mortality. Alcohol/substance misuse and male sex were associated with a near-doubling in unnatural-cause mortality risk, whereas Black Caribbean individuals with depression had a reduced unnatural-cause mortality risk, relative to White British people with depression.

CONCLUSIONS

Although individuals with depression experience an increased mortality risk, marked heterogeneity exists by ethnicity. Research and practice should focus on addressing tractable causes underlying increased mortality in depression.

Depression may not be a risk factor for mortality in stroke patients with nonsurgical treatment: A retrospective case-controlled study

Patients with depression have more comorbidities than those without depression. The cost of depression-associated comorbidities accounts for the largest portion of the growing cost of depression treatment. Patients with depression have a higher risk of stroke with poor prognoses than those without depression; however, previous studies evaluating the relationship between depression and stroke prognosis have not accounted for surgical treatment or other risk factors. Therefore, we investigated whether depression is a risk factor for mortality in stroke patients with nonsurgical treatment after adjusting for other risk factors.We retrospectively analyzed the data of patients with major depressive disorder (MDD) and age and sex-matched controls without MDD during 1999 to 2005. We then identified patients who developed stroke in both groups and analyzed risk factors for death in these stroke patients who received nonsurgical treatments during a follow-up period from 2006 to 2012.Patients with MDD had higher Charlson Comorbidity Index Scores (CCISs) and exhibited higher frequencies of comorbidities such as diabetes mellitus, hypertension, hyperlipidemia, and coronary heart disease than controls without MDD, and most of MDD patients had very low or high socioeconomic status (SES) and lived in urban settings. Most stroke patients with MDD who received nonsurgical treatment were female, had very low or high SES, and lived in urban settings; in addition, stroke patients with MDD who received nonsurgical treatment had higher CCISs and frequencies of hyperlipidemia and coronary heart disease than those without MDD who received nonsurgical treatment. However, depression was not a risk factor for death in stroke patients with nonsurgical treatment.Hemorrhagic stroke, age, sex, and CCISs were risk factors for death in stroke patients with nonsurgical treatment, but depression did not affect the mortality rate in these patients.

The Association Between Major Depressive Disorder and Outcomes in Older Veterans Hospitalized With Pneumonia

BACKGROUND

Major depressive disorder ("depression") has been identified as an independent risk factor for mortality for many comorbid conditions, including heart failure, cancer and stroke. Major depressive disorder has also been linked to immune suppression by generating a chronic inflammatory state. However, the association between major depression and pneumonia has not been examined. The aim of this study was to examine the association between depression and outcomes, including mortality and intensive care unit admission, in Veterans hospitalized with pneumonia.

MATERIALS AND METHODS

We conducted a retrospective national study using administrative data of patients hospitalized at any Veterans Administration acute care hospital. We included patients ≥65 years old hospitalized with pneumonia from 2002-2012. Depressed patients were further analyzed based on whether they were receiving medications to treat depression. We used generalized linear mixed effect models to examine the association of depression with the outcomes of interest after controlling for potential confounders.

RESULTS

Patients with depression had a significantly higher 90-day mortality (odds ratio 1.12, 95% confidence interval 1.07-1.17) compared to patients without depression. Patients with untreated depression had a significantly higher 30-day (1.11, 1.04-1.20) and 90-day (1.20, 1.13-1.28) mortality, as well as significantly higher intensive care unit admission rates (1.12, 1.03-1.21), compared to patients with treated depression.

CONCLUSION

For older veterans hospitalized with pneumonia, a concurrent diagnosis of major depressive disorder, and especially untreated depression, was associated with higher mortality. This highlights that untreated major depressive disorder is an independent risk factor for mortality for patients with pneumonia.

Neuropathy and presence of emotional distress and depression in longstanding diabetes: Results from the Canadian study of longevity in type 1 diabetes

AIM

To determine the association of neuropathy and other complications with emotional distress and depression among patients with longstanding type 1 diabetes (T1DM).

METHODS

Canadians with ≥50years of T1DM completed a questionnaire including assessment of distress and depression by the Problem Areas in Diabetes Scale (PAID) and Geriatric Depression Scale (GDS), respectively. Complications were determined using the Michigan Neuropathy Screening Instrument (Questionnaire Component), fundoscopy reports, renal function tests, and self-reported peripheral-(PVD) and cardiovascular (CVD) disease. Associations were analyzed by Poisson regression.

RESULTS

Among 323 participants, 137 (42.4%) had neuropathy, 113 (36.5%) nephropathy, 207 (69.5%) retinopathy, 95 (29.4%) CVD, and 31 (9.8%) PVD. The neuropathy subgroup had higher prevalence of distress (13 (9.5%) vs. 6 (3.3%), p=0.029) and depression (34 (24.9%) vs. 12 (6.5%), p<0.001). Adjusting for diabetes complications, neuropathy was associated with higher PAID (adjusted RR 1.44 (95% CI 1.14-1.82), p=0.003) and GDS scores (adjusted RR1.57 (1.18-2.11), p=0.002). Independent of potential confounders, neuropathy remained associated with higher PAID (adjusted RR 1.39 (1.10-1.76), p=0.006) and GDS scores (adjusted RR 1.37 (1.03-1.83), p=0.032). Associations with neuropathy were not fully explained by neuropathic pain.

CONCLUSION

Compared to other complications, neuropathy had the greatest association with distress and depression in longstanding T1DM, independent of pain. Strategies beyond pain management are needed to improve quality of life in diabetic neuropathy.

[Correlation between treatment of depression and suicide mortality in Hungary -- focus on the effects of the 2007 healthcare reform]

Major depression is a common but still underdiagnosed and undertreated illness which, with its complications (suicide, secondary alcoholism, loss of productivity, increased cardiovascular morbidity and mortality), is a major public health problem worldwide. Implementing the present pharmacological and non-pharmacological treatment strategies, major depression can be successfully treated resulting in a significant decline in suicide risk and the economic burden caused by untreated depression is much higher than the cost of treatment. In the present paper the authors also discuss the impact of the development of the Hungarian psychiatric care system in the past three decades and the 2008 recession on the changing national suicide rate. Like international data, Hungarian studies also show that more widespread and effective treatment of depression is the main component of the more than 50-percent decline of suicide mortality in Hungary during the last 30 years.

Rate of stroke death after depression: a 40-year longitudinal study extension of Chichester/Salisbury Catchment area study

BACKGROUND

This study examined clinically diagnosed depression as a risk factor for incidence of death by stroke in a prospective clinically based design study. Risk for stroke was examined separately by sex in a long-term follow-up study spanning 40 years.

METHODS

Patients who were diagnosed with depression in the Chichester (population 100,000)/Salisbury (population 85,000) Catchment Area Study were followed up for 40 years. Death certificates were used to determine the cause of death in the cohort. Death rates in the general population, adjusted for age, gender, and year, were used as a control.

RESULTS

Clinical depression was found to be a risk factor for subsequent death from stroke in men but not in women. Death by stroke was a statistically significant cause of death in the men with diagnoses of endogenous depression but not in those men diagnosed with reactive depression. The strength of the relationship of depression with stroke increased over time.

CONCLUSIONS

These findings suggest that the identification of depressive symptoms at younger ages may have an impact on the primary prevention of stroke in later life. The notion that depression has stronger effects over a long period is consistent with a view that severe clinical depression and physical illness occur concurrently, one exacerbating the other, and health is degraded through slow-acting, cumulative processes. Data were unavailable for the type of stroke or the health-risk behaviors (smoking, diet, and so forth) in the cohort which constituted a limitation of the study. Neither is it known what proportion of the cohort suffered a nonlethal stroke nor to what extent the treatment of clinical depression militates against suffering a lethal stroke.

[A psychocardiology update on depression and coronary heart disease]

The prevalence of a major depressive disorder in patients after myocardial infarction is 20%. Depression is a risk factor for incident coronary heart disease and poor prognosis after myocardial infarction. Poor lifestyle habits and adherence to cardiac therapy as well as metabolic and pathophysiologic changes may partially explain this link. The threatening experience of an acute coronary event and immune and inflammatory changes may be unique features contributing to incident depression after myocardial infarction. While psychotherapy, antidepressants, and physical exercise may alleviate depressive symptoms in patients with coronary heart disease, cardiac rehabilitation additionally reduces mortality risk. Attempts are being undertaken to identify the cardiotoxic characteristics of depression to develop even more effective therapies in the future.

Changes in severity of depressive symptoms and mortality: the Italian Longitudinal Study on Aging

BACKGROUND

Depression is recognized as being associated with increased mortality. However, there has been little previous research on the impact of longitudinal changes in late-life depressive symptoms on mortality, and of their remission in particular.

METHOD

As part of a prospective, population-based study on a random sample of 5632 subjects aged 65-84 years, with a 10-year follow-up of vital status, depressive symptoms were assessed by the 30-item Italian version of the Geriatric Depression Scale (GDS). The number of participants in the GDS measurements was 3214 at baseline and 2070 at the second survey, 3 years later. Longitudinal changes in depressive symptoms (stable, remitted, worsened) were examined in participants in both evaluations (n=1941). Mortality hazard ratios (MHRs) according to severity of symptoms and their changes over time were obtained by means of Cox proportional hazards regression models, adjusting for age and other potentially confounding factors.

RESULTS

Severity is significantly associated with excess mortality in both genders. Compared to the stability of depressive symptoms, a worsened condition shows a higher 7-year mortality risk [MHR 1.46, 95% confidence interval (CI) 1.15-1.84], whereas remission reduces by about 40% the risk of mortality in both genders (women MHR 0.55, 95% CI 0.32-0.95; men MHR 0.59, 95% CI 0.37-0.93). Neither sociodemographic nor medical confounders significantly modified these associations.

CONCLUSIONS

Consistent with previous reports, the severity and persistence of depression are associated with higher mortality risks. Our findings extend the magnitude of the association demonstrating that remission of symptoms is related to a significant reduction in mortality, highlighting the need to enhance case-finding and successful treatment of late-life depression.

[Antidepressant therapy in coronary artery disease]

Depression is considered an independent risk factor for coronary artery disease (CAD) and other vascular conditions. Moreover, comorbid depressive disorder in CAD patients carries an increased risk of cardiac events and mortality. Among survivors of acute myocardial infarction, up to 20% meet diagnostic criteria for major depression, the presence of which carries a fivefold increased risk of cardiac death within 6 months. Heart patients with depressive comorbidity require particular care for both adequate treatment of their affective disorder and reduction of their cardiac risk. Antidepressant treatment must follow established guidelines; special care is needed to avoid cardiac side effects. In this review, we discuss the pathophysiological and prognostic significance of comorbid depression in CAD and weigh risks and benefits of available treatment options - particularly different drug classes and psychotherapy - in light of recent study results.

Effect of comorbid alcohol and drug use disorders on premature death among unipolar and bipolar disorder decedents in the United States, 1999 to 2006

OBJECTIVE

The aim of this study was to quantify the effect of comorbid alcohol and drug use disorders on premature death, as reflected by the manner of death (suicide and other unnatural death versus natural death) and the age at death, among decedents with unipolar and bipolar disorders.

METHODS

This study is based on the US Multiple Cause of Death public-use data files for 1999 to 2006. Secondary data analysis was conducted comparing decedents with unipolar/bipolar disorders and decedents with all other causes of death, based on the death records of 19,052,468 decedents in the Multiple Cause of Death data files who died at 15 years and older. Poisson regression models were used to derive prevalence ratios to assess the effect of comorbid substance use disorders (SUD) on the risks for being an unnatural death among mood disorder deaths. Multiple-cause life table analysis and mean age at death were used to quantify the effect of comorbid SUDs on premature mortality among mood disorder deaths.

RESULTS

Prevalence of comorbid SUDs was higher among unipolar and bipolar disorder deaths than that among all other deaths. Among unipolar and bipolar disorder deaths, comorbid SUDs were associated with elevated risks for suicide and other unnatural death in both men and women (prevalence ratios ranging 1.49-9.46, P < .05). They also were associated with reductions in mean ages at death (ranging 11.7-33.8 years, P < .05). In general, these effects were much stronger for drug use disorders than for alcohol use disorders. Both SUDs had stronger effects on suicide among women, whereas their effects on other unnatural deaths were stronger among men.

CONCLUSIONS

This study is among the first to provide population mortality-based evidence to further establish comorbid SUD as one of the key risk factors for premature death among individuals with unipolar or bipolar disorders in the United States. Clinicians need to be aware of the potentially lethal risk associated with these comorbid conditions.

Do risk factors for suicidal behavior differ by affective disorder polarity?

BACKGROUND

Suicide is a leading cause of death and has been strongly associated with affective disorders. The influence of affective disorder polarity on subsequent suicide attempts or completions and any differential effect of suicide risk factors by polarity were assessed in a prospective cohort.

METHOD

Participants with major affective disorders in the National Institute of Mental Health (NIMH) Collaborative Depression Study (CDS) were followed prospectively for up to 25 years. A total of 909 participants meeting prospective diagnostic criteria for major depressive and bipolar disorders were followed through 4204 mood cycles. Suicidal behavior was defined as suicide attempts or completions. Mixed-effects, grouped-time survival analysis assessed risk of suicidal behavior and differential effects of risk factors for suicidal behavior by polarity. In addition to polarity, the main effects of age, gender, hopelessness, married status, prior suicide attempts and active substance abuse were modeled, with mood cycle as the unit of analysis.

RESULTS

After controlling for age of onset, there were no differences in prior suicide attempts by polarity although bipolar participants had more prior severe attempts. During follow-up, 40 cycles ended in suicide and 384 cycles contained at least one suicide attempt. Age, hopelessness and active substance abuse but not polarity predicted suicidal behavior. The effects of risk factors did not differ by polarity.

CONCLUSIONS

Bipolarity does not independently influence risk of suicidal behavior or alter the influence of well-established suicide risk factors within affective disorders. Suicide risk assessment strategies may continue to appraise these common risk factors without regard to mood polarity.

CSF 5-HIAA and DST non-suppression--orthogonal biologic risk factors for suicide in male mood disorder inpatients

Two biomarkers of suicide risk; non-suppression in the dexamethasone suppression test (DST) and low 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) have been reported to be predictors of suicide in mood disorders. The interrelation of the two systems seems to be different in suicide attempters compared with depressed inpatients who have not made a suicide attempt, indicating that the two biomarkers may be seen as independent. This investigation examined the interrelation of low CSF 5-HIAA and DST non-suppression in suicide victims with mood disorder. Fifty-eight mood disorder inpatients not receiving any treatment with antidepressants underwent lumbar puncture and the DST. Plasma cortisol levels at 8:00 a.m., 4:00 p.m. and 11:00 p.m. were analysed in relation to CSF 5-HIAA. All patients were followed up for causes of death and suicides were verified with death certificates. During follow-up (mean 21 years), 11 (19%) patients had committed suicide. In male suicide victims (n=6), the serum cortisol level at 4:00 p.m. showed a significant positive correlation with CSF 5-HIAA. Low CSF 5-HIAA predicted all early suicides (within 1 year), whereas all males who committed suicide after 1 year were DST non-suppressors. In female suicide victims (n=5), the post-DST serum cortisol did not correlate with CSF 5-HIAA. Low CSF 5-HIAA and DST non-suppression are orthogonal biologic risk factors for suicide in male mood disorder inpatients. CSF 5-HIAA is associated with short-term suicide risk; dysregulation of the hypothalamic-pituitary-adrenal axis seems to be a long-term suicide predictor.

Psychiatric disorders and suicide in the nation's largest state prison system

This study examined the relationship between the overall rate of psychiatric disorders and suicides in the nation's largest state prison population. Data from 234,031 Texas Department of Criminal Justice inmates who were incarcerated for any duration between September 2006 and September 2007 were analyzed by Poisson regression, to assess the independent associations of major psychiatric disorders and demographic characteristics with suicide. Across the entire study cohort, 41 inmates (18 per 100,000) were reported to have committed suicide during the 12-month follow-up period; 21 of them had a diagnosis of a serious mental illness. An elevated risk of suicide was observed among inmates with major depressive disorder (relative risk [RR] = 5.1, 95% confidence interval [CI] = 1.9-13.8), bipolar disorder (RR = 4.6, CI = 1.3-15.9), and schizophrenia (RR = 7.3, CI = 1.7-15.9). The highest overall risk was present in those inmates with a nonschizophrenic psychotic disorder (RR = 13.8, CI = 5.8-32.9). These findings highlight the importance of maintaining suicide prevention programs in correctional settings, with particular emphasis on screening and monitoring of patients with severe psychiatric disorders.

HPA-axis hyperactivity and mortality in psychotic depressive disorder: preliminary findings

BACKGROUND

The excess mortality associated with depressive disorders has been most often attributed to risks for suicide but diverse findings indicate that depressive disorders also increase risks for cardiovascular (CV) mortality. Among the possible mediators is the hypothalamic-pituitary-adrenal (HPA)-axis hyperactivity that characterizes many cases of relatively severe depressive disorder and severity is characteristic of psychotic depressive disorder.

METHODS

The following describes a 17-year mortality follow-up of 54 patients with Research Diagnostic Criteria (RDC) psychotic major depression or schizoaffective, mainly affective, depression. All had baseline assessments that included a 1mg dexamethasone suppression test with post-dexamethasone samples at 8 a.m., 4 p.m. and 11 p.m.

RESULTS

Regression analyses showed that both greater age and higher maximum post-dexamethasone cortisol concentrations predicted deaths due to CV causes (t=4.01, p<0.001 and t=3.03, p=0.004, respectively). The 4 who died from CV disease had a mean (SD) post-dexamethasone cortisol concentration of 18.0 (6.0)microg/dl while the mean (SD) value for the remaining 50 patients was 7.6 (6.6)microg/dl (t=3.03, df=53, p=0.004). Regression analyses showed the 11 p.m. post-dexamethasone value to be predictive of suicide (t=2.05, p=0.048).

CONCLUSIONS

Conclusions should be tentative because an earlier follow-up of a more heterogeneous, but larger, sample did not find a relationship between DST results and CV mortality, and because only 4 CV deaths occurred in the present study. HPA-axis hyperactivity is probably only one of a number of factors that link depressive disorder to CV mortality.

ROC analysis of dexamethasone suppression test threshold in suicide prediction after attempted suicide

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis function is associated with suicidal behavior. In suicide attempters with mood disorder, the non-suppressor status in the dexamethasone suppression test (DST) is associated with suicide indicating that HPA-axis hyperactivity is a biological risk factor for suicide and may be a useful predictor. The threshold of 5 microg/dl for cortisol levels measured at 08:00 a.m. or 4:00 p.m. following dexamethasone at 11:00 p.m. to define the DTS nonsuppression was derived as being optimal for the separation of melancholia and nonmelancholic conditions rather than the prediction of suicide. A different threshold may offer a better identification of suicide. The aim of this study was to find the optimal threshold level of post DST plasma cortisol at 4 p.m. for suicide prediction using receiver operating characteristics (ROC) analysis. A cohort of 106 depressed inpatients with an index suicide attempt admitted to the department of Psychiatry at the Karolinska University Hospital between 1980 and 2000, were submitted to DST and followed up for causes of death. During the follow-up (mean 17 years), 25 suicides (24%) were identified. The ROC analysis revealed that a lower threshold of 3.3 microg/dl for the nonsuppressor status predicted 17 of 25 suicides (sensitivity of 68%) compared with 15 of 25 suicides (sensitivity 60%) with a conventional threshold of 5 microg/dl at 4:00 p.m. In male suicide attempters the lower threshold for pathological DST result (3.3 microg/dl) changed the Odds ratio from 6.7 till 18. In female suicide attempters a higher threshold (7.3 microg/dl) optimised the value of DST as a biological test for suicide prediction indicating a gender difference.

Deliberate self-harm in older adults: a review of the literature from 1995 to 2004

BACKGROUND

The prevention of suicide is a national and international policy priority. Old age is an important predictor of completed suicide. Suicide rates in old age differ markedly from country to country but there is a general trend towards increasing rates with increasing age. In 1996 Draper reviewed critically the evidence on attempted suicide in old age in the 10 years between 1985 and 1994. The review highlighted a need for prospective controlled studies in older people with more representative samples as well as studies examining the interaction of risk factors, precipitants, motivations, psychopathology and response to treatment. The aim of this paper is to update this review and to summarise the advances in our understanding of DSH in later life.

METHOD

We have critically reviewed relevant studies published between 1995 and 2004 to summarise the advances in our understanding of factors associated with deliberate self-harm in later life.

RESULTS

The main advances in understanding have been to clarify the effect of personality and cultural factors, service utilisation pre and post attempt, and the (lesser) impact of socio-economic status and physical illness. Methodological weaknesses continue to include inadequate sample sizes performed on highly selected populations, inconsistent age criteria and lack of informant data on studies relating to role of personality.

CONCLUSIONS

Future studies should include prospective, cross-cultural research with adequate sample sizes and which are population-based. Such approaches might confirm or refute the results generated to date and improve knowledge on factors such as the biological correlates of deliberate self-harm, service utilisation, costs and barriers to health care, and the interaction of these factors. Intervention studies to elucidate the impact of modifying these factors and of specific treatment packages are also needed.

Psychiatric comorbidity and suicide risk in adolescents with chronic daily headache

OBJECTIVES

To investigate the prevalence and correlates of comorbid psychiatric disorders and suicidal risk in community-based adolescents with chronic daily headache (CDH).

METHODS

We identified and recruited 122 adolescents with CDH from a non-referral student sample (n = 7,900). CDH subtypes were classified according to the most updated criteria of the International Classification of Headache Disorders, 2nd edition (ICHD-2). An in-person psychiatric interview was performed with each subject with CDH to assess depressive and anxiety disorders and suicidal risk based on the Mini-International Neuropsychiatric Interview-Kid (MINI-Kid). Clinical correlates and impacts were investigated.

RESULTS

A total of 121 subjects (31 male/90 female, mean age 13.8 years) finished the psychiatric interview. Fifty-seven subjects (47%) had > or =1 assessed psychiatric comorbidity with major depression (21%) and panic disorder (19%) as the two most common diagnoses. Current suicidal risk was assessed as high (score > or = 10) in 20% of subjects. Female gender and older age were associated with depressive disorders. Presence of migraine was associated with psychiatric comorbidities (OR = 3.5, p = 0.002). The associations with psychiatric disorders were stronger for migraine with aura than for migraine without aura. Migraine with aura also independently predicted a high suicidal risk (score > or = 10) (adjusted OR = 6.0, p = 0.028). In contrast, CDH subtypes, headache frequencies, or medication overuse were not correlated. Comorbid psychiatric disorders were not related to physician consultations or more days of sick leave.

CONCLUSIONS

This community-based study showed high comorbidity of psychiatric disorders and suicidal risk in adolescents with chronic daily headache. The presence of migraine attacks, especially migraine with aura, was the major predictor for these associations.

Switching to the bingeing/purging subtype of anorexia nervosa is frequently associated with suicidal attempts

OBJECTIVE

Anorexia nervosa has the highest suicide mortality ratio of psychiatric disorders, suicide being associated with many factors. We assessed the first lifetime occurrence of these factors taking into account their possible overlap.

METHOD

Three hundred and four in- and out-patients with anorexia nervosa (DSM-IV) were systematically recruited in three hospitals of Paris suburbs, between December 1999 and January 2003. Patients were assessed by a face-to-face interview (DIGS). Current eating disorder dimensions were measured, and patients interviewed by a trained clinician to assess minimal BMI and, retrospectively, the age at which anorexia nervosa, major depressive disorder, anxiety disorders and switch to bingeing/purging type occurred for the first time, if applicable.

RESULTS

Major depressive disorder (p<0.001) and subtype switch from the restrictive to the bingeing/purging type (p<0.001) were the two factors significantly more frequently occurring before suicidal attempts, and remained involved when a multivariate analysis is performed, whether syndromic or dimensional measures are being used. Taking into account lifetime occurrence with a survival analysis, the switch to bingeing/purging type of anorexia appears as a major predictive factor, with a large increase of the frequency of suicidal attempts (OR=15) when compared to patients with neither major depressive disorder nor bingeing/purging type.

CONCLUSIONS

Bingeing/purging type of anorexia nervosa is largely associated with suicidal attempts, and may deserve specific attention. If confirmed on a prospectively designed study, these results would argue for early detection and/or more intensive and specific therapeutic intervention on this aspect of bingeing and purging behaviors.

Sex differences in cardiac vagal control in a depressed sample: implications for differential cardiovascular mortality

Previous studies suggest depression is a risk factor for all cause mortality, with depressed men at greater risk than depressed women. Diminished cardiac vagal control (CVC) in depressed patients has also been found to increase risk of cardiac mortality. Previous research found that depressed women have higher CVC than depressed men suggesting CVC might be related to the discrepancy in mortality rates between depressed men and women. This finding, however, was in the context of a study with several methodological weaknesses. The current study sought to replicate the sex difference in CVC in a sample of 137 medically healthy and clinically diagnosed depressed patients. Main effects of sex and age significantly predicted CVC such that depressed women had greater CVC and CVC decreased with age in the cross-sectional sample. The results suggest greater CVC in depressed women might confer cardioprotective functions, which may partially explain the sex difference in mortality rates in the depressed population.

Psychosocial treatment of depression and suicidality in adolescents

Depression is a common disorder among adolescents and is associated with a high risk of suicide. Suicide is the third leading cause of death among adolescents in the United States. Currently, there are only two evidence-based psychotherapies for adolescence depression: cognitive-behavioral therapy and interpersonal psychotherapy. Furthermore, psychosocial interventions that specifically target suicidal behavior in adolescents are even fewer in number than treatments for depression. This article will review the psychosocial interventions for depression and suicidality in adolescents and will describe a recently developed treatment that is under study for depressed suicidal adolescents.

[Diabetes and depression--a life-endangering interaction]

In the past decade, research has increasingly discovered the relevance of depressive symptoms for the development and course of diabetes, particularly in diabetes type 2. The present paper provides an update on the present state of empirical research concerning this question.One fourth of all patients with diabetes mellitus suffer from depressive symptoms up to and including states of depressive disorders. The studies reviewed advise that depression in patients with diabetes concur with an unfavourable attitude towards the illness as well as towards treatment, a reduction in quality of life, an increased risk for the development of follow-up diseases as well as an increase in mortality risk. As a cause for the increasing risk in morbidity and mortality in depressive patients with diabetes, both neuroendocrinologic changes as well as unfavourable therapy and illness attitudes are discussed. First studies document that psychotherapeutic interventions are helpful in increasing the quality of life of depressive patients with diabetes and improving therapy behaviour.

Does the FDA proposed list of possible correlates of suicidality associated with antidepressants apply to an adult private practice population?

BACKGROUND

In issuing an advisory about a relationship of suicidality emerging during antidepressant use in mood and other psychiatric disorders in juvenile and, possibly patients of all ages, the FDA listed such warning symptomatologic correlates as psychomotor agitation, panic, insomnia, irritability, aggressiveness, and impulsivity, and additionally urged screening for personal and family history for bipolar disorder. It must be recalled that the FDA warning was based on post hoc examination of antidepressant trial data pertaining largely to emergent suicidal ideation rather than attempts. In this report we examine the relevance of the "FDA list" for adults.

METHODS

Consecutive 650 outpatients presenting with a major depressive episode (MDE) in the second author's (FB) private practice were interviewed using the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide, and the Family History Screen. The threshold for a bipolar II (BP-II) diagnosis was broadened by bypassing the stem-A probes on hypomanic mood, lowering the duration of hypomanic episodes to as short as 2 days and, most importantly, eliciting hypomanic intrusions into depressive episodes. Beyond the FDA proposed list and in line with previous work by us, we considered symptoms of depressive mixed state (DMX, an MDE plus 3 or more DSM-IV intradepressive non-euphoric hypomanic symptoms) as possible substrates for suicidality.

RESULTS

Suicidal ideation was present in 49.3% of the sample, and significantly greater in BP-II versus MDD (OR=1.46). Odds ratio for patients with suicidal ideas, versus those without suicidal ideas in univariate analyses were as follows: irritability (1.32), psychomotor agitation (1.48) and racing/crowded thoughts (2.0). In DMX, irritability was present in 76.4% and in non-DMX in 23.8% (OR=10.3), psychomotor agitation in 51.3% versus 4.4%, (OR=22.6), and racing/crowded thoughts in 89.2% versus 45.3% (OR=9.9). Insomnia and family history for bipolarity were not associated with suicidal ideation. Racing/crowded thoughts emerged as the only significant independent predictor in multiple logistic regression.

LIMITATION

Panic was not specifically tested, because it was not systematically entered into our clinical database. Furthermore, we studied a population which was not taking antidepressants. Our operating hypothesis was that the FDA listed correlates of suicidality are pre-existing baseline substrates that might be potentially further activated by antidepressants.

CONCLUSION

Going beyond previous work by us, the present data further refine the "FDA list" under scrutiny. While not designed to test whether antidepressants induce suicidality, the present report shows that the type of depression associated with suicidal ideas is an agitated, irritable, and especially mentally overactive syndrome (i.e. a DMX). Bipolarity falling short of the DSM-IV schema (represented by BP-II with brief hypomania and DMX) appears to represent the main diagnostic substrate for the occurrence of suicidality. Although controlled trials of antidepressants in adults have not been specifically conducted in DMX patients, it would be clinically prudent to avoid the prescription of antidepressant monotherapy to such patients to avert any potential iatrogenic aggravation of their condition.

Mortality among first-admission patients with psychosis

OBJECTIVE

This study compared 5- and 10-year survival and absolute and relative mortality rates among first-admission patients with 1 of 4 psychotic disorders: schizophrenia/schizoaffective disorder, bipolar disorder, major depression, and other nonorganic psychoses.

METHOD

The authors conducted a prospective 10-year follow-up of subjects first admitted with a diagnosis of nonorganic psychosis to any of 12 hospitals in Suffolk County, New York, during the period 1989 to 1995. Information on their death status since study entry was ascertained from the Social Security Death Index and the National Death Index. Survival analyses were conducted using the Kaplan-Meier product-limit estimator.

RESULTS

There were no significant differences in survival rates among the 4 diagnostic groups at 5-year (range, 96.3%-97.8%) or 10-year (range, 90.2%-97.8%) follow-up. Absolute mortality over the study period ranged from 2.8% of bipolars to 6.7% of those with major depression. About 60% of deaths among schizophrenic/schizoaffective subjects were due to unnatural causes, whereas for the other 3 groups, deaths were more evenly split between natural and unnatural causes. Suicides comprised most deaths from unnatural causes, most of which occurred during the 2- to 5-year follow-up period. Deaths due to natural causes tended to be related to lifestyle factors.

CONCLUSIONS

First-admission patients with psychosis experience similar patterns of mortality risk over the first 10 years after index admission regardless of underlying diagnosis. Causes of death (both natural and unnatural) were potentially preventable with more intensive medical and psychiatric follow-up and intervention. Many deaths from unnatural causes occurred during or shortly after discharge from an inpatient or residential treatment setting, highlighting this period as one needing close scrutiny by treating clinicians.

Hyperactivity of the hypothalamic-pituitary-adrenal axis and mortality in major depressive disorder

Convergent evidence indicates that HPA-axis hyperactivity is a risk factor for suicide in major depressive disorder, and seven independent reports have shown that patients with abnormal dexamethasone suppression test (DST) results have significantly higher rates of eventual suicide. The identification of interactions between DST results and other clinical predictors would enhance risk assessment, but modest sample sizes have limited such analyses in earlier cohorts. Subjects with major depressive disorder who participated in research protocols at the University of Michigan between 1980 and 1991, who had fully structured diagnostic interviews, and who underwent a 1-mg DST while actively depressed were screened with the National Death Index for a mean (S.D.) follow-up period of 18.0 (5.5) years. Of 334 subjects, 69 (20.7%) were identified as having died. Of these, 13 (18.8%) had died by suicide and 32 (46.4%) from cardiovascular causes. Baseline DST results did not significantly predict death from suicide or from cardiovascular disease for the sample as a whole. Significant relationships between DST results and later suicide did exist for inpatients, for patients with manifest suicidality and, in particular, for inpatients with manifest suicidality. Because nearly all previous reports of DST results and suicide described depressed inpatients, it is possible that the DST is a useful predictor only within this population.

Course and outcomes of depression in the elderly

Major depressive disorder is a potentially debilitating condition that often is unrecognized or undertreated in the elderly. Even when aggressively treated, the course of geriatric depression can be severe. There is growing evidence that suggests that late-life depression may carry a higher illness burden than depression with onset earlier in life, and that severity is linked to medical and psychiatric comorbidity. Data continue to accumulate in support of various treatment modalities, including medication, electroconvulsive therapy, and psychotherapy. Given the increased risk of adverse outcomes associated with geriatric depression, such as dementia and suicide, it is essential that future investigations continue to build on the evidence base supporting improved diagnosis and treatment of this complex disorder.

STin2 variant and family history of suicide as significant predictors of suicide completion in major depression

BACKGROUND

Suicide is the most serious outcome of major depression, yet not all depressed patients will commit suicide. Genes, along with other factors, might account for this difference. Serotonergic alterations have been observed in suicide and depression and impulsive-aggressive behaviors. Therefore, we aimed to identify predictors of suicide, considering genetic variation at the serotonin transporter (5-HTT) gene.

METHODS

We investigated the 5-HTT gene-linked polymorphic region (5-HTTLPR) and intron 2 (STin2) variants of this gene and their relationship to behavioral and clinical risk factors for suicide in a sample of depressed suicides (n =106) and depressed control subjects (n =152), diagnosed by means of proxy-based interviews.

RESULTS

We found a significant association of suicide completion with having at least one copy of the STin2 10 allele [chi(2)(1) = 10.833, p = .002]. No differences were found for the 5-HTTLPR variable number of tandem repeats. After controlling for behavioral and clinical risk factors for suicide, the STin2 variant remained a significant predictor of suicide in major depression when jointly considered with a family history of suicide (odds ratio 5.560, 95% confidence interval 1.057-29.247).

CONCLUSIONS

The STin2 locus might account, at least in part, for the observed familial aggregation of suicidal behavior. These results should be further explored in families where clustering of suicidal behavior is observed.

Prognosis of late life depression: a three-year cohort study of outcome and potential predictors

BACKGROUND

Late-onset depression (LOD) has a poor prognosis which may be worsened by the presence of cerebrovascular disease. Few studies have explored prospectively the influence of vascular risk factors on longer term prognosis.

METHODS

The original study involved 50 patients with LOD and 35 healthy age matched controls. Follow-up was at three years. Baseline measures included clinical, neuroradiological and neuropsychological variables. Outcome was assessed by mortality, progression to dementia and clinical course of depressive disorder.

RESULTS

Sixty-two (73%) of the original cohort agreed to be re-interviewed. Seven participants had died (all from the depressed group) and six developed dementia, all but one from the depressed group. Vascular dementia predominated (although not significantly so) among those with dementia at follow-up. For 28 depressed patients with complete follow-up data (56% of the original sample), poor outcome was predicted by lower High Density Lipoprotein (HDL), raised Erythrocyte Sedimentation Rate (ESR) and a higher score on the Hachinski Index scale and one test of immediate memory. Initial response to treatment was not associated with later outcome.

CONCLUSION

Late-onset depressive disorder is associated with a high rate of mortality and possibly dementia. Biochemical and inflammatory markers may be important in prognosis and their role should be confirmed in future studies.

[Age and gender: confounders for axis I disorders as risk factors for suicide]

OBJECTIVES AND METHODS

Aim of the study was to identify and estimate psychiatric axis I disorders as risk factors for suicide in different age groups using a psychological autopsy study with case-control design. 163 suicides and 396 population-based control persons were assessed with a standardized semi-structured interview including SCID-I (for DSM-IV).

RESULTS

Logistic regression analyses revealed significantly elevated odds ratios for alcohol-related disorders in men aged 31 to 45, 46 to 60, and 61 to 75 years (OR = 9.0, OR = 7.5, and OR = 10.7, respectively) and for Major Depression, single episode, in men and women aged 61 to 75 years (OR = 42.7 and OR = 15.9). In males aged 31 to 45 years polysubstance-related disorders (OR = 9.5) and in females aged 61 to 75 years cognitive and mental disorders due to a general medical condition (OR = 12.2) were significantly and independently associated with suicide.

CONCLUSIONS

Alcohol-related disorders and Major Depression differently contribute to male and female suicide risk in special age groups. These findings imply differentiated prevention strategies.

The association of comorbid depression with mortality in patients with type 2 diabetes

OBJECTIVE

We assessed whether patients with comorbid minor and major depression and type 2 diabetes had a higher mortality rate over a 3-year period compared with patients with diabetes alone.

RESEARCH DESIGN AND METHODS

In a large health maintenance organization (HMO), 4,154 patients with type 2 diabetes were surveyed and followed for up to 3 years. Patients initially filled out a written questionnaire, and HMO-automated diagnostic, laboratory, and pharmacy data and Washington State mortality data were collected to assess diabetes complications and deaths. Cox proportional hazards regression models were used to calculate adjusted hazard ratios of death for each group compared with the reference group.

RESULTS

There were 275 (8.3%) deaths in 3,303 patients without depression compared with 48 (13.6%) deaths in 354 patients with minor depression and 59 (11.9%) deaths among 497 patients with major depression. A proportional hazards model with adjustment for age, sex, race/ethnicity, and educational attainment found that compared with the nondepressed group, minor depression was associated with a 1.67-fold increase in mortality (P = 0.003), and major depression was associated with a 2.30-fold increase (P < 0.0001). In a second model that controlled for multiple potential mediators, both minor and major depression remained significant predictors of mortality.

CONCLUSIONS

Among patients with diabetes, both minor and major depression are strongly associated with increased mortality. Further research will be necessary to disentangle causal relationships among depression, behavioral risk factors (adherence to medical regimens), diabetes complications, and mortality.

Clinical predictors of suicide in primary major depressive disorder

OBJECTIVE

Follow-up studies of patients with depressive disorders have identified only a few replicable predictors of suicide and have not explored possible interactions between them. The following analysis takes advantage of a large cohort of depressed patients given detailed, structured interviews 2 decades ago.

METHOD

The data set on which this analysis is based was collected between 1976 and 1990. Research personnel administered the Schedule for Affective Disorders and Schizophrenia to 785 adults who had major depressive disorder (Research Diagnostic Criteria) but who lacked other Axis I disorders. The current analysis used the National Death Index to determine mortality status as of 2003.

RESULTS

One in 4 of the 134 deaths were by suicide for an overall suicide rate of 4.2%. In comparison to the remaining 752 patients, the 33 who died by suicide were more likely to have been inpatients and to have had a history of suicide attempts at the time of baseline assessment. They had also expressed more hopelessness and had higher ratings of suicidal tendency. The last of these variables was the most robust by far and, when tested with other predictors in regression analyses, was the only one to retain significance (p < .0001). No interactions between predictors emerged. As in an earlier, similar study, the suicidal tendency rating was predictive of suicides that occurred after the first year of follow-up, which suggests that suicidal tendencies comprise a trait that persists across episodes.

CONCLUSION

A global rating of suicidality appears to be the single most important predictor of eventual suicide in patients with major depressive disorder.

Is depression in old age fatal only when people feel lonely?

OBJECTIVE

The impact of depression and perceived loneliness in the oldest old is largely unknown. The authors studied the relationship between the presence of depressive symptoms and all-cause mortality in old age, especially the potential distorting effect of perceived loneliness.

METHOD

Within a prospective population-based study of 85-year-olds, the 15-item Geriatric Depression Scale and the Loneliness Scale were annually applied in all 476 participants with a Mini-Mental State Examination score of 18 points or more.

RESULTS

Depression was present in 23% and associated with marital state, institutionalization, and perceived loneliness. When depression and perceived loneliness were assessed during follow-up, neither depression nor perceived loneliness had a significant effect on mortality. However, those who suffered from both depression and feelings of loneliness had a 2.1 times higher mortality risk.

CONCLUSIONS

The data suggest that the increased mortality risk attributable to depression in the presence of perceived loneliness may result from motivational depletion.

The dexamethasone suppression test as a predictor of suicidal behavior in unipolar depression

BACKGROUND

Non-suppression on the dexamethasone suppression test (DST) in unipolar depression has been found to be associated with completed suicide, with less consistent data for attempted suicide and hospitalizations for suicidality. The purpose of this study was to examine DST non-suppression as a predictor of these three aspects of suicidal behavior.

METHODS

Records were reviewed for 101 patients who met criteria for major depressive disorder and/or dysthymic disorder and had a DST performed. All patients were treated naturalistically and were followed for an average of 2 years. DST suppressors and non-suppressors were compared with respect to three outcomes: (1) completed suicide; (2) attempted suicide; and (3) hospitalizations for suicidality.

RESULTS

DST non-suppressors were significantly more likely to have completed suicide or be hospitalized for suicidality than DST suppressors, with a non-significant trend for attempts. Total suicidal events were also significantly more frequent in the non-suppressor group.

LIMITATIONS

Axis II diagnoses and severity of illness were not assessed. Knowledge of DST results may have influenced the decision to hospitalize patients.

CONCLUSIONS

DST non-suppression identifies unipolar depressed patients with a higher risk for future suicide completion or hospitalization for suicidality. Performance of DST upon initiation of treatment may be a useful adjunct in identifying suicidal risk.

Heart rate variability in coronary artery disease patients with and without panic disorder

Panic disorder (PD) and coronary artery disease (CAD) often co-occur, and CAD patients with comorbid PD suffer greater cardiovascular morbidity and mortality relative to CAD patients without PD. However, the mechanisms underlying these associations are still unknown. Reduced heart rate variability (HRV), a non-invasive measure of cardiac autonomic modulation, is an important predictor of adverse cardiac events. Interestingly, reduced HRV has been observed in patients with panic-like anxiety and PD, as well as in various CAD populations. However, the extent to which HRV is altered in patients with both PD and CAD is unknown. This study evaluated HRV in 42 CAD patients with (n=20) and without (n=22) PD. Patients underwent 48-h electrocardiographic monitoring. Power spectral analysis of HRV indicated that CAD patients with PD exhibited significantly lower LF/HF ratios, which may reflect lower sympathetic modulation, compared with non-PD patients. Additionally, total power in PD patients was made up of a significantly higher proportion of HF power and a significantly lower proportion of VLF power than in non-PD patients. No other significant differences in HRV indices were observed. Results suggest that contrary to what has been observed in the majority of PD-only and CAD-only populations; patients with both PD and CAD appear to exhibit lower sympathetic modulation during ordinary daily life conditions. Though preliminary, these findings suggest that changes in HRV may not be the mechanism underlying greater cardiovascular morbidity and mortality among CAD patients with PD.

Is low dietary intake of omega-3 fatty acids associated with depression?

OBJECTIVE

This study examined the association between the dietary intake of omega-3 fatty acids and low mood, major depression, and suicide.

METHOD

A total of 29,133 men ages 50 to 69 years participated in a population-based trial in Finland. The intake of fatty acids and fish consumption were calculated from a diet history questionnaire. Self-reported depressed mood was recorded three times annually, data on hospital treatments due to a major depressive disorder were derived from the National Hospital Discharge Register, and suicides were identified from death certificates.

RESULTS

There were no associations between the dietary intake of omega-3 fatty acids or fish consumption and depressed mood, major depressive episodes, or suicide.

CONCLUSIONS

Dietary intake of omega-3 fatty acids showed no association with low mood level.

A suicide peak after weekends and holidays in patients with alcohol dependence

This paper analyzes the variation of suicide by day of the week in alcohol dependence, with public holidays taken into consideration. From 1949 through 1969, 1,312 patients with alcohol dependence were admitted to the Department of Psychiatry in Lund. By 1997, a total of 102 (99 men) alcoholic patients had taken their own life. Suicide victims with severe depression and other diagnoses were compared. There was a suicide peak on the first two days after weekends and holidays in patients with alcohol dependence (p < .05). Alcohol withdrawal is proposed as a contributor to the suicide peak.

Association of depression, CD8+ T lymphocytes, and natural killer cell activity: implications for morbidity and mortality in Human immunodeficiency virus disease

A heightened risk of mood disorders, such as major depression, and acute depressive symptoms has been observed among HIV-seropositive individuals since the start of the AIDS epidemic, and an accumulating body of data now shows that depression may have an impact on morbidity and mortality among individuals with HIV disease. Although the specific physiologic mechanisms involved in this process have not been delineated, there is some evidence to suggest that certain components of innate immunity, including killer lymphocytes such as CD8+ T lymphocytes and natural killer cells, may represent key pathways through which depression affects HIV disease progression. This paper reviews some of the main studies examining the effects of depression on immunity and HIV disease progression and discusses the potential role of killer lymphocytes as an underlying mechanism by which depression may impact morbidity and mortality.

The antisuicidal and mortality-reducing effect of lithium prophylaxis: consequences for guidelines in clinical psychiatry

The suicide-related mortality among patients with affective disorders is approximately 30 times higher, and overall mortality 2 to 3 times higher, than suicide-related mortality in the general population. Lithium has demonstrated possibly specific antisuicidal effects apart from its prophylactic efficacy: it significantly reduces the high excess mortality of patients with affective disorders. To date, suicide-prevention effects have not been shown for antidepressant or anticonvulsant long-term treatment. Clozapine appears to reduce the suicide rate in schizophrenia patients. Against this background, guidelines and algorithms for selecting an appropriate prophylactic strategy for affective disorders should consider the presence of suicidality in patient history. Appropriate lithium prophylaxis prevents approximately 250 suicides yearly in Germany, although lithium salts are infrequently prescribed within the National Health Scheme (specifically, to 0.06% of the population). Rational treatment strategies most likely would demand that prescription rates be about 10 times higher.

[Poststroke depression: risk factors and effects on the course of the stroke]

The incidence of poststroke depression (PSD) varies between 20% and 25% as a major variant and an additional 10% and 20% as a minor variant. Its prevalence peaks 3-6 months after stroke onset. In nearly a quarter of all PSD patients, depressive symptoms persist over at least 2 years.Several longitudinal studies have identified different factors which may increase the risk of PSD. Most probably, the severity of the neurological deficit, female gender, history of previous psychiatric disorders, and bad social living conditions increase the risk of PSD. It is uncertain whether lesion location or size modulate PSD risk. Increasing age is not associated with a higher PSD incidence. In contrast, it is obvious that PSD is associated with less favorable outcome and higher mortality. The degree of disability and quality of life are significantly reduced in PSD patients. In conclusion, PSD is presently a not predictable complication of ischemic stroke which is significantly associated with less favorable outcome.Early diagnosis and adequate therapy are still necessary in stroke rehabilitation.

The prognosis of depression in old age: outcome six to eight years after clinical treatment

Previous studies suggest that the short-term outcome in severely depressed elderly in The Netherlands is worse compared to other studies in the Western world. The present study examines the long-term prognosis of hospitalized elderly patients with major depressive disorder and possible predictors of outcome. One hundred and five elderly inpatients with unipolar major depression, admitted by regional mental health services in a geographically delimited area, were evaluated six to eight years after index episode by trained residents using a structured diagnostic interview (C.I.D.I.) The GP was interviewed using a standard questionnaire. At follow-up 40% of the original sample had died. Of the survivors 33% had fared well, 24% had a relapsing course, 22% had residual symptoms, 11% were continuously ill, and 9% had probable dementia. With respect to prognostic factors, personality disorder predicted a worse outcome. All patients with a major depressive disorder at follow-up received specialised care and used antidepressants. None of the patients received ECT. The mortality rate in clinically treated elderly with major depressive disorder is high. Among survivors the long-term prognosis in The Netherlands is comparable with other studies to date. The presence of a personality disorder predicts worse outcome. Though the accessibility of services seems to be good, more vigorous treatment was not applied.

Site variability in treatment outcome in antidepressant trials

OBJECTIVE

Site-specific differences in treatment outcome during multisite antidepressant drug trials may contribute to a negative or failed clinical trial. As part of a five-site, long-term, double-blind, placebo-controlled, relapse prevention trial with fluoxetine in major depression, the authors examined site-specific variability in outcome ratings.

METHODS

Data from 390 patients with major depression who participated in a 64-week, placebo-controlled trial were retrospectively analyzed. chi 2 Analyses and Kaplan-Meier survival estimates were used to examine site-specific differences in relapse rates during 14 weeks of maintenance treatment following randomization to fluoxetine or placebo after remission with fluoxetine treatment.

RESULTS

Results from chi 2 analysis (P < .001) and Kaplan-Meier survival rates (P < .001) following randomization to placebo after 12 weeks of fluoxetine treatment showed a fluoxetine superiority over placebo among all five sites combined. Individually, however, only three of the five sites (60%) were able to distinguish fluoxetine superiority. In contrast, there was no fluoxetine versus placebo difference observed among all five sites after randomization following 26 weeks of fluoxetine treatment (P = .11, Fisher's exact test). However, one site (20%) individually could still distinguish a drug versus placebo difference (P < .05).

LIMITATIONS

Analyses were performed retrospectively, with individual sites not specifically powered to distinguish a drug-placebo difference.

CONCLUSION

Substantial site differences were observed in the ability to distinguish drug superiority over placebo, and this variability may contribute to a negative or failed clinical drug trial.

A study of suicides of older people in Sydney

BACKGROUND

Reports based on studies of coroner's files show that suicides in old age are commonly related to depression, but that in a majority of cases disability or ill-health is also a major factor. The aim of this study was to try to understand more clearly the precipitant causes of suicide in an older population.

METHOD

An Australian metropolitan coroner's office provided data concerning suicides in 1994-1998 of persons aged over 65 years.

RESULTS

Of 210 elderly people who killed themselves, 160 (76%) were clearly depressed, including a majority of the 24% deemed to have understandable reasons for suicide. Physical ill-health or disability was the major factor leading to suicide in 34% and appeared to contribute to suicidal ideation in another 24% of those who died; they had usually not been seen by psychiatrists.

CONCLUSION

Because depression is often treatable, even when associated with depressing circumstances, there is potential for further reduction of old age suicide rates by recognising and appropriately responding to symptoms of depression and distress.

The occurrence of suicide in severe depression related to the months of the year and the days of the week

The purpose of the present study was to investigate the distribution of suicide during the months of the year and the days of the week in severe depression. A total of 1206 in-patients rated at discharge from the Department of Psychiatry, Lund, Sweden, on a multiaxial diagnostic schedule received the diagnosis severe depression/melancholia between 1956 to 1969. When followed up to 1998, a total of 114 depressed patients had taken their own life. Out of these, 98 patients appeared to have a primary depression. The monthly distribution of suicides showed a significant peak in October/November for men (41 % of all male suicides). No correlation with the onset of depression could be detected. Furthermore, there was a preponderance of suicide on Sundays for both sexes (31 % of all suicides).

Indicators of suicide over 10 years in a specialist mood disorders unit sample

BACKGROUND

There are few firm data to guide the clinician in identifying individual depressed patients who may be at high risk for completing suicide. In particular, there have been few prospective studies of well-characterized depressed patients to determine indicators of such future events.

METHOD

Eight hundred thirteen patients with a major depressive episode (DSM-III, DSM-III-R, or DSM-IV criteria) were assessed in detail in a specialist Mood Disorders Unit (MDU) over a 10-year period. Follow-up at the end of that period (mean = 5.1 years) confirmed that 31 patients (3.8%) had completed suicide. The suicide completers were compared on a broad range of clinical and demographic variables obtained at baseline with (1) the total remaining depressed sample, (2) 31 age- and sex-matched subjects who were confirmed to be alive and had never attempted suicide, and (3) 24 age- and sex-matched living subjects who had made at least 1 suicide attempt.

RESULTS

The most consistent finding, across all 3 comparisons, was that the suicide completers were more likely to have been inpatients at the time of the index MDU assessment. Other characteristics of completers were a greater number of prior admissions for depression, being older and in a relationship, and being male and married or female and single. Somewhat paradoxically, suicide completers also evidenced fewer previous suicide attempts and less suicidal ideation compared with living subjects who had attempted suicide at the time of index assessment.

CONCLUSION

Overall, we were able to find few predictors of later suicide in this sample. Those who completed suicide demonstrated evidence of more severe illness over a lifetime (for example, having more admissions). but revealed less suicidal ideation at the time of the index MDU assessment. While these features were statistically significant, they are of limited usefulness in predicting suicide in an individual patient.