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Suicide attempts and clinical risk factors in patients with bipolar and unipolar affective disorders
General Hospital Psychiatry 35 (2013) 427–432
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Suicide attempts and clinical risk factors in patients with bipolar and unipolar affective disorders☆ Joanna Pawlak, Ph.D, M.D. a,⁎, Monika Dmitrzak-Węglarz, Ph.D. a, Maria Skibińska, Ph.D. a, Aleksandra Szczepankiewicz, Ph.D. a,c, Anna Leszczyńska-Rodziewicz, Ph.D., M.D. a, Aleksandra Rajewska-Rager, Ph.D., M.D. b, Dorota Zaremba a, Piotr Czerski, Ph.D. a, Joanna Hauser, Ph.D., M.D. a a b c
Laboratory of Psychiatric Genetics, Department of Psychiatry, University of Medical Sciences, ul. Szpitalna 27/33, 60–572 Poznan, Poland Department of Adult Psychiatry, Poznan University of Medical Sciences, Poland Laboratory of Molecular and Cell Biology, PUMS, Poland
a r t i c l e
i n f o
Article history: Received 26 November 2012 Revised 18 March 2013 Accepted 19 March 2013 Keywords: Suicide Affective disorder Risk factors
a b s t r a c t Background: Suicide is an important clinical problem in psychiatric patients. The highest risk of suicide attempts is noted in affective disorders. Objective: The aim of the study was to look for suicide risk factors among sociodemographic and clinical factors, family history and stressful life events in patients with diagnosis of unipolar and bipolar affective disorder (597 patients, 563 controls). Method: In the study, the Structured Clinical Interview for DSM-IV Axis I Disorders and the Operational Criteria Diagnostic Checklist questionnaires, a questionnaire of family history, and a questionnaire of personality disorders and life events were used. Results: In the bipolar and unipolar affective disorders sample, we observed an association between suicidal attempts and the following: family history of psychiatric disorders, affective disorders and psychoactive substance abuse/dependence; inappropriate guilt in depression; chronic insomnia and early onset of unipolar disorder. The risk of suicide attempt differs in separate age brackets (it is greater in patients under 45 years old). No difference in family history of suicide and suicide attempts; marital status; offspring; living with family; psychotic symptoms and irritability; and coexistence of personality disorder, anxiety disorder or substance abuse/dependence with affective disorder was observed in the groups of patients with and without suicide attempt in lifetime history. © 2013 Elsevier Inc. All rights reserved.
1. Introduction The average global rate of mortality due to suicide is 16/100,000. Statistically speaking, on the global scale, a single suicidal death takes place every 40 s, and an attempt takes place every 3 s [1]. About 5% of the overall population makes at least one suicidal attempt in the entire life cycle [2]. Ninety-five percent patients of emergency rooms after a suicidal attempt were diagnosed with psychiatric disorders, most often depression [3]. It is estimated that 20% with bipolar affective disorders commit suicide [4], while 25%–50% make suicide attempts [5]. Lists of factors that are significant in the assessment of risk of suicidal behaviors are published. The following factors have been listed as increasing the risk of suicide: previous suicide attempts; ☆ This research was supported by grant 2011/01/B/NZ5/02795, financed by the Ministry of Science and Higher Education of Poland. ⁎ Corresponding author. Tel.: +48 61 8491311; fax: +48 61 8480392. E-mail address: [email protected] (J. Pawlak). 0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2013.03.014
history of psychiatric disorders, particularly depression; suicide in family history; history of maltreatment during childhood; hopelessness, tendency to impulsivity or aggression; barriers in access to psychiatric treatment; sense of loss (in personal or social relations, at work, financial loss); somatic disease; easy access to lethal substances; lack of willingness to seek help due to stigmatization associated with emotional problems, abuse of drugs or suicidal thoughts; cultural or religious beliefs, such as belief that suicide is a sublime solution to personal dilemmas; local “epidemics” of suicide; and isolation, sense of loneliness or separation from other people [6]. In the case of emergence of a depression, Pużyński refers to such factors as severe depression, sense of guilt, hopelessness, low selfesteem, anhedonia, chronic anxiety, insomnia, disclosed suicidal thoughts or intentions and chronic subdepression. The demographic traits include age, gender: male, widow/widower and divorced. As for the social situation, the author lists the following factors: loneliness, inability to get help from others, bad financial condition and loss of job or sources of income. The following are of significance in the patient's history and among coexisting disorders: suicide attempts in the past,
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suicides of close relatives and persons who were important to the patient, the period of bereavement, poor social adaptation, abuse of alcohol, personality disorders (cyclothymic, antisocial), chronic somatic illnesses, chronic insomnia, chronic pain and organic brain disorders (chronic) [7,8]. The suicide risk factors listed above have been confirmed by other authors [9–13]. Numerous studies confirm the higher risk of suicidal behaviors in patients with early onset of affective disorder [14–17]. The risk factors for suicide attempts include history of head injuries [2,14,18], abuse in childhood [2], mania induced by antidepressive treatment [18], more severe course of mania [19], emergence of mixed states and rapid cycling [17], mood instability and coemergence of panic disorder [15]. Many authors point to correlation between suicidal behaviors and abuse of alcohol, other psychoactive substances and drugs [14,15,17,20]. Twenty-five percent of persons consume alcohol prior to suicidal attempt [21]. Leverich et al. also point to family history of abuse of medicinal drugs as a suicide risk factor [19]. 2. Objective, material and method of research The objective of the study is to identify factors associated with a risk of suicide attempts in persons with diagnosed uni- (UP) and bipolar (BP) affective disorders. The scope of factors analyzed included sociodemographic factors, clinical features: the characteristics and course of affective disorders, family history, and coexisting diseases and stress-inducing situations. The inclusion criteria were diagnosis of UP or BP [meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria] and being 18 years or older. The exclusion criteria were serious somatic diseases or states that currently demand therapeutic intervention and being younger than 18 years. The research has been conducted with 597 patients (367 women, 230 men), aged 18–84 (average=47, SD±14), who met the criteria of DSM-IV for BP (BP I n=391; BP II n= 104) or recurrent depression (UP n= 102) from the region of Wielkopolska. Patients were recruited among patients of both psychiatric wards (on average, 120 admissions with UP or BP diagnosis annually) and mental health centre (330 patients with UP or BP diagnosis annually). Among patients with suicide attempts, there were 151 women (66.81%) and 75 men (33.19%). In the examined group of patients with BP, one or more suicide attempts were made by 40.0% persons (n= 198); among patients with UP, 27.5% (n= 28). History of suicide attempts was recorded in 44.1% of women diagnosed with BP and 34.3% of men with BP. In the group diagnosed with UP, these values amounted to 30.4% and 17.4%, respectively. Patients with history of suicide attempts were divided into two subgroups, depending on the method of this attempt. The first group (n= 71) consisted of persons who engaged in violent or lifethreatening attempts [22,23] (hanging, jumping from heights, throwing oneself under a vehicle, shooting, bleeding, drowning). The second group (n=139) consisted of persons who did not apply these methods. In 16 patients, the method of the suicide attempt made was not determined. The control group consisted of 563 persons with no history of psychiatric disorders (333 women, 230 men), aged 18–83 (average= 42 years, SD±13), from the area of Wielkopolska. The control group was recruited among blood donors, students, hospital staff and nonpsychiatric patients of general practitioners using advertisements placed in general practices. Some of the volunteers in the control group (65 persons) were subjected to psychiatric tests in order to eliminate any Axis I disorders. The following scales and questionnaires were used in the study: the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) questionnaire [24]; the Operational Criteria Diagnostic Checklist questionnaire [25] (information on psychopathological symptoms throughout the entire course of the disease and the possible suicide attempts); the personality disorders questionnaire according to the
International Classification of Diseases, 10th Revision (ICD-10) (prepared for the purpose of this study at the Laboratory of Psychiatric Genetics); and the questionnaire of life events (modified as in Ref. [26]). The basic diagnosis was determined by two psychiatrists using the SCID questionnaire. The lifetime presence/absence of manic, hypomanic and depressive symptoms was assessed to distinguish BP I, BP II and UP patients. Patients who underwent a single affective episode, need immediate somatic medical intervention or committed suicide during clinical observation were excluded. On the basis of the SCID questionnaire, coexistence of anxiety disorders (the number of patients examined was n= 419, coexistence was found in n=42 patients) or abuse/dependence to psychoactive substances (patients examined n=528, coexistence found in n=117) was determined. In the group examined, coexistence of affective disorders and the following anxiety disorders was found: agoraphobia with panic disorder (0.716% patients), agoraphobia without history of panic disorder (0.477%), social phobia (1.670%), specific phobias (1.670%), general anxiety disorder (0.955%), panic disorder (1.670%), mixed anxiety and depressive disorder (0.239%) and obsessive– compulsive disorder (2.864%). Using the personality disorder questionnaire according to ICD-10, coexistence of personality disorders and the basic diagnosis was found. The patients met criteria of the following disorders: paranoid personality (1.613% patients), emotionally unstable personality (1.613%), schizoid (1.613%), histrionic (3.226%), passive–aggressive (1.613%), narcissistic (3.226%) and mixed personality disorders (6.452%). On the basis of the family history questionnaire, family history of psychiatric disorders and suicidal behaviors was determined. Information was also obtained on stress events preceding the current illness episode. The study was approved by local Ethics Committee. All patients gave written informed consent. Data on persons who refused participating in the study were not stored. 3. Results We divided the analyzed group of patients into 5-year age brackets. The most (15.3%) suicide attempts were observed in the 35–39 age bracket. In BP patients, the most abundant suicide attempts were in the 20–24 age bracket (14.8%). In UP patients, the most abundant attempts were in the 35–39 age bracket (23.1%). Differences were discovered between male and female groups. In female samples, the most abundant (17%) suicide attempts appeared in the 35–39 age bracket, whereas, in the male group, the situation appeared in the 40–44 age bracket (17.6% of attempts). Patients with BP and UP diagnoses were divided into subgroups taking into account presence or absence of suicidal attempts in lifetime history. Distributions of age of onset of the disease were compared, and a statistically significant difference (P=.013) was observed in UP. Mean age of onset in UP suicide attempters amounted to 34.3 and 42.0 years in nonattempters. No statistical significance was discovered in BP attempters and nonattempters (P= .155). Fig. 1 shows the difference between age of onset and age of suicide attempt. In the investigated group, 17 of all attempts (6.5%) occurred earlier than the onset of affective disorder. In the whole sample analyzed, most numerous suicide attempts occurred in the first year of the disease. No difference between male and female subgroups was observed. In the subsequent years in the course the of illness, the number of suicide attempts appeared less frequently in the bipolar disorder group. The situation was not so clear in unipolar affective disorder (Fig. 1). Table 1 shows the relations between suicide attempts and selected clinical factors. We found association of suicide attempts and: − family history of affective disorder [P= .009, odds ratio (OR)= 1.797; 95% confidence interval: 1.159 to 2.785)
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429
60 50 40 30 20 10 0 age, when the patient attempted suicide age of onset of the disease
-7
0
5
all patients
10
15
BP
20
27
32
UP
Fig. 1. Suicide attempts and period between onset of the disease and attempt (taking into account the diagnosis).
− family history of substance abuse/dependence (P= .001; OR= 2.217; 95% confidence interval: 1.380 to 3.562) − family history of psychiatric disorders (P=.013; OR=1.594; 95% confidence interval: 1.100 to 2.308) − inappropriate guilt in depression (P= .016, OR=1.590; 95% confidence interval: 1.088 to 2.326). Four depressive symptoms (inappropriate guilt, worthlessness, insomnia and agitation) were analyzed as suicide risk factors employing logistic regression. The model confirmed significance of inappropriate guilt (odds ratio: 1.590; 95% confidence interval: 1.087 to 2.328). We checked the relation between suicide attempts and selected life events in the 6 months before the episode. Association between suicide attempts and chronic insomnia during that period (P= .013, OR=20.172; 95% confidence interval: 1.017 to 400.07) appeared (Table 1). 4. Discussion of results Suicidal attempts were found more often in patients with diagnosed BP than in those with UP (40.0% and 27.5%, respectively). Similar results were obtained by other authors [21,27,28], on the basis of examination of both inpatients and the population sample. Tondo et al. examined the risk of suicidal behaviors in patients with bipolar disorders and major depression. The frequency of committed and attempted suicide in BP was higher in comparison with major depression. Respectively: in BP II 0.16; in BP I 0.14; in major depression 0.05 (expressed as the % of patients/year); and for attempts: 1.52 in BP I; 0.82 in BP II and 0.48 in major depression [29]. Many authors observed no significant difference between BPI and BPII in the frequency of attempted suicide [18,30,31]. In the statistics of committed suicide, men are prevalent. In research based on WHO or domestic data, it was observed that, in the group who committed suicide, the number of men is greater in all countries analyzed in comparison with women [32–34]. In the investigated group, women constituted about two thirds of those who made suicide attempts. The dominance of women among those who show suicidal behaviors not resulting in death is consistent with the observations of numerous authors [15,35–37]. On the other hand, Slama et al. [18] and Van Gastel et al. [38] showed no correlation between suicidal attempts and gender.
The most frequent suicidal attempts in the investigated group were found in the age group of 20–24 for BP and in the group of 35–39 for UP. Lecrubier states that the peak of emergence of suicidal thoughts and attempts is in the age range of 14–20 [39]. Many studies have confirmed that suicidal attempts are made by relatively young patients [2,28,35,36,40]. On the other hand, the committed suicide rates are higher among the elderly (above 65 years of age) in comparison with young people (15–34 years of age) [32]. Tsai et al. have examined the risk factors for committed suicide in bipolar affective disorders. The average age of the first suicidal attempt was 31.1. The period associated with increased risk of suicide in patients with bipolar disorders was the age below 35 years [41]. This study confirms the observations made by other authors: young adults are predisposed to suicide attempts. It can be assumed that the typical age of committed suicide (according to Pużyński, N45 years of age) is higher in comparison with attempted suicide. In the investigated group of patients, no correlation was found between suicide attempts and such sociodemographic factors as breakup of marriage, lack of children and living alone. Similar results were obtained by other authors. In the study conducted by Oquendo et al., persons with and without history of suicide attempts did not differ in terms of gender, education, number of children, employment or marriage [2]. Mann et al. examined a less homogeneous group with regard to diagnosis in comparison with this analysis. No differences were found between patients with and without suicide attempt history with regard to age, gender, percentage of married persons, race origin, height or number of children [14]. Van Gastel et al. proved the lack of correlation between the notions and suicide attempts and civil status and employment [38]. In research on male twins, the following predictive factors for suicide attempts were found: suicide of the other twin, no employment, breakup of marriage, low level of education and presence of psychiatric disorders (except for conduct disorders in children) [42]. In the investigated group, a correlation was found between suicide attempts and family history of affective disorders, substance abuse/ dependence and general family history of mental disorders. The significance of family history of affective disorders for the risk of suicide has been found by other authors [5,27]. Oquendo et al., in a study in the year 2000, found no differences between patients with and without history of suicide attempts with regard to family history of such attempts or committed suicides [43]. However, other studies
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Table 1 Relation between suicide attempts and selected clinical factors Clinical factors Family history
Age of onset
Psychopatological symptoms
Coexistence of another psychiatric diagnosis with affective disorder
Life events in 6 months before episode
Number of nonattempters Relation between suicide attempts in investigated group and family history of suicide attempts Relation between suicide attempts in investigated group and family history of completed suicides Relation between suicide attempts in investigated group and family history of attempted and completed suicides Relation between suicide attempts in investigated group and family history of affective disorders Relation between suicide attempts in investigated group and family history of substance abuse/dependence Relation between suicide attempts in investigated group and family history of psychiatric disorders Relation between suicide attempts in investigated group and age of onset of BP Relation between suicide attempts in investigated group and age of onset of UP Relation between suicide attempts in investigated group and insomnia in depressive episode Relation between suicide attempts in investigated group and inappropriate guilt in depressive episode Relation between suicide attempts in investigated group and worthlessness in depressive episode Relation between suicide attempts in investigated group and agitation in depressive episode Relation between suicide attempts in investigated group and psychotic symptoms In affective disorder Relation between suicide attempts in investigated group and irritable mood In hypomanic or manic episode of BP Relation between suicide attempts in investigated group and coexistence of anxiety disorder with affective disorder Relation between suicide attempts in investigated group and coexistence of personality disorder with affective disorder Relation between suicide attempts in investigated group and coexistence of substance abuse/dependence with affective disorder Permanent breakup with an important person (e.g., close friend) Death of a close friend, a close family member, a spouse or a child Chronic somatic illness (causing lower quality of life) Chronic brain diseases (SM, Parkinson’s disease, epilepsy, paresis) Chronic pain Chronic insomnia Start new type of work A change in work hours and conditions, a change in responsibilities at work Trouble with teacher, principal, boss or co-workers Fired from work Business failure Loneliness, inability to get help from others
provided opposite conclusions. Some authors state that the risk factor is the presence of suicidal behaviors in first-degree relatives and not the family history of affective disorders [14,18,44]. Leverich et al. have found a correlation between suicidal behaviors and the family history of suicide attempts or committed suicides, as well as the family history of abuse of medicinal drugs [19]. The group included in this study, however, is more numerous than those described in the studies referred to above. There are also differences in terms of the scope of diagnoses of patients included in the analyses. MacKinnon et al. have shown that family history of suicide is a factor that increases the risk of acting under the influence of suicidal thoughts [15]. Hawton et al. have conducted a meta-analysis of studies done in the years 1872–2003 on suicide risk factors. In the first place, they list previous suicide attempts and hopelessness. The next most significant factor is family history of suicide [17]. Burke et al. have analyzed the impact of exposure to suicidal behaviors on the risk of such behaviors in children of parents suffering from depression. Analysis of the time correlation between exposure and suicidal attempts of the patients has shown that the phenomenon cannot be fully explained by imitation [45].
Number of attempters
P
41
35
P=.725
66
53
P=.887
65
52
P=.836
215
136
P=.009
241
160
P=.001
299
195
P=.013
292
196
P=.155
43
23
P=.013
335
209
P=.314
334
211
P=.016
319
205
P=.087
329
207
P=.863
324
207
P=.336
281
182
P=.474
249
170
P=.327
37
25
323
205
P=.442
4 4 4 4 4 4 4 4
47 47 47 45 47 46 44 44
P=1 P=1 P=1 P=1 P=1 P=.013 P=1 P=1
7 4 4 4
41 59 42 47
P=1 P=1 P=1 P=1
P=1
In the group investigated, no significant difference in the age of onset of BP was found between patients with and without suicide attempts. On the other hand, among patients with UP, persons with history of suicide attempts were characterized by earlier onset of the disease. This result deviates from those provided in literature. Studies based on logistic regression point to a correlation between suicidal behaviors and the earlier onset of bipolar affective disorder [41,46]. In research encompassing patients with BP and major depression, a correlation between suicidal acts and the earlier onset of the disease and greater number of hospitalizations of a given person has also been found [29]. Lopez et al., analyzing the variables using the univariate method, found a significant correlation between early onset of BP I and suicide attempts. However, logistic regression did not confirm the significance of the age of onset of the disease for the risk of suicide in the same group of patients [5]. In the investigated groups, the most frequent suicide attempts are found at the early stage of the disease. This result confirms those obtained by other authors [30,40,47]. The period associated with increased risk of suicide in patients with bipolar affective disorders consists of the first 7 to 12 years from onset of the disease [41]. In the
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study, about one third of all suicidal behaviors occur in the first year after onset of the disease. A total of 54.9% suicide attempts take place within the first 5 years since onset of the disease, and among these, 32.9% attempts are made within the first year of the illness [29]. Khalsa et al. state that 87% of suicidal acts among patients with diagnosed BP I took place during 1 year from the first episode of the illness [48]. In the context of these results, it is necessary to underline the significance of the proper prevention of suicide in the early years of treatment of affective disorders. The analyzed psychopathological symptoms included correlation between suicide attempts and the inappropriate guilt during a depression episode. Akiskal and Benazzi, examining patients with major depression episodes, found a correlation between suicidal thoughts and the following psychopathological symptoms: crowded, racing thoughts, psychomotor agitation, mood lability, low self-esteem, anorexia and the presence of melancholic features or psychotic symptoms [49]. In another study, a factor associated with suicidal notions was dysphoria in manic episode [50]. In the study of Van Gastel et al., the sense of guilt was associated with increased risk of suicide ideations. Moreover, suicide ideations were associated with more depressive mood, hopelessness, lowered self-esteem and loss of interest. No correlation between any of these parameters with suicide attempts was found [38]. In another study in persons with suicide attempts, there was a tendency to a lower intensity of psychotic symptoms, a lower number of declared reasons to live and a greater sense of hopelessness in comparison with patients with no history of such attempts [43]. In the investigated group, no correlation was found between suicidal attempts and coexistence of mood disorders or other psychiatric disorders. Lecrubier underlines the significance of emergence of psychiatric disorders in persons with suicidal behavior. Diagnosis of psychiatric disorders explains in many cases the correlation between sociodemographic variables (gender, civil status, education level) and suicide. The risk of such behaviors as acting out is increased, in particular, by coexistence of anxiety disorders and a tendency to impulsivity. Factors associated with impulsivity, according to the author, include personality disorders belonging to cluster B and use of psychoactive substances [39]. The present analysis includes all anxiety disorders—without dividing them into specific diagnoses—that coexist with affective disorders. No significant correlation has been found between coexisting disorders in this regard and the risk of suicide attempts. Other authors have found a correlation between suicidal attempts and panic disorder [15,51]. Many studies point to a significant correlation between substance abuse/dependence and suicides [5,52–54], which has not been confirmed by this study. As for investigation of coexistence of BP and UP and personality disorders, due to the small number of patients included, the analysis was conducted without taking into account the specific diagnoses of such disorders. No correlation was found between coexistence of personality disorders and affective disorders and suicide attempts. In other studies, in suicide attempters, coexistence of diagnosis of personality disorders of cluster B was observed more often than in nonattempters [19]; in particular, borderline personality disorder is associated with more numerous and serious suicide attempts [14,30,38,44,55]. Among the factors classified as the life events and circumstances, a correlation was found between suicide attempts and chronic insomnia. Events of loss are believed to be a risk factor for suicide. However, in some studies, no correlation was found between suicide ideations and attempts and psychosocial stressors that occurred within the last 6 months [38,43]. Caspi et al. have shown that life events more often result in depression or suicide thoughts and behavior not among the general population but among those who are 5-HTT promoter region s allele carriers [56].
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Chronic insomnia is also of significance in the context of residual symptoms during partial remission periods, observed in patients with recurring affective disorders. Early diagnosis and the proper, effective treatment of bipolar affective disorders are perhaps the most effective steps in reducing the risk of suicide in patients with BP [57]. A correlation was also shown between suicide attempts in BP I and the late inclusion of pharmacotherapy using mood stabilizers [58]. 5. Conclusions In the BP and UP sample, we observed an association between suicidal attempts and the following: family history of psychiatric disorders, affective disorders and psychoactive substance abuse/ dependence; inappropriate guilt in depression; chronic insomnia; and early onset of unipolar disorder. The risk of suicide attempt differs in separate age brackets (it is greater in patients under 45 years old). No difference in family history of suicide and suicide attempts; marital status; offspring; living with family; psychotic symptoms and irritability; and coexistence of personality disorder, anxiety disorder or substance abuse/dependence with affective disorder was observed in groups of patients with and without suicide attempt in lifetime history. References [1] www.who.int. [2] Oquendo MA, et al. Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder. Am J Psychiatry 2004;161(8):1433–41. [3] Yamada T, et al. Psychiatric assessment of suicide attempters in Japan: a pilot study at a critical emergency unit in an urban area. BMC Psychiatry 2007;7:64. [4] Malafosse A. Introduction. Am J Med Genet 2005;133C:1–2. [5] Lopez P, et al. Suicide attempts in bipolar patients. J Clin Psychiatry 2001;62(12): 963–6. [6] www.cdc.gov/ncipc/factsheets/suifacts.htm. [7] Pużyński S, et al. Samobójstwo. Warszawa, 2002. [8] Pużyński S, Zaburzenia afektywne. Depresje — obraz kliniczny, przyczyny, klasyfikacja. Terapia, numer specjalny, 2004. [9] Cheung YB, et al. Suicidal ideation and suicidal attempts in a population-based study of Chinese people: risk attributable to hopelessness, depression, and social factors. J Affect Disord 2006;90(2–3):193–9. [10] Brezo J, Paris J, Turecki G. Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completions: a systematic review. Acta Psychiatr Scand 2006;113(3):180–206. [11] Lewis G, Sloggett A. Suicide, deprivation, and unemployment: record linkage study. BMJ 1998;317(7168):1283–6. [12] Sher L. Alcoholism and suicidal behavior: a clinical overview. Acta Psychiatr Scand 2006;113(1):13–22. [13] Brzozowska A, et al. Samobójstwo. Warszawa, 2002. [14] Mann JJ, et al. Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 1999;156(2):181–9. [15] MacKinnon DF, et al. Rapid mood switching and suicidality in familial bipolar disorder. Bipolar Disord 2005;7(5):441–8. [16] Tsai SJ, Hong CJ, Wang YC. Tryptophan hydroxylase gene polymorphism (A218C) and suicidal behaviors. Neuroreport 1999;10(18):3773–5. [17] Hawton K, et al. Suicide and attempted suicide in bipolar disorder: a systematic review of risk factors. J Clin Psychiatry 2005;66(6):693–704. [18] Slama F, et al. Bipolar patients with suicidal behavior: toward the identification of a clinical subgroup. J Clin Psychiatry 2004;65(8):1035–9. [19] Leverich GS, et al. Factors associated with suicide attempts in 648 patients with bipolar disorder in the Stanley Foundation Bipolar Network. J Clin Psychiatry 2003;64(5):506–15. [20] Dutta R, et al. Suicide and other causes of mortality in bipolar disorder: a longitudinal study. Psychol Med 2007;37(6):839–47. [21] Raja M, Azzoni A. Suicide attempts: differences between unipolar and bipolar patients and among groups with different lethality risk. J Affect Disord 2004; 82(3):437–42. [22] Asberg M, Traskman L, Thoren P. 5-HIAA in the cerebrospinal fluid. A biochemical suicide predictor? Arch Gen Psychiatry 1976;33(10):1193–7. [23] Beautrais AL. Suicides and serious suicide attempts: two populations or one? Psychol Med 2001;31(5):837–45. [24] First M, et al. Structured clinical interview for DSM-IV axis I disorders, clinician version (SCID-CV). Washington, DC: American Psychiatric Press. Inc; 1996. [25] McGuffin P, Farmer A, Harvey I. A polydiagnostic application of operational criteria in studies of psychotic illness. Development and reliability of the OPCRIT system. Arch Gen Psychiatry 1991;48(8):764–70. [26] Rietschel M, Psychiatric–genetic research questionnaire. 2004. [27] Bottlender R, et al. Suicidality in bipolar compared to unipolar depressed inpatients. Eur Arch Psychiatry Clin Neurosci 2000;250(5):257–61.
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[45] Burke AK, et al. Effect of exposure to suicidal behavior on suicide attempt in a high-risk sample of offspring of depressed parents. J Am Acad Child Adolesc Psychiatry 2010;49(2):114–21. [46] Grunebaum MF, et al. Correlates of suicide attempt history in bipolar disorder: a stress–diathesis perspective. Bipolar Disord 2006;8(5 Pt 2):551–7. [47] Malone KM, et al. Major depression and the risk of attempted suicide. J Affect Disord 1995;34(3):173–85. [48] Khalsa HM, et al. Suicidal events and accidents in 216 first-episode bipolar I disorder patients: predictive factors. J Affect Disord 2008;106(1–2):179–84. [49] Akiskal HS, Benazzi F. Psychopathologic correlates of suicidal ideation in major depressive outpatients: is it all due to unrecognized (bipolar) depressive mixed states? Psychopathology 2005;38(5):273–80. [50] Goldberg JF, et al. Correlates of suicidal ideation in dysphoric mania. J Affect Disord 1999;56(1):75–81. [51] Kilbane EJ, et al. A review of panic and suicide in bipolar disorder: does comorbidity increase risk? J Affect Disord 2009;115(1–2):1–10. [52] Hołyst B. Samobójstwo — przypadek czy konieczność. Warszawa: PWN; 1983. [53] Yoon YH, et al. Effect of comorbid alcohol and drug use disorders on premature death among unipolar and bipolar disorder decedents in the United States, 1999 to 2006. Compr Psychiatry 2010. [54] Oquendo MA, et al. Increased risk for suicidal behavior in comorbid bipolar disorder and alcohol use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). J Clin Psychiatry 2010;71(7): 902–9. [55] Soloff PH, et al. Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. Am J Psychiatry 2000;157(4):601–8. [56] Caspi A, et al. Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science 2003;301(5631):386–9. [57] Davis A, et al. Suicide risk and choice of antidepressant. Psychiatr Danub 2010; 22(2):358–9. [58] Nery-Fernandes F, et al. Is there an association between suicide attempt and delay of initiation of mood stabilizers in bipolar I disorder? J Affect Disord 2012;136(3): 1082–7.
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Suicide attempts and clinical risk factors in patients with bipolar and unipolar affective disorders☆ Joanna Pawlak, Ph.D, M.D. a,⁎, Monika Dmitrzak-Węglarz, Ph.D. a, Maria Skibińska, Ph.D. a, Aleksandra Szczepankiewicz, Ph.D. a,c, Anna Leszczyńska-Rodziewicz, Ph.D., M.D. a, Aleksandra Rajewska-Rager, Ph.D., M.D. b, Dorota Zaremba a, Piotr Czerski, Ph.D. a, Joanna Hauser, Ph.D., M.D. a a b c
Laboratory of Psychiatric Genetics, Department of Psychiatry, University of Medical Sciences, ul. Szpitalna 27/33, 60–572 Poznan, Poland Department of Adult Psychiatry, Poznan University of Medical Sciences, Poland Laboratory of Molecular and Cell Biology, PUMS, Poland
a r t i c l e
i n f o
Article history: Received 26 November 2012 Revised 18 March 2013 Accepted 19 March 2013 Keywords: Suicide Affective disorder Risk factors
a b s t r a c t Background: Suicide is an important clinical problem in psychiatric patients. The highest risk of suicide attempts is noted in affective disorders. Objective: The aim of the study was to look for suicide risk factors among sociodemographic and clinical factors, family history and stressful life events in patients with diagnosis of unipolar and bipolar affective disorder (597 patients, 563 controls). Method: In the study, the Structured Clinical Interview for DSM-IV Axis I Disorders and the Operational Criteria Diagnostic Checklist questionnaires, a questionnaire of family history, and a questionnaire of personality disorders and life events were used. Results: In the bipolar and unipolar affective disorders sample, we observed an association between suicidal attempts and the following: family history of psychiatric disorders, affective disorders and psychoactive substance abuse/dependence; inappropriate guilt in depression; chronic insomnia and early onset of unipolar disorder. The risk of suicide attempt differs in separate age brackets (it is greater in patients under 45 years old). No difference in family history of suicide and suicide attempts; marital status; offspring; living with family; psychotic symptoms and irritability; and coexistence of personality disorder, anxiety disorder or substance abuse/dependence with affective disorder was observed in the groups of patients with and without suicide attempt in lifetime history. © 2013 Elsevier Inc. All rights reserved.
1. Introduction The average global rate of mortality due to suicide is 16/100,000. Statistically speaking, on the global scale, a single suicidal death takes place every 40 s, and an attempt takes place every 3 s [1]. About 5% of the overall population makes at least one suicidal attempt in the entire life cycle [2]. Ninety-five percent patients of emergency rooms after a suicidal attempt were diagnosed with psychiatric disorders, most often depression [3]. It is estimated that 20% with bipolar affective disorders commit suicide [4], while 25%–50% make suicide attempts [5]. Lists of factors that are significant in the assessment of risk of suicidal behaviors are published. The following factors have been listed as increasing the risk of suicide: previous suicide attempts; ☆ This research was supported by grant 2011/01/B/NZ5/02795, financed by the Ministry of Science and Higher Education of Poland. ⁎ Corresponding author. Tel.: +48 61 8491311; fax: +48 61 8480392. E-mail address: [email protected] (J. Pawlak). 0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2013.03.014
history of psychiatric disorders, particularly depression; suicide in family history; history of maltreatment during childhood; hopelessness, tendency to impulsivity or aggression; barriers in access to psychiatric treatment; sense of loss (in personal or social relations, at work, financial loss); somatic disease; easy access to lethal substances; lack of willingness to seek help due to stigmatization associated with emotional problems, abuse of drugs or suicidal thoughts; cultural or religious beliefs, such as belief that suicide is a sublime solution to personal dilemmas; local “epidemics” of suicide; and isolation, sense of loneliness or separation from other people [6]. In the case of emergence of a depression, Pużyński refers to such factors as severe depression, sense of guilt, hopelessness, low selfesteem, anhedonia, chronic anxiety, insomnia, disclosed suicidal thoughts or intentions and chronic subdepression. The demographic traits include age, gender: male, widow/widower and divorced. As for the social situation, the author lists the following factors: loneliness, inability to get help from others, bad financial condition and loss of job or sources of income. The following are of significance in the patient's history and among coexisting disorders: suicide attempts in the past,
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suicides of close relatives and persons who were important to the patient, the period of bereavement, poor social adaptation, abuse of alcohol, personality disorders (cyclothymic, antisocial), chronic somatic illnesses, chronic insomnia, chronic pain and organic brain disorders (chronic) [7,8]. The suicide risk factors listed above have been confirmed by other authors [9–13]. Numerous studies confirm the higher risk of suicidal behaviors in patients with early onset of affective disorder [14–17]. The risk factors for suicide attempts include history of head injuries [2,14,18], abuse in childhood [2], mania induced by antidepressive treatment [18], more severe course of mania [19], emergence of mixed states and rapid cycling [17], mood instability and coemergence of panic disorder [15]. Many authors point to correlation between suicidal behaviors and abuse of alcohol, other psychoactive substances and drugs [14,15,17,20]. Twenty-five percent of persons consume alcohol prior to suicidal attempt [21]. Leverich et al. also point to family history of abuse of medicinal drugs as a suicide risk factor [19]. 2. Objective, material and method of research The objective of the study is to identify factors associated with a risk of suicide attempts in persons with diagnosed uni- (UP) and bipolar (BP) affective disorders. The scope of factors analyzed included sociodemographic factors, clinical features: the characteristics and course of affective disorders, family history, and coexisting diseases and stress-inducing situations. The inclusion criteria were diagnosis of UP or BP [meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria] and being 18 years or older. The exclusion criteria were serious somatic diseases or states that currently demand therapeutic intervention and being younger than 18 years. The research has been conducted with 597 patients (367 women, 230 men), aged 18–84 (average=47, SD±14), who met the criteria of DSM-IV for BP (BP I n=391; BP II n= 104) or recurrent depression (UP n= 102) from the region of Wielkopolska. Patients were recruited among patients of both psychiatric wards (on average, 120 admissions with UP or BP diagnosis annually) and mental health centre (330 patients with UP or BP diagnosis annually). Among patients with suicide attempts, there were 151 women (66.81%) and 75 men (33.19%). In the examined group of patients with BP, one or more suicide attempts were made by 40.0% persons (n= 198); among patients with UP, 27.5% (n= 28). History of suicide attempts was recorded in 44.1% of women diagnosed with BP and 34.3% of men with BP. In the group diagnosed with UP, these values amounted to 30.4% and 17.4%, respectively. Patients with history of suicide attempts were divided into two subgroups, depending on the method of this attempt. The first group (n= 71) consisted of persons who engaged in violent or lifethreatening attempts [22,23] (hanging, jumping from heights, throwing oneself under a vehicle, shooting, bleeding, drowning). The second group (n=139) consisted of persons who did not apply these methods. In 16 patients, the method of the suicide attempt made was not determined. The control group consisted of 563 persons with no history of psychiatric disorders (333 women, 230 men), aged 18–83 (average= 42 years, SD±13), from the area of Wielkopolska. The control group was recruited among blood donors, students, hospital staff and nonpsychiatric patients of general practitioners using advertisements placed in general practices. Some of the volunteers in the control group (65 persons) were subjected to psychiatric tests in order to eliminate any Axis I disorders. The following scales and questionnaires were used in the study: the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) questionnaire [24]; the Operational Criteria Diagnostic Checklist questionnaire [25] (information on psychopathological symptoms throughout the entire course of the disease and the possible suicide attempts); the personality disorders questionnaire according to the
International Classification of Diseases, 10th Revision (ICD-10) (prepared for the purpose of this study at the Laboratory of Psychiatric Genetics); and the questionnaire of life events (modified as in Ref. [26]). The basic diagnosis was determined by two psychiatrists using the SCID questionnaire. The lifetime presence/absence of manic, hypomanic and depressive symptoms was assessed to distinguish BP I, BP II and UP patients. Patients who underwent a single affective episode, need immediate somatic medical intervention or committed suicide during clinical observation were excluded. On the basis of the SCID questionnaire, coexistence of anxiety disorders (the number of patients examined was n= 419, coexistence was found in n=42 patients) or abuse/dependence to psychoactive substances (patients examined n=528, coexistence found in n=117) was determined. In the group examined, coexistence of affective disorders and the following anxiety disorders was found: agoraphobia with panic disorder (0.716% patients), agoraphobia without history of panic disorder (0.477%), social phobia (1.670%), specific phobias (1.670%), general anxiety disorder (0.955%), panic disorder (1.670%), mixed anxiety and depressive disorder (0.239%) and obsessive– compulsive disorder (2.864%). Using the personality disorder questionnaire according to ICD-10, coexistence of personality disorders and the basic diagnosis was found. The patients met criteria of the following disorders: paranoid personality (1.613% patients), emotionally unstable personality (1.613%), schizoid (1.613%), histrionic (3.226%), passive–aggressive (1.613%), narcissistic (3.226%) and mixed personality disorders (6.452%). On the basis of the family history questionnaire, family history of psychiatric disorders and suicidal behaviors was determined. Information was also obtained on stress events preceding the current illness episode. The study was approved by local Ethics Committee. All patients gave written informed consent. Data on persons who refused participating in the study were not stored. 3. Results We divided the analyzed group of patients into 5-year age brackets. The most (15.3%) suicide attempts were observed in the 35–39 age bracket. In BP patients, the most abundant suicide attempts were in the 20–24 age bracket (14.8%). In UP patients, the most abundant attempts were in the 35–39 age bracket (23.1%). Differences were discovered between male and female groups. In female samples, the most abundant (17%) suicide attempts appeared in the 35–39 age bracket, whereas, in the male group, the situation appeared in the 40–44 age bracket (17.6% of attempts). Patients with BP and UP diagnoses were divided into subgroups taking into account presence or absence of suicidal attempts in lifetime history. Distributions of age of onset of the disease were compared, and a statistically significant difference (P=.013) was observed in UP. Mean age of onset in UP suicide attempters amounted to 34.3 and 42.0 years in nonattempters. No statistical significance was discovered in BP attempters and nonattempters (P= .155). Fig. 1 shows the difference between age of onset and age of suicide attempt. In the investigated group, 17 of all attempts (6.5%) occurred earlier than the onset of affective disorder. In the whole sample analyzed, most numerous suicide attempts occurred in the first year of the disease. No difference between male and female subgroups was observed. In the subsequent years in the course the of illness, the number of suicide attempts appeared less frequently in the bipolar disorder group. The situation was not so clear in unipolar affective disorder (Fig. 1). Table 1 shows the relations between suicide attempts and selected clinical factors. We found association of suicide attempts and: − family history of affective disorder [P= .009, odds ratio (OR)= 1.797; 95% confidence interval: 1.159 to 2.785)
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429
60 50 40 30 20 10 0 age, when the patient attempted suicide age of onset of the disease
-7
0
5
all patients
10
15
BP
20
27
32
UP
Fig. 1. Suicide attempts and period between onset of the disease and attempt (taking into account the diagnosis).
− family history of substance abuse/dependence (P= .001; OR= 2.217; 95% confidence interval: 1.380 to 3.562) − family history of psychiatric disorders (P=.013; OR=1.594; 95% confidence interval: 1.100 to 2.308) − inappropriate guilt in depression (P= .016, OR=1.590; 95% confidence interval: 1.088 to 2.326). Four depressive symptoms (inappropriate guilt, worthlessness, insomnia and agitation) were analyzed as suicide risk factors employing logistic regression. The model confirmed significance of inappropriate guilt (odds ratio: 1.590; 95% confidence interval: 1.087 to 2.328). We checked the relation between suicide attempts and selected life events in the 6 months before the episode. Association between suicide attempts and chronic insomnia during that period (P= .013, OR=20.172; 95% confidence interval: 1.017 to 400.07) appeared (Table 1). 4. Discussion of results Suicidal attempts were found more often in patients with diagnosed BP than in those with UP (40.0% and 27.5%, respectively). Similar results were obtained by other authors [21,27,28], on the basis of examination of both inpatients and the population sample. Tondo et al. examined the risk of suicidal behaviors in patients with bipolar disorders and major depression. The frequency of committed and attempted suicide in BP was higher in comparison with major depression. Respectively: in BP II 0.16; in BP I 0.14; in major depression 0.05 (expressed as the % of patients/year); and for attempts: 1.52 in BP I; 0.82 in BP II and 0.48 in major depression [29]. Many authors observed no significant difference between BPI and BPII in the frequency of attempted suicide [18,30,31]. In the statistics of committed suicide, men are prevalent. In research based on WHO or domestic data, it was observed that, in the group who committed suicide, the number of men is greater in all countries analyzed in comparison with women [32–34]. In the investigated group, women constituted about two thirds of those who made suicide attempts. The dominance of women among those who show suicidal behaviors not resulting in death is consistent with the observations of numerous authors [15,35–37]. On the other hand, Slama et al. [18] and Van Gastel et al. [38] showed no correlation between suicidal attempts and gender.
The most frequent suicidal attempts in the investigated group were found in the age group of 20–24 for BP and in the group of 35–39 for UP. Lecrubier states that the peak of emergence of suicidal thoughts and attempts is in the age range of 14–20 [39]. Many studies have confirmed that suicidal attempts are made by relatively young patients [2,28,35,36,40]. On the other hand, the committed suicide rates are higher among the elderly (above 65 years of age) in comparison with young people (15–34 years of age) [32]. Tsai et al. have examined the risk factors for committed suicide in bipolar affective disorders. The average age of the first suicidal attempt was 31.1. The period associated with increased risk of suicide in patients with bipolar disorders was the age below 35 years [41]. This study confirms the observations made by other authors: young adults are predisposed to suicide attempts. It can be assumed that the typical age of committed suicide (according to Pużyński, N45 years of age) is higher in comparison with attempted suicide. In the investigated group of patients, no correlation was found between suicide attempts and such sociodemographic factors as breakup of marriage, lack of children and living alone. Similar results were obtained by other authors. In the study conducted by Oquendo et al., persons with and without history of suicide attempts did not differ in terms of gender, education, number of children, employment or marriage [2]. Mann et al. examined a less homogeneous group with regard to diagnosis in comparison with this analysis. No differences were found between patients with and without suicide attempt history with regard to age, gender, percentage of married persons, race origin, height or number of children [14]. Van Gastel et al. proved the lack of correlation between the notions and suicide attempts and civil status and employment [38]. In research on male twins, the following predictive factors for suicide attempts were found: suicide of the other twin, no employment, breakup of marriage, low level of education and presence of psychiatric disorders (except for conduct disorders in children) [42]. In the investigated group, a correlation was found between suicide attempts and family history of affective disorders, substance abuse/ dependence and general family history of mental disorders. The significance of family history of affective disorders for the risk of suicide has been found by other authors [5,27]. Oquendo et al., in a study in the year 2000, found no differences between patients with and without history of suicide attempts with regard to family history of such attempts or committed suicides [43]. However, other studies
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Table 1 Relation between suicide attempts and selected clinical factors Clinical factors Family history
Age of onset
Psychopatological symptoms
Coexistence of another psychiatric diagnosis with affective disorder
Life events in 6 months before episode
Number of nonattempters Relation between suicide attempts in investigated group and family history of suicide attempts Relation between suicide attempts in investigated group and family history of completed suicides Relation between suicide attempts in investigated group and family history of attempted and completed suicides Relation between suicide attempts in investigated group and family history of affective disorders Relation between suicide attempts in investigated group and family history of substance abuse/dependence Relation between suicide attempts in investigated group and family history of psychiatric disorders Relation between suicide attempts in investigated group and age of onset of BP Relation between suicide attempts in investigated group and age of onset of UP Relation between suicide attempts in investigated group and insomnia in depressive episode Relation between suicide attempts in investigated group and inappropriate guilt in depressive episode Relation between suicide attempts in investigated group and worthlessness in depressive episode Relation between suicide attempts in investigated group and agitation in depressive episode Relation between suicide attempts in investigated group and psychotic symptoms In affective disorder Relation between suicide attempts in investigated group and irritable mood In hypomanic or manic episode of BP Relation between suicide attempts in investigated group and coexistence of anxiety disorder with affective disorder Relation between suicide attempts in investigated group and coexistence of personality disorder with affective disorder Relation between suicide attempts in investigated group and coexistence of substance abuse/dependence with affective disorder Permanent breakup with an important person (e.g., close friend) Death of a close friend, a close family member, a spouse or a child Chronic somatic illness (causing lower quality of life) Chronic brain diseases (SM, Parkinson’s disease, epilepsy, paresis) Chronic pain Chronic insomnia Start new type of work A change in work hours and conditions, a change in responsibilities at work Trouble with teacher, principal, boss or co-workers Fired from work Business failure Loneliness, inability to get help from others
provided opposite conclusions. Some authors state that the risk factor is the presence of suicidal behaviors in first-degree relatives and not the family history of affective disorders [14,18,44]. Leverich et al. have found a correlation between suicidal behaviors and the family history of suicide attempts or committed suicides, as well as the family history of abuse of medicinal drugs [19]. The group included in this study, however, is more numerous than those described in the studies referred to above. There are also differences in terms of the scope of diagnoses of patients included in the analyses. MacKinnon et al. have shown that family history of suicide is a factor that increases the risk of acting under the influence of suicidal thoughts [15]. Hawton et al. have conducted a meta-analysis of studies done in the years 1872–2003 on suicide risk factors. In the first place, they list previous suicide attempts and hopelessness. The next most significant factor is family history of suicide [17]. Burke et al. have analyzed the impact of exposure to suicidal behaviors on the risk of such behaviors in children of parents suffering from depression. Analysis of the time correlation between exposure and suicidal attempts of the patients has shown that the phenomenon cannot be fully explained by imitation [45].
Number of attempters
P
41
35
P=.725
66
53
P=.887
65
52
P=.836
215
136
P=.009
241
160
P=.001
299
195
P=.013
292
196
P=.155
43
23
P=.013
335
209
P=.314
334
211
P=.016
319
205
P=.087
329
207
P=.863
324
207
P=.336
281
182
P=.474
249
170
P=.327
37
25
323
205
P=.442
4 4 4 4 4 4 4 4
47 47 47 45 47 46 44 44
P=1 P=1 P=1 P=1 P=1 P=.013 P=1 P=1
7 4 4 4
41 59 42 47
P=1 P=1 P=1 P=1
P=1
In the group investigated, no significant difference in the age of onset of BP was found between patients with and without suicide attempts. On the other hand, among patients with UP, persons with history of suicide attempts were characterized by earlier onset of the disease. This result deviates from those provided in literature. Studies based on logistic regression point to a correlation between suicidal behaviors and the earlier onset of bipolar affective disorder [41,46]. In research encompassing patients with BP and major depression, a correlation between suicidal acts and the earlier onset of the disease and greater number of hospitalizations of a given person has also been found [29]. Lopez et al., analyzing the variables using the univariate method, found a significant correlation between early onset of BP I and suicide attempts. However, logistic regression did not confirm the significance of the age of onset of the disease for the risk of suicide in the same group of patients [5]. In the investigated groups, the most frequent suicide attempts are found at the early stage of the disease. This result confirms those obtained by other authors [30,40,47]. The period associated with increased risk of suicide in patients with bipolar affective disorders consists of the first 7 to 12 years from onset of the disease [41]. In the
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study, about one third of all suicidal behaviors occur in the first year after onset of the disease. A total of 54.9% suicide attempts take place within the first 5 years since onset of the disease, and among these, 32.9% attempts are made within the first year of the illness [29]. Khalsa et al. state that 87% of suicidal acts among patients with diagnosed BP I took place during 1 year from the first episode of the illness [48]. In the context of these results, it is necessary to underline the significance of the proper prevention of suicide in the early years of treatment of affective disorders. The analyzed psychopathological symptoms included correlation between suicide attempts and the inappropriate guilt during a depression episode. Akiskal and Benazzi, examining patients with major depression episodes, found a correlation between suicidal thoughts and the following psychopathological symptoms: crowded, racing thoughts, psychomotor agitation, mood lability, low self-esteem, anorexia and the presence of melancholic features or psychotic symptoms [49]. In another study, a factor associated with suicidal notions was dysphoria in manic episode [50]. In the study of Van Gastel et al., the sense of guilt was associated with increased risk of suicide ideations. Moreover, suicide ideations were associated with more depressive mood, hopelessness, lowered self-esteem and loss of interest. No correlation between any of these parameters with suicide attempts was found [38]. In another study in persons with suicide attempts, there was a tendency to a lower intensity of psychotic symptoms, a lower number of declared reasons to live and a greater sense of hopelessness in comparison with patients with no history of such attempts [43]. In the investigated group, no correlation was found between suicidal attempts and coexistence of mood disorders or other psychiatric disorders. Lecrubier underlines the significance of emergence of psychiatric disorders in persons with suicidal behavior. Diagnosis of psychiatric disorders explains in many cases the correlation between sociodemographic variables (gender, civil status, education level) and suicide. The risk of such behaviors as acting out is increased, in particular, by coexistence of anxiety disorders and a tendency to impulsivity. Factors associated with impulsivity, according to the author, include personality disorders belonging to cluster B and use of psychoactive substances [39]. The present analysis includes all anxiety disorders—without dividing them into specific diagnoses—that coexist with affective disorders. No significant correlation has been found between coexisting disorders in this regard and the risk of suicide attempts. Other authors have found a correlation between suicidal attempts and panic disorder [15,51]. Many studies point to a significant correlation between substance abuse/dependence and suicides [5,52–54], which has not been confirmed by this study. As for investigation of coexistence of BP and UP and personality disorders, due to the small number of patients included, the analysis was conducted without taking into account the specific diagnoses of such disorders. No correlation was found between coexistence of personality disorders and affective disorders and suicide attempts. In other studies, in suicide attempters, coexistence of diagnosis of personality disorders of cluster B was observed more often than in nonattempters [19]; in particular, borderline personality disorder is associated with more numerous and serious suicide attempts [14,30,38,44,55]. Among the factors classified as the life events and circumstances, a correlation was found between suicide attempts and chronic insomnia. Events of loss are believed to be a risk factor for suicide. However, in some studies, no correlation was found between suicide ideations and attempts and psychosocial stressors that occurred within the last 6 months [38,43]. Caspi et al. have shown that life events more often result in depression or suicide thoughts and behavior not among the general population but among those who are 5-HTT promoter region s allele carriers [56].
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Chronic insomnia is also of significance in the context of residual symptoms during partial remission periods, observed in patients with recurring affective disorders. Early diagnosis and the proper, effective treatment of bipolar affective disorders are perhaps the most effective steps in reducing the risk of suicide in patients with BP [57]. A correlation was also shown between suicide attempts in BP I and the late inclusion of pharmacotherapy using mood stabilizers [58]. 5. Conclusions In the BP and UP sample, we observed an association between suicidal attempts and the following: family history of psychiatric disorders, affective disorders and psychoactive substance abuse/ dependence; inappropriate guilt in depression; chronic insomnia; and early onset of unipolar disorder. The risk of suicide attempt differs in separate age brackets (it is greater in patients under 45 years old). No difference in family history of suicide and suicide attempts; marital status; offspring; living with family; psychotic symptoms and irritability; and coexistence of personality disorder, anxiety disorder or substance abuse/dependence with affective disorder was observed in groups of patients with and without suicide attempt in lifetime history. References [1] www.who.int. [2] Oquendo MA, et al. Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder. Am J Psychiatry 2004;161(8):1433–41. [3] Yamada T, et al. Psychiatric assessment of suicide attempters in Japan: a pilot study at a critical emergency unit in an urban area. BMC Psychiatry 2007;7:64. [4] Malafosse A. Introduction. Am J Med Genet 2005;133C:1–2. [5] Lopez P, et al. Suicide attempts in bipolar patients. J Clin Psychiatry 2001;62(12): 963–6. [6] www.cdc.gov/ncipc/factsheets/suifacts.htm. [7] Pużyński S, et al. Samobójstwo. Warszawa, 2002. [8] Pużyński S, Zaburzenia afektywne. Depresje — obraz kliniczny, przyczyny, klasyfikacja. Terapia, numer specjalny, 2004. [9] Cheung YB, et al. Suicidal ideation and suicidal attempts in a population-based study of Chinese people: risk attributable to hopelessness, depression, and social factors. J Affect Disord 2006;90(2–3):193–9. [10] Brezo J, Paris J, Turecki G. Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completions: a systematic review. Acta Psychiatr Scand 2006;113(3):180–206. [11] Lewis G, Sloggett A. Suicide, deprivation, and unemployment: record linkage study. BMJ 1998;317(7168):1283–6. [12] Sher L. Alcoholism and suicidal behavior: a clinical overview. Acta Psychiatr Scand 2006;113(1):13–22. [13] Brzozowska A, et al. Samobójstwo. Warszawa, 2002. [14] Mann JJ, et al. Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 1999;156(2):181–9. [15] MacKinnon DF, et al. Rapid mood switching and suicidality in familial bipolar disorder. Bipolar Disord 2005;7(5):441–8. [16] Tsai SJ, Hong CJ, Wang YC. Tryptophan hydroxylase gene polymorphism (A218C) and suicidal behaviors. Neuroreport 1999;10(18):3773–5. [17] Hawton K, et al. Suicide and attempted suicide in bipolar disorder: a systematic review of risk factors. J Clin Psychiatry 2005;66(6):693–704. [18] Slama F, et al. Bipolar patients with suicidal behavior: toward the identification of a clinical subgroup. J Clin Psychiatry 2004;65(8):1035–9. [19] Leverich GS, et al. Factors associated with suicide attempts in 648 patients with bipolar disorder in the Stanley Foundation Bipolar Network. J Clin Psychiatry 2003;64(5):506–15. [20] Dutta R, et al. Suicide and other causes of mortality in bipolar disorder: a longitudinal study. Psychol Med 2007;37(6):839–47. [21] Raja M, Azzoni A. Suicide attempts: differences between unipolar and bipolar patients and among groups with different lethality risk. J Affect Disord 2004; 82(3):437–42. [22] Asberg M, Traskman L, Thoren P. 5-HIAA in the cerebrospinal fluid. A biochemical suicide predictor? Arch Gen Psychiatry 1976;33(10):1193–7. [23] Beautrais AL. Suicides and serious suicide attempts: two populations or one? Psychol Med 2001;31(5):837–45. [24] First M, et al. Structured clinical interview for DSM-IV axis I disorders, clinician version (SCID-CV). Washington, DC: American Psychiatric Press. Inc; 1996. [25] McGuffin P, Farmer A, Harvey I. A polydiagnostic application of operational criteria in studies of psychotic illness. Development and reliability of the OPCRIT system. Arch Gen Psychiatry 1991;48(8):764–70. [26] Rietschel M, Psychiatric–genetic research questionnaire. 2004. [27] Bottlender R, et al. Suicidality in bipolar compared to unipolar depressed inpatients. Eur Arch Psychiatry Clin Neurosci 2000;250(5):257–61.
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