- Email: [email protected]
Suicide in subtypes of primary major depression
Journal
of Affectiue
Dtsorders.
18 (1990) 221-225
221
Elsevier
JAD 00679
Short Communication
Suicide in subtypes of primary major depression ZoltSln Rihmer t Natmnal
for Neroouc
Institute
‘, Judit Barsi ‘, Mihily and Mental
Diseases, Budapest
Semmelweis
Medical
Untuersrty, (Received
(Revision
Aratb ’ and Erzskbet Demeter
27, P/: 1, 1281 Hungary Budapest.
IX,
iill&
und ’ Department
2
of Forensic Medicrne,
u 93. Hungary
26 July 1988)
received 4 July 1989)
(Accepted
12 July 1989)
Summary
Among 100 consecutive suicide victims with primary major depression at the time of their suicide, 46% were found to have had bipolar II depression, 1% bipolar I disorder and 53% non-bipolar major depression. Since the lifetime prevalence rates of bipolar II and bipolar I depressions are relatively low compared to primary major non-bipolar depression, the present findings suggest that bipolar II disorder gives a particularly high risk of suicide among the different subtypes of primary major affective illness. Fifty-nine percent of the patients had medical contact during the depressive episode, but the depression was frequently undiagnosed, untreated or undertreated. The implications of these findings for suicide prevention are discussed briefly.
Kry
Suicide;
words:
Primary
major depression;
Depression
Introduction
It has been demonstrated that primary affective disorder is associated with a high risk of suicide. In comparisons with unipolar major depression, bipolar depressions have been reported to show increased (Dunner et al., 1976; Morrison, 1982) decreased (McGlashan, 1984; Martin et al., 1985) or similar (Pert% and D’Elia, 1966; Tsuang, 1978; Weeke and Vaeth, 1986) suicide rates.
Address Institute
for correspondence:
for Nervous
Dr. Zoltin
and Mental Diseases,
Rihmer, Budapest
National 27, Pf. 1,
1281 Hungary. 0165-0327/90/$03.50
0 1990 Elsevier Science
Publishers
subtypes;
Medical
contact;
Suicide prevention
Because specific subtypes of primary major affective disorder - unipolar, bipolar II and bipolar I - differ from both a clinical and a research perspective (Dunner et al., 1976; Rihmer, 1980; Rihmer et al., 1982; Endicott et al., 1985) it is logical to assume that each subgroup might have its own suicide risk. Where the subtype of bipolar II depression was not considered separately, this subgroup would probably be included with unipolar depression; thus a very interesting issue might be concealed. Unfortunately, only two studies have examined suicidality in unipolar, bipolar II and bipolar I depression separately (Dunner et al., 1976; Endicott et al., 1985). In both papers, the lifetime
B.V. (Biomedical
Division)
222
history of suicide attempts was highest in bipolar II and lowest in unipolar patients, while the bipolar I subgroup took an intermediate position. Using a different research strategy ~ retrospective psychiatric assessment of suicide completers ~ we also have found that the bipolar ILbipolar II-unipolar distinction may have great importance in suicide mortality. In this paper we report the diagnostic subclassification and some demographic and clinical features of 100 consecutive suicide victims with primary major depression. Method
Two hundred and seventeen consecutive cases of completed suicide in Budapest during the year 1985 were investigated using the life-time version of the Schedule for Affective Disorders and Schizophrenia (SADS; Spitzer and Endicott. 1978). Based on semistructured interviews with the closest family members or friends, the suicide victims were retrospectively classified according to Research Diagnostic Criteria (RDC; Spitzer et al., 1978) if applicable. Data on method of suicide, medical contact, treatment of the recent depression and communication of suicidal intent to family members were also obtained. In three cases the relatives refused to collaborate, and in a further 14 cases the information obtained was not sufficient to make a reliable diagnostic assessment. A detailed clinical analysis of the original sample (n = 200) has been reported previously (Arato et al., 1988). In this report we focus on those persons who had primary major depression at the time of suicide.
TABLE
1
DEMOGRAPHIC FEATURES AND DIAGNOSTIC SUBCLASSIFICATION OF THE 100 PERSONS WITH PRIMARY MAJOR DEPRESSION AT THE TIME OF THEIR SUICIDE Diagnostic subgroup
Number
Mean age (years)
Female Male
:
%of sample
(*SD) Non-bipolar (recurrent unipolar and first episode combined)
53
Bipolar
II
46
Bipolar
I
1
55.7 (16.1) 42.4 (13.6) 50.0
25:28
53
20:26
46
0:I
1
each diagnostic subgroup. Table 3 displays the method of suicide, medical contact during the last depressive episode, drug treatment of the depression. and communication of suicidal intent to family members in the three diagnostic subgroups. Discussion
The main finding of our study is that of the 100 persons with primary major depression at the time of their suicide, nearly half (46%) had bipolar II depression (Table 1). As the lifetime prevalence rates of definite and probable RDC diagnoses of bipolar I. bipolar II and primary major unipolar depressions have been reported to be 0.6%, 0.6%. and 17.2% respectively (Weissman and Myers, 1978), the relatively high rate of bipolar II depression (46%) compared to the other two subtypes in
Results
Of the 200 consecutive suicides (97 females and 103 males) 100 (50%: 45 females and 55 males) had RDC definite or probable primary (unipolar and bipolar) major depression at the time of their suicide. Of the 100 suicides with primary major depression, one person (1%) had bipolar I depression, 46 (46%) had bipolar II depression and 53 (53%) had non-bipolar (recurrent unipolar and first episode combined) depression (Table 1). Table 2 shows the distribution of violent/nonviolent methods of suicide according to sex in
TABLE
2
DISTRIBUTION OF VIOLENT/NON-VIOLENT METHODS OF SUICIDE ACCORDING TO SEX IN EACH DIAGNOSTIC SUBGROUP Non-bipolar
Bipolar
Females (n=45) Males (n = 55)
8/18
5/14
20,‘7
Total
28/25
II
Bipolar
I
Total
O/O
13,‘32
17/10
O/l
37/18
22/24
O/l
so/so
223 TABLE
3
METHOD OF SUICIDE. MEDICAL CONTACT, DRUG TREATMENT OF RECENT DEPRESSION AND TION OF SUICIDAL INTENT TO FAMILY MEMBERS IN THE THREE DIAGNOSTIC SUBGROUPS
Number
of persons
COMMUNICA-
Non-bipolar
Bipolar
53
46
1
100
19 8 1
8 12 2
0 0 0
27 20 3
25
24
1
50
14 19
2 23
0 1
16 43
6 13
11 20
1 0
18 33
10
7
1
18
II
Bipolar
I
Total
Method of suicide Violent Hanging Jumping Other a Non-violent Drug overdose
’
Medical contact Primary care only Secondary or tertiary Treatment Treatment
care ’
with antidepressants with anxiolytics and/or
Communication
of suicidal
sleeping pills only
intent to family members
a Train. shooting, arterial section. h Including three cases of carbon monoxide poisoning. ’ Secondary care: outpatient psychiatric department; tertiary
care: inpatient
psychiatric
department.
our sample shows a marked overrepresentation and suggests a very high risk of suicide in this subgroup. Unfortunately, no data are available on the prevalence of unipolar, bipolar II and bipolar
sions, it suggests that in Budapest - at least in hospitalized patients - bipolar II depression may be more prevalent then bipolar I disorder, but less frequent than unipolar depression. On the other
I depression in the population of Hungary. For this reason, we have cited the data of Weissman and Myers (1978) from New Haven (CT, U.S.A.), which are, to our knowledge, the only report on the prevalence of unipolar, bipolar II and bipolar I depression in the general population. We can only speculate about the rates of these three subtypes of primary major depression in Hungary, based on a re-analysis of our previous data on hospitalized patients with primary major depression. In our previous work we carried out dexamethasone suppression tests (DST) in 74 consecutively admitted female inpatients with primary major depression (Rihmer and Arato, 1984). Only patients who met the exclusion criteria for the DST were not included, i.e., no diagnostic preselection was made in this study. Of these 74 inpatients, 47% had unipolar depression, 38% had bipolar II depression and 15% had bipolar I disorder (Rihmer and Arato, 1984). Although this sample was not large enough to draw firm conclu-
hand, Endicott et al. (1985) reported from the U.S.A. that among 382 in- and outpatients with primary major depression 53% had unipolar, 15% had bipolar II and 32% had bipolar I depression. This indicates that, at least in a treated sample of primary depressives, in the United States the rate of unipolar depression may be the same, but the ratio of bipolar II to bipolar I disorder may be the opposite of that found in our country. If from these figures we conclude that bipolar II depression is about twice as prevalent in Hungary as in the United States, we may estimate that the frequency of bipolar II disorder is about 1.2% in the general population of Hungary. However, this postulated relatively higher prevalence of bipolar II depression in Hungary does not fully explain our results, and the extreme overrepresentation of bipolar II depression among our suicides might not be simply a reflection of the higher incidence of bipolar II disorder. Our findings are in agreement with previous
224
reports (Dunner et al.. 1976; Endicott et al., 1985) that suicidal behavior is more frequent in bipolar II than in bipolar I and unipolar depression. One possible explanation for this higher incidence of suicidality in the bipolar II subgroup is that these patients have been reported to have a higher comorbidity of alcoholism, personality disorders, migraine headache and (in females) premenstrual dysphoria than bipolar I and unipolar patients (Endicott et al.. 1985). Half of our depressed suicides (50/100 = 50%) chose violent methods, and males did so more frequently (37/55 = 67%) than females (13/45 = 29%) (Table 2). Sixteen patients (16%) had medical contact only at primary care level, while 43 persons (43%) were seen by psychiatrists either at outpatient or at inpatient psychiatric departments during their last depressive episode. Antidepressant pharmacotherapy (imipramine, maprotiline, amitriptyline, dibenzepin) was prescribed for only 18 persons (18%), including only two persons who were on lithium prophylaxis at the time of their suicide. Precise estimation of the dose of prescribed antidepressants was not possible in all cases, but in six patients the daily dose was lower than 125 mg. Thirty-three patients (33%) were treated with anxiolytics and/or sleeping pills only (Table 3). The fact that antidepressants were prescribed for only 18 patients (18%) indicates that in the majority of our depressed suicides the depression was undiagnosed. The facts that half (100/200 = 50%) of our consecutive suicides had primary major depression and that the depression was frequently undiagnosed, untreated or undertreated are similar to the findings of Barraclough et al. (1974) who collected their sample in the U.K. between 1966 and 1967. This extremely high degree of underdiagnosis of depression in Hungary was not completely unexpected, as we have previously shown that the officially registered number of patients with various forms of depression was about half that of the registered number of schizophrenic patients (Rihmer, 1982). In reality, the rate of primary major affective disorder to schizophrenia is clearly the opposite (Glass and Freedman, 1985). Our results support the opinion of Khuri and Akiskal (1983) that undiagnosed and inadequately
treated affective disorders are the leading cause of completed suicide. and that energetic treatment (acute and prophylactic management) of affective disorders might prove to be an effective method of preventing suicide. The number of persons living in Hungary is 10.5 million. About 5000 people kill themselves each year. At least 2500 of these might have primary major depression. The correct diagnosis and treatment of this population may substantially reduce the suicide mortality in Hungary, which is the highest in the world.
References Arat&
M..
Demeter.
Retrospective Budapest.
Acta
Barraclough,
D.L.,
table
E. (198X)
200
suicides
in
77, 454-456.
J.. Nelson,
of suicide:
Gershon,
factors
atry
B. and
clinical
Sainsbury.
aspects.
P. (1974)
Br. J. Psych]-
E.S. and
in the severity
Goodwin.
of affective
F.K.
(1976)
illness.
Heri-
Biol.
Psychi-
11. 31-42.
Endicott.
J., Nee.
and
Coryell.
arate
J. Affect.
R.M.
Khuri.
J.. Andreasen. W. (1985)
R. and of
Psychiatr.
Clin.
Martin,
R.L.,
(1985) tients.
orders. tion. Perris.
J. Clin. C.
and
Z.
Lodge
and
Clayton,
psychiatric
P.
outpa-
follow-up and
study
III.
affectwe
dia-
41. 586-601. m psychiatric
G.
(1966)
(Ed.).
Mortality,
The Study (Recurrent
42, Suppl.
Season
in bipolar
the
disorders.
practice
popula-
suicide
and
43, 34X-352.
Stand.
(1980)
S.B.
schizophrenia
Suicide
Unipolar
Psychiatr.
admission
of
D’Eha,
prevention:
42. 58-66.
Psychiatry
In: C. Perris
pressive)
Contempo
psychiatric
of 500
Chestnut
Psychiatry
and
cycles. Acta
Gen. (1982)
Suicide
Guze,
Psychiatry
(1984)
Arch.
M. sep-
6, 193-207. C.R.,
outcome
J.R.
(1983)
in a follow-up
Gen.
Long-term
Psychiatry.
contributory
N. Am.
T.H.
Morrison,
H.S.
Cloninger.
Arch.
or keep
D.X. (1985)
treating
Mortality
McGlashan.
P.. Keller.
Ass. 254. 22X0-2283.
Akiskal,
necessity
Clayton,
11. Combine
X, 17-28.
Freedman, Med.
N..
Bipolar
Disord.
and
‘85. J. Am.
Rihmer.
Stand.
Somogyi. of
125, 355-373.
Dunner.
Glass.
cases
Z. and
assessment
Psychiatr.
B.. Bunch,
A hundred atQ
E., Rihmer.
psychiatric
of
birth
depressed
of Bipolar
life
(Manic-De-
Depressive)
Psychoses.
194. 172-183. and female
season
of
patients.
hospital Psychiatr.
Res. 3, 247-251. Rihmer.
Z. (1982)
(Nosological
A depress%
and other
nozolhgiai
dilemmas
123. 946-949 (in Hungarian). Rihmer. R. and Arath, M. (1984) research pharmacol. Rihmer.
tool
in patients
Bull.
Z.. Arath,
The red blood
with
Cs egyeb
of depression).
The
dilemmLi Orv.
DST as a clinical
affective
disorders.
Hetil.
aid and Psycho-
20. 1744177. M.. Szentistvlnyi,
cell/plasma
lithium
1. and ratio:
BBnki, marker
M.C.
(1982)
of biologi-
225 cal heterogeneity within bipolar affective illness? Psychiatr. Res. 6. 197-201. Spitzer. R.L. and Endicott. J. (1978) Schedule for Affective Disorders and Schizophrenia (SADS), 3rd edn. New York State Psychiatric Institute, New York. NY. Spitzer. R.L.. Endicott, J. and Robins. E. (1978) Research Diagnostic Criteria: rationale and reliability. Arch. Gen. Psychiatry 35, 773-782. Twang. M.T. (1978) Suicide in schizophrenics, manics. depres-
sives and surgical controls. Arch. Gen. Psychiatry 35. 153-155. Weeke, A. and Vaeth. M. (1986) Excess mortality of bipolar and unipolar (manic-depressive) patients. J. Affect. Disord. 11. 227-234. Weissman. M.M. and Myers. J.K. (1978) Affective disorders in a US urban community. Arch. Gem Psychiatry 35. 1304-1311.
of Affectiue
Dtsorders.
18 (1990) 221-225
221
Elsevier
JAD 00679
Short Communication
Suicide in subtypes of primary major depression ZoltSln Rihmer t Natmnal
for Neroouc
Institute
‘, Judit Barsi ‘, Mihily and Mental
Diseases, Budapest
Semmelweis
Medical
Untuersrty, (Received
(Revision
Aratb ’ and Erzskbet Demeter
27, P/: 1, 1281 Hungary Budapest.
IX,
iill&
und ’ Department
2
of Forensic Medicrne,
u 93. Hungary
26 July 1988)
received 4 July 1989)
(Accepted
12 July 1989)
Summary
Among 100 consecutive suicide victims with primary major depression at the time of their suicide, 46% were found to have had bipolar II depression, 1% bipolar I disorder and 53% non-bipolar major depression. Since the lifetime prevalence rates of bipolar II and bipolar I depressions are relatively low compared to primary major non-bipolar depression, the present findings suggest that bipolar II disorder gives a particularly high risk of suicide among the different subtypes of primary major affective illness. Fifty-nine percent of the patients had medical contact during the depressive episode, but the depression was frequently undiagnosed, untreated or undertreated. The implications of these findings for suicide prevention are discussed briefly.
Kry
Suicide;
words:
Primary
major depression;
Depression
Introduction
It has been demonstrated that primary affective disorder is associated with a high risk of suicide. In comparisons with unipolar major depression, bipolar depressions have been reported to show increased (Dunner et al., 1976; Morrison, 1982) decreased (McGlashan, 1984; Martin et al., 1985) or similar (Pert% and D’Elia, 1966; Tsuang, 1978; Weeke and Vaeth, 1986) suicide rates.
Address Institute
for correspondence:
for Nervous
Dr. Zoltin
and Mental Diseases,
Rihmer, Budapest
National 27, Pf. 1,
1281 Hungary. 0165-0327/90/$03.50
0 1990 Elsevier Science
Publishers
subtypes;
Medical
contact;
Suicide prevention
Because specific subtypes of primary major affective disorder - unipolar, bipolar II and bipolar I - differ from both a clinical and a research perspective (Dunner et al., 1976; Rihmer, 1980; Rihmer et al., 1982; Endicott et al., 1985) it is logical to assume that each subgroup might have its own suicide risk. Where the subtype of bipolar II depression was not considered separately, this subgroup would probably be included with unipolar depression; thus a very interesting issue might be concealed. Unfortunately, only two studies have examined suicidality in unipolar, bipolar II and bipolar I depression separately (Dunner et al., 1976; Endicott et al., 1985). In both papers, the lifetime
B.V. (Biomedical
Division)
222
history of suicide attempts was highest in bipolar II and lowest in unipolar patients, while the bipolar I subgroup took an intermediate position. Using a different research strategy ~ retrospective psychiatric assessment of suicide completers ~ we also have found that the bipolar ILbipolar II-unipolar distinction may have great importance in suicide mortality. In this paper we report the diagnostic subclassification and some demographic and clinical features of 100 consecutive suicide victims with primary major depression. Method
Two hundred and seventeen consecutive cases of completed suicide in Budapest during the year 1985 were investigated using the life-time version of the Schedule for Affective Disorders and Schizophrenia (SADS; Spitzer and Endicott. 1978). Based on semistructured interviews with the closest family members or friends, the suicide victims were retrospectively classified according to Research Diagnostic Criteria (RDC; Spitzer et al., 1978) if applicable. Data on method of suicide, medical contact, treatment of the recent depression and communication of suicidal intent to family members were also obtained. In three cases the relatives refused to collaborate, and in a further 14 cases the information obtained was not sufficient to make a reliable diagnostic assessment. A detailed clinical analysis of the original sample (n = 200) has been reported previously (Arato et al., 1988). In this report we focus on those persons who had primary major depression at the time of suicide.
TABLE
1
DEMOGRAPHIC FEATURES AND DIAGNOSTIC SUBCLASSIFICATION OF THE 100 PERSONS WITH PRIMARY MAJOR DEPRESSION AT THE TIME OF THEIR SUICIDE Diagnostic subgroup
Number
Mean age (years)
Female Male
:
%of sample
(*SD) Non-bipolar (recurrent unipolar and first episode combined)
53
Bipolar
II
46
Bipolar
I
1
55.7 (16.1) 42.4 (13.6) 50.0
25:28
53
20:26
46
0:I
1
each diagnostic subgroup. Table 3 displays the method of suicide, medical contact during the last depressive episode, drug treatment of the depression. and communication of suicidal intent to family members in the three diagnostic subgroups. Discussion
The main finding of our study is that of the 100 persons with primary major depression at the time of their suicide, nearly half (46%) had bipolar II depression (Table 1). As the lifetime prevalence rates of definite and probable RDC diagnoses of bipolar I. bipolar II and primary major unipolar depressions have been reported to be 0.6%, 0.6%. and 17.2% respectively (Weissman and Myers, 1978), the relatively high rate of bipolar II depression (46%) compared to the other two subtypes in
Results
Of the 200 consecutive suicides (97 females and 103 males) 100 (50%: 45 females and 55 males) had RDC definite or probable primary (unipolar and bipolar) major depression at the time of their suicide. Of the 100 suicides with primary major depression, one person (1%) had bipolar I depression, 46 (46%) had bipolar II depression and 53 (53%) had non-bipolar (recurrent unipolar and first episode combined) depression (Table 1). Table 2 shows the distribution of violent/nonviolent methods of suicide according to sex in
TABLE
2
DISTRIBUTION OF VIOLENT/NON-VIOLENT METHODS OF SUICIDE ACCORDING TO SEX IN EACH DIAGNOSTIC SUBGROUP Non-bipolar
Bipolar
Females (n=45) Males (n = 55)
8/18
5/14
20,‘7
Total
28/25
II
Bipolar
I
Total
O/O
13,‘32
17/10
O/l
37/18
22/24
O/l
so/so
223 TABLE
3
METHOD OF SUICIDE. MEDICAL CONTACT, DRUG TREATMENT OF RECENT DEPRESSION AND TION OF SUICIDAL INTENT TO FAMILY MEMBERS IN THE THREE DIAGNOSTIC SUBGROUPS
Number
of persons
COMMUNICA-
Non-bipolar
Bipolar
53
46
1
100
19 8 1
8 12 2
0 0 0
27 20 3
25
24
1
50
14 19
2 23
0 1
16 43
6 13
11 20
1 0
18 33
10
7
1
18
II
Bipolar
I
Total
Method of suicide Violent Hanging Jumping Other a Non-violent Drug overdose
’
Medical contact Primary care only Secondary or tertiary Treatment Treatment
care ’
with antidepressants with anxiolytics and/or
Communication
of suicidal
sleeping pills only
intent to family members
a Train. shooting, arterial section. h Including three cases of carbon monoxide poisoning. ’ Secondary care: outpatient psychiatric department; tertiary
care: inpatient
psychiatric
department.
our sample shows a marked overrepresentation and suggests a very high risk of suicide in this subgroup. Unfortunately, no data are available on the prevalence of unipolar, bipolar II and bipolar
sions, it suggests that in Budapest - at least in hospitalized patients - bipolar II depression may be more prevalent then bipolar I disorder, but less frequent than unipolar depression. On the other
I depression in the population of Hungary. For this reason, we have cited the data of Weissman and Myers (1978) from New Haven (CT, U.S.A.), which are, to our knowledge, the only report on the prevalence of unipolar, bipolar II and bipolar I depression in the general population. We can only speculate about the rates of these three subtypes of primary major depression in Hungary, based on a re-analysis of our previous data on hospitalized patients with primary major depression. In our previous work we carried out dexamethasone suppression tests (DST) in 74 consecutively admitted female inpatients with primary major depression (Rihmer and Arato, 1984). Only patients who met the exclusion criteria for the DST were not included, i.e., no diagnostic preselection was made in this study. Of these 74 inpatients, 47% had unipolar depression, 38% had bipolar II depression and 15% had bipolar I disorder (Rihmer and Arato, 1984). Although this sample was not large enough to draw firm conclu-
hand, Endicott et al. (1985) reported from the U.S.A. that among 382 in- and outpatients with primary major depression 53% had unipolar, 15% had bipolar II and 32% had bipolar I depression. This indicates that, at least in a treated sample of primary depressives, in the United States the rate of unipolar depression may be the same, but the ratio of bipolar II to bipolar I disorder may be the opposite of that found in our country. If from these figures we conclude that bipolar II depression is about twice as prevalent in Hungary as in the United States, we may estimate that the frequency of bipolar II disorder is about 1.2% in the general population of Hungary. However, this postulated relatively higher prevalence of bipolar II depression in Hungary does not fully explain our results, and the extreme overrepresentation of bipolar II depression among our suicides might not be simply a reflection of the higher incidence of bipolar II disorder. Our findings are in agreement with previous
224
reports (Dunner et al.. 1976; Endicott et al., 1985) that suicidal behavior is more frequent in bipolar II than in bipolar I and unipolar depression. One possible explanation for this higher incidence of suicidality in the bipolar II subgroup is that these patients have been reported to have a higher comorbidity of alcoholism, personality disorders, migraine headache and (in females) premenstrual dysphoria than bipolar I and unipolar patients (Endicott et al.. 1985). Half of our depressed suicides (50/100 = 50%) chose violent methods, and males did so more frequently (37/55 = 67%) than females (13/45 = 29%) (Table 2). Sixteen patients (16%) had medical contact only at primary care level, while 43 persons (43%) were seen by psychiatrists either at outpatient or at inpatient psychiatric departments during their last depressive episode. Antidepressant pharmacotherapy (imipramine, maprotiline, amitriptyline, dibenzepin) was prescribed for only 18 persons (18%), including only two persons who were on lithium prophylaxis at the time of their suicide. Precise estimation of the dose of prescribed antidepressants was not possible in all cases, but in six patients the daily dose was lower than 125 mg. Thirty-three patients (33%) were treated with anxiolytics and/or sleeping pills only (Table 3). The fact that antidepressants were prescribed for only 18 patients (18%) indicates that in the majority of our depressed suicides the depression was undiagnosed. The facts that half (100/200 = 50%) of our consecutive suicides had primary major depression and that the depression was frequently undiagnosed, untreated or undertreated are similar to the findings of Barraclough et al. (1974) who collected their sample in the U.K. between 1966 and 1967. This extremely high degree of underdiagnosis of depression in Hungary was not completely unexpected, as we have previously shown that the officially registered number of patients with various forms of depression was about half that of the registered number of schizophrenic patients (Rihmer, 1982). In reality, the rate of primary major affective disorder to schizophrenia is clearly the opposite (Glass and Freedman, 1985). Our results support the opinion of Khuri and Akiskal (1983) that undiagnosed and inadequately
treated affective disorders are the leading cause of completed suicide. and that energetic treatment (acute and prophylactic management) of affective disorders might prove to be an effective method of preventing suicide. The number of persons living in Hungary is 10.5 million. About 5000 people kill themselves each year. At least 2500 of these might have primary major depression. The correct diagnosis and treatment of this population may substantially reduce the suicide mortality in Hungary, which is the highest in the world.
References Arat&
M..
Demeter.
Retrospective Budapest.
Acta
Barraclough,
D.L.,
table
E. (198X)
200
suicides
in
77, 454-456.
J.. Nelson,
of suicide:
Gershon,
factors
atry
B. and
clinical
Sainsbury.
aspects.
P. (1974)
Br. J. Psych]-
E.S. and
in the severity
Goodwin.
of affective
F.K.
(1976)
illness.
Heri-
Biol.
Psychi-
11. 31-42.
Endicott.
J., Nee.
and
Coryell.
arate
J. Affect.
R.M.
Khuri.
J.. Andreasen. W. (1985)
R. and of
Psychiatr.
Clin.
Martin,
R.L.,
(1985) tients.
orders. tion. Perris.
J. Clin. C.
and
Z.
Lodge
and
Clayton,
psychiatric
P.
outpa-
follow-up and
study
III.
affectwe
dia-
41. 586-601. m psychiatric
G.
(1966)
(Ed.).
Mortality,
The Study (Recurrent
42, Suppl.
Season
in bipolar
the
disorders.
practice
popula-
suicide
and
43, 34X-352.
Stand.
(1980)
S.B.
schizophrenia
Suicide
Unipolar
Psychiatr.
admission
of
D’Eha,
prevention:
42. 58-66.
Psychiatry
In: C. Perris
pressive)
Contempo
psychiatric
of 500
Chestnut
Psychiatry
and
cycles. Acta
Gen. (1982)
Suicide
Guze,
Psychiatry
(1984)
Arch.
M. sep-
6, 193-207. C.R.,
outcome
J.R.
(1983)
in a follow-up
Gen.
Long-term
Psychiatry.
contributory
N. Am.
T.H.
Morrison,
H.S.
Cloninger.
Arch.
or keep
D.X. (1985)
treating
Mortality
McGlashan.
P.. Keller.
Ass. 254. 22X0-2283.
Akiskal,
necessity
Clayton,
11. Combine
X, 17-28.
Freedman, Med.
N..
Bipolar
Disord.
and
‘85. J. Am.
Rihmer.
Stand.
Somogyi. of
125, 355-373.
Dunner.
Glass.
cases
Z. and
assessment
Psychiatr.
B.. Bunch,
A hundred atQ
E., Rihmer.
psychiatric
of
birth
depressed
of Bipolar
life
(Manic-De-
Depressive)
Psychoses.
194. 172-183. and female
season
of
patients.
hospital Psychiatr.
Res. 3, 247-251. Rihmer.
Z. (1982)
(Nosological
A depress%
and other
nozolhgiai
dilemmas
123. 946-949 (in Hungarian). Rihmer. R. and Arath, M. (1984) research pharmacol. Rihmer.
tool
in patients
Bull.
Z.. Arath,
The red blood
with
Cs egyeb
of depression).
The
dilemmLi Orv.
DST as a clinical
affective
disorders.
Hetil.
aid and Psycho-
20. 1744177. M.. Szentistvlnyi,
cell/plasma
lithium
1. and ratio:
BBnki, marker
M.C.
(1982)
of biologi-
225 cal heterogeneity within bipolar affective illness? Psychiatr. Res. 6. 197-201. Spitzer. R.L. and Endicott. J. (1978) Schedule for Affective Disorders and Schizophrenia (SADS), 3rd edn. New York State Psychiatric Institute, New York. NY. Spitzer. R.L.. Endicott, J. and Robins. E. (1978) Research Diagnostic Criteria: rationale and reliability. Arch. Gen. Psychiatry 35, 773-782. Twang. M.T. (1978) Suicide in schizophrenics, manics. depres-
sives and surgical controls. Arch. Gen. Psychiatry 35. 153-155. Weeke, A. and Vaeth. M. (1986) Excess mortality of bipolar and unipolar (manic-depressive) patients. J. Affect. Disord. 11. 227-234. Weissman. M.M. and Myers. J.K. (1978) Affective disorders in a US urban community. Arch. Gem Psychiatry 35. 1304-1311.