Type-D personality and depersonalization are associated with suicidal ideation in the German general population aged 35–74: Results from the Gutenberg Heart Study

Journal of Affective Disorders 125 (2010) 227–233

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Journal of Affective Disorders j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d

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Type-D personality and depersonalization are associated with suicidal ideation in the German general population aged 35–74: Results from the Gutenberg Heart Study Matthias Michal a,⁎, Jörg Wiltink a, Yvonne Till a,b, Philipp S. Wild b, Thomas Münzel b, Stefan Blankenberg b, Manfred E. Beutel a a b

Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Germany Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany

a r t i c l e

i n f o

a b s t r a c t

Article history: Received 11 November 2009 Received in revised form 5 February 2010 Accepted 5 February 2010 Available online 4 March 2010

Background: Suicidal ideation (SID) is a major risk factor for suicide attempts. Mental disorders are among the strongest correlates of suicide, with depression and anxiety disorders playing a major role. The present study aims to investigate the contribution of under researched factors contributing to SID such as depersonalization, Type-D personality and cardiovascular risk factors.

Keywords: Suicidal ideation Type-D personality Depression Anxiety Depersonalization Cardiovascular risk factors

Methods: Factors associated with SID were investigated in a sample of N = 5000 participants (aged 35–74 years) of the community-based survey “Gutenberg Heart Study”. The factors were assessed by self-report instruments, computer-assisted interviews and medical examination. Results: 7.5% of the sample reported SID over the last 2 weeks. In the univariate analysis SID was significantly associated with female sex, living without a partner, low socioeconomic status, diagnosis of coronary heart disease, family history of myocardial infarction, smoking and mental distress. In the full adjusted model significant associations remained with age (in years) OR 1.02 (95%CI 1.01–1.04, p = 0.002), self-reported depression OR 3.21 (95%CI 2.23–4.62, p b 0.0001), panic disorder OR 1.56 (95%CI 1.03–2.36, p = 0.036), depersonalization OR 2.45 (95%CI 1.78–3.38, p b 0.0001), Type-D personality OR 1.98 (95%CI 1.49–2.63, p b 0.0001) and impairment by mental distress OR 2.15 (95%CI 1.74–2.67, p b 0.0001). Limitations: Main limitations are the reliance on self-report measures of SID and of mental distress. Conclusions: For the first time it has been shown that in the general population depersonalization and Type-D personality are uniquely associated with SID. These associations need further elucidation. © 2010 Elsevier B.V. All rights reserved.

1. Introduction Suicidal ideation and death wishes are risk factors for suicide attempts (Kuo et al., 2001) and they usually precede suicide

⁎ Corresponding author. Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Untere Zahlbacher Str. 8, D-55131 Mainz, Germany. Tel.: + 49 6131172841; fax: + 49 6131176688. E-mail address: [email protected] (M. Michal). 0165-0327/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2010.02.108

(Kessler et al., 1999). Sokero et al. (2003) reported that almost all individuals (95%) attempting suicide had reported suicidal ideation previously. Suicidal ideation is considered a prevalent symptom of major depressive disorder. A number of studies also reported a greater risk of suicidal ideation and suicide attempts in patients with comorbid anxiety disorders. Occurrences of panic attacks, agoraphobic symptoms, shyness, non-specific anxiety, and anticipatory worry have been shown to be associated with greater suicidal ideation (Spijker et al., 2009; Simon et al., 2007). With respect to generalized anxiety disorder a unique and

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independent association of suicidal ideation has been found (Weisberg, 2009). Regarding personality disorders a study in patients with panic disorder and agoraphobia found that SID was predicted by any DSM-IV Cluster C personality disorder, any DSM-IV Cluster B personality disorder, any comorbid mood disorder, and severity of panic disorder with agoraphobia (Starcevic et al., 1999). To our knowledge, there are only two studies which reported an association between occurrence of symptoms of depersonalization and suicidality for patients with major depression and schizophrenia (Cem Atbaşoglu et al., 2001; Yoshimasu et al., 2006). In general studies emphasize the close association between suicidal ideation and mental disorders (Nock et al., 2009). With respect to the epidemiology of SID it has been found that the prevalence of SID is much more common than suicide attempts (Bertolote et al., 2005). The lifetime prevalence of suicidal ideation varies across countries from 8 to 18% (Ladwig et al., 2008). Surveys on the prevalence of current suicidal ideation however are sparse. In the Australian population Goldney et al. (2001) found a prevalence for suicidal ideation of 2.6% and Gili-Planas et al. (2001) of 6.5%. A recent communitybased survey of N = 3154 persons aged 35 to 84 years conducted in 2004/2005 in southern Germany, identified a prevalence of 5.4% with suicidal ideation within the last 14 days. The authors found that prevalence increased significantly with age and was higher in women than in men (Ladwig et al., 2008). The aim of the present study was to investigate the contribution of under researched and presumably important factors contributing to SID such as depersonalization, Type-D personality and coronary heart disease. First there is accumulating evidence that in mood and anxiety disorders depersonalization represents a clinical index of disease severity, poorer response to treatment and high level of comorbidity (Mula et al., 2007; Michal et al., 2009; Michal and Beutel, 2009). Second the Type-D personality pattern consisting of the joint tendencies of negative affectivity and social inhibition emerged as a factor of poor prognosis with respect to somatic and mental endpoints in cardiac patients (Denollet, 2005; Pedersen and Denollet, 2003). For these reasons one could expect that there could be an unrevealed association between these variables with SID. Third recent studies reported on a close bidirectional relationship between depression and coronary heart disease (CHD) (López-León et al., 2010; von Känel, 2008), however with the exception of smoking (Boden et al., 2008; Bronisch et al., 2008; Hintikka et al., 2009) the association of cardiovascular risk factors with SID was up to date not subject of investigation. 2. Methods 2.1. Study sample We investigated cross-sectional data of the first N = 5000 participants enrolled in the Gutenberg Heart Study (GHS) from April 2007 to October 2008. The GHS is a communitybased, prospective, observational single-center cohort study in the Rhein-Main-Region in western Mid-Germany. The GHS has been approved by the local ethics committee and by the local and federal data safety commissioners. The primary aim of the study is to evaluate and improve cardiovascular risk stratification. The sample was drawn randomly from the local registry in the city of Mainz and the district of Mainz-Bingen.

The sample was stratified 1:1 for gender and residence an in equal strata for decades of age. Inclusion criteria were age 35 to 74 years and written informed consent. Persons with insufficient knowledge of German language, or physical and mental inability to participate were excluded. The response rate, defined as the number of persons with participation in or appointment for the baseline examination divided by the sum of number of persons with participation in or appointment for the baseline examination plus those with refusal and those who were not contactable was 60.3%. Due to the ongoing recruitment of the GHS, which is conducted in waves, a concluding statement concerning the response rate cannot be made. 2.2. Assessment The 5-h baseline examination in the study center comprised evaluation of prevalent classical cardiovascular risk factors and clinical variables, a computer-assisted personal interview, laboratory examinations from a venous blood sample, blood pressure and anthropometric measurements. In general, all examinations were taken out according to standard operating procedures (SOPs) by certified medical technical assistants. According to the recent studies of Goldney et al. (2001, 2000, 2003), Ladwig et al. (2008) and Pietrzak et al. (2010) suicidal ideation was assessed by the item “In the last 2 weeks, have you had thoughts that you would be better off dead or of hurting yourself in some way?” of the depression module of the Patient Health Questionnaire (PHQ-9 (Spitzer et al., 1999; Löwe et al., 2004a)). Subjects were identified as cases with suicidal ideation if they indicated that they were bothered by SID at least for several days over the past two weeks on the 4 point-Likert scale (0=not at all to 3=nearly every day). Depression was measured with the German version of the Patient Health Questionnaire depression module (PHQ-9). Caseness of depression was defined with a score of PHQ-9≥10, indicating moderate to severe depressive symptoms for the last 2 weeks (Löwe et al., 2004b). Additionally we used for case definition the PHQ-8 with a cut-off of ≥10. The PHQ-8, which excludes the thoughts of death or suicide item, was as useful as the PHQ-9 in measuring depression in population based studies (Kroenke et al., 2009). Social anxiety was assessed using the 3-item version of the Social Phobia Inventory (MiniSpin, (Connor et al., 2001)). A cut-off score of 6 has been shown to demonstrate a sensitivity of 89% and a specificity of 90% in detecting current social phobia and was defined as threshold for caseness. Generalized anxiety was assessed using the 2-item version of the GAD-7 (Kroenke et al., 2007; Löwe et al., 2010). A cut-off score of 3 or more detects a current Generalized Anxiety Disorder (GAD) with a sensitivity of 86% and a specificity of 83%, and any current anxiety disorder (GAD, panic disorder, social phobia, post-traumatic stress disorder) with a sensitivity of 65% and specificity of 88% (Skapinakis, 2007). Panic was screened with the brief PHQ panic module. Caseness was defined if at least two of the first four PHQ panic questions are answered with “yes”. For the detection of panic disorder this algorithm yields a sensitivity of 91% and a specificity of 88% (Löwe et al., 2003). Depersonalization was assessed with the 2 item version of the Cambridge Depersonalization Scale (Michal et al., 2010; Sierra and Berrios, 2000, Michal et al., 2004). The CDS-2 sum score (range 0–6, scoring format is identical with the GAD-2) correlates

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strongly with clinician rated depersonalization severity (r=0.77, Michal et al., 2010). For the detection of clinically significant depersonalization the CDS-2 a cut-off of CDS-2≥3 yielded a sensitivity of 78.9% and a specificity of 85.7%. The distressed Personality or Type-D personality was assessed with the German version of the Type-D scale (ds14, (Denollet, 2005; Grande et al., 2004). The ds14 comprises two subscales, 7 items for negative affectivity (NA) and 7 items for social inhibition (SI). The Type-D personality is defined as a pattern consisting of significant negative affectivity (NA≥10) in conjunction with significant social inhibition (SI≥10). Participants also rated the level of impairment by symptoms of mental distress (PHQ: “How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?”) on a 4 point-Likert scale from not difficult at all (=0) to extremely difficult (=3). As compound variables we defined “any mental disorder” comprising positive screening for depression, GAD, panic disorder, social phobia or depersonalization and “any anxiety disorder” comprising positive screening for GAD, panic disorder or social phobia. Further all participants were asked during the computerassisted personal interview (CAPI) a) whether they have ever received the definite diagnosis of depressive disorder by a physician (medical history of lifetime diagnosis of depression, MH of depression) or anxiety disorder (medical history of lifetime diagnosis of anxiety disorder MH of anxiety disorder) and b) their alcohol consumption. Alcohol abuse was defined as the alcohol intake of more than 40 g/day for women and more than 60 g/day for men. Cardiovascular risk factors were defined as follows: Smoking was dichotomized into non-smokers (never smoker and exsmoker) and smokers (occasional smoker, i.e. b1 cigarette/day, and smoker, i.e. N1 cigarette/day). Obesity was defined as a bodymass index ≥30 m2/kg. Diabetes was defined in individuals with a definite diagnosis of diabetes by a physician or a blood glucose level of ≥ 126 mg/dl in the baseline examination after an overnight fast of at least 8 h or a blood glucose level of ≥ 200 mg/ dl in the baseline examination after a fasting period b 8 h. Dyslipidemia was defined as a definite diagnosis of dyslipidemia by a physician or a LDL/HDL-ratio of N3.5. Hypertension was diagnosed, if antihypertensive drugs were taken, or a mean systolic blood pressure of ≥140mm Hg in the 2nd and 3rd standardized measurement after 8 and 11 min of rest or a mean diastolic blood pressure of ≥90 mm Hg in the 2nd and 3rd standardized measurement after 8 and 11 min of rest. A positive (strict) family history of myocardial infarction (FH-MI) was defined as at least one myocardial infarction in a female firstdegree relative of b65 years and a male first-degree relative of b60 years. The socioeconomic status (SES) was defined according to Lampert's and Kroll's Scores (Lampert and Kroll, 2006) of SES with a range from 3 to 27 while 3 indicates the lowest SES and 27 the highest SES. 2.3. Statistics All data have been quality checked. For statistical analyses a pvalue of alphab 0.05 was considered to indicate a significant difference. All tests were two-tailed. The evaluations were performed with the statistical software package SAS (Version 9.2, SAS-Institute Inc., Cary, NC, USA). Associations between

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suicidal ideation and the factors were quantified by odds ratios (ORs) derived from logistic regression with 95%-confidence intervals (95%CIs). Univariate and multivariate linear models were used. Differences in the distribution of paired categorical variables were tested with McNemars' test. 3. Results Overall 7.5% (N = 374) of the participants reported suicidal ideation over the last 2 weeks, 7.0% (N = 349) endorsed occurrence of suicidal ideation for several days, 0.3% (N = 16) for more than half the days, and 0.2% (N = 9) nearly every day over the last 2 weeks. Table 1 shows the study sample stratified for presence of suicidal ideation. In the univariate analysis persons with suicidal ideation differ from persons free of thoughts of death wishes and suicide with respect to the following sociodemographic and clinical variables: Individuals with suicidal ideation were more often female, had a lower SES, and were less often living in a partnership. With respect to cardiovascular risk factors diagnosis of CHD, a family history of MI and smoking were significantly more prevalent in persons with suicidal ideation. Symptoms of anxiety, depression and depersonalization were overall more prevalent in subjects with suicidal ideation. Of the significant correlates of suicidal ideation the most prevalent were a positive screening for “any mental disorder” with 56.5%, “Type-D personality” with 51.6%, depression according to PHQ-9 with 43.6% and “any anxiety” with 42.1%. Fig. 1 shows that after stratification for age decades the prevalence of positive screening for depression according to PHQ-9 diverges from the prevalence of suicidal ideation. In the last decade (65–74 years) the difference is significant (McNemars' test: Chi2 = 7.69, df = 1, p = 0.006). To identify factors associated with suicidal ideation we calculated a logistic regression analysis. At the first stage PHQ-8, GAD-2, Mini-Spin and CDS-2 were put simultaneously in the equation as continuous variables. In the full adjusted model only GAD-2, CDS-2, impairment by symptoms of mental distress and Type-D personality remained significantly associated with suicidal ideation and of the factors adjusted for only age with OR 1.03 (95%CI 1.01–1.04, p = 0.0003) remained significant (Table 2). However if only binary variables were used, depression according to PHQ-8 ≥ 10 with OR 3.21(95%CI 2.23–4.62, p b 0.0001), depersonalization according to CDS2 ≥ 3 OR 2.45 (95%CI 1.78–3.38, p b 0.0001), panic disorder according to PHQ screening with OR 1.56 (95%CI 1.03–2.36, p = 0.036), Type-D personality with OR 1.98 (95%CI 1.49–2.63, p b 0.0001) and impairment by symptoms of mental distress with OR 2.15 (95%CI 1.74–2.67, p b 0.0001) as well as age in years (OR 1.02, 95%CI 1.01–1.04, p = 0.002) showed an independent association with suicidal ideation after full adjustment (depression, panic disorder, GAD, depersonalization, age, sex, partnership, SES, CHD, FH of MI, hypertension, dyslipidemia, diabetes, BMI ≥ 30, smoking and alcohol abuse). 4. Discussion One major finding was the surprisingly high prevalence rate of 7.5% for thoughts of suicidal ideation in this middle aged representative German community sample. Ladwig et al.

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Table 1 Baseline characteristics of the sample stratified by presence of suicidal ideation.*

Female, % (N) Age (in years) Partnership SES (3–21) Coronary heart disease Family history of MI Hypertension Dyslipidemia Diabetes Smoking (current) BMI ≥30 m2/kg Alcohol abuse Depression according to PHQ-9 ≥10 Depression according to PHQ-8 ≥ 10 PHQ-8 (0–24) MH of depression Panic disorder according to the PHQ Social anxiety according to MINI-SPIN MINI-SPIN (0–12) Depersonalisation (CDS-2 ≥ 3) CDS-2 (0–6) Generalized anxiety disorder (GAD-2≥3) GAD-2 (0–6) Any anxiety disorder MH of anxiety disorder Any mental disorder Type-D personality Impairment by mental distress (0–3) *Missing cases: N = 88

Persons with suicidal ideation

Persons without suicidal ideation

Test

7.5% (N = 374)

90.8% (N = 4538)

OR (95%CI), p

59.6% (223) 55.4 ± 10.4 74.1% (277) 11.7 ± 4.3 7.6% (28) 24.1% (90) 49.1% (183) 30.8% (115) 7.5% (28) 25.1% (94) 26.7% (100) 2.1% (8) 43.6% (163) 35.0% (131) 8.40 ± 4.22 36.6% (137) 18.4% (65) 23.4% (87) 3.84 ± 2.53 6.2% (23) 0.74 ± 1.16 16.8% (62) 1.86 ± 1.50 42.1% (146) 18.2% (68) 56.5% (195) 51.6% (193) 0.97 ± 0.81

48.3% (2191) 55.4 ± 11.0 83.3% (3775) 12.9 ± 4.4 4.3% (192) 18.2% (824) 51.3% (2327) 29.1% (1320) 7.4% (334) 18.7% (848) 23.8% (1079) 3.8% (171) 4.2% (190) 4.2% (190) 3.48 ± 2.90 9.2% (415) 3.4% (149) 5.7% (255) 2.00 ± 1.93 0.4% (18) 0.10 ± 0.43 2.3% (103) 0.49 ± 1.01 9.6% (415) 5.5% (249) 11.8% (508) 19.7% (893) 0.29 ± 0.53

1.58 1.00 0.57 0.94 1.83 1.43 0.92 1.08 1.02 1.46 1.17 0.56 17.68 12.34 1.41 5.73 6.42 5.10 1.42 16.53 2.93 8.59 2.04 6.87 3.83 9.76 4.35 3.99

(2008) reported from a survey, which was conducted with identical measures in 2004/05 in southern Germany, a prevalence rate of only 5.4%. The age distribution of SID was a further difference to the survey of Ladwig et al. (2008). Ladwig et al. (2008) found that SID prevalence increased with age and that the prevalence was highest in the oldest age group (75–84 years). In the GHS sample however the

Fig. 1. Prevalences of depression according to PHQ-9 ≥10 and of suicidal ideation stratified by decades of age.

(1.28–1.96), p b 0.0001 (0.99–1.01), p = 0.987 (0.45–0.73), p b 0.0001 (0.92–0.97), p b 0.0001 (1.21–2.77), p = 0.004 (1.11–1.83), p = 0.005 (0.74–1.13), p = 0.411 (0.86–1.36), p = 0.499 (0.68–1.52), p = 0.928 (1.14–1.86) p = 0.003 (0.92–1.49) p = 0.198 (0.27–1.14), p = 0.111 (13.76–22.72), p b 0.0001 (9.54–15.96), p b 0.0001 (1.37–1.46), p b 0.0001 (4.54–7.24), p b 0.0001 (4.68–8.79), p b 0.0001 (3.89–6.69), p b 0.0001 (1.36–1.49), p b 0.0001 (8.83–30.92), p b 0.0001 (2.56–3.36), p b 0.0001 (6.14–12.01), p b 0.0001 (1.89–2.19), p b 0.0001 (5.43–8.70), p b 0.0001 (2.86–5.13), p b 0.0001 (7.74–12.31), p b 0.0001 (3.50–5.39), p b 0.0001 (3.42–4.64), p b 0.0001

maximum prevalence of SID laid in the decade of 45–54 years with 8.8%. For this decade Ladwig et al. (2008) reported with the identical measures a prevalence of only 3.6% for men and of 5.5% for women. This means that prevalence and age distribution of SID in the Rhein-Main-Region in western MidGermany are quite different from the Augsburg region (i.e. approx. 300 km south east from Rhein-Main-Region). Further we found that the prevalence of depression and SID was not equally distributed over the decades of age in our sample. In our oldest decade (64–75 years) we found that the prevalence of depression (4.8%) was significantly exceeded by the prevalence of SID (7.1%). This discrepancy could allude to other factors beyond depression contributing to SID. With respect to the role of mental distress for SID our findings support and extend previous results. Our study confirmed the strong association of depression with SID (Casey et al., 2006). With respect to the role of anxiety, we found that symptoms of GAD were independently associated with suicidal ideation in a dose like relationship. However while using binary variables, GAD lost significance in the full adjusted model and self-reported panic disorder emerged as a significant factor. In general the present findings support the important role of anxiety for SID (Nock et al., 2009). Furthermore impairment by symptoms of mental distress was universally associated with SID. This supports the view that SID is a marker of disease severity (Gaudiano et al., 2009). A novel finding was detected in our study such the way that symptoms of depersonalization as well as clinically significant depersonalization were uniquely associated with suicidal ideation in the general population. This corroborates

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Table 2 Factors associated with suicidal ideation in the GHS sample aged 35–74 years. Factor

Model 1

Model 2

Model 3

PHQ-8 (range 0–24) Panic disorder (PHQ) GAD-2 (range 0–6) CDS-2 (range 0–6) MINI-SPIN (range 0–12) Typ-D personality Impairment (range 0–3)

1.25 (1.20–1.31)*** 1.17 (0.77–1.76) 1.25 (1.12–1.38)*** 1.30 (1.11–1.52)** 1.06 (0.99–1.12) 1.30 (0.97–1.74) 1.34 (1.07–1.67)*

1.25 (1.20–1.31)*** 1.19 (0.78–1.81) 1.24 (1.11–1.38)*** 1.28 (1.09–1.51)** 1.06 (0.99–1.13) 1.34 (0.99–1.81) 1.42 (1.13–1.79)**

1.26 (1.20–1.32)*** 1.18 (0.77–1.80) 1.26 (1.13–1.41)*** 1.28 (1.09–1.51)** 1.06 (0.99–1.13) 1.42 (1.05–1.93)* 1.39 (1.10–1.75)**

Model 1: adjusted for the factors in the left column. Model 2: adjusted for the factors of model 1 + age, sex, partnership and SES. Model 3: adjusted for the factors of model 1 + model 2 + CHD, FH of MI, hypertension, dyslipidemia, diabetes, BMI ≥ 30, smoking and alcohol abuse. significance level: *p b 0.05, **p b 0.01, ***p b 0.001 in bold emphasis, without asterisk p N 0.05.

findings from clinical samples. Yoshimasu et al. (2006) found that derealization, depersonalization, depressive moods, and anxiety traits were statistically significantly associated with suicidal ideation in a sample of N = 199 patients with diagnosis of a major depressive disorder. Foote et al. (2008) compared patients receiving a dissociative disorder diagnosis compared with nondissociative patients on measures of selfharm and suicidality. They found that presence of a dissociative disorder was strongly associated with all measures of self-harm and suicidality even after adjustment for borderline personality disorder, post-traumatic stress disorder and alcohol abuse/dependence. Furthermore the association of depersonalization with suicidal ideation could be related to the finding of reduced electrodermal activity in suicidal patients with major depression (Jandl et al., 2009; Thorell, 2009), because reduced autonomic responsivity to emotional stimulation tasks has been repeatedly reported for patients with depersonalization disorder too (Sierra et al., 2002; Sierra et al., 2006). In addition depersonalization is commonly comorbid with depression (Baker et al., 2003; Michal et al., 2009; Lambert et al., 2001). Although the use of self-report instruments does not allow the clinical determination of the corresponding diagnostic classifications, it might be allowed to speculate about the underlying psychopathological syndromes. With respect to the context of depression, it has been found that depersonalization is related to atypical depression (Seemüller et al., 2008), to an “anxious depression phenotype” (Halbreich and Kahn, 2007) and above all to bipolar mood disorders (Oedegaard et al., 2008; Mula et al., 2009). With respect to suicide prevention our finding might support efforts to detect symptoms of depersonalization more effectively than it happens up to day (Simeon, 2004; Michal and Beutel, 2009). Whereas the above found associations have been reported previously, the association of Type-D personality with SID has never been reported before. Up to day it has only been shown that Type-D personality is associated with a wide range of emotional distress including anxiety, depressive symptoms, post-traumatic stress disorder, and that Type-D personality predicts recurrent cardiac events and poor prognosis, independent of biomedical risk factors (Denollet, 2005; Denollet and van Heck, 2001; Pedersen et al., 2004; Pedersen and Denollet, 2003). In our study, half of the persons (51.6%) with suicidal ideation showed the Type-D personality pattern of negative affectivity in conjunction with social inhibition, and Type-D increased likelihood for suicidal ideation almost 2-

fold independently from depression, anxiety, depersonalization, and cardiovascular or sociodemographic risk factors. Although there are no preceding reports on the relationship between Type-D and SID, the present finding could remind to a study on personality factors contributing to suicidal ideation. The authors found that in a sample of patients with affective disorders the risk of suicide was correlated with being more socially introverted, schizoid mechanism, and severity of depression amongst others (Pompili et al., 2008). This combination showed characteristics similar to Type-D personality pattern defined by the combination of social inhibition and negative affectivity. The association between Type-D personality and suicidal ideation urgently needs further investigation, first because of the surprisingly high prevalence of the Type-D personality pattern in individuals with suicidal ideation exceeding the prevalence of depression according to the PHQ-9 and second because the relationship of the Type-D personality construct to the classification of mental disorders has not yet been investigated thoroughly. The Type-D pattern is defined as a personality trait solely by means of a psychometric instrument. Up to date it has not been clarified whether the Type-D pattern is a distinct personality trait or the intersection of different psychopathological classified mental disorders. Limitations of the present study are the use of self-report instruments for the assessment of suicidal ideation and mental disorders. Further the results do not allow conclusions to the impact on suicidal risk because of the cross-sectional methodology. Strengths of the study are the use of common and validated instruments, which allow the comparison of our results to other studies, and the sample size. Future studies on SID and suicidal behavior could profit by the assessment of Type-D personality and depersonalization.

Role of funding source No funding was granted.

Conflict of interest The authors have no conflicts of interest in connection with this paper.

Acknowledgements We thank the team of the Gutenberg Heart Study and all persons participating in it.

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