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This issue contains two reviews, one on how well the Beck Hopelessness Scale can predict suicide and self-harm, and one on the validity of the distinction between bereavement-related and non-bereavement-related depression. Other sets of papers examine various aspects of suicide and depression.
Background. Hopelessness is considered a pre-eminent risk factor for suicide and non-fatal self-harm. We aimed to quantify the ability of the Beck Hopelessness Scale (BHS) to predict these two outcomes.
Method. Medline, Embase, PsycINFO and Cinahl were searched to January 2006. We included cohort studies in which the BHS was applied and patients were followed-up to establish subsequent suicide or non-fatal self-harm. Four studies provided usable data on suicide, and six studies provided data on non-fatal self-harm. Summary sensitivity, specificity, likelihood ratios and diagnostic odds ratios (DORs) were calculated for each study. Random effects meta-analytic pooling across studies at the standard cut-off point ([ges ]9) was undertaken and summary receiver operating characteristic (ROC) curves constructed.
Results. For suicide, pooled sensitivity was 0·80 [95% confidence interval (CI) 0·68–0·90], pooled specificity was 0·42 (95% CI 0·41–0·44), and the pooled DOR was 3·39 (95% CI 1·29–8·88). For non-fatal self-harm, pooled sensitivity was 0·78 (95% CI 0·74–0·82), pooled specificity was 0·42 (95% CI 0·38–0·45), and the pooled DOR was 2·27 (95% CI 1·53–3·37).
Conclusion. The standard cut-off point on the BHS identifies a high-risk group for potential suicide, but the magnitude of the risk is lower than previously reported estimates. The standard cut-off point is also capable of identifying those who are at risk of future self-harm, but the low specificity rate means it is unlikely to be of use in targeting treatment designed to lower the rate of repetition.
Background. This review tackles the question: ‘Is bereavement related depression (BRD) the same or different from standard (non-bereavement-related) major depression (SMD)?’ To answer this question, we examined published data on key characteristics that define and characterize SMD to assess whether they also characterize BRD.
Method. We searched all English-language reports in Medline up to November 2006 to identify relevant studies. Bibliographies of located articles were searched for additional studies.
Results. Consistent with the position that BRD is distinct from SMD, some, but not all, studies report that men are as likely as women to have BRD and that past or family histories of SMD do not predict BRD. With greater consistency, studies suggest that, like SMD, BRD is: more common in younger than in older adults, predicated by poor health or low social support, followed by recurrent episodes of major depressive episode (MDE), and associated with impaired immunological responses, altered sleep architecture, and responsivity to antidepressant treatment.
Conclusions. Overall, the prevailing evidence more strongly supports similarities than differences between BRD and SMD. Because so few studies focus on BRD occurring within the first 2 months of bereavement, the period identified by the DSM to exclude the diagnosis of MDE, more research is needed specifically on this group to help us evaluate the validity of this important diagnostic convention.
Background. Previous studies have examined suicidal ideation in older populations and emphasized the strong association with the presence of psychiatric disorder. However, associations with the presence of psychiatric disorder across the age range are unclear. Representative epidemiological estimates are needed.
Method. In a national survey of psychiatric morbidity in Great Britain, 8580 randomly selected adults were interviewed. Three questions were asked to assess suicidal ideation, and psychiatric disorder was identified using the revised Clinical Interview Schedule (CIS-R).
Results. Suicidal ideation was up to three times commoner in younger adults than in those aged 55–74 years but the odds of depression in those with suicidal thoughts was significantly greater in the older age group (p<0·01). Tiredness with life (p<0·01) and thoughts of death (p<0·01) were also more strongly associated with depression in the older age group. Other major associations of suicidal ideation for all ages were: smaller social support group, being divorced or separated, poor self-rated general health, and limitations in activities of daily living (ADL). Being single was an important factor for younger age groups, and widowhood for older people. Life events were also important in younger people, but not in those aged 55–74 years.
Conclusions. Suicidal thoughts and death wishes are comparatively more unusual in older people; however, they are more likely to be associated with clinical depression. In terms of suicide prevention this study emphasizes the importance of improving rates of recognition and treatment of depression in older people.
Background. Because the suicide rates in Eastern Europe have increased, the epidemiology of suicide behaviors in this part of the world is in urgent need of study. Using data from the Ukraine site of the World Mental Health (WMH) Survey Initiative, we present the first population-based findings from a former Soviet country on the descriptive epidemiology of suicide ideation, plans and attempts, and their links to current functioning and service utilization.
Method. In 2002, a nationally representative sample of 4725 adults in Ukraine was interviewed with the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Risk factors included demographic characteristics, trauma, smoking, and parental and personal psychiatric disorders. Current functional impairments and recent service utilization were assessed.
Results. The lifetime prevalence of suicide ideation was 8·2%. The average age of onset was 31. The key risk factors were female sex, younger age, trauma, parental depression, and prior alcohol, depressive and intermittent explosive disorders, especially the presence of co-morbidity. Ideators had poorer functioning and greater use of health services. One-third of ideators had a plan, and one-fifth made an attempt. Among ideators, young age, smoking and prior psychiatric disorders were risk factors for these behaviors.
Conclusions. Together with the increasing suicide rate, these results suggest that suicide intervention programs in Ukraine should focus on the generation of young adults under 30. The associations with co-morbidity, impairments in current functioning and greater service use indicate that a physician education program on suicidality should be comprehensive in scope and a public health priority in Ukraine.
Background. Suicide is a leading cause of death worldwide but information about it is sparse in Sub-Saharan Africa. Suicide-related behaviours can provide an insight into the extent of this compelling consequence of mental illness.
Method. Face-to-face interviews were conducted with a representative sample of persons aged 18 years and over (n=6752) in 21 of Nigeria's 36 states (representing about 57% of the national population). Suicide-related outcomes, mental disorders, as well as history of childhood adversities were assessed using the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI).
Results. Lifetime prevalence estimates of suicide ideation, plan and attempts were 3·2% [95% confidence interval (CI) 1·4–6·5], 1·0% (95% CI 0·4–7·5) and 0·7% (95% CI 0·5–1·0) respectively. Almost two of every three ideators who made a plan went on to make an attempt. The highest risks for transition from ideation to plan and from plan to attempt were in the first year of having ideation or plan respectively. Mental disorders, especially mood disorders, were significant correlates of suicide-related outcomes. Childhood adversities of long separation from biological parents, being raised in a household with much conflict, being physically abused, or being brought up by a woman who had suffered from depression, anxiety disorder, or who had attempted suicide were risk factors for lifetime suicide attempt.
Conclusions. History of childhood adversities and of lifetime mental disorders identify persons at high-risk for suicide-related outcomes. Preventive measures are best delivered within the first year of suicide ideation being expressed.
Background. Few controlled studies have investigated factors associated with suicide in current in-patients. We aimed to identify psychosocial, behavioural and clinical risk factors, including variations in care, for in-patient suicide.
Method. We conducted a national population-based case-control study of people who died by suicide between 1 April 1999 and 31 December 2000 while in psychiatric in-patient care in England. Cases were 222 adult mental health in-patients who died by suicide matched on date of death with 222 living controls.
Results. Nearly a quarter of suicides took place within the first week of admission; most of these died on the ward or after absconding. After the first week, however, most suicides occurred away from the ward, the majority of patients having left the ward with staff agreement. Previous deliberate self-harm, recent adverse life events, symptoms of mental illness at last contact with staff and a co-morbid psychiatric disorder were associated with increased risk for suicide. Being off the ward without staff agreement was a particularly strong predictor. Those patients who were detained for compulsory treatment were less likely to die by suicide. Independent predictors of in-patient suicide were male sex, a primary diagnosis of affective disorder and a history of self-harm. Being unemployed or on long-term sick leave appeared to be independently protective.
Conclusion. Prevention of in-patient suicide should emphasize adequate treatment of affective disorder, vigilance in the first week of admission and regular risk assessments during recovery and prior to granting leave. Use of compulsory treatment may reduce risk.
Background. The high risk of suicide in bipolar disorder is well recognized, but may have been overestimated. There is conflicting evidence about deaths from other causes and little known about risk factors for suicide. We aimed to estimate suicide and mortality rates in a cohort of bipolar patients and to identify risk factors for suicide.
Method. All patients who presented for the first time with a DSM-IV diagnosis of bipolar I disorder in a defined area of southeast London over a 35-year period (1965–1999) were identified. Mortality rates were compared with those of the 1991 England and Wales population, indirectly standardized for age and gender. Univariate and multivariate analyses were used to test potential risk factors for suicide.
Results. Of the 239 patients in the cohort, 235 (98·3%) were traced. Forty-two died during the 4422 person-years of follow-up, eight from suicide. The standardized mortality ratio (SMR) for suicide was 9·77 [95% confidence interval (CI) 4·22–19·24], which, although significantly elevated compared to the general population, represented a lower case fatality than expected from previous literature. Deaths from all other causes were not excessive for the age groups studied in this cohort. Alcohol abuse [hazard ratio (HR) 6·81, 95% CI 1·69–27·36, p=0·007] and deterioration from pre-morbid level of functioning up to a year after onset (HR 5·20, 95% CI 1·24–21·89, p=0·024) were associated with increased risk of suicide.
Conclusions. Suicide is significantly increased in unselected bipolar patients but actual case fatality is not as high as previously claimed. A history of alcohol abuse and deterioration in function predict suicide in bipolar disorder.
Background. The long-term outcome of major depression is often unfavorable, and because most cases of depression are managed by general practitioners (GPs), this places stress on the need to improve treatment in primary care. This study evaluated the long-term effects of enhancing the GP's usual care (UC) with three experimental interventions.
Method. A randomized controlled trial was conducted from 1998 to 2003. The main inclusion criterion was receiving GP treatment for a depressive episode. We compared: (1) UC (n=72) with UC enhanced with: (2) a psycho-educational prevention (PEP) program (n=112); (3) psychiatrist-enhanced PEP (n=37); and (4) brief cognitive behavioral therapy followed by PEP (CBT-enhanced PEP) (n=44). We assessed depression status quarterly during a 3-year follow-up.
Results. Pooled across groups, depressive disorder-free and symptom-free times during follow-up were 83% and 17% respectively. Almost 64% of the patients had a relapse or recurrence, the median time to recurrence was 96 weeks, and the mean Beck Depression Inventory (BDI) score over 12 follow-up assessments was 9·6. Unexpectedly, PEP patients had no better outcomes than UC patients. However, psychiatrist-enhanced PEP and CBT-enhanced PEP patients reported lower BDI severity during follow-up than UC patients [mean difference 2·07 (95% confidence interval (CI) 1·13–3·00) and 1·62 (95% CI 0·70–2·55) respectively] and PEP patients [2·37 (95% CI 1·35–3·39) and 1·93 (95% CI 0·92–2·94) respectively].
Conclusions. The PEP program had no extra benefit compared to UC and may even worsen outcome in severely depressed patients. Enhancing treatment of depression in primary care with psychiatric consultation or brief CBT seems to improve the long-term outcome, but findings need replication as the interventions were combined with the ineffective PEP program.
Background. A long-standing debate concerns whether dysfunctional cognitive processes and content play a causal role in the etiology of depression or more simply represent correlates of the disorder. There has been insufficient appreciation in this debate of specific predictions afforded by cognitive theory in relation to major life stress and changes in cognition over time. In this paper we present a novel perspective for investigating the etiological relevance of cognitive factors in depression. We hypothesize that individuals who experienced a severe life event prior to the onset of major depression will exhibit greater changes in dysfunctional attitudes over the course of the episode than will individuals without a severe life event.
Method. Fifty-three participants diagnosed with major depression were assessed longitudinally, approximately 1 year apart, with state-of-the-art measures of life stress and dysfunctional attitudes.
Results. Depressed individuals with a severe life event prior to episode onset exhibited greater changes in cognitive biases over time than did depressed individuals without a prior severe event. These results were especially pronounced for individuals who no longer met diagnostic criteria for major depression at the second assessment.
Conclusions. Specific patterns of change in cognitive biases over the course of depression as a function of major life stress support the etiological relevance of cognition in major depression.
Background. Intellectual disabilities (ID) are common and lifelong. People with ID have health inequalities compared with the general population, but little is known about the epidemiology of affective disorders in this population. This study was undertaken to determine the point prevalence of affective disorders, and to investigate factors associated with depression.
Method. This population-based study (n=1023) included comprehensive individual assessments with each person. A two-stage process was used for diagnosis of affective disorders. Factors independently associated with depression were investigated through logistic regression analysis.
Results. The point prevalence was higher than that reported previously for the general population; DC-LD yielded 3·8% for depression and 0·6% for mania. Additionally, 1·0% had bipolar disorder currently in remission, and 0·1% first episode of mania currently in remission. Similar to general population findings, depression was associated with female gender, smoking, number of preceding family physician appointments, and preceding life events. Important differences were the association of not having a hearing impairment, and the trends for not living in deprived areas, and being married. Unlike general population findings, not having daytime occupation and obesity were not independently associated; nor was previous long-stay hospital residence, severity of ID, or sensory impairments.
Conclusions. This study has found a high point prevalence of affective disorders in adults with ID. The factors associated with depression have differences to general population findings. An understanding of this is important in order to develop appropriate interventions, public strategy and policy, to reduce existing health inequalities.
Background. The Lundby Study is a longitudinal cohort study on a geographically defined population consisting of 3563 subjects. Information about episodes of different disorders was collected during field investigations in 1947, 1957, 1972 and in 1997. Interviews were carried out about current health and past episodes since the last investigation; for all subjects information was also collected from registers, case-notes and key informants. This paper describes the course and outcome of 344 subjects who had their first onset of depression during the follow-up.
Method. In this study individuals who had experienced their first episode of depression were followed up. Their course was studied with regard to recurrence of depression related to duration of follow-up, transition to other psychiatric disorders including alcohol disorders, as well as incidence and risk factors of suicide.
Results. Median age at first onset of depression was around 35 years for individuals followed up for 30–49 years. The recurrence rate was about 40% and varied from 17% to 76% depending on length of follow-up. Transition to diagnoses other than depression was registered in 21% of the total sample, alcohol disorders in 7% and bipolar disorder in 2%. Five per cent committed suicide; male gender and severity of depression were significant risk factors.
Conclusion. The low rates of recurrence and suicide suggest a better prognosis for community samples than for in- and out-patient samples.
Background. Despite the need for rational allocation of resources and cooperation between different treatment settings, clinical differences in patients with major depressive disorder (MDD) between primary and psychiatric care remain obscure. We investigated these differences in representative patient populations from primary care versus secondary level psychiatric care in the city of Vantaa, Finland.
Method. We compared MDD patients from primary care in the Vantaa Primary Care Depression Study (PC-VDS) (n=79) with psychiatric out-patients (n=223) and in-patients (n=46) in the Vantaa Depression Study (VDS). DSM-IV diagnoses were assigned by the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I in PC-VDS) or Schedules for Clinical Assessment in Neuropsychiatry (SCAN in VDS), and SCID-II interviews. Comparable information was collected on depression severity, Axis I and II co-morbidity, suicidal behaviour, preceding clinical course, and attitudes towards and pathways to treatment.
Results. Prevalence of psychotic subtype and severity of depression were highest among in-patients, but otherwise few clinical differences between psychiatric and primary care patients were detected. Suicide attempts, alcohol dependence, and cluster A personality disorder were associated with treatment in psychiatric care, whereas cluster B personality disorder was associated with primary care treatment. Patients' choice of the initial point of contact for current depressive symptoms seemed to be independent of prior clinical history or attitude towards treatment.
Conclusions. Severe, suicidal and psychotic depression cluster in psychiatric in-patient settings, as expected. However, MDD patients in primary care or psychiatric out-patient settings may not differ markedly in their clinical characteristics. This apparent blurring of boundaries between treatment settings calls for enhanced cooperation between settings, and clearer and more structured division of labour.