Suicidality and the economic crisis in Greece - Authors’ reply

Abstract

The time series published in July, 2012, by the Greek Statistics Authority does not suggest any increase in suicide rates throughout the decade: the number of completed suicides for 2010 was 377, similar to that of 2009 (391) and 2008 (373).
As we have suggested, and Economou and colleagues agree, attempts and reported attempts or suicidal thoughts are quite different from completed suicides. Although it is good news that so far there is no increase in completed suicides, it is important to note that Greece experienced extreme indices of crisis
(eg, unemployment rate above 17%) only after late 2011, so any conclusions might be immature.

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Correspondence
www.thelancet.com Vol 380 July 28, 2012 337
there are data that suggest improved
congestive heart failure outcomes
while patients are taking thyroxine
compared with when they are not,3
and one study4 has shown that serum
TSH concentrations of 10 mU/L or
above are a risk factor for progression
to overt thyroid failure even in people
aged 65 years and older, suggesting
benefi t of treatment in this group
of patients, consistent with the
recommendations in our Seminar.
Also consistent with our recom-
mendations to consider treatment in
younger and middle-aged people with
serum TSH between 5 and 10 mU/L, but
not older people, is a paper published
after ours appeared,5 showing that there
were fewer ischaemic heart disease
events in a cohort aged 40–70 years
with mild subclinical hypothyroidism
who were treated with levothyroxine,
but no benefi t in patients with similar
TSH concentrations who were older
than 70 years.
We are not surprised that the
recommendations in our Seminar
raised serious and legitimate con-
cerns, because the management
of subclinical thyroid disease will
remain a subject of discussion and
controversy until the results of the two
randomised trials to assess treatment
of subclinical hypothyroidism are
available. It is unfortunate that there
are evidently still no planned trials to
examine the treatment of subclinical
hyperthyroidism—an equally problem-
atic, albeit less common, disorder.
We declare that we have no confl icts of interest.
*David S Cooper, Bernadette Biondi
dscooper@jhmi.edu
Division of Endocrinology and Metabolism,
Johns Hopkins University School of Medicine,
Baltimore, MD 21287, USA (DSC); and Department
of Clinical and Molecular Endocrinology and
Oncology, University of Naples Federico II, Naples,
Italy (BB)
1 Bahn RS, Burch HB, Cooper DS, American
Thyroid Association, American Association of
Clinical Endocrinologists. Hyperthyroidism and
other causes of thyrotoxicosis: management
guidelines of the American Thyroid
Association and American Association of
Clinical Endocrinologists. Thyroid 2011;
21: 593–646.
2 Collet TH, Gussekloo J, Bauer DC, et al, for the
Thyroid Studies Collaboration. Subclinical
hyperthyroidism and the risk of coronary heart
disease and mortality. Arch Intern Med 2012;
172: 799–809.
Nanchen D, Gussekloo J, Westendorp RG, et al,
for the PROSPER Group. Subclinical thyroid
dysfunction and the risk of heart failure in
older persons at high cardiovascular risk.
J Clin Endocrinol Metab 2012; 97: 852–61.
Somwaru LL, Rariy CM, Arnold AM,
Cappola AR. The natural history of subclinical
hypothyroidism in the elderly: the
Cardiovascular Health Study.
J Clin Endocrinol Metab 2012; 97: 1962–69.
Razvi S, Weaver JU, Butler TJ, Pearce SH.
Levothyroxine treatment of subclinical
hypothyroidism, fatal and nonfatal
cardiovascular events, and mortality.
Arch Intern Med 2012; 172: 811–17.
3
4
5
which usually pertains to correlating
aggregated estimates of suicide and
unemployment without adequately
addressing ecological and contextual
confounding. Furthermore, reports
by the Hellenic Statistical Authority5
have documented a 19% increase in
recorded cases of completed suicides
from 2007 to 2009 nationwide.
The 5 years Fountoulakis and
colleagues rightly require for drawing
epidemiological conclusions might
be too long if people have died3 in
the meantime owing to a dearth of
preventive strategies for suicide.
We declare that we have no confl icts of interest.
*Marina Economou,
Michael Madianos, Lily E Peppou,
Christos Theleritis, Costas N Stefanis
antistigma@epipsi.eu
University Mental Health Research Institute (UMHRI),
University of Athens, 11527 Papayou, Athens, Greece
(ME, LEP, CT, CNS); and Department of Mental Health
& Behavioural Sciences, School of Health Sciences,
University of Athens, Athens, Greece (MM)
1 Fountoulakis KN, Grammatikopoulos IA,
Koupidis SA, Siamouli M, Theodorakis PN.
Health and the fi nancial crisis in Greece. Lancet
2012; 379: 1001–02.
Economou M, Madianos M, Theleritis C,
Peppou LE, Stefanis CN. Increased suicidality
amid economic crisis in Greece. Lancet 2011;
378: 1459.
Anon. Suicides up 22.5 percent in last three
years. ekathimerini.com Jan 11, 2012. http://
www.ekathimerini.com/4dcgi/_w_articles_
wsite1_1_11/01/2012_422174 (accessed
March 22, 2012).
Madianos M, Economou M, Alexiou T,
Stefanis C. Depression and economic hardship
across Greece in 2008 and 2009: two
cross-sectional surveys nationwide.
Soc Psychiatry Psychiatr Epidemiol 2011;
46: 943–52.
Hellenic Statistical Authority. Annual vital
statistic report. Piraeus: Hellenic Statistical
Authority, 2011.
2
3
4
5
Suicidality and the
economic crisis in Greece
Konstantinos Fountoulakis and col-
leagues (March 17, p 1001)1 state
that there is no evidence of a causal
link between the economic crisis and
suicide in Greece. Although only a
cohort study would enable causal
inferences, converging evidence from
diff erent sources points towards a
similar direction: eff orts should be
focused on prevention of suicides.2,3
In a previous Correspondence letter2
we noted a 36% increase, albeit non-
signifi cant, in the proportion of people
reporting attempted suicide between
2009 and 2011. Yet as Fountoulakis
and colleagues acknow ledge, in 2009
“Greece had begun to see indices of
extreme fi nancial crisis”. A similar
survey before the crisis4 showed that
the proportion of attempted suicides
in 2008 was 0·6%, which is signifi cantly
lower than for 2009 (1·1%) and 2011
(1·5%). We agree that a reported suicide
attempt is not equivalent to suicide;
nonetheless, this fi nding indicates
a substantial change, which can be
accounted for by the onset of the crisis.
To support this
we provided further evidence in
our previous letter to confi rm an
association between fi nancial hard-
ship and suicidality.2 This fi nding
is important because it is not
susceptible to ecological
assumption,
fallacy,
Authors’ reply
Essentially we agree with Marina
Economou and
reducing suicide rates, or preventing
their rise, are challenges not only for
psychiatry but for the whole of society.
The time series published in July, 2012,
by the Greek Statistics Authority1 does
not suggest any increase in suicide
rates throughout the decade: the
number of completed suicides for 2010
was 377, similar to that of 2009 (391)
colleagues that
De Russe Axelle/ABACA/Press Association Images
See World Report page 326

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Correspondence
338
www.thelancet.com Vol 380 July 28, 2012
and 2008 (373). As we have suggested,
and Economou and colleagues agree,
attempts and reported attempts or
suicidal thoughts are quite diff erent
from completed suicides. Although
it is good news that so far there is
no increase in completed suicides,
it is important to note that Greece
experienced extreme indices of crisis
(eg, unemployment rate above 17%)
only after late 2011, so any conclusions
might be immature.
Although we think that it might take
years before one can confi rm or reject
an increase in the suicide rate, we
agree with Economou and colleagues
that by then it might be too late and
there is an urgent need for intensive
screening, follow-up, and treatment
of people with suicidal ideation. Often
caring for public health might imply
forecasting rather than confi rmation
of statistics since human lives and not
numbers are at risk.
A substantial decline in suicide
rates throughout Europe, the USA,
and Canada has happened in the
past two decades;2 however, with
the global economic crisis, the future
of these rates is unknown. Targeted
interventions of proven effi cacy
should be applied, including specifi c
psychoeducational
They should use long-term and
repeated interventions as well as
community networking, and should
not be restricted to gatekeepers’
training and general (theoretical)
education of the public.
programmes.3
We declare that we have no confl icts of interest.
*Konstantinos N Fountoulakis,
Melina Siamouli,
Ilias A Grammatikopoulos,
Sotirios A Koupidis,
Pavlos N Theodorakis
kfount@med.auth.gr
3rd Department of Psychiatry, School of Medicine,
Aristotle University of Thessaloniki, 54634
Thessaloniki ,Greece (KNF, MS); Private Practice,
Thessaloniki, Greece (IAG); Evaggelismos General
Hospital, Athens, Greece (SAK); Social Cooperative,
“New Horizons”, Corfu Mental Health Sector,
Corfu, Greece (SAK); and Social Cooperative,
8th Athens Mental Health Sector, Athens,
Greece (PNT)
1 Hellenic Statistical Authority. Vital statistics:
deaths. http://www.statistics.gr/portal/page/
portal/ESYE/PAGE-themes?p_param=A1605
(accessed July 10, 2012).
Henriques GR, Brown GK, Berk MS, Beck AT.
Marked increases in psychopathology found in
a 30-year cohort comparison of suicide
attempters. Psychological Med 2004;
34: 833–41.
Fountoulakis KN, Gonda X, Rihmer Z. Suicide
prevention programs through community
intervention. J Aff ect Disord 2010; 130: 10–16.
2
3
to the sIL-6R and this complex can
stimulate all cell s of the body via gp130
alone.4 Specifi c inhibition of inter leukin
6 trans-signalling by an sgp130-Fc
fusion protein is suffi cient to block
the development of atherosclerosis in
mice, underlining the proinfl ammatory
role of interleukin 6 trans-signalling via
the sIL-6R.5
We therefore think that the decreased
risk of coronary heart disease in homo-
zygous carriers of the rs7529229
SNP is not necessarily due to reduced
interleukin 6 signalling on hepatocytes,
monocytes, and macrophages but to
a more effi cient buff ering of secreted
interleukin 6 by the sIL-6R/sgp130
system and consequently to lower
overall interleukin 6 activity.
We declare that we have no confl icts of interest.
Jürgen Scheller, *Stefan Rose-John
rosejohn@biochem.uni-kiel.de
Institute of Biochemistry and Molecular Biology II,
Medical Faculty, Heinrich-Heine University,
Düsseldorf, Germany (JS); and Institute of
Biochemistry, Medical Faculty, Christian-Albrechts-
University, 24098 Kiel, Germany (SR-J)
1 IL6R Genetics Consortium Emerging Risk
Factors Collaboration. Interleukin-6 receptor
pathways in coronary heart disease: a
collaborative meta-analysis of 82 studies.
Lancet 2012; 379: 1205–13.
The Interleukin-6 Receptor Mendelian
Randomisation Analysis (IL6R MR)
Consortium. The interleukin-6 receptor as a
target for prevention of coronary heart
disease: a mendelian randomisation analysis.
Lancet 2012; 379: 1214–24.
Boekholdt SM, Stroes ES. The interleukin-6
pathway and atherosclerosis. Lancet 2012;
379: 1176–78.
Jones SA, Scheller J, Rose-John S. Therapeutic
strategies for the clinical blockade of IL-6/gp130
signaling. J Clin Invest 2011; 121: 3375–83.
Schuett H, Oestreich R, Waetzig GH, et al.
Transsignaling of interleukin-6 crucially
contributes to atherosclerosis in mice.
Arterioscler Thromb Vasc Biol 2012; 32: 281–90.
2
3
4
5
Why a Youth Commission
on Global Governance for
Health?
The University of Oslo and The Lancet
is announcing a Youth Commission
on Global Governance for Health.
The initiative follows The Lancet–
University of Oslo Commission on
The interleukin 6
pathway and
atherosclerosis
Two Articles (March 31, pp 1205
and 1214)1,2 showed that the single
nucleotide polymorphism
rs7529229 of the interleukin 6 receptor
(IL-6R D358A), which results in higher
serum concentrations of the soluble
IL-6R (sIL-6R), is connected to a lower
risk of coronary heart disease. As
an explanation, the accompanying
Comment3 states that the point
mutation led to increased cleavage
of the IL-6R from the cell surface
of hepatocytes,
macrophages and concomitantly to
less interleukin-6-induced signalling by
these cells.
We would like to put forward
an alternative explanation. Inter-
leukin 6 is present in the blood at a
con cen tration of 1–5 ng/L, the sIL-6R
at a concentration of around 50 μg/L,
and a soluble form of gp130 (sgp130)
at a concentration of 100–200 μg/L.4
Secreted interleukin 6 will bind
to sIL-6R, and the interleukin-6/
sIL-6R complex will bind to sgp130,
which is the natural inhibitor of
this complex.4 An increase in sIL-6R
caused by the SNP will lead to
increased buff er capacity for secreted
interleukin 6 and therefore to reduced
interleukin 6 activity. Interleukin 6
acts on cells such as hepatocytes,
monocytes, and macrophages via
the membrane-bound IL-6R and the
ubiquitously expressed receptor gp130.
Alternatively, by a mechanism called
trans-signalling, interleukin 6 can bind
(SNP)
monocytes, and
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