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Depression and suicidal behaviour - gender issues and management
Abstract
Depression may be a sufficient but not a necessary condition for either suicide or attempted suicide. However, it is the depressive aspect of psychopathology which has been consistently found to be related to suicidality. Depression may be present before or during or after suicidality and its role and function may change according to various factors. The relationship between depression and suicidality is extremely important and simultaneously complex. This chapter will examine some of the most important studies on the links of depression to suicidality in adults. It will focus on an often-forgotten vulnerability: gender. It will present clinically useful findings from selected reviews and studies, both cross-sectional and longitudinal. This chapter also examines the treatment options for those who are depressed and or suicidal. Some case-histories are used as illustrative examples.
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Growing out of work at the (Los Angeles) Suicide Prevention Center, a theoretical re-examination of the concepts of death and suicide is proposed. In lieu of "death" and "suicide," other concepts are developed: Cessation (final); interruption (periodical); and continuation (modal, partial, critical, and focal). Examples of behaviors and psychological states for each of these are given. A set of cross-behavioral congruencies focusing especially on the similarities between sleep phenomena (seen as interruption) and self-destructive phenomena (seen as cessation), is developed under the headings of beliefs, motives, affects, cognitive patterns, sociocultural influences, etc. In addition, relevant sources of data––primarily from a variety of types of personal documents and anamnestic data––for each type of behavior are suggested. The focus of the paper is the investigation of cessation (death and suicidal) phenomena through the study of paradigmatically useful interruption and continuation states. (35 ref.)
To investigate the differential impact of DSM-IV axis-I and axis-II disorders on completed suicide and to study if psychiatric comorbidity increases the risk of suicide in currently and previously hospitalized psychiatric patients.
A nested case-control design based on case notes from 136 suicides and 166 matched controls. All cases and controls were rediagnosed using the SCID-CV for axis-I and the DSM-IV criteria for axis-II disorders and the inter-rater reliability was satisfactory. Raters were blind to the case and control status and the original hospital diagnoses.
Depressive disorders and bipolar disorders were associated with an increased risk of suicide. No such effect was found for comorbidity between axis-I disorders and for comorbidity between axis-I and axis-II disorders.
Psychiatric diagnoses, although made using a structured and criteria-based approach, was based on information recorded in case notes. Axis-II comorbidity could only be investigated at an aggregated level.
Psychiatric comorbidity did not predict suicide in this sample. Mood disorders did, however, increase the risk significantly independent of history of previous suicide attempts. Both findings can inform identification and treatment of patients at high risk for completed suicide.
Despite voluminous research on the role of hopelessness and depression in suicidality, a systematic examination of various causal models pertaining to these variables is conspicuous in its absence.
The directions of relationships between the three variables were examined by means of a prospective-longitudinal, cross-lagged, three-wave design in a severely suicidal young adults.
Structural Equation Modeling (SEM) analyses revealed synchronous, but not longitudinal, associations between hopelessness, depressive symptoms, and suicidal ideation.
In severely suicidal young adults, the three clinical constructs appear to constitute a single depressive syndrome.
To consider 2 current controversies about the treatment of depressed suicidal patients: 1) whether they are undertreated by physicians and 2) whether the increase in antidepressant prescribing in recent years is responsible for the observed fall in suicide rates in some countries.
Systematic review of the literature. Analysis of Canadian data.
There is evidence that depressive illness in suicidal persons has been undertreated, but there has been improvement, possibly in response to enhanced public and professional awareness. There continues to be public resistance to taking antidepressants and (among men) to seeking professional help for suicidal depression. Because of inconsistencies, the epidemiologic evidence (although sometimes compelling) remains inconclusive for attributing the decline in suicide rates in some countries to the increase in new-generation antidepressants supply.
Physicians should aggressively pursue recognition and treatment of depression and suicidality but not put their entire faith in medication. Suicide is the product of complex factors that become the person's individual predicament, some of them beyond the capacity of antidepressant drugs to control. The physician should endeavour to assist the patient either to alter the personal predicament or to come to terms with it, as well as prescribing medication appropriately.
To examine the role of depressive symptoms and disorders as associates and predictors of suicidal acts across adolescence.
A representative sample of Norwegian school students (N = 2464, mean age 13.7 years) in grades 8 and 9 was reassessed after one year (T2) with the same questionnaire. All high scorers of depressive symptoms on the Mood and Feelings Questionnaire (MFQ) at T2 were defined as cases. One control from low or middle scorers, matched for age and gender, was randomly assigned to every two cases. This subset (n = 345) was diagnostically assessed by face-to-face K-SADS-PL interviews (mean age = 14.9 years). The same subset was reassessed after 5 years (T3) by using the same questionnaire (n = 252, mean age = 20.0 years) and telephone K-SADS-PL interviews (n = 242). The participation rate was 76.9% (n = 265).
Cognitive symptoms dominated the depressive symptom profile among suicide attempters, irrespective of age and time. Among younger adolescents, suicidal thoughts and acts of self-harm without suicidal intent were associated with suicidal acts. Recurrent thoughts about death, hopelessness, disturbed concentration and middle insomnia were associates of suicidal acts among older adolescents. Worthlessness by 15 years was a significant predictor of suicidal acts between 15 to 20 years. MDD and a depressive episode, not otherwise specified, continued to be significant associates among younger adolescents, while dysthymia by 15 years remained a predictor of suicidal acts between 15 to 20 years, even when controlled for depressive symptoms.
Self-harm without suicidal intent, middle insomnia, cognitive depressive symptoms and a formal psychiatric diagnosis of any depressive disorder should alert professionals in the risk assessment of suicidal adolescents.
Sixty-three adolescent suicide victims with a history of affective illness were compared to 23 adolescent community controls with a lifetime history of affective illness, using a case-control design. Suicide victims were more likely to have had major depression, comorbid substance abuse, a past suicide attempt, family history of major depression, treatment with a tricyclic antidepressant, history of legal problems, and a handgun available in the home. There was a non-significant trend for bipolar depression to convey a higher risk for completed suicide than unipolar depression. Recommendations for the prevention of suicide among those with early onset affective illness are discussed in light of these findings.
A common sense view in psychotherapy holds that there are individual differences in response to different treatments. However, despite considerable effort, no clear rationale exists to guide the selection of therapy for individual patients.
Rather than focusing on specific components of therapy as a basis to predict interactions between patients and treatments, we draw on motivational concordance theory and a contextual model of psychotherapy to test whether, in an analogue study, perceived effectiveness of different therapy vignettes is related to human values.
Two samples (undergraduates and members of the public) read short vignettes, informed by six therapies for depression (cognitive behaviour therapy, client-centred therapy, antidepressant medication, existential psychotherapy, psychodynamic psychotherapy, and a complementary medicine: Bach flower essences), provided ratings of perceived effectiveness, and completed questionnaire measures of dispositional motivations (Schwartz Values Scale and the Spiritual Connection Questionnaire-14). Responses were analysed using multidimensional scaling (MDS).
In both samples, expectancy for the cognitive behavioural-informed vignette was related to Self-direction and Stimulation, and was opposed to Tradition, Conformity and Security. Expectancies for the Drug vignette were associated with Power and Security.
People perceive therapies as more effective if the therapy is congruent with their values. These preliminary data suggest motivational concordance is a useful framework for predicting client-treatment interactions.
To determine the specificity to major depressive disorder (MDD) of a wide array of psychosocial risk factors in older adolescents (aged 14 through 18 years).
Diagnostic and psychosocial assessments were conducted with 1,507 randomly selected high school students at T1 and after approximately 1 year (T2). Three diagnostic groups were compared: those who had an episode of MDD during that year (n = 90), those who had an episode of substance use disorder during that year (SUD) (n = 42), and a control group with no disorder (n = 1,189).
Risk factors specific to MDD were stress (minor and major events), emotional reliance, physical symptoms and disease, history of suicide attempt, and a past episode of depression or anxiety disorder. Risk factors specific to SUD were tobacco use, academic difficulties, and a past episode of SUD. Risk factors that were shared were current depression symptoms, internalizing and externalizing behavior problems, coping skills, interpersonal conflict with parents, and dissatisfaction with grades.
By determining the number of risk factors for MDD, for SUD, or those that are general to both disorders, clinicians can make informed predictions concerning the probable future onset of a full-fledged episode of MDD and/or SUD in individual cases. The results of this study allow for the identification of adolescents who are at elevated risk for MDD and SUD. The results also have implications for the design of interventions aimed at preventing the occurrence of these disorders. Such interventions should target change on risk factors of the type identified in this study.
Rates and psychosocial risk factors for suicide attempts during a 6 to 8-year follow-up period were compared for 25 predominantly prepubertal inpatient suicide attempters, 28 inpatient suicidal ideators, 16 nonsuicidal inpatients, and 64 nonpatients.
Standard research instruments were used to interview subjects and parents. Cox proportional hazard regression analyses were used to identify risk factors for a suicide attempt in the follow-up.
No deaths occurred during follow-up. Suicide attempters were six times and suicidal ideators were three times more likely than were nonpatients to attempt suicide during follow-up. Poor social adjustment and mood disorder close to a recurrent suicide attempt were the strongest risk factors.
Risk assessment should focus on identifying symptoms of mood disorders and impaired social adjustment in children with histories of suicide attempts and psychiatric hospitalization.
The goal of this study was to investigate the stability and correlates of adolescent suicidal risk across adolescence.
Suicidal risk was studied longitudinally in N = 593 subjects in 1994, 1997, and 2001 at mean ages of 13, 16, and 20 years. Three partly overlapping suicidal risk groups were compared to three control groups matched by age and gender regarding behavioural and emotional problems, number and impact of life events, coping capacities, self-related cognitions, and the size and efficiency of the social network. Psychiatric diagnoses were obtained in young adulthood.
The group stability of suicidal risk was 43% from time 1 to time 2 and 18% from time 1 to time 3. Intra-individual stability of suicidal risks across adolescence was significantly higher than expected. At all three times of assessment, there was a clear excess of abnormal psychosocial findings in the suicidal risk groups as compared to the matched controls. Substance abuse disorders, depressive disorders, phobias and any psychiatric disorders in young adulthood were predicted by suicidal risk in preadolescence irrespective of behavioural and emotional disorders.
Suicidal risk individuals are remarkably stable across adolescence and show a very consistent pattern of associated behavioural and emotional problems and psychosocial variables across time from preadolescence to young adulthood. They also display an increased risk for some mental disorders in young adulthood.
The authors discuss the active engagement of suicidally depressed individuals in several interpersonal processes that elicit the rejection of others and withdrawal of interpersonal support. In addition, such processes may increase future risk for suicidal behavior. These processes include ways in which suicidal individuals group themselves (e.g., assortative relationship formation) and relate to others (e.g., help negation, negative feedback seeking, excessive reassurance seeking). Implications of these behaviors for the therapeutic setting are discussed, as well as potential ways to respond to and treat them.
Age of onset of major depression seems to be dropping in Western nations. Early onset usually predicts a more serious illness with a relatively poor prognosis. Since depression is associated with suicide, this begs the question of whether early onset of depression is associated with the degree of intent of suicidal behaviour, and whether this relationship differs according to gender.
Relevant responses from 9,282 residents of the United States were drawn from a nationally representative community survey conducted in 2001 through 2003 using the W.H.O. version of the Composite International Diagnostic Interview. The primary outcome measure was the retrospectively determined age of first major depressive episode.
Younger age of onset for depression was associated with higher levels of suicidal intent, irrespective of age at the time of interview. A significant interaction between level of intent and age at interview appeared to be accounted for by the later onset among those in the eldest cohort who reported an absence of suicidal behaviour. The influence of suicidal intent on onset of depression was greater for women than for men.
The earlier the age of first symptoms of major depressive episode, the higher the degree of suicidal intent, irrespective of age at interview and gender, although the more pronounced trend for women suggests a greater sensitivity to underlying factors that may involve depression and lead to suicide risk.