ArticleLiterature Review

Suicidal disorders: A nosological entity per se?

Authors:
  • Université Paris-Est Créteil Val de Marne - Inserm- AP-HP
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Abstract

An extensive body of data has repeatedly shown in the past decades that suicidal behaviors are associated with several external validators such as low serotonergic activity in body fluids and in brains of suicide victims, genetic transmission of suicide risk independently of transmission of associated major psychiatric disorders, and more recently association with several serotonin-related genes. Despite these concordant findings, suicidal behaviors are still not considered as a nosological entity per se in standardized classification. The aim of this study is to review the existing literature establishing the validity of this entity through clinical, genetic, biochemical, and therapeutic arguments all leading to the need to recognizing suicidal behavior as an independent and possibly dimensional clinical entity.

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... Are suicidal and substance abuse behaviors dimensional and continuously distributed, with quantitative (but not qualitative) differences based on levels of severity or between continua of severity, with "pathological" and "non-pathological" existing at opposite ends of the distribution but without clear cut points? In contrast, are there actual cut points that demarcate discrete taxa or diagnostic subgroups (Hill, 2002;Hinshaw et al. 2002;Leboyer et al. 2005)? Arguably, psychopathology has properties that are amenable to dimensional and categorical assessment, and therefore both types of assessment should be used. ...
... Recent fi ndings show that a dimensional analysis of suicidal behavior and related risk factors yield dimensions that are opposite and independent, such as under-versus over-engagement and rejection-turmoil (Hyde et al. 2005). Furthermore, it may be the case that suicidal behavior is itself an independent clinical outcome with both dimensional and categorical properties (Leboyer et al. 2005;Windle, 2004). ...
... While formal diagnostic entities exist in the Diagnostic and Statistical Manual of Mental Disorders, the evidence is mixed regarding how these and other diagnostic categories, obtained from psychiatric interviews, relate to suicidal behavior and risk factors for suicide (see DSM-IV-TR, APA, 2000;Leboyer et al. 2005). For example, DSM criteria for a psychiatric disorder such as Major Depressive Episode states that a specifi c number of symptoms (5 or more of 9 symptoms) must be present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms must be either depressed mood or loss of pleasure or interest. ...
Article
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Adolescent suicidal behaviors and substance use are disturbingly common. Research suggests overlap of some of the etiological mechanisms for both adolescent suicidal behavior and substance use, yet clear understanding of the complex relations between these behaviors and their causal underpinnings is lacking. A growing body of evidence and a diathesis model (Mann et al. 1999; Mann, 2003) highlight the importance of impulse control as a proximal risk factor for adolescent suicidal and substance use behaviors. This literature review extends current theory on the relationships between adolescent suicidal behavior and substance use by: (1) examining how, when, and to what extent adolescent development is affected by poor impulse control, stressful life events, substance use behavior, and biological factors; (2) presenting proposed causal mechanisms by which these risk factors interact to increase risk for suicidal behaviors and substance use; and (3) proposing specific new hypotheses to extend the diathesis model to adolescents at risk for suicide and substance use. More specifically, new hypotheses are presented that predict bidirectional relationships between stressful life events and genetic markers of 5-HT dysregulation; substance use behavior and impulsivity; and substance use behavior and suicide attempts. The importance of distinguishing between different developmental trajectories of suicidal and substance use behaviors, and the effects of specific risk and protective mechanisms are discussed. Use of new statistical approaches that provide for the comparison of latent growth curves and latent class models is recommended to identify differences in developmental trajectories of suicidal behavior and substance use. Knowledge gained from these prospective longitudinal methods should lead to greater understanding on the timing, duration, and extent to which specific risk and protective factors influence the outcomes of suicidal behavior and substance use. In turn, findings from these studies should inform researchers who conduct future treatment and prevention studies.
... However, despite being correlated with depression, recent evidence suggests that suicidal ideation may be more than a symptom or mere consequence of an affective disorder. Leboyer and colleagues [9] noted that suicidal thoughts and behaviour might constitute a potentially isolated psychological phenomenon, partially independent from other expressions of psychopathology [10,11]. Diefenbach and colleagues [12] interpreted their results in a similar way and stated that suicidal ideation may be associated with nonspecific subclinical psychopathological features such as emotional instability, together with anxiety, social inhibition, and possibly hostility and negative affectivity. ...
... Recent research indicates that suicidal thoughts and behaviour are not merely parts or symptoms of a depressive disorder but represent a nosological entity in their own right [9][10][11][12]14,15,17]. This suggests that it cannot be assumed that psychotherapy for depressive disorders will be equally effective in reducing suicidal thoughts and behaviour [19]. ...
... Although it seems plausible to assume that psychological treatments for depression not only affect depressed affect but also SI, this assumption has lately been called into question (Cuijpers et al., 2013). Recent research suggests that suicidal thoughts and behavior are not merely a part or a symptom of a depressive disorder but represent a separate nosological entity (Ahrens and Linden, 1996;Ahrens et al., 2000;Forkmann et al., 2013;Kendel et al., 2010;Leboyer et al., 2005;Van Orden et al., 2011). Cuijpers et al. (2013) found in a recent meta-analysis only three randomized controlled studies for adult depression in which SI and suicidal behavior was used as a clearly specified outcome measure. ...
... However, our results also show that both MBCT and CBASP can have an additional effect on suicidality above that of change in depression. This result corroborates the view that it cannot be assumed that depression focused interventions will be effective in reducing suicidal thoughts and behavior (Cuijpers et al., 2013) and that suicidal thoughts and behavior are not merely a part or a symptom of a depressive disorder but represent a separate nosological entity (Ahrens and Linden, 1996;Ahrens et al., 2000;Forkmann et al., 2013;Kendel et al., 2010;Leboyer et al., 2005;Van Orden et al., 2011). ...
Article
Background: Suicidal ideation (SI) is common in chronic depression, but only limited evidence exists for the assumption that psychological treatments for depression are effective for reducing SI. Methods: In the present study, the effects of Mindfulness-based Cognitive Therapy (MBCT; group version) plus treatment-as-usual (TAU: individual treatment by either a psychiatrist or a licensed psychotherapist, including medication when indicated) and Cognitive Behavioral Analysis System of Psychotherapy (CBASP; group version) plus TAU on SI was compared to TAU alone in a prospective, bi-center, randomized controlled trial. The sample consisted of 106 outpatients with chronic depression. Results: Multivariate regression analyses revealed different results, depending on whether SI was assessed via self-report (Beck Depression Inventory suicide item) or via clinician rating (Hamilton Depression Rating Scale suicide item). Whereas significant reduction of SI emerged when assessed via clinician rating in the MBCT and CBASP group, but not in the TAU group while controlling for changes in depression, there was no significant effect of treatment on SI when assessed via self-report. Limitations: SI was measured with only two single items. Conclusions: Because all effects were of small to medium size and were independent of effects from other depression symptoms, the present results warrant the application of such psychotherapeutical treatment strategies like MBCT and CBASP for SI in patients with chronic depression.
... Low levels of 5-hydroxyindoleacetic acid (5-HIAA), the main 5-HT metabolite, in cerebrospinal fluid (CSF) have been found in persons who had made a violent suicide attempt [S34]. It has been suggested that low CSF 5-HIAA is specific to suicide as it was found only in suicidal patients [12]. It has been postulated that this biochemical trait may be considered a predictor of suicide attempts and completions; it is consistent with low postmortem brainstem levels of 5-HIAA in suicide victims [6]. ...
... a Schematic human brain, sagittal section; b 9chematic human brain, external view. PFC prefrontal cortex [10,15,21,22, S23, S25, S29, S31, S53, S58, S63, S76, S82, S91-S93, S98, S110], VPFC ventral prefrontal cortex, including the orbitofrontal cortex [8,[11][12][13], S33, S37, S85, S87, S88, S95, S99, S104, S105], DLPFC dorsolateral prefrontal cortex [10,24,26, S43, S108, S109], Wernicke's area [20, S89], Hippocampus [18, 19, S58, S82, S85, S91, S94, S96, S98, S110, S111], Amygdale [S122], ACC anterior cingulate cortex [10, 25, S25, S120, S121], Adrenergic transmission has been hypothesized to play a role in suicide. The main findings related to the decreased noradrenalin levels in the brainstem and increased α2adrenergic receptor densities due to a noradrenaline deficit [11]. ...
Article
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Clinical risk factors have a low predictive value on suicide. This may explain the increasing interest in potential neurobiological correlates and specific heritable markers of suicide vulnerability. This review aims to present the current neurobiological findings that have been shown to be implicated in suicide completers and to discuss how postmortem studies may be useful in characterizing these individuals. Data on the role of the main neurobiological systems in suicidality, such as the neurotransmitter families, hypothalamic-pituitary-adrenal axis, neurotrophic factors, and polyamines, are exposed at the different biochemical, genetic, and epigenetic levels. Some neuroanatomic and neuropathological aspects as well as their in vivo morphological and functional neuroimaging correlates are also described. Except for the serotoninergic system, particularly with respect to the polymorphism of the gene coding for the serotonin transporter (5-HTTLPR) and brain-derived neurotrophic factor, data did not converge to produce a univocal consensus. The possible limitations of currently published studies are discussed, as well as the scope for long-term prospective studies.
... SB is a complex entity, involving biological, genetic and environmental risk factors. Research aiming at the identification of risk factors (especially biological and genetic studies) is hampered by the heterogeneity of SB (Leboyer et al., 2005;Malafosse, 2005). Many explanatory models of SB have been proposed. ...
... Overall, these studies suggest that violent and serious SB may constitute subgroups with specific risk factors and outcome. Considering those arguments which strengthen the diagnostic validity of SB, it has been recently suggested that suicidal behavior may represent a specific nosological entity (Leboyer et al., 2005), and that SB should be considered as a separate diagnostic category in the further DSM-V (Oquendo et al., 2008). ...
Article
Suicidal behavior is a heterogeneous entity, determined by multiple factors. This heterogeneity has major implications for clinical management of patients and identification of risk factors. Our study aims at identifying homogeneous subgroups of patients with suicidal behavior. We used two validated questionnaires to assess the intent (Suicidal Intent Scale, SIS) and lethality (Risk-Rescue Rating Scale, RRRS) of the most severe suicide attempt in a sample of 608 patients recruited consecutively. We first explored the factorial structure of the two scales, using a principal component analysis, and then tested the relationship between sub-scores identified and subtypes of suicide attempts (violent, serious overdose) using a backward logistic regression. A four-factor structure was retained for the SIS (conception, preparation, precautions and communication). The RRRS, for which a factorial structure has not been previously published, had a three-factor structure (medical damage, implementation and rescue conditions). This structure was valid, stable and clinically relevant. Serious suicide attempts were characterized by less communication and more precautions against discovery, whereas violent attempts were associated with higher risk acts. Neither violent nor serious attempts were characterized by more planning. The SIS and RRRS were assessed retrospectively, and so could have been influenced by recall bias. Finally, censoring bias may have affected our results. The characterization of suicidal behaviors using SIS and RRRS sub-scores constitutes a first step toward the identification of homogeneous subgroups of suicide attempters. Prospective studies are needed to test the predictive value of these sub-scores for subsequent suicidal acts.
... Le « trouble suicidaire » n'est à ce jour toujours pas reconnu, comme une entité nosologique à part entière dans les classifications standardisées (Leboyer, Slama, Siever, Bellivier, 2005). En effet, la notion de trouble correspond à une définition précise au sens des classifications standardisées, tels le DSM-IV ou la CIM-10, que le suicide ne remplit pas encore officiellement. ...
Thesis
Childhood maltreatment and genes underlie vulnerability to suicidal behaviours (SB), possibly by affecting the constitution of endophenotypes such as anger traits. The CREB protein has been implicated in antidepressant response, suicide and mood disorders in general. The aim of this study was to investigate if CREB1 gene is associated with SB and/or anger-related traits and if these associations are modulated by childhood maltreatment. Five hundred and thirty-four male suicide attempters and 357 male non-suicide attempters were genotyped for several polymorphisms within CREB1 gene. Four hundred and thirty-seven (156 non-suicide attempters and 281 suicide attempters) completed the State-Trait Anger Expression Inventory (STAXI) and 288 (265 suicide attempters and 23 controls) fulfilled the Childhood Trauma Questionnaire (CTQ). In total, 72 males had experienced childhood sexual abuse. Our results did not show any significant association between CREB1 and suicide behaviour. We found a significant interaction showing that CREB1 rs4675690 polymorphism modulated the effect of childhood sexual abuse on adulthood angerout levels (P = 0.003). Sexually abused subjects carrying the CC genotype showed higher anger-out scores than T allele carriers, whereas no difference was observed in non-sexually abused subjects. CREB1 rs4675690 polymorphism modulates the association between childhood sexual abuse and adulthood anger-trait level. This is, to our knowledge, the first study to show such an interaction and to highlight the main effect of this gene on modulating the effect of child abuse on psychopathologies andwarrant further investigation on this topic.
... First, the s allele of 5-HTTLPR is known to be associated with reduced transcriptional activity [26]. The resulting altered serotonergic signaling may, via platelet aggregation, influence the predisposition toward ACS and may mediate cognitive inflexibility and aggressive behavior [28], which would, in turn, impair the ability to cope with stressful events (e.g., an ACSrelated event). However, further studies on the underlying mechanisms of dysregulated serotonergic systems related to 5-HTTLPR and SI in ACS are required as other polymorphisms associated with serotonergic function (STin2 VNTR and 5-HTR2a polymorphisms) did not show any significant associations. ...
Article
Full-text available
The genetic predisposition toward suicidal ideation has been explored to identify subgroups at high risk and to prevent suicide. Acute coronary syndrome (ACS) is associated with an increased risk of suicide, but few studies have explored the genetic predisposition toward suicide in ACS populations. Therefore, this longitudinal study explored the genetic predisposition toward suicidal ideation in ACS patients. In total, of 969 patients within 2 weeks after ACS, 711 were followed at 1 year after ACS. Suicidal ideation was evaluated with the relevant items on the Montgomery-Åsberg Depression Rating Scale. Ten genetic polymorphisms associated with serotonergic systems, neurotrophic factors, carbon metabolism, and inflammatory cytokines were examined. Associations between genetic polymorphisms and suicidal ideation within 2 weeks and 1 year of ACS were investigated using logistic regression models. The 5-HTTLPR s allele was significantly associated with suicidal ideation within 2 weeks of ACS after adjusting for covariates and after the Bonferroni correction. TNF-a -308G/A, IL-1β -511C/T, and IL-1β + 3953C/T were significantly associated with suicidal ideation within 2 weeks after ACS, but these associations did not reach significance after the Bonferroni correction in unadjusted analyses and after adjusting for covariance. However, no significant association between genetic polymorphisms and suicidal ideation was found at 1 year. Genetic predisposition, 5-HTTLPR s allele in particular, may confer susceptibility to suicidal ideation in ACS patients during the acute phase of ACS.
... Suicidal behavior is defined as encompassing a broad semantic spectrum: from suicidal ideation, verbalization, planning, intent and self-harming to attempted suicides and their execution, i.e., committing suicide. Suicidal behavior is an etiologically complex phenomenon predicated on biological, environmental, developmental and learned factors [28][29][30][31]. With BAD, there is a high rate of suicidal risk of approximately 15 percent. ...
Article
Full-text available
The aim of study is to evaluate the impact of body dissatisfaction and obesity on suicide attempts in patients suffering from Bipolar Affective Disorder (BAD). The study included a cross-sectional cohort of patients diagnosed with BAD who were treated at Sveti Ivan Psychiatric Hospital in Zagreb. The studied group was composed of female patients in the remission phase of BAD, aged 18 to 65 years. Through evaluation of the Body Mass Index (BMI), patients were divided into two groups: the study group (BMI>30), and a control group (BMI ranging from 18 to 25). Following this segmentation, the patients filled out two questionnaires: a schematic perception test (Figure Rating Scale) to determine body dissatisfaction, and a modified Beck Scale for Suicidal Ideation to determine suicidal intensity. The study established a difference in body dissatisfaction between obese patients and patients with average body weight suffering from BAD. Higher BMI corresponded with higher dissatisfaction with body appearance. In addition, the study determined a statistically significant difference in suicidal intensity according to the Beck scale with regard to the level of satisfaction with body appearance. A significant correlation between dissatisfaction with body appearance and suicidal intensity according to the Beck Scale for Suicidal Ideation indicates that evaluation of dissatisfaction with body appearance could be used in daily clinical work as an indicator for suicidality in patients suffering from BAD. Statistically significant body dissatisfaction and a generally higher level of dissatisfaction, which have been confirmed as predictors of suicidality, were found in obese patients.
... Suicidal behavior is an important and grave social problem with complex and intricate clinical implications which might constitute the fi nal outcome of several psychiatric conditions (although it may also be an existential choice, in some cases) (Leboyer et al 2005). Among the neurotransmitters associated with neuropsychiatric disorders, noradrenaline and serotonin are closely associated with depression and suicide. ...
... The ventral prefrontal cortex is implicated in the behavioral and cognitive inhibition. The disrupted function of serotonin signaling in this region may mediate insufficient inhibition of aggressive behavior (Leboyer et al., 2005). There were numerous studies of serotonergic candidate genes, investigating simultaneously only few polymorphisms . ...
Article
Introduction: Studies have not given yet a clear answer what is the genetic background of suicidal predisposition. The associations between polymorphisms of the TPH1 and 5-HTTLPR genes and violent suicidal behavior was revealed with the least inconsistencies. Method: We selected 10 "strong candidate genes" and 35 SNPs, SLC6A4 and ACP1 for replication study. We searched associations between precisely described suicidal phenotype in 825 affective patients and polymorphisms of selected neurobiological pathways genes as well as their interactions that constitute suicidal risk. Results: The results confirm the role of TPH1, TPH2, 5HT2A, CRHR1 and ACP1 variants in the risk of suicidal behavior. Limitations: In our study we analyzed limited number of candidate genes and only one of them is linked to lithium mechanism of action. We had no data on pharmacological treatment of investigated patients and its relation to the time of suicide attempt. Conclusion: Our results indicate that polymorphisms of various signaling pathways are involved in the pathogenesis of suicidal behavior. Non-genetic factors are also involved in the risk of suicidal attempts.
... Risk factors for suicide are heritable: multiple lines of evidence -family, twin, and adoption studies (Baldessarini & Hennen 2004;Brent & Mann 2005); molecular genetical studies , supplemented by suggestive findings from geographical studies (Marušič 2005;Voracek & Formann 2004;Voracek et al. 2003) -converge to this conclusion (Bondy et al. 2006). And, finally, suicidal behavior may well be a distinct mental disorder: It is increasingly regarded as an independent, possibly dimensional, nosological entity (Leboyer et al. 2005). This emerging view is based mainly on genetic evidence that its transmission is noticeably independent of the transmission of the risk for mental disorders. ...
... Researchers evaluating the PHQ-9 in a population-based sample of older adults in Germany also noted problems with this item, reporting its low reliability and suggesting that suicidality may be only loosely related to depression (45). A group studying psychiatric genetics contended that suicidal behavior is more appropriately regarded as an independent clinical entity than as a symptom of major psychiatric disorders (46). As an indicator of depression severity, low self-worth was stronger at baseline than at follow-up. ...
Article
Context: Families of intensive care unit (ICU) patients are at risk for depression, and are important targets for depression-reducing interventions. Multi-item scores for evaluating such interventions should meet criteria for unidimensionality and longitudinal measurement invariance. The Patient Health Questionnaire (PHQ), widely used for measuring depression severity, provides standard nine-, eight-, and two-item scores. However, published studies often report no (or weak) evidence of these scores' unidimensionality/invariance, and no tests have evaluated them as measures of depression severity in ICU patients' families. Objectives: To identify multi-item PHQ constructs with promise for evaluating change in depression severity among family members of critically ill patients. Methods: Structural equation models with rigorous fit criterion (χ(2)P>0.05) tested the standard nine-, eight-, and two-item PHQ, and other item subsets, for unidimensionality and longitudinal invariance, using data from a trial evaluating an intervention to reduce depressive symptoms in family members. Results: Neither the standard nine-item nor eight-item PHQ construct showed longitudinal invariance, although the standard two-item construct and other item subsets did. Conclusion: The longer eight- and nine-item PHQ scores appear inappropriate for assessing depression severity in this population, with constructs based on smaller subsets of items being more promising targets for future trials. The CONSORT (Consolidated Standards of Reporting Trials) requirement for pre-specified trial outcomes is problematic because unidimensionality/invariance testing must occur after trial completion. CONSORT could be strengthened by endorsing rigorous assessment of composite scores and encouraging use of the most appropriate substitute, should trial-based evidence challenge the legitimacy of pre-specified multi-item scores.
... 17 As a heuristic model, one can consider a cascade from the studied phenotypic syndrome to the genes, with different levels of analysis: syndrome-mediating dimension/trait; self-report measure/clinical interview; laboratory behavioral task performance; cognitive task performance; psychophysiological task performance; functional, structural and neurochemical imaging; postmortem neurochemistry, cell structure, mRNA expression; genotype. 19 These complementary approaches, when used in the identification of endophenotypes for SB may provide convergent validity for the most promising endophenotypes, 17,[19][20][21] while noting that predicting rare events such as SB (especially completed suicides) adds to the difficulties of such research. 22,23 It is known from twin studies that genetic susceptibility factors, independent of an additional psychiatric diagnosis, modify the risk of SB. 6,24,25 Therefore, it is probable that genetically delineated endophenotypes exist that are asso-ciated with such behaviors. ...
Article
Vulnerability to suicidal behavior (SB) is likely mediated by an underlying genetic predisposition interacting with environmental and probable epigenetic factors throughout the lifespan to modify the function of neuronal circuits, thus rendering an individual more likely to engage in a suicidal act. Improving our understanding of the neuroscience underlying SBs, both attempts and completions, at all developmental stages is crucial for more effective preventive treatments and for better identification of vulnerable individuals. Recent studies have characterized SB using an endophenotype strategy, which aims to identify quantitative measures that reflect genetically influenced stable changes in brain function. In addition to aiding in the functional characterization of susceptibility genes, endophenotypic research strategies may have a wider impact in determining vulnerability to SB, as well as the translation of human findings to animal models, and vice versa. Endophenotypes associated with vulnerability to SB include impulsive/aggressive personality traits and disadvantageous decision making. Deficits in realistic risk evaluation represent key processes in vulnerability to SB. Serotonin dysfunction, indicated by neuroendocrine responses and neuroimaging, is also strongly implicated as a potential endophenotype and is linked with impulsive aggression and disadvantageous decision making. Specific endophenotypes may represent heritable markers for the identification of vulnerable patients and may be relevant targets for successful suicide prevention and treatments.
... Risk factors for suicide are heritable: multiple lines of evidence -family, twin, and adoption studies (Baldessarini & Hennen 2004;Brent & Mann 2005); molecular genetical studies , supplemented by suggestive findings from geographical studies (Marušič 2005;Voracek & Formann 2004;Voracek et al. 2003) -converge to this conclusion (Bondy et al. 2006). And, finally, suicidal behavior may well be a distinct mental disorder: It is increasingly regarded as an independent, possibly dimensional, nosological entity (Leboyer et al. 2005). This emerging view is based mainly on genetic evidence that its transmission is noticeably independent of the transmission of the risk for mental disorders. ...
... 17 Given this evidence, it has been proposed that SB in patients with MDD might represent a separate nosological (sub-)entity which might be independent of MDD itself. 16,18 However, considering the fact that SB is a highly complex human behavior, genetic effects are believed to act through intermediate phenotypes, which are conceptualized as mediators between genes and SB. 19 There are considerable data suggesting that impulsive-aggressive personality traits may act as such an intermediate phenotype of SB. 8 Dumais et al 20 and McGirr et al 21 reported that higher levels of impulsive behavior were related to increased suicide risk among patients with the same psychiatric diagnosis, such as major depression. ...
Article
Full-text available
Suicidal behavior (SB) is characterized by the occurrence of suicide attempts with substantial intent to die. SB is a major health problem worldwide. In the great majority of cases, SB occurs in patients suffering from psychiatric disorders, mainly from affective disorders or schizophrenia. Despite this high association, there is growing evidence from genetic studies that SB might represent a psychiatric condition on its own. This review provides an overview of the most significant neurobiological and neurocognitive findings in SB. We provide evidence for specific dysfunctions within the serotonergic system, for distinct morphological abnormalities in the gray and white matter composition as well as for neurofunctional alterations in the fronto-striatal network. Additionally, the putative role of impulsivity and hopelessness as trait-like risk factors for SB is outlined. Both the personality traits are associated with altered prefrontal cortex function and deficits in cognitive and affective control similar to the findings in SB. Given the difficulties of clinical risk assessment, there is a need to identify specific markers that can predict SB more reliably. Some recent neurocognitive and functional/structural neuroimaging findings might be appropriate to use as SB indicators in the close future.
... First of all, general limitations and methodological challenges related to ambulatory assessment methods (e.g., intrusiveness and participant burden, data security and privacy issues [12], data analysis [20], or item development [21]) apply to ambulatory assess-nomenon [17,18]. For clinicians, these findings underline the importance of repeated assessments of current mood or presence of suicidal ideation of their patients. ...
Article
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Ambulatory assessment studies may provide important insights in the etiology of suicidal behaviors, because suicidal behaviors and their risk factors fluctuate over time.The review aims at (1) evaluating the current state of research and (2) summarizing main findings in this field. Reviewed studies (N = 4) were heterogeneous. Up to 74 % of participants reported suicidal ideation during ambulatory assessment sampling. Suicidal ideation was predicted by intensity and instability of negative affective states (e.g., worry, sadness). Ambulatory assessment studies seem a promising approach to uncover the dynamic course of suicidal ideation and its risk factors in clinically relevant time frames (i.e., real-time).
... Wie vorgeschlagen, sollte das Setting die Verfahrensauswahl bestimmen (Kroenke et al. 2009): So ist dem PHQ-8 bei populationsbasierten, epidemiologischen und bei speziellen Befragungsmodi (postalisch, telefonisch, online) der Vorrang zu geben. In der klinischen Praxis beziehungsweise in klinischen Stichproben wiederum ist die Abklärung von Suizidalität, die ja auch eine eigene klinische Entität darstellen kann (Leboyer et al. 2005), von größerer Bedeutung und sollte gegebenenfalls auch Interventionen nach sich ziehen. Insofern ist hier der PHQ-9 vorzuziehen. ...
Article
Identifying depression in the general population – A comparison of PHQ-9, PHQ-8 and PHQ-2 Objective: To examine the comparability of depression as defined by PHQ-9, PHQ-8 and PHQ-2 in the German general population. Methods: The PHQ-9 was assessed in a representative sample (N = 2524). Depression diagnosis and depression severity as measured either by PHQ-9, PHQ-8 or PHQ-2 were compared. Results: PHQ-8 and PHQ-9 performed comparably in identifying depressive persons, though there are slight differences in rating depression severity. In comparison, the PHQ-2 showed the best performance in the detection of any depressive disorder. Conclusions: The PHQ-9 should be used in clinical settings, whereas in research and when persons are being approached via telephone/mail/internet the PHQ-8 is preferable. The PHQ-2 is recommended as a very economic and brief screener for depressive disorders. Fragestellung: Es soll die Vergleichbarkeit von PHQ-9 und den Kurzformen PHQ-8/PHQ-2 in der Allgemeinbevölkerung untersucht werden. Methode: Der PHQ-9 wurde an einer repräsentativen Stichprobe (N = 2524) eingesetzt und die dimensionale Bewertung der Depressionsschwere sowie die Fallidentifikation durch die verschiedenen Versionen verglichen. Ergebnisse: PHQ-8 und PHQ-9 sind hinsichtlich der Identifikation Depressiver vergleichbar, bei dimensionaler Anwendung ergeben sich Unterschiede. Als Screener ist der PHQ-2 überle-gen. Diskussion: In der Praxis ist der PHQ-9, in der Forschung und bei speziellen Befragungsmodi der PHQ-8 vorzuziehen. Als ökonomischer Ultrakurzscreener empfiehlt sich der PHQ-2.
... In fact, some researchers have suggested that suicidality should be a separate diagnostic category in the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (Leboyer, Slama, Siever, & Bellivier, 2005;Oquendo et al., 2008). In addition, there is some evidence that suicidal ideation is highly consistent across depressive episodes; only the severity seems to fluctuate (Antypa, Van der Does, & Pennix, 2010;Borges, Angst, Nock, Ruscio, & Kessler, 2008). ...
... 5,6 Although the precise clinical definition of suicidal behavior remains less than satisfactory, the phenomenon of suicidality is frequently viewed as occurring on a continuum of increasing severity from ideation, to attempts, to completed suicide, 7 and can be classified in terms of the degree of actual intent to die, the method employed, the lethality of the method (violent or non-violent), the degree of cognitive impairment involved (impulsivity, aggressiveness), and the mitigating circumstances inherent to the subject's situation. 8 ...
Article
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Suicide is a major public health issue and a signifi-cant cause of death worldwide. Many animal, post-mortem, clinical, and genetic studies have produced results implicating at least 3 neurobiological systems in the pathogenesis of suicidal behavior: a deficiency in the serotonergic system, hyperactivity of the hypothala-mic-pituitary-adrenal axis, and excess of norepineph-rine release followed by norepinephrine deficiency. In addition, several studies have pointed to the involve-ment of the dopaminergic system, neurotrophic factors, cholesterol, and cytokines in the pathogenesis of suici-dal behavior. However, more research will be required in order to confirm these associations. In the future, a greater understanding of suicidal behavior and its neu-robiology may facilitate the detection of at-risk indi-viduals, and contribute to the development of more effective interventions.
... However, different forms of suicidal behaviour may share common causal factors and there are proposals to make suicide disorders a distinct group in psychiatric diagnostic systems(Leboyer, et al. 2005).2 The higher rates for adolescents and for 12-month rather than lifetime rates may reflect recall bias; in one study, fully 40% of adolescents who initially reported suicide ideation deny any lifetime history when ...
Article
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Across Canada, many Aboriginal communities continue to suffer from elevated rates of youth suicide. Although much can be learned from research on the general population there are important gender, age, social and cultural variations. Therefore, there is a need to develop and assess suicide prevention approaches specific to Aboriginal youth. Our review of the published and gray literature (2003—2008) on current suicide prevention strategies for Aboriginal youth in Canada and comparable populations in the US, Australia, New Zealand and Greenland, identified general principles guiding best practices, which are described in detail. There is a need to improve communications strategies that support knowledge exchange in suicide prevention. Communities may need assistance in establishing the specific human and material resources necessary to set up appropriate programs and interventions. They may also need assistance in evaluating the success of programs. A national network should be developed for supporting suicide prevention and mental health promotion activities among Aboriginal youth across the country, especially in rural and remote communities.
... However, despite being correlated with depression, recent evidence suggests that suicidal ideation may be more than a symptom or mere consequence of an affective disorder. Leboyer and colleagues [9] noted that suicidal thoughts and behaviour might constitute a potentially isolated psychological phenomenon, partially independent from other expressions of psychopathology [10,11]. Diefenbach and colleagues [12] interpreted their results in a similar way and stated that suicidal ideation may be associated with non-specific subclinical psychopathological features such as emotional instability, together with anxiety, social inhibition, and possibly hostility and negative affectivity. ...
Article
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Introduction The aim of the present study was to investigate the effects of mindfulness-based cognitive therapy (MBCT) on suicidal ideation in an open-label randomised controlled trial of patients with residual depressive symptoms. Furthermore, this study aimed at examining whether an effect of MBCT on suicidal ideation was dependent on a reduction in depression severity, worry and rumination, or an increase in mindfulness. Methods One hundred and thirty participants were randomised to a treatment arm (treatment as usual plus MBCT) or a wait list arm. Change in depression, change in worry, change in rumination and change in mindfulness were entered as covariates in a repeated measures ANOVA in order to assess to what degree MBCT-induced changes in suicidal ideation were independent from changes in these parameters. Results There was a significant group x time (pre vs. post) interaction on suicidal ideation indicating a significant reduction of suicidal ideation in the MBCT group, but not in the control group. The interaction remained significant after addition of the above covariates. Change in worry was the only covariate associated with change in suicidal ideation, causing a moderate reduction in the interaction effect size. Conclusions The results suggest that MBCT may affect suicidal ideation in patients with residual depressive symptoms and that this effect may be mediated, in part, by participants’ enhanced capacity to distance themselves from worrying thoughts.
... Alternatively, it is possible that instead of suicide attempts being a "consequence" of particular classifications of disorders and comorbidities, suicidal behavior can be conceptualized as a disorder itself. This is supported by findings that suggest there are neurochemical and genetic differences in suicide survivors from those with psychiatric illnesses (Leboyer et al., 2005). If suicide attempts are conceptualized as a disorder, it is possible that this may differentiate the HP class from the Int and Ext classes, as did the affective disorders. ...
... This is in accordance with the literature. In the light of results of prior studies (e.g., Forkmann et al., 2009aForkmann et al., , 2009bKendel et al., 2010) it is an open question how closely suicidal ideation might be linked to a depressive syndrome or whether it may rather be regarded as a unique nosological entity (Leboyer et al., 2005). Recent studies even discuss whether suicide risk assessment should be included in DSM-V on a sixth axis (Van Orden et al., 2011). ...
... Risk factors for suicide are heritable: multiple lines of evidence -family, twin, and adoption studies (Baldessarini & Hennen 2004;Brent & Mann 2005); molecular genetical studies , supplemented by suggestive findings from geographical studies (Marušič 2005;Voracek & Formann 2004;Voracek et al. 2003) -converge to this conclusion (Bondy et al. 2006). And, finally, suicidal behavior may well be a distinct mental disorder: It is increasingly regarded as an independent, possibly dimensional, nosological entity (Leboyer et al. 2005). This emerging view is based mainly on genetic evidence that its transmission is noticeably independent of the transmission of the risk for mental disorders. ...
Article
Full-text available
This response (a) integrates non-equilibrium evolutionary genetic models, such as coevolutionary arms-races and recent selective sweeps, into a framework for understanding common, harmful, heritable mental disorders; (b) discusses the forms of ancestral neutrality or balancing selection that may explain some portion of mental disorder risk; and (c) emphasizes that normally functioning psychological adaptations work against a backdrop of mutational and environmental noise.
... Secondly, SSAT down-regulation was demonstrated in the VPFC of suicide completers with or without major psychiatric pathologies including schizophrenia, bipolar disorder, and major depression disorder, suggesting that this molecular signature might be specific for suicidal behavior and independent of the presence of underlying psychopathology. Even though these preliminary results clearly need replication in a much larger independent cohort of patients, they are consistent with numerous recent studies, which have provided evidence that there are specific genetic vulnerability factors for suicidal behavior that are partly independent of those for psychiatric disorders [Courtet et al., 2005;Leboyer et al., 2005]. ...
Article
It has recently been proposed that the SSAT gene plays a role in the predisposition to suicidal behavior. SSAT expression was found to be down-regulated in the brain of suicide completers. In addition, a single nucleotide polymorphism (SNP) rs6526342 was associated both with variation in SSAT expression and with suicidal behavior. In this study, we aimed to characterize the relationship between SSAT dysregulation and suicide behavior. To this end, we measured SSAT expression levels in the ventral prefrontal cortex (VPFC) of suicide completers (n ¼ 20) and controls (n ¼ 20) and found them to be significantly down-regulated in suicide victims (P ¼ 0.007). To identify the basis of the regulation of SSAT expression, we performed an association analysis of 309 SNPs with SSAT transcript levels in 53 lympho-blastoid cell lines from the CEPH collection. We then examined the methylation status of the SSAT promoter region in males and females suicide completers and control subjects whose SSAT brain expression had been measured. We found no evidence to support a role for SNPs in controlling the level of SSAT expression. SSAT promoter methylation levels were not different between suicide completers and controls and did not correlate with SSAT expression levels. In addition, we found no indication of a genetic association between suicidal behavior and SNPs located within the SSAT gene. Our study provides new results which show that dysregulation of SSAT expression does play a role in suicide behavior. However, our data do not support any association between rs6526342 and variation in SSAT expression or suicidal behavior.
... Because correlations between depression and anxiety on the one side and suicidal ideation on the other side were only moderate (but still significant), the presented results further suggest that suicidal ideation might be ''more'' than a symptom or a mere consequence of an affective disorder. Leboyer et al. (2005) noted that suicidal thoughts and behavior might constitute its own nosological entity. Recently, Diefenbach et al. (2009) interpreted their results in a similar way and stated that suicidal ideation may be associated with subclinical features of emotional disability, together with anxiety, social inhibition, possible hostility, and negative affectivity. ...
Article
The present study aimed to determine the prevalence of suicidal ideation in a representative sample of the German general population and examined its relation to potential risk factors. The study sample consisted of 2509 persons. Mean age was 49.4 years (SD, 18.2 years; 55.8% women). Participants filled in the Hospital Anxiety and Depression Scale and two items from the Rasch-based Depression Screening measuring suicidal ideation. Suicidal ideation was reported by 8.0% (n = 211) of all participants. People reporting suicidal ideation were less likely to be married or living together with a partner and to have children aged 6 to 13 years and were more likely to be divorced. They reported significantly higher levels of a depressive syndrome (t = 17.78; p < 0.001) and an anxiety syndrome (t = 18.43; p < 0.001). The study showed high point prevalence for suicidal ideation in the general German population. In concordance with results from similar studies in other countries, living alone and reporting anxious and depressive syndromes was associated with suicidal ideation.
... Wie vorgeschlagen, sollte das Setting die Verfahrensauswahl bestimmen (Kroenke et al. 2009): So ist dem PHQ-8 bei populationsbasierten, epidemiologischen und bei speziellen Befragungsmodi (postalisch, telefonisch, online) der Vorrang zu geben. In der klinischen Praxis beziehungsweise in klinischen Stichproben wiederum ist die Abklärung von Suizidalität, die ja auch eine eigene klinische Entität darstellen kann (Leboyer et al. 2005), von größerer Bedeutung und sollte gegebenenfalls auch Interventionen nach sich ziehen. Insofern ist hier der PHQ-9 vorzuziehen. ...
Article
To examine the comparability of depression as defined by PHQ-9, PHQ-8 and PHQ-2 in the German general population. The PHQ-9 was assessed in a representative sample (N = 2524). Depression diagnosis and depression severity as measured either by PHQ-9, PHQ-8 or PHQ-2 were compared. PHQ-8 and PHQ-9 performed comparably in identifying depressive persons, though there are slight differences in rating depression severity. In comparison, the PHQ-2 showed the best performance in the detection of any depressive disorder. The PHQ-9 should be used in clinical settings, whereas in research and when persons are being approached via telephone/mail/internet the PHQ-8 is preferable. The PHQ-2 is recommended as a very economic and brief screener for depressive disorders.
... The item bank contains no other appropriate item referring to ''loss of joy'' that could have been included in the DESC-I instead. Furthermore, all suicide items of the item bank showed some kind of DIF, corroborating the assumption of some authors that suicide might constitute a nosological entity (e.g., Leboyer, Slama, Siever, & Bellivier, 2005). Second, the DIF for these items occurred in a way that depressed and non-depressed patients can be clearly discriminated. ...
... The item bank contains no other appropriate item referring to ''loss of joy'' that could have been included in the DESC-I instead. Furthermore, all suicide items of the item bank showed some kind of DIF, corroborating the assumption of some authors that suicide might constitute a nosological entity (e.g., Leboyer, Slama, Siever, & Bellivier, 2005). Second, the DIF for these items occurred in a way that depressed and non-depressed patients can be clearly discriminated. ...
... Examination of dimensionality and residual variance exhibited minor signs of a potential secondary dimension constituted by items about suicidal ideation and behavior. This finding might be interpretable in line with some researchers who consider suicidal behavior to be a nosological entity due to evidence from clinical, genetic, and biochemical data (e.g., Leboyer, Slama, Siever, & Bellivier, 2005). However, we decided to keep these items in the item bank because they fit the model (infit MS Յ 1.3) and constituted only a minor dimension that does not threaten acceptable unidimensionality of the full scale. ...
Article
Depression gehört zu den häufigsten psychischen Erkrankungen unserer Zeit und geht häufig mit weiteren psychischen und somatischen Komorbiditäten einher. Für die Betroffenen verursacht diese Erkrankung erhebliches Leid und ein deutlich reduziertes psychosoziales Funktionsniveau. Neben dem klinischen Interview gehören Fragebögen zu den in der Diagnostik und Schweregradbestimmung der Depression am häufigsten eingesetzten Instrumenten. Eine Vielzahl weithin etablierter diagnostischer Fragebögen zur Depression wurde in den vergangenen Jahrzehnten entwickelt. In den letzten Jahren haben jedoch Studien zu einigen dieser Verfahren verschiedene Einschränkungen der psychometrischen Qualität aufgezeigt, sodass weitere Verbesserungen in diesem Bereich notwendig erscheinen. Die vorliegende Arbeit umfasst drei Studien mit dem gemeinsamen Ziel, die Vorteile moderner testtheoretischer Ansätze, insbesondere des Rasch-Models aus der Familie der Item-Response-Modelle, für die klinische Praxis der Depressionsdiagnostik nutzbar zu machen. Die erste Studie hatte zum Ziel einen umfassenden Pool relevanter Items zur Depressionsdiagnostik zusammenzustellen. Hierzu wurden englisch- und deutschsprachige Depressionsfragebögen, Beschwerdelisten sowie diesbezügliche Literatur nach Items durchsucht sowie weitere aus klinischer Sicht relevante Items konstruiert. Die zusammengestellten Items wurden auf ein einheitliches Format gebracht, randomisiert und einer Gruppe erfahrener Psychiater und klinischer Psychologen zur Beurteilung ihrer Relevanz hinsichtlich einer depressiven Episode vorgelegt. Die Experten zeigten eine hohe Übereinstimmung in ihren Relevanzurteilen. 157 Items wurden als mindestens teilweise relevant eingestuft, diese Items bilden den „Aachen Depression Itempool (ADIP)“. Items zu somatischen Symptomen wurden übereinstimmend als nicht relevant beurteilt. In der zweiten Studie wurde ausgehend von dem ADIP mittels der Rasch-Analyse eine kalibrierte Itembank entwickelt. 367 Patienten beantworteten den auf 182 Items ergänzten ADIP auf einer fünfstufigen Likert-Skala. Die Rasch-Analyse ergab eine Bank von 79 Items, die hinsichtlich der relevanten Rasch-Modelparameter gute psychometrische Eigenschaften aufwiesen. Einige wenige Items zeigten Differential Item Functioning (DIF), das in der weiteren Anwendung der Itembank z.B. durch alters- und/ oder geschlechtsabhängige Normen bzw. Schwierigkeitsparameter Berücksichtigung finden sollte. Diese Rasch-homogene Itembank („Aachen Depression Item Bank, ADIB“) kann als Grundlage für die Entwicklung Computer-adaptiver Testverfahren (CAT) sowie als „Steinbruch“ für Rasch-homogene Kurzfragenbögen genutzt werden. Die dritte Studie hatte zum Ziel, die letztgenannte Verwendung der Itembank durch die Entwicklung eines Rasch-homogenen Kurzfragebogens zu demonstrieren. Dabei sollte ein Instrument in zwei parallelen Versionen entwickelt werden, da dies erhebliche Vorteile für die Anwendung in wiederholten Testungen innerhalb kurzer Zeitabstände eröffnen würde. Auf Basis der Rasch-homogenen Itembank wurden mittels Strukturgleichungsmodellierung zwei parallele, jeweils 10 Items umfassende eindimensionale Skalen konstruiert (das Rasch-basierte Depressionsscreening DESC-I und –II), die gute psychometrische Eigenschaften aufwiesen. Insgesamt zeigen die Ergebnisse der vorliegenden Arbeit, dass die Anwendung der Rasch-Analyse bei der Konstruktion von Selbstbeurteilungsinstrumenten neue Möglichkeiten in der Diagnostik von Depressionen eröffnen kann. Die entwickelte Rasch-homogene Itembank ADIB stellt eine gut fundierte Grundlage für CAT-Anwendungen dar. Die Entwicklung entsprechender Algorithmen sollte eines der zentralen Ziele weiterer Studien sein. Mit dem DESC-I und -II wurden darüber hinaus weitere Anwendungsmöglichkeiten der Itembank demonstriert und ein viel versprechendes, direkt einsetzbares Screeninginstrument zur Depressionsdiagnostik entwickelt. Depressive disorders are among the most prevalent mental disorders and cause substantial harm and affliction as well as reduced quality of life and impaired psychosocial functioning. Apart from the clinical interview, questionnaires represent the most established and economic diagnostic instruments for depression. A multiplicity of questionnaires for depression has been developed across the past decades. However, several studies demonstrated substantial psychometric shortcomings of many depression questionnaires. Thus, further enhancements in this area appear to be mandatory. The present thesis comprises three studies that aim at further improving the quality of diagnostic methods for depression by making the benefits of modern test theoretical approaches, particularly the Rasch-Model, one of the Item-Response-Theory-Models, available for clinical practice. The first study aimed at providing an ample pool of depression items – the basic requirement for item bank calibration. A thorough review of existing diagnostic tools for depression and relevant literature led to a comprehensive compilation of depression items. Based on the relevance judgments of 49 adept clinical experts 157 relevant items were identified. An additional major finding of Study One was that clinical psychologists tended to regard emotional/ cognitive items as more important than psychiatrists while the latter tended to judge somatic items as more relevant than clinical psychologists. However, across all experts items about somatic complaints were considered as not relevant. The second study was the core of the current thesis and – based on the item pool of Study One – aimed at developing a calibrated item bank for depression and evaluating its psychometric properties. Evaluation of Rasch Model fit, differential item functioning (DIF), dimensionality, local independence, item spread, item and person separation, and reliability resulted in a bank of 79 items that showed good psychometric properties. However, a minority of items showed DIF that must be dealt with in all future applications and utilizations of the bank. Thus, CAT applications on the basis of the item bank should incorporate separate item difficulty estimates for the respective groups (e.g., female vs. male test takers) and questionnaires derived from the bank should hold gender or age dependent norms. Study Three aimed at exemplifying how the Rasch calibrated item bank for depression may be utilized by the derivation of two parallel short but sensitive static depression questionnaires that should cover a sufficiently high spread of depression severities with high test accuracy. This major aim was achieved with the development of the Rasch-based Screening for Depression I and II (DESC-I/ -II), a short depression scale in two parallel forms comprising 10 items each. This instrument may provide considerable benefits in retest applications and for screening purposes in mentally as well as somatically ill patients. Future investigations should engage in validating item calibrations and Rasch model fit of the item bank in a larger sample and DIF analyses should be repeated. Furthermore, psychometric properties of DESC-I and -II should be further investigated, including e.g. evaluation of its retest reliability and sensitivity to change, especially in heterogeneously composed samples that realistically reflect the patient mixture encountered by the practitioner. Finally, the adaptive algorithm that accesses the calibrated item bank should be built and evaluated to allow for computer-adaptive test applications. Taken together, the results of the present thesis constitute a psychometrically sound basis for computer-adaptive testing and provide a promising new screening instrument for depression ready for use. If the major suggestions for future investigations on the basis of the current findings are further pursued, a substantial leap towards better quality and heightened convenience for both patient and diagnostician in depression diagnostics is in near reach.
... The item bank contains no other appropriate item referring to ''loss of joy'' that could have been included in the DESC-I instead. Furthermore, all suicide items of the item bank showed some kind of DIF, corroborating the assumption of some authors that suicide might constitute a nosological entity (e.g., Leboyer, Slama, Siever, & Bellivier, 2005). Second, the DIF for these items occurred in a way that depressed and non-depressed patients can be clearly discriminated. ...
Article
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Questionnaires for the assessment of depression benefit from modern test construction like item-response-modelling. We developed two parallel 10 item depression questionnaires, the Rasch-based Depression Screening version 1 (DESC-I) and 2 (DESC-II), by combining Rasch analysis and structural equation modelling on patient samples suffering primarily from a mental disorder or from somatic diseases. Both scales base upon a Rasch homogeneous item bank and proved unidimensionality and good model fit. Cut-off scores with good sensitivity and specificity were developed using ROC analyses. Results suggest that DESC may be appropriately used to screen for depression and may be beneficial for repeated measurements.
... Examination of dimensionality and residual variance exhibited minor signs of a potential secondary dimension constituted by items about suicidal ideation and behavior. This finding might be interpretable in line with some researchers who consider suicidal behavior to be a nosological entity due to evidence from clinical, genetic, and biochemical data (e.g., Leboyer, Slama, Siever, & Bellivier, 2005). However, we decided to keep these items in the item bank because they fit the model (infit MS Յ 1.3) and constituted only a minor dimension that does not threaten acceptable unidimensionality of the full scale. ...
Article
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The calibration of item banks provides the basis for computerized adaptive testing that ensures high diagnostic precision and minimizes participants' test burden. The present study aimed at developing a new item bank that allows for assessing depression in persons with mental and persons with somatic diseases. The sample consisted of 161 participants treated for a depressive syndrome, and 206 participants with somatic illnesses (103 cardiologic, 103 otorhinolaryngologic; overall mean age = 44.1 years, SD =14.0; 44.7% women) to allow for validation of the item bank in both groups. Persons answered a pool of 182 depression items on a 5-point Likert scale. Evaluation of Rasch model fit (infit < 1.3), differential item functioning, dimensionality, local independence, item spread, item and person separation (>2.0), and reliability (>.80) resulted in a bank of 79 items with good psychometric properties. The bank provides items with a wide range of content coverage and may serve as a sound basis for computerized adaptive testing applications. It might also be useful for researchers who wish to develop new fixed-length scales for the assessment of depression in specific rehabilitation settings.
... Suicidal behavior, as defined by suicide attempts (SA), is a heterogeneous multifactor entity. Suicidal behavior is a frequent complication of psychiatric disorders, but several external validators have suggested that suicidal behavior could be considered a nosological entity in itself (Leboyer et al., 2005). Indeed, low serotonergic activity in the body fluids and brains of suicide victims, the genetic transmission of suicide risk independently of the transmission of associated major psychiatric disorders and recently discovered associations with several serotonin-related genes support this conclusion (Anguelova et al., 2003;Arango et al., 2003;Asberg et al., 1976;Bellivier et al., 2004;Brent et al., 1996;Roy, 1983;Roy et al., 1991;Schulsinger et al., 1979;Statham et al., 1998). ...
Article
Clinical and familial studies have suggested that age at first suicide attempt (SA) is a marker for different subtypes of suicidal behaviors. However, none of the various thresholds used to define subgroups according to the age at first suicide attempt have been validated. The aim of this study was to try to define different subgroups according to age at first SA subtypes using admixture analysis. In a sample of 368 consecutively recruited patients from Sept. 2001 to Sept. 2005 with a personal history of suicide attempt, admixture analysis was used to determine the best-fitting model for the observed distribution of age at first SA. The theoretical model that best explains the observed distribution of age at first SA was a mixture of two Gaussian distributions with mean ages (+/-SD) of 19.5 +/- 4.3 and 38.5 +/- 12.4 years with a cut-off point of 26 years for the two subgroups. In multivariate analyses, the early onset subgroup was characterized by more frequent comorbid anxiety disorders, cannabis misuse and personal history of emotional and sexual abuse. Patients belonging to the late onset subgroup were more likely to suffer from major depressive disorders (single or recurrent). This study provides a mathematical modelisation suggesting the existence of two age at onset subgroups in suicidal behaviors with different clinical picture and history of childhood trauma. Given the heterogeneity of suicidal behavior, these results suggest that the age at first SA may represent a valid 'candidate symptom' for future investigations of vulnerability factors.
... Secondly, SSAT down-regulation was demonstrated in the VPFC of suicide completers with or without major psychiatric pathologies including schizophrenia, bipolar disorder, and major depression disorder, suggesting that this molecular signature might be specific for suicidal behavior and independent of the presence of underlying psychopathology. Even though these preliminary results clearly need replication in a much larger independent cohort of patients, they are consistent with numerous recent studies, which have provided evidence that there are specific genetic vulnerability factors for suicidal behavior that are partly independent of those for psychiatric disorders [Courtet et al., 2005;Leboyer et al., 2005]. ...
Article
It has recently been proposed that the SSAT gene plays a role in the predisposition to suicidal behavior. SSAT expression was found to be down-regulated in the brain of suicide completers. In addition, a single nucleotide polymorphism (SNP) rs6526342 was associated both with variation in SSAT expression and with suicidal behavior. In this study, we aimed to characterize the relationship between SSAT dysregulation and suicide behavior. To this end, we measured SSAT expression levels in the ventral prefrontal cortex (VPFC) of suicide completers (n = 20) and controls (n = 20) and found them to be significantly down-regulated in suicide victims (P = 0.007). To identify the basis of the regulation of SSAT expression, we performed an association analysis of 309 SNPs with SSAT transcript levels in 53 lymphoblastoid cell lines from the CEPH collection. We then examined the methylation status of the SSAT promoter region in males and females suicide completers and control subjects whose SSAT brain expression had been measured. We found no evidence to support a role for SNPs in controlling the level of SSAT expression. SSAT promoter methylation levels were not different between suicide completers and controls and did not correlate with SSAT expression levels. In addition, we found no indication of a genetic association between suicidal behavior and SNPs located within the SSAT gene. Our study provides new results which show that dysregulation of SSAT expression does play a role in suicide behavior. However, our data do not support any association between rs6526342 and variation in SSAT expression or suicidal behavior.
Thesis
Dans la littérature scientifique actuelle, des études ont mis en évidence par une approche transdiagnostique, l’implication de facteurs cliniques, biologiques et génétiques spécifiques des conduites suicidaires indépendamment d’un diagnostic de trouble psychiatrique de l’Axe I ou II du Manuel Diagnostique et Statistique des Troubles Mentaux (DSM) (1–3). De plus, l’existence d’un trouble psychiatrique n’apparaît pas être discriminante pour définir certains types de profils de patients à risque de suicide (4–6). En effet, le suicide peut toucher à la fois des personnes dites en situation de crise mais il est largement reconnu que les pathologies psychiatriques restent à haut risque de suicide, notamment les troubles de l’humeur tels que les troubles bipolaires et les dépressions unipolaires, et plus particulièrement avec caractéristiques psychotiques (7,8). De plus, des facteurs de risque spécifiques de suicide ont été retrouvés dans chacune de ces différentes populations (9,10). Ainsi, avec cette conception moderne du suicide, il semble pertinent d’étudier le risque suicidaire dans diverses populations de suicidants, souffrant ou non de troubles psychiatriques, et en utilisant une approche tant épidémiologique, dynamique avec l’actigraphie, et biologique (3,11,12). En me basant sur cette approche, mon projet de thèse s’articule en 3 axes décrits ci-après, et consiste à identifier des facteurs de risque de récidive de tentative de suicide ainsi qu’à définir des profils de patients suicidants dans des populations différentes. Pour cela, plusieurs études coordonnées permettront de réaliser une évaluation multi-échelles de la vulnérabilité suicidaire de façon transdiagnostique et de façon ciblée dans les troubles de l’humeur uni- et bi-polaires.
Book
Helping People Overcome Suicidal Thoughts, Urges and Behaviour draws together practical and effective approaches to help individuals at risk of suicide. The book provides a framework and outlines skills for anyone working with adults who present with suicidal thoughts or intent. Part 1 introduces a basic understanding of our knowledge about suicide and UK policy; Part 2 outlines the research into the treatment of suicidality and the general principles for working in the safest possible way. Part 3 outlines ten key psychological skills in the context of evidence-based best practice. The book also discusses the role of health and social care professionals in the prevention of suicide in the context of Covid-19. The book will be a valuable addition to the resources of professionals including psychotherapists, nurses, social workers, occupational therapists, prison and probation officers, drug and alcohol workers, general practitioners and support staff in any health or social care context.
Article
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Introduction: Suicidal behaviors are common in the general population and are so a major public health problem. In order to improve suicide prevention and to reduce the mortality by suicide, it appears essential to better identify suicide risk factors. Seasonality, circadian rhythms and sleep abnormalities have been already associated with numerous psychiatric disorders. This review aimed to characterize the associations between seasonality, circadian rhythms, sleep and suicidal behaviors including suicide attempts and completed suicides. Methods: We conducted a literature search between 1973 and 2015 in PubMed databases using the following terms: ("suicide" OR "suicidality" OR "suicide attempts" OR "suicidal behavior") AND ("circadian rhythms" OR "seasons" OR "sleep"). Results: Many studies confirm a specific seasonality for suicide with a higher peak of suicides in spring for both sex and a lower peak in autumn especially for women. This distribution seems to correlate with depressive symptoms (especially for the autumn peak), gender and different types of suicide. Regarding gender and type of suicide differences, males more commonly commit violent suicide with a higher rate of suicides in spring. Suicide behaviors appear to be influenced by climatic and biological factors like sunshine, daylight cycles, temperature, air pollutants, viruses, parasites and aeroallergens. Circadian variations exist in suicide rates depending on age with a morning peak for elder and an evening peak for youth. In addition, completed suicide peak in early morning whereas suicide attempts peak rather in later afternoon. Several biomarkers dysregulation like melatonin, serotonin and cortisol may be implicated in suicide circadian variations. Furthermore, specific sleep disorders like insomnia, nightmares and sleep deprivation are common risk factors of suicide and possibly independently of the presence of depressive symptoms. Finally, the efficacy of chronotherapeutics (such as luminotherapy, dark therapy, sleep deprivation and melatonin drugs) has been suggested in the reduction of suicidal behaviors. Conclusion: The suicide seasonality is very well documented showing a main peak in spring and another one in autumn. A suicide circadian distribution also exists depending of the suicidal behavior intensity and of the age. Numerous sleep disorders are also suicide risk factors and can be treated with chronotherapeutics. A better identification of seasonality, circadian rhythms and sleep abnormalities in suicidal behaviors could allow a better prevention in suicidal attempts and a reduction in death by suicide.
Article
The concept that the interaction between a number of neurobiological systems and environmental stimuli, such as stressful life events contribute to the complex trait of suicidal behavior has stimulated much work aimed to identify the underlying susceptibility factors. This review examines the current knowledge about the behavioral triggers in suicidal behavior and neurobiological alterations, including disturbances in neurotransmitter-, signal transduction- and stress regulation systems, genetics and epigenetics and presents new approaches to investigate the complex phenotype of suicidal behavior.
Article
This work starts with the report of the phenotypic heterogeneity of suicidal behavior jointly tothat of the existence of several nosological validity factors. While following the candidatesymptom approach, we could show that the distribution of the age at first suicide attempt(SA) was a mixture of two Gaussian distributions. This candidate symptom enabled us todelimit two distinct groups of patients in term of clinical characteristics. In parallel, theexploration of the cognitive dysfunctions among suicidal patients enabled us to propose asecond candidate symptom: the impaired cognitive inhibition. Lastly, by the study of asuicidal lethality scale, we could show that the "patient's implementation" represented acandidate symptom because of its probable relationship with suicidal intent, two intricate anddetermining dimensions in the genesis of suicidal behavior. Our contribution to thenosological validation of suicidal behavior relates to the results obtained from the study of apopulation of bipolar patients within whom the heritability of suicidal behavior appearedindependent of that of the bipolar disorder. Lastly, among an Afro-Caribbeanepidemiological psychiatric sample, 18% of the patients had a history of SA. This rate islower than that measured within studies conducted among mainly Caucasian clinical samplesand strengthen the idea of a "hypo-suicidality" in the populations of African origin.
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Zusammenfassung. Theoretischer Hintergrund: Vor dem Hintergrund hoher Pravalenzraten fur depressive Storungen bei somatisch Erkrankten sowie artifizieller Effekte bei wiederholten Messungen wurde das Rasch-basierte Depressionsscreening (DESC) entwickelt. Fragestellung: Der Entwicklungs-, Validierungs- und Normierungsprozess des Verfahrens wird zusammengefasst und die Nutzlichkeit fur die klinische Praxis diskutiert. Methoden: Ausgehend von der Aachener Depressionsitembank (Forkmann et al., 2009) wurde das DESC anhand von N = 333 psychisch/somatisch erkrankten Patienten (Alter M = 43,6 Jahre; 46,2% Frauen) mittels Strukturmodellierung und Rasch-Analyse entwickelt, an verschiedenen klinischen Stichproben uberpruft und bevolkerungsreprasentativ normiert (N = 2 .509). Ergebnisse: Eindimensionalitat und Rasch-Modellkonformitat der Parallelformen wurden bestatigt und Cut-Off-Werte mit guter Sensitivitat und Spezifitat bestimmt. Die Paralleltestreliabilitat war in allen Stichproben >0.9. Schlussfolgerungen: Mit ...
Article
This study conducted a simulation study for computer-adaptive testing based on the Aachen Depression Item Bank (ADIB), which was developed for the assessment of depression in persons with somatic diseases. Prior to computer-adaptive test simulation, the ADIB was newly calibrated. Recalibration was performed in a sample of 161 patients treated for a depressive syndrome, 103 patients from cardiology, and 103 patients from otorhinolaryngology (mean age 44.1, SD=14.0; 44.7% female) and was cross-validated in a sample of 117 patients undergoing rehabilitation for cardiac diseases (mean age 58.4, SD=10.5; 24.8% women). Unidimensionality of the itembank was checked and a Rasch analysis was performed that evaluated local dependency (LD), differential item functioning (DIF), item fit and reliability. CAT-simulation was conducted with the total sample and additional simulated data. Recalibration resulted in a strictly unidimensional item bank with 36 items, showing good Rasch model fit (item fit residuals<|2.5|) and no DIF or LD. CAT simulation revealed that 13 items on average were necessary to estimate depression in the range of -2 and +2 logits when terminating at SE≤0.32 and 4 items if using SE≤0.50. Receiver Operating Characteristics analysis showed that θ estimates based on the CAT algorithm have good criterion validity with regard to depression diagnoses (Area Under the Curve≥.78 for all cut-off criteria). The recalibration of the ADIB succeeded and the simulation studies conducted suggest that it has good screening performance in the samples investigated and that it may reasonably add to the improvement of depression assessment.
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Vulnerability to suicidal behavior (SB) is likely mediated by an underlying genetic predisposition interacting with environmental and probable epigenetic factors throughout the lifespan to modify the function of neuronal circuits, thus rendering an individual more likely to engage in a suicidal act. Improving our understanding of the neuroscience underlying SBs, both attempts and completions, at all developmental stages is crucial for more effective preventive treatments and for better identification of vulnerable individuals. Recent studies have characterized SB using an endophenotype strategy, which aims to identify quantitative measures that reflect genetically influenced stable changes in brain function. In addition to aiding in the functional characterization of susceptibility genes, endophenotypic research strategies may have a wider impact in determining vulnerability to SB, as well as the translation of human findings to animal models, and vice versa. Endophenotypes associated with vulnerability to SB include impulsive/aggressive personality traits and disadvantageous decision making. Deficits in realistic risk evaluation represent key processes in vulnerability to SB. Serotonin dysfunction, indicated by neuroendocrine responses and neuroimaging, is also strongly implicated as a potential endophenotype and is linked with impulsive aggression and disadvantageous decision making. Specific endophenotypes may represent heritable markers for the identification of vulnerable patients and may be relevant targets for successful suicide prevention and treatments.
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Vulnerability to suicidal behavior (SB) is likely mediated by an underlying genetic predisposition interacting with environmental and probable epigenetic factors throughout the lifespan to modify the function of neuronal circuits, thus rendering an individual more likely to engage in a suicidal act. Improving our understanding of the neuroscience underlying SBs, both attempts and completions, at all developmental stages is crucial for more effective preventive treatments and for better identification of vulnerable individuals. Recent studies have characterized SB using an endophenotype strategy, which aims to identify quantitative measures that reflect genetically influenced stable changes in brain function. In addition to aiding in the functional characterization of susceptibility genes, endophenotypic research strategies may have a wider impact in determining vulnerability to SB, as well as the translation of human findings to animal models, and vice versa. Endophenotypes associated with vulnerability to SB include impulsive/aggressive personality traits and disadvantageous decision making. Deficits in realistic risk evaluation represent key processes in vulnerability to SB. Serotonin dysfunction, indicated by neuroendocrine responses and neuroimaging, is also strongly implicated as a potential endophenotype and is linked with impulsive aggression and disadvantageous decision making. Specific endophenotypes may represent heritable markers for the identification of vulnerable patients and may be relevant targets for successful suicide prevention and treatments.
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Suicidal behavior (SB) represents a major public health issue. Clinical and basic research suggests that SB is a specific entity in psychiatric nosology involving a combination of personality traits, genetic factors, childhood abuse and neuroanatomical abnormalities. The principal risk factor for suicide is depression. More than 60% of patients who complete suicide are depressed at the time of suicide, most of them untreated. There has been a controversy concerning a possible increased risk of SB in some depressed patients treated with antidepressants. Most recent evidence suggests, however, that treatment of depressed patients is associated with a favorable benefit-risk ratio. A recent study has determined the effects of 6 weeks of antidepressant treatment with the serotonin and norepinephrine reuptake inhibitor, milnacipran, on suicidality in a cohort of 30 patients with mild to moderate depression. At baseline, mild suicidal thoughts were present in 46.7% of patients. Suicidal thoughts decreased progressively throughout the study in parallel with other depressive symptoms and were essentially absent at the end of the study. At no time during treatment was there any indication of an increased suicidal risk. Retardation and psychic anxiety decreased in parallel possibly explaining the lack of any "activation syndrome" in this study.
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Describes the rationale, development, and validation of the Scale for Suicide Ideation, a 19-item clinical research instrument designed to quantify and assess suicidal intention. In a sample with 90 hospitalized Ss, the scale was found to have high internal consistency and moderately high correlations with clinical ratings of suicidal risk and self-administered measures of self-harm. Furthermore, it was sensitive to changes in levels of depression and hopelessness (Beck Depression Inventory and Hopelessness Scale, respectively) over time. Its construct validity was supported by 2 studies by different investigators testing the relationship between hopelessness, depression, and suicidal ideation and by a study demonstrating a significant relationship between high level of suicidal ideation and "dichotomous" attitudes about life and related concepts on a semantic differential test. Factor analysis yielded 3 meaningful factors: Active Suicidal Desire, Specific Plans for Suicide, and Passive Suicidal Desire. (29 ref)
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When the landmark patient Phineas Gage died in 1861, no autopsy was performed, but his skull was later recovered. The brain lesion that caused the profound personality changes for which his case became famous has been presumed to have involved the left frontal region, but questions have been raised about the involvement of other regions and about the exact placement of the lesion within the vast frontal territory. Measurements from Gage's skull and modern neuroimaging techniques were used to reconstitute the accident and determine the probable location of the lesion. The damage involved both left and right prefrontal cortices in a pattern that, as confirmed by Gage's modern counterparts, causes a defect in rational decision making and the processing of emotion.
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Transporter-facilitated uptake of serotonin (5-hydroxytryptamine or 5-HT) has been implicated in anxiety in humans and animal models and is the site of action of widely used uptake-inhibiting antidepressant and antianxiety drugs. Human 5-HT transporter (5-HTT) gene transcription is modulated by a common polymorphism in its upstream regulatory region. The short variant of the polymorphism reduces the transcriptional efficiency of the 5-HTT gene promoter, resulting in decreased 5-HTT expression and 5-HT uptake in lymphoblasts. Association studies in two independent samples totaling 505 individuals revealed that the 5-HTT polymorphism accounts for 3 to 4 percent of total variation and 7 to 9 percent of inherited variance in anxiety-related personality traits in individuals as well as sibships.
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Suicidal behavior has been associated with reduced central serotonergic function. Because selective serotonin reuptake inhibitors (SSRIs) enhance serotonergic function, the authors studied the efficacy of an SSRI, paroxetine, in the prevention of recurrent suicidal behavior. They conducted a 1-year double-blind study comparing paroxetine (40 mg/day) and placebo in 91 patients who had recently attempted suicide for at least a second time. None of the patients had experienced a major depressive episode or had any other major DSM-III-R axis I diagnoses. At least one cluster B personality disorder was present in 74 patients. With adjustment for the number of previous suicide attempts, paroxetine showed significant efficacy in the prevention of recurrent suicidal behavior. Among the patients who had attempted suicide fewer than five times, 12 (36%) in the placebo group (N = 33) and five (17%) in the paroxetine group (N = 30) made a subsequent suicide attempt. Paroxetine was also significantly more effective in patients who met fewer than 15 criteria for cluster B personality disorders than in those who met more than 15 criteria. Overall, paroxetine was not significantly different from placebo in its effect on depressive mood, hopelessness, and anger. However, the data suggest that paroxetine may have some temporary effect in reducing anger. This study indicates that enhancing serotonergic function with an SSRI may reduce suicidal behavior in a subgroup of patients who have attempted suicide more than once but who do not suffer from major depression.
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Risk factors for suicide attempts have rarely been studied comprehensively in more than one psychiatric disorder, preventing estimation of the relative importance and the generalizability of different putative risk factors across psychiatric diagnoses. The authors conducted a study of suicide attempts in patients with mood disorders, psychoses, and other diagnoses. Their goal was to determine the generalizability and relative importance of risk factors for suicidal acts across diagnostic boundaries and to develop a hypothetical, explanatory, and predictive model of suicidal behavior that can subsequently be tested in a prospective study. Following admission to a university psychiatric hospital, 347 consecutive patients who were 14-72 years old (51% were male and 68% were Caucasian) were recruited for study. Structured clinical interviews generated axis I and axis II diagnoses. Lifetime suicidal acts, traits of aggression and impulsivity, objective and subjective severity of acute psychopathology, developmental and family history, and past substance abuse or alcoholism were assessed. Objective severity of current depression or psychosis did not distinguish the 184 patients who had attempted suicide from those who had never attempted suicide. However, higher scores on subjective depression, higher scores on suicidal ideation, and fewer reasons for living were reported by suicide attempters. Rates of lifetime aggression and impulsivity were also greater in attempters. Comorbid borderline personality disorder, smoking, past substance use disorder or alcoholism, family history of suicidal acts, head injury, and childhood abuse history were more frequent in suicide attempters. The authors propose a stress-diathesis model in which the risk for suicidal acts is determined not merely by a psychiatric illness (the stressor) but also by a diathesis. This diathesis may be reflected in tendencies to experience more suicidal ideation and to be more impulsive and, therefore, more likely to act on suicidal feelings. Prospective studies are proposed to test this model.
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There is compelling evidence that serotonin system dysfunction is associated with certain behavioral disorders, such as suicidal behavior and impulsive aggression. A functional polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) was recently identified and the presence of the short allele found to be associated with a lower level of expression of the gene, lower levels of 5-HT uptake, suicidal behavior and anxiety-related traits. We genotyped 51 West European Caucasians who had made violent suicide attempts and 139 controls of the same ethnic origin, with no history of suicidal behavior. The frequencies of the S allele and the SS genotype were significantly higher in the violent suicide attempters than in the controls. The odds ratio for the SS genotype vs the LL genotype was 3.63 (95% CI (1.27--10.40)). This suggests that a change in expression of the gene encoding the 5-HT transporter may be involved in violent suicidal behavior.
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Tryptophan hydroxylase (TPH) is the rate-limiting enzyme of serotonin synthesis. In this case-control study, we investigated whether the TPH gene was a susceptibility factor for suicidal behavior. Seven polymorphisms spanning the entire gene were studied in a case-control study including 231 individuals who had attempted suicide and 281 controls. Significant associations were found between variants in introns 7, 8 and 9 (chi(2) = 11.2, df = 1, P< 0.0008 for the allele distribution; these loci are in complete linkage disequilibrium) and in the 3' noncoding region (chi(2) = 30.94, P = 0.0014) and suicide attempt. The association was strongest for subjects who had attempted suicide by violent means and who had a history of major depression. No significant association was observed between suicide attempts and polymorphisms in the promoter, intron 1 and intron 3. The results presented here, and those of previous studies, suggest that a genetic variant of the 3' part of the TPH gene may be a susceptibility factor for a phenotype combining suicidal behavior, mood disorder and impulsive aggression.
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Background Although adoption, twin, and family studies have shown that suicidal behavior is familial, the risk factors for familial transmission from parent to child remain unclear.Methods A high-risk family study was conducted comparing the offspring of 2 mood-disordered groups: suicide attempters and nonattempters. Recruited from 2 sites, probands were 81 attempters and 55 nonattempters, with 183 and 116 offspring, respectively. Offspring were assessed by investigators masked to proband status. Probands and offspring were assessed with respect to psychopathologic findings, suicide attempt history, impulsive aggression, and exposure to familial environmental stressors.Results Offspring of attempters had a 6-fold increased risk of suicide attempts relative to offspring of nonattempters. Familial transmission of suicide attempt was more likely if (1) probands had a history of sexual abuse and (2) offspring were female and had a mood disorder, substance abuse disorder, increased impulsive aggression, and a history of sexual abuse.Conclusions The offspring of mood-disordered suicide attempters are at markedly increased risk for suicide attempts themselves. Familial transmission of suicidal behavior in families with mood disorders almost always requires transmission of a mood disorder and is also related to the offspring's impulsive aggression and the familial transmission of sexual abuse. Early treatment of mood disorders and targeting impulsive aggression and sexual trauma may be helpful in the prevention and treatment of suicidal behavior in families with mood disorders.
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• Dysfunction of the central serotonergic system has been variously associated with depression and with suicidal and/or impulsive aggressive behavior. To evaluate central serotonergic function in relation to these variables, prolactin responses to a singledose challenge with fenfluramine hydrochloride (60 mg orally), a serotonin releasing/uptake-inhibiting agent, were examined in 45 male patients with clearly defined major affective (n = 25) and/or personality disorder (n 20) and in 18 normal male control patients. Prolactin responses to fenfluramine among all patients were reduced compared with responses of controls. Reduced prolactin responses to fenfluramine were correlated with history of suicide attempt in all patients but with clinician and selfreported ratings of impulsive aggression in patients with personality disorder only; there was no correlation with depression. These results suggest that reduced central serotonergic function is present in a subgroup of patients with major affective and/or personality disorder and is associated with history of suicide attempt in patients with either disorder, but with impulsive aggression in patients with personality disorder only.
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Background: While previous studies have shown an increased rate of suicidal behavior in the relatives of suicide victims, it is unclear if this is attributable merely to increased familial rates of psychiatric disorders. Therefore, we conducted a family study of adolescent suicide victims (suicide probands) and community control probands (controls) to determine if the rates of suicidal behavior were higher in the relatives of adolescent suicide probands even after adjusting for differences in the familial rates of psychiatric disorders. Method: The relatives of 58 adolescent suicide probands and 55 demographically similar controls underwent assessment for Axis I and II psychiatric disorders, lifetime history of aggression, and history of suicidal behavior (attempts and completions) using a combination of family study and family history approaches. Results: The rate of suicide attempts was increased in the first-degree relatives of suicide probands compared with the relatives of controls, even after adjusting for differences in rates of proband and familial Axis I and II disorders (odds ratio, 4.3; 95% confidence intervals, 1.1-16.6). On the other hand, the excess rate of suicidal ideation found in the relatives of suicide probands was explained by increased familial rates of psychiatric disorders. Among suicide probands, higher ratings of aggression were associated with higher familial loading for suicide attempts. Conclusions: Liability to suicidal behavior might be familially transmitted as a trait independent of Axis I and II disorders. The transmitted spectrum of suicidal behavior includes attempts and completions, but not ideation, and the transmission of suicidal behavior and aggression are related.
Article
• The characteristics of adolescent suicide victims (n = 27) were compared with those of a group at high risk for suicide, suicidal psychiatric inpatients (n = 56) who had either seriously considered (n = 18) or actually attempted (n = 38) suicide. The suicide victims and suicidal inpatients showed similarly high rates of affective disorder and family histories of affective disorder, antisocial disorder, and suicide, suggesting that among adolescents there is a continuum of suicidality from ideation to completion. However, four putative risk factors were more prevalent among the suicide victims: (1) diagnosis of bipolar disorder; (2) affective disorder with comorbidity; (3) lack of previous mental health treatment; and (4) availability of firearms in the homes, which taken together accurately classified 81.9% of cases. In addition, suicide completers showed higher suicidal intent than did suicide attempters. These findings suggest a profile of psychiatric patients at high risk for suicide, and the proper identification and treatment of such patients may prevent suicide in highrisk clinical populations.
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• Suicide appears to cluster in fanmilies, suggesting that genetic factors may play a role in this behavior. We studied 176 twin pairs in which one or both twins had committed suicide. Seven of the 62 monozygotic twin pairs were concordant for suicide compared with two of the 114 dizygotic twin pairs (11.3% vs 1.8%). The presence of psychiatric disorder in the twins and their families was examined in a subsample of 11 twin pairs, two of whom were concordant for suicide. Eleven of these 13 twin suicide victims had been treated for psychiatric disorder, as had eight of their nine surviving cotwins. In addition, twins in 10 pairs had other first- or second-degree relatives who had been treated for psychiatric disorder. Thus, these twin data suggest that genetic factors related to suicide may largely represent a genetic predisposition for the psychiatric disorders associated with suicide. However, they leave open the question of whether there may be an independent genetic component for suicide.
Article
All suicides were ascertained for a 100-year period (1880 to 1980) in a study of mental illness among the Old Order Amish. The majority (92%) of the 26 cases were diagnosed with a major affective disorder and were situated in multigenerational families with heavy loading for bipolar, unipolar, and other affective-spectrum illnesses. The suicides clustered in four primary pedigrees, and the role of inheritance was suggested by the way in which suicides followed the distribution of affective disorders in these kinship lines. We believe these extended pedigrees provide presumptive evidence of genetic factors in both suicides and affective disorders. (JAMA 1985;254:915-918)
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• Few attempts have been made to look for potential correlations between psychiatric diagnoses and psychosocial Stressors in suicides. In this study, we examine relationships between the most common psychiatric illnesses and the most common Stressors in 283 suicides from San Diego County. We found that interpersonal loss/conflicts occurred more frequently near the time of death for substance abusers with and without depression than for persons with "pure" affective disorder. These findings are consistent with those of previous reports, suggesting a difference between the way suicidal persons with substance abuse and pure affective disorder respond to certain external Stressors.
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Serotonergic systems have been reported to mediate the control of aggression and/or impulsivity in humans and to be involved in suicidal behavior. Neurochemical studies showing serotonergic dysfunction in suicide appear to support the functional alteration of serotonergic systems due to gene polymorphisms. Knock-out mice of the 5HT1B receptor gene have been reported to result in increased aggression. We hypothesized that the 5HT1B receptor-mediated serotonergic dysfunction was implicated in suicide through disinhibition of aggression and/or impulsivity. To explore this hypothesis, we examined the association between suicide victims who completed suicide and the 5HT1B receptor gene G861C polymorphism. No significant differences in genotype distribution and allele frequencies were found between suicide victims and controls. Though there is the possibility of failing to detect small effects, these results show no evidence of an association between the 5HT1B receptor gene G861C polymorphism and suicide victims in a Japanese population and indicate that it is unlikely that the 5HT1B receptor is implicated in the susceptibility to suicide. © 2001 Wiley-Liss, Inc.
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Suicidology finds itself confused and stagnated for lack of a standard nomenclature. This paper proposes a nomenclature for suicide-related behavior in the hope of improving the clarity and precision of communications, advancing suicidological research and knowledge, and improving the efficacy of clinical interventions.
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Mood, emotion, cognition, and motor functions as well as circadian and neuroendocrine rhythms, including food intake, sleep, and reproductive activity, are modulated by the midbrain raphe serotonin (5-HT) system. By directing the magnitude and duration of postsynaptic responses, carrier-facilitated 5-HT transport into and release from the presynaptic neuron are essential for the fine tuning of serotonergic neurotransmission. Interest in the mechanism of environmental factor-, disease-, and therapy-induced modification of 5-HT transporter (5-HTT) function and its impact on early brain development, event-related synaptic plasticity, and neurodegeneration is widespread and intensifying. We have recently characterized the human and murine 5-HTT genes and performed functional analyses of their 5′-flanking regulatory regions. A tandemly repeated sequence associated with the transcriptional apparatus of the human 5-HTT gene displays a complex secondary structure, represses promoter activity in nonserotonergic neuronal cells, and contains positive regulatory components. We now report a novel polymorphism of this repetitive element and provide evidence for allele-dependent differential 5-HTT promoter activity. Allelic variation in 5-HTT-related functions may play a role in the expression and modulation of complex traits and behavior.
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Altered serotonin indices have been reported in the brain of suicide victims. We sought to localize the changes in presynaptic and postsynaptic serotonin receptors and identify an area of prefrontal cortex that may influence suicide risk. Quantitative autoradiography was performed in coronal sections of prefrontal cortex to determine whether serotonin 5-HT1A receptor (postsynaptic in cortex) and serotonin transporter (presynaptic) binding are different in suicide victims compared to matched controls. 5-HT1A receptor binding was higher in 85 of the 103 sampled areas in the suicide group (n = 18 pairs; P < 0.0001). The increase ranged from 17 to 30%. The increase was more pronounced in the ventrolateral prefrontal cortex. Serotonin transporter binding was found to be lower in the suicide group in all but one of the 43 sampled regions (n = 22 pairs; P < 0.0001). The reduction in binding was most pronounced in the ventrolateral prefrontal cortex, where the difference between suicides and controls ranged between 15 and 27%. Serotonin transporter and 5-HT1A binding were negatively correlated (r = −0.35 to − 0.44, P = 0.04 to 0.007) within the same brain areas, suggesting common regulatory factors with opposite effects on binding to the two receptors. We conclude that suicide victims have an abnormality in the serotonin system involving predominatly the ventrolateral prefrontal cortex, and hypothesize that the serotonergic dysfunction in this brain region contributes to the risk for suicidal behavior.
Article
Of 1397 completed suicides in Finland in one year, all victims (N = 20) that had used lithium in prophylaxis and treatment of a mood disorder during the three final months were carefully examined. Eight victims (40%) fulfilled the criteria of recent adequate lithium prophylaxis. Continuous or intermittent noncompliance with psychopharmacological treatment during the last two years was reported in the majority (85%) of the victims. Only two cases used lithium as a suicide method. The study suggests that problems especially in compliance but also in quality of treatment are likely to limit the usefulness of lithium treatment in suicide prevention.
Article
Low concentrations of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in cerebrospinal fluid (CSF) are associated with suicidal behaviour in patients with depressive illness, but studies of the relation between CSF 5-HIAA and suicide in schizophrenia have been inconclusive and have not included long-term follow-up. In a prospective study, we measured 5-HIAA in CSF taken from 30 schizophrenic patients in a drug-free state, and followed these patients for 11 years. 10 patients made suicide attempts during follow-up. Suicide attempters had significantly lower concentrations of CSF 5-HIAA at initial evaluation than non-attempters (mean [SE] 6.7 [2.2] vs 23.6 [5.6] ng/ml, p < 0.05). Our findings provide further evidence of the relation between serotoninergic dysfunction and suicide, and suggest a role for drugs with serotoninergic effects in schizophrenia.
Article
Suicide appears to cluster in families, suggesting that genetic factors may play a role in this behavior. We studied 176 twin pairs in which one or both twins had committed suicide. Seven of the 62 monozygotic twin pairs were concordant for suicide compared with two of the 114 dizygotic twin pairs (11.3% vs 1.8%). The presence of psychiatric disorder in the twins and their families was examined in a subsample of 11 twin pairs, two of whom were concordant for suicide. Eleven of these 13 twin suicide victims had been treated for psychiatric disorder, as had eight of their nine surviving cotwins. In addition, twins in 10 pairs had other first- or second-degree relatives who had been treated for psychiatric disorder. Thus, these twin data suggest that genetic factors related to suicide may largely represent a genetic predisposition for the psychiatric disorders associated with suicide. However, they leave open the question of whether there may be an independent genetic component for suicide.
Article
The question of what role genetic factors have in the transmission of suicidal behavior, in particular suicide itself, is discussed on the basis of five studies of an epidemiologically clearly defined region (the Province of Salzburg, Austria). The high percentage of suicide-positive family histories as compared with the literature is due to exceptionally good sources of information. It could be shown that in suicide cases also suffering from endogenous depression, both endogenous psychoses and suicides appeared to a greater extent in their families. However, in contrast to current assumptions, the suicide disposition is not just found in those with endogenous psychoses, but shows a separate genetic determination. The author concludes that the genetic factor in suicide research and in the evaluation of suicidality should be considered equally along with psychodynamic and sociodynamic factors.
Article
In the chain of events that terminates in a suicide, biological factors may be more important than previously thought. Recent research has identified two clusters of biological factors that tend to correlate with suicidal behavior, namely, variables associated with monoaminergic neurotransmission and variables associated with certain neuroendocrine functions. The most convincing evidence for an involvement of monoamines in suicide stems from measurements of serotonin and its main metabolite, 5-hydroxyindoleacetic acid (5-HIAA), in brains from suicide victims and in cerebrospinal fluid (CSF) from patients who have attempted suicide. Initially, such investigations were performed in order to study the biological correlates of depressive disorders, but more recently, interest has focused on the possible biological background of suicidal behavior as such. The present article will review CSF studies of monoamine metabolites in suicidal individuals, published until 1984, and also discuss some possible mechanisms for the relationship between suicide and serotonin.
Article
Dysfunction of the central serotonergic system has been variously associated with depression and with suicidal and/or impulsive aggressive behavior. To evaluate central serotonergic function in relation to these variables, prolactin responses to a single-dose challenge with fenfluramine hydrochloride (60 mg orally), a serotonin releasing/uptake-inhibiting agent, were examined in 45 male patients with clearly defined major affective (n = 25) and/or personality disorder (n = 20) and in 18 normal male control patients. Prolactin responses to fenfluramine among all patients were reduced compared with responses of controls. Reduced prolactin responses to fenfluramine were correlated with history of suicide attempt in all patients but with clinician and self-reported ratings of impulsive aggression in patients with personality disorder only; there was no correlation with depression. These results suggest that reduced central serotonergic function is present in a subgroup of patients with major affective and/or personality disorder and is associated with history of suicide attempt in patients with either disorder, but with impulsive aggression in patients with personality disorder only.
Article
Few attempts have been made to look for potential correlations between psychiatric diagnoses and psychosocial stressors in suicides. In this study, we examine relationships between the most common psychiatric illnesses and the most common stressors in 283 suicides from San Diego County. We found that interpersonal loss/conflicts occurred more frequently near the time of death for substance abusers with and without depression than for persons with "pure" affective disorder. These findings are consistent with those of previous reports, suggesting a difference between the way suicidal persons with substance abuse and pure affective disorder respond to certain external stressors.
Article
The characteristics of adolescent suicide victims (n = 27) were compared with those of a group at high risk for suicide, suicidal psychiatric inpatients (n = 56) who had either seriously considered (n = 18) or actually attempted (n = 38) suicide. The suicide victims and suicidal inpatients showed similarly high rates of affective disorder and family histories of affective disorder, antisocial disorder, and suicide, suggesting that among adolescents there is a continuum of suicidality from ideation to completion. However, four putative risk factors were more prevalent among the suicide victims: (1) diagnosis of bipolar disorder; (2) affective disorder with comorbidity; (3) lack of previous mental health treatment; and (4) availability of firearms in the homes, which taken together accurately classified 81.9% of cases. In addition, suicide completers showed higher suicidal intent than did suicide attempters. These findings suggest a profile of psychiatric patients at high risk for suicide, and the proper identification and treatment of such patients may prevent suicide in high-risk clinical populations.
Article
All suicides were ascertained for a 100-year period (1880 to 1980) in a study of mental illness among the Old Order Amish. The majority (92%) of the 26 cases were diagnosed with a major affective disorder and were situated in multigenerational families with heavy loading for bipolar, unipolar, and other affective-spectrum illnesses. The suicides clustered in four primary pedigrees, and the role of inheritance was suggested by the way in which suicides followed the distribution of affective disorders in these kinship lines. We believe these extended pedigrees provide presumptive evidence of genetic factors in both suicides and affective disorders.
Article
Historically, doctors have not always acknowledged that they have an obligation to prevent suicide, partly because they shared the prevalent idea that most suicides were caused by moral crises, no concern of theirs—and indeed suicide was a criminal matter until quite recently; but more, perhaps, because a fatalism has characterized their attitudes to its prevention, even where the suicide was clearly suffering from mental illness. Yet two recent American studies have shown more than 90 per cent of suicides to be mentally ill before their death (17, 8); this finding and the familiar clinical observation that suicidal thoughts disappear when the illness is successfully treated provide a strong case for a medical policy of prevention.
Article
This study investigated the validity and reliability of the Suicidal Intent Scale as a measure of the seriousness of a suicide attempt. 194 completed suicides had higher scores on the scale than 231 attempters (nonfatal). In addition, 19 attempters who reattempted suicide within 1 yr of discharge had greater suicidal intent than attempters who did not.
Article
The Risk-Rescue Rating is a descriptive and quantitative method of assessing the lethality of suicide attempts. Its underlying hypothesis is that the lethality of implementation, defined as the probability of inflicting irreversible damage, may be expressed as a ratio of factors influencing risk and rescue. Five risk and five rescue factors have been operationally defined, weighted, and scored. Illustrations of typical high risk/high rescue, high risk/low rescue, low risk/high rescue, and low risk/low rescue are presented, together with scoring instructions and tables of values. Risk-rescue ratings correlate well with the level of treatment recommended (none, emergency ward only, hospital admission, and intensive care), with the subject's sex, and whether the subjects lived or died. There is less decisive correlation with age and little correlation with marital status and multiple attempts. Taken by itself, the risk-rescue rating is not a predictive instrument. However, when considered along with other kinds of lethality, such as that of intentionality and psychosocial involvement, the lethality of implementation can add to the basis of individualized suicide prognosis.
Article
A method for achieving diagnostic validity in psychiatric illness is described, consisting of five phases: clinical description, laboratory study, exclusion of other disorders, follow-up study, and family study. The method was applied in this paper to patients with the diagnosis of schizophrenia, and it was shown by follow-up and family studies that poor prognosis cases can be validly separated clinically from good prognosis cases. The authors conclude that good prognosis "schizophrenia" is not mild schizophrenia, but a different illness.
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Differences in serotonin-2 (5-HT2) receptor properties were studied in frontal cortex from suicide victims and controls. The number of 5-HT2 receptors was significantly higher (44%) in the suicide group. The postsynaptic receptor changes were consistent with previous findings of a reduced number of presynaptic serotonin receptors in the same post-mortem series. The combined findings of both studies support the decreased use of serotonin in suicide victims and may also throw light on the mechanism of action of antidepressant drugs.
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Suicide has been reported to occur in 9%-13% of schizophrenic patients. It has been suggested that neuroleptic-resistant or neuroleptic-intolerant schizophrenic patients are at higher risk for suicide than neuroleptic-responsive patients. Clozapine is the treatment of choice for neuroleptic-resistant patients, but its use has been greatly limited because of its ability to cause potentially fatal agranulocytosis. The purpose of this study was to compare the suicidality of neuroleptic-resistant and neuroleptic-responsive patients and to determine if clozapine treatment decreased suicidality in the former group. Prior episodes of suicidality were assessed in a total of 237 neuroleptic-responsive and 184 neuroleptic-resistant patients with schizophrenia or schizoaffective disorder. Eighty-eight of the neuroleptic-resistant patients were treated with clozapine and prospectively evaluated for suicidality for periods of 6 months to 7 years. There was no significant difference in prior suicidal episodes between neuroleptic-responsive and neuroleptic-resistant patients. Clozapine treatment of the neuroleptic-resistant patients during the follow-up period resulted in markedly less suicidality. The number of suicide attempts with a high-probability of success decreased from five to zero. This decrease in suicidality was associated with improvement in depression and hopelessness. These results suggest a basis for reevaluation of the risk-benefit assessment of clozapine, i.e., that the overall morbidity and mortality of patients with neuroleptic-resistant schizophrenia are less with clozapine treatment than with typical neuroleptic drugs because of less suicidality. This conclusion also has implications for increasing the use of clozapine with neuroleptic-responsive patients.
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Alterations in both serotonergic and noradrenergic indices have been found in the brain of suicide victims. In order to better understand the role of the noradrenergic system in suicide, we carried out quantitative autoradiography of alpha 1- and alpha 2-adrenergic receptors using [3H]prazosin and [3H]-p-aminoclonidine respectively. We compared the distribution and relative density of these receptors in the prefrontal (PFC) and alpha 1-adrenergic receptors in the temporal cortex (TC) of suicide victims and controls matched for postmortem delay, age, side of brain and sex. We found that: (1) the laminar patterns of alpha 1-adrenergic receptors in the PFC (n = 20) and the TC (n = 16) were different (P = 0.022); (2) there was a 37% increase in alpha 1-adrenergic binding corresponding to layers IV-V of PFC of suicide victims compared to controls (P = 0.029); (3) the TC had a greater density of alpha 1-adrenergic binding sites than the PFC across all cortical layers (P = 0.006); (4) alpha 2-adrenergic binding sites had a specific laminar distribution in the PFC (n = 24) which did not differ in controls and suicide victims; (5) binding to alpha 2-adrenergic sites in the PFC of suicide victims did not differ from controls; and (6) norepinephrine concentrations in the same brain areas