Alain Lesage

Impulsive-aggressive behaviours and completed suicide across the life cycle: a predisposition for younger age of suicide

BACKGROUND It is unclear whether the association between impulsive-aggressive behaviours and suicide exists across different ages. METHOD Via psychological autopsy, we examined a total of 645 subjects aged 11-87 years who died by suicide. Proxy-based interviews were conducted using the SCID-I & SCID-II or K-SADS interviews and a series of behavioural and personality-trait assessments. Secondarily, 246 living controls were similarly assessed. RESULTS Higher levels of impulsivity, lifetime history of aggression, and novelty seeking were associated with younger age of death by suicide, while increasing levels of harm avoidance were associated with increasing age of suicide. This effect was observed after accounting for age-related psychopathology (current and lifetime depressive disorders, lifetime anxiety disorders, current and lifetime substance abuse disorders, psychotic disorders and cluster B personality disorders). Age effects were not due to the characteristics of informants, and such effects were not observed among living controls. When directly controlling for major psychopathology, the interaction between age, levels of impulsivity, aggression and novelty seeking predicted suicide status while controlling for the independent contributions of age and these traits. CONCLUSIONS Higher levels of impulsive-aggressive traits play a greater role in suicide occurring among younger individuals, with decreasing importance with increasing age.

Cognitive predictors of psychosocial functioning outcome in schizophrenia: A follow-up study of subjects participating in a rehabilitation program

The aims of this prospective study were to explore in subjects with psychosis participating in a rehabilitation program whether cognitive performances at baseline predicted (i) psychosocial functioning over a 15-16 month follow-up; (ii) improvement in psychosocial functioning over the rehabilitation program. Visuo-spatial tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB) were administered to assess cognitive performance in 55 subjects with schizophrenia spectrum disorders who completed a rehabilitation program. The Multnomah Community Ability Scale (MCAS) was used to measure dimensions of community functioning. One subscale of the Clients Assessment of Strengths, Interests, and Goals (CASIG) provided a measure of subjective quality of life (QoL). Improvement was defined as a 15% or more increase in psychosocial scores between baseline and follow-up. Worse baseline sustained attention predicted better self-rated quality of life, and better baseline visual memory predicted better community functioning over the rehabilitation follow-up period, in particular, higher autonomy in activities of daily living, and less physical and psychiatric symptoms that could interfere with rehabilitation. Baseline cognitive performances predicted community functioning improvement during the follow-up period: visual memory predicted improvement in daily living autonomy and in social competence; sustained attention predicted improvement in behavioral problems (such as medication compliance, collaboration with treatment providers or impulse control) and social competence; planning performances predicted improvement in social competence. These cognitive functions could be specifically targeted in a rehabilitation program aimed at enhancing functioning in those particular dimensions.

Familial Aggregation of Suicide Explained by Cluster B Traits: A Three-Group Family Study of Suicide Controlling for Major Depressive Disorder

OBJECTIVE There is substantial evidence suggesting that suicide aggregates in families. However, the extent of overlap between the liability to suicide and psychiatric disorders, particularly major depressive disorder, remains an important issue. Similarly, factors that account for the familial transmission of suicidal behavior remain unclear. Thus, through direct and blind assessment of first-degree relatives, the authors conducted a family study of suicide by examining three proband groups: probands who committed suicide in the context of major depressive disorder, living depressed probands with no history of suicidal behavior, and psychiatrically normal community comparison probands. METHOD Participants were 718 first-degree relatives from 120 families: 296 relatives of 51 depressed probands who committed suicide, 185 relatives of 34 nonsuicidal depressed probands, and 237 relatives of 35 community comparison subjects. Psychopathology, suicidal behavior, and behavioral measures were assessed via interviews. RESULTS The relatives of probands who committed suicide had higher levels of suicidal behavior (10.8%) than the relatives of nonsuicidal depressed probands (6.5%) and community comparison probands (3.4%). Testing cluster B traits as intermediate phenotypes of suicide showed that the relatives of depressed probands who committed suicide had elevated levels of cluster B traits; familial predisposition to suicide was associated with increased levels of cluster B traits; cluster B traits demonstrated familial aggregation and were associated with suicide attempts among relatives; and cluster B traits mediated, at least in part, the relationship between familial predisposition and suicide attempts among relatives. Analyses were repeated for severity of attempts, where cluster B traits also met criteria for endophenotypes of suicide. CONCLUSIONS Familial transmission of suicide and major depression, while partially overlapping, are distinct. Cluster B traits and impulsive-aggressive behavior represent intermediate phenotypes of suicide.

Do Canada and the United States differ in prevalence of depression and utilization of services

OBJECTIVE This study compared the prevalence of depression and the determinants of mental health service use in Canada and the United States. METHODS The study used data from preliminary analyses of the 2003 Joint Canada/United States Survey of Health, which measured Canadian (N=3,505) and United States (N=5,183) resident ratings of health and health care services. Cross-national comparisons were made for the 12-month prevalence of DSM-IV major depression, 12-month service use for mental health reasons according to the type of professional seen, and determinants of service use. RESULTS The rates of depression were similar in Canada (8.2%) and the United States (8.7%). However, U.S. respondents without medical insurance were twice as likely as Canadian respondents and U.S. respondents with medical insurance to meet the criteria for depression. Rates of mental health service use did not differ between Canada (10.1%) and the United States (10.6%). In the United States, medical insurance was not a determinant factor of service use. However, U.S. respondents with no medical insurance were more likely than the other two groups to report an unmet need. Also, among those with depression, U.S. respondents with no medical insurance were less likely to use any type of mental health service (36.5%) than U.S. respondents with medical insurance (55.7%) and Canadians (55.7%). Further, a positive correlation between a mental health need and service use was observed in Canada but not for those without medical insurance in the United States. CONCLUSIONS There was no difference in the prevalence of depression and mental health service use between Canada and the United States. Among those with depression, however, disparities in treatment seeking were found to be associated with medical insurance in the United States. Both Canada and the United States need to improve access to health services for those with mental disorders, and special attention is needed for those without medical insurance in the United States.

The relationship between work stress and mental disorders in men and women: findings from a population-based study

Objectives: This analysis estimated the gender-specific associations between work stress, major depression, anxiety disorders and any mental disorder, adjusting for the effects of demographic, socioeconomic, psychological and clinical variables. Methods: Data from the Canadian national mental health survey were used to examine the gender-specific relationships between work stress dimensions and mental disorders in the working population (n  =  24 277). Mental disorders were assessed using a modified version of the World Mental Health—Composite International Diagnostic Interview. Results: In multivariate analysis, male workers who reported high demand and low control in the workplace were more likely to have had major depression (OR 1.74, 95% CI 1.12 to 2.69) and any depressive or anxiety disorders (OR 1.47, 95% CI 1.05 to 2.04) in the past 12 months. In women, high demand and low control was only associated with having any depressive or anxiety disorder (OR 1.39, 95% CI 1.05 to 1.84). Job insecurity was positively associated with major depression in men but not in women. Imbalance between work and family life was the strongest factor associated with having mental disorders, regardless of gender. Conclusions: Policies improving the work environment may have positive effects on workers’ mental health status. Imbalance between work and family life may be a stronger risk factor than work stress for mental disorders. Longitudinal studies incorporating important workplace health research models are needed to delineate causal relationships between work characteristics and mental disorders.

Service Use for Mental Health Reasons: Cross-Provincial Differences in Rates, Determinants, and Equity of Access

Objectives: In 2002, Canada undertook its first national survey on mental health and well-being, including detailed questioning on service use. Mental disorders may affect more than 1 person in 5, according to past regional and less comprehensive mental health surveys in Canada, and most do not seek help. Individual determinants play a role in health resource use for mental health (MH) reasons. This study aimed to provide prevalence rates of health care service use for MH reasons by province and according to service type and to examine determinants of MH service use in Canada and across provinces. Methods: We assessed the prevalence rate (95% confidence interval [CI]) of past-year health service use for MH reasons, and we assessed potential determinants cross-sectionally, using data collected from the Statistics Canada Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). We estimated models of resource use with logistic regression (using odds ratios and 95%CIs). Results: The prevalence of health service use for MH reasons in Canada was 9.5% (95%CI, 9.1% to 10.0%). The highest rates, on average, were observed in Nova Scotia (11.3%; 95%CI, 9.6% to 13.0%) and British Columbia (11.3%; 95%CI, 10.1% to 12.6%). The lowest rates were observed in Newfoundland and Labrador (6.7%; 95%CI, 5.3% to 8.0%) and Prince Edward Island (7.5%; 95%CI, 5.8% to 9.3%). In Canada, the general medical system was the most used for MH reasons (5.4%; 95%CI, 5.1% to 5.8%) and the voluntary network sector was the least used (1.9%; 95%CI, 1.7% to 2.1%). No difference was observed in the rate of service use between specialty MH (3.5%; 95%CI, 3.2% to 3.8%) and other professional providers (4.0%; 95%CI, 3.7% to 4.3%). In multivariate analyses, after adjusting for age and sex, the presence of a mental disorder was a consistent predictor of health service use for MH across the provinces. Conclusions: There is up to a twofold difference in the type of service used for MH reasons across provinces. The primary care general medical system is the most widely used service for MH. Need remains the strongest predictor of use, especially when a mental disorder is present. Barriers to access, such as income, were not identified in all provinces. Different sociodemographic variables played a role in service seeking within each province. This suggests different attitudes toward common mental disorders and toward care seeking among the provinces.

joint effect of depression and chronic conditions on disability: Results from a population-based study

Objectives: To estimate and compare the prevalence of functional disability in individuals with both chronic medical conditions and comorbid major depression and individuals with either chronic medical conditions or major depression alone and to determine the joint effect of depression and chronic conditions on functional disability. Evidence exists that major depression interacts with physical illness to amplify the functional disability associated with many medical conditions. Methods: We used data from the Canadian Community and Health Survey Cycle 2.1 (n = 46,262), a nationally representative survey conducted in 2003 by Statistics Canada. Depression, chronic conditions, and functional disability were assessed by personal/telephone interview. Results: Prevalence of functional disability was higher in subjects with chronic conditions and comorbid major depression (46.3%) than in individuals with either chronic conditions (20.9%) or major depression (27.8%) alone. With no chronic conditions and no major depression as reference and after adjusting for relevant covariates, the odds ratio of functional disability was 2.49 (95% confidence interval (CI), 1.91–3.26) for major depression, 2.12 (95% CI, 1.93–2.32) for chronic conditions, and 6.34 (95% CI, 5.35–7.51) for chronic conditions and comorbid major depression. Conclusions: The results suggest that there is a joint effect of depression and chronic conditions on functional disability. Research and social policies should focus on the treatment of depression in chronic conditions. CCHS = Canadian Community and Health Survey; CIDI-SFMD = Composite International Diagnostic Interview-Short Form for Major Depression; SE = standard error; OR = odds ratio; CI = confidence interval.

Factors related to utilization of services for mental health reasons in Montreal, Canada.

Abstract This study examines factors related to the utilization of services for mental health reasons by Montreal residents. Data were drawn from telephone interviews. A random sample of 893 respondents completed a questionnaire on service utilization and the Diagnostic Interview Schedule Self Administered to assess DSM-III-R psychiatric disorders. Results indicate that 12.8% of the population had used such services in the past year. Medical doctors and psychiatrists, whose services are free of charge under universal health coverage, were consulted, respectively, by 4.1% and 2.0% of respondents. Psychologists, whose services are not free, were seen by 3.4% of respondents. In all, 42.0% of respondents who presented a current diagnosis used services in the past year. The highest proportion of users (48.0%) was found among respondents who presented both current and lifetime diagnoses and among respondents with comorbidity. The choice of caregiver was related also to pattern of disorders: respondents with current and comorbid disorders tended to consult general practitioners, while respondents with lifetime disorders or with lifetime and current disorders favoured specialized care. In line with other studies, self-perception of mental health, gender and marital status were related to utilization; unlike other studies, attitudes and age were not. It is argued that particularities found in this study stem not only from methodological considerations, but also from the configuration of the mental health system in Quebec, where the greater availability of psychologists may facilitate service utilization.

Suicide and no axis I psychopathology

BackgroundIt is unclear why approximately 10% of suicide completers seem to be psychiatrically normal. To better understand this issue, we studied suicide completers without an axis I diagnosis and compared them, on measures of psychopathology other than axis I, to normal controls and suicide cases with axis I psychopathology.Methods168 suicide cases were examined by way of a psychological autopsy with the best possible informant. Sixteen cases did not meet criteria for an axis I diagnosis; each of these cases was then age and gender matched to 52 suicide completers with an axis I disorder and 110 normal controls.ResultsFourteen of sixteen suicide cases without an axis I diagnosis had detectable abnormalities that were more similar to the axis I diagnosed suicide group than to a living group. Both suicide groups were similar in the total number of past suicide attempts, the total number of individuals with an axis II disorder, and similar scores on measures of impulsive-aggressive behaviors.ConclusionsThese findings suggest that most of the individuals who committed suicide and appeared psychiatrically normal after a psychological autopsy may probably have an underlying psychiatric process that the psychological autopsy method, as commonly carried out, failed to detect.

Patterns of co-morbidity in male suicide completers

BACKGROUND Psychiatric co-morbidity is thought to be an important problem in suicide, but it has been little investigated. This study aims to investigate patterns of co-morbidity in a group of male suicide completers. METHOD One hundred and fifteen male suicide completers from the Greater Montreal Area and 82 matched community controls were assessed using proxy-based diagnostic interviews. Patterns of co-morbidity were investigated using latent class analysis. RESULTS Three subgroups of male suicide completers were identified (L2 = 171.62, df = 2012, P < 0.05). they differed significantly in the amount of co-morbidity (Kruskal-Wallis chi2 = 71.227, df = 2. P < 0.000) and exhibited different diagnostic profiles. Co-morbidity was particularly found in subjects with disorders characterized by impulsive and impulsive-aggressive traits, whereas subjects without those traits had levels of co-morbidity which were not significantly different from those of controls (chi2 = 8.17, df = 4, P = 0.086). CONCLUSIONS Suicide completers can be divided into at least three subgroups according to co-morbidity: a low co-morbidity group, a substance-dependent group and a group exhibiting childhood onset of psychopathology.