Camilla Haw

Risk factors for suicide in individuals with depression: A systematic review

BACKGROUND Depression is the most common psychiatric disorder in people who die by suicide. Awareness of risk factors for suicide in depression is important for clinicians. METHODS In a systematic review of the international literature we identified cohort and case-control studies of people with depression in which suicide was an outcome, and conducted meta-analyses of potential risk factors. RESULTS Nineteen studies (28 publications) were included. Factors significantly associated with suicide were: male gender (OR=1.76, 95% CI=1.08-2.86), family history of psychiatric disorder (OR=1.41, 95% CI=1.00-1.97), previous attempted suicide (OR=4.84, 95% CI=3.26-7.20), more severe depression (OR=2.20, 95% CI=1.05-4.60), hopelessness (OR=2.20, 95% CI=1.49-3.23) and comorbid disorders, including anxiety (OR=1.59, 95% CI=1.03-2.45) and misuse of alcohol and drugs (OR=2.17, 95% CI=1.77-2.66). LIMITATIONS There were fewer studies than suspected. Interdependence between risk factors could not be examined. CONCLUSIONS The factors identified should be included in clinical assessment of risk in depressed patients. Further large-scale studies are required to identify other relevant factors.

Dementia and suicidal behavior: a review of the literature

BACKGROUND While dementia is more common in older people and suicide rates in many countries are higher among the elderly, there is some doubt about the association between these two phenomena. METHODS A search of the major relevant databases was carried out to examine the evidence for this possible association. RESULTS The association between dementia and suicide and also non-fatal self-harm did not appear strong but many studies have significant methodological limitations and there are few studies of suicide or self-harm in vascular, frontotemporal, Lewy body and HIV dementia where such behavior might be expected to be more common. Rates of self-harm may be increased in mild dementia and are higher before than after predictive testing for Huntingtons disease. Overall, the risk of suicide in dementia appears to be the same or less than that of the age-matched general population but is increased soon after diagnosis, in patients diagnosed with dementia during hospitalization and in Huntingtons disease. Putative risk factors for suicide in dementia include depression, hopelessness, mild cognitive impairment, preserved insight, younger age and failure to respond to anti-dementia drugs. Large, good quality prospective studies are needed to confirm these findings. CONCLUSIONS Further research should be undertaken to examine how rates of suicide and self-harm change during the course of the illness and vary according to the specific sub-type of dementia.

Suicide Clusters: A Review of Risk Factors and Mechanisms

Suicide clusters, although uncommon, cause great concern in the communities in which they occur. We searched the world literature on suicide clusters and describe the risk factors and proposed psychological mechanisms underlying the spatio-temporal clustering of suicides (point clusters). Potential risk factors include male gender, being an adolescent or young adult, drug or alcohol abuse, and past history of self-harm. However, the majority of studies lack methodological rigor. Many different psychological mechanisms are described, including contagion, imitation, suggestion, learning, and assortative relating, but supporting empirical evidence is generally lacking. More scientifically rigorous studies are needed to improve understanding of suicide clusters.

Psychiatric disorders in patients presenting to hospital following self-harm: a systematic review.

BACKGROUND Psychiatric disorders occur in approximately 90% of individuals dying by suicide. The prevalence of psychiatric disorders in people who engage in non-fatal self-harm has received less attention. METHOD Systematic review using electronic databases (Embase, PsychINFO and Medline) for English language publications of studies in which psychiatric disorders have been assessed using research or clinical diagnostic schedules in self-harm patients of all ages presenting to general hospitals, followed by meta-analyses using random effects methods. RESULTS A total of 50 studies from 24 countries were identified. Psychiatric (Axis I) disorders were identified in 83.9% (95% CI 74.7-91.3%) of adults and 81.2% (95% CI 60.9-95.5%) of adolescents and young persons. The most frequent disorders were depression, anxiety and alcohol misuse, and additionally attention deficit hyperactivity disorder (ADHD) and conduct disorder in younger patients. Personality (Axis II) disorders were found in 27.5% (95% CI 17.6-38.7%) of adult patients. Psychiatric disorders were somewhat more common in patients in Western (89.6%, 95% CI 83.0-94.7%) than non-Western countries (70.6%, 95% CI 50.1-87.6%). LIMITATIONS Heterogeneity between study results was generally high. There were differences between studies in identification of study participants and diagnostic procedures. CONCLUSIONS Most self-harm patients have psychiatric disorders, as found in people dying by suicide. Depression and anxiety disorders are particularly common, together with ADHD and conduct disorder in adolescents. Psychosocial assessment and aftercare of self-harm patients should include careful screening for such disorders and appropriate therapeutic interventions. Longitudinal studies of the progress of these disorders are required.

Life problems and deliberate self-harm: associations with gender, age, suicidal intent and psychiatric and personality disorder.

BACKGROUND Deliberate self-harm (DSH) may occur in response to negative life events and life problems. High suicidal intent may be a risk factor for subsequent suicide but little is known about how life problems and suicidal intent are related. The aims of this study were to examine life problems according to age, gender, suicidal intent and other patient characteristics in DSH patients. METHODS Data from the Oxford Monitoring System for Attempted Suicide were used to investigate life problems contributing to DSH and their relationship to patient variables including Suicide Intent Scale (SIS) scores in DSH patients presenting to the general hospital in Oxford between 1993 and 2000. Of 4391 persons included in the study 80.6% reported multiple life problems, the most common being in the relationship with spouse or partner. The nature of the most frequent problems changed over the life-span and there were gender differences. Females, but not males, with high suicidal intent had more problems than those with low intent and for females with no past history of DSH there was a weak positive correlation between the number of life problems and total SIS score. Patients with high intent more frequently experienced psychiatric and social isolation problems than those with low intent. Females with high intent more frequently reported bereavement or loss and eating problems. LIMITATIONS The study population was not entirely representative of all DSH patients presenting to hospital. CONCLUSIONS Most DSH patients have multiple life problems and the type of problems may be associated with varying degrees of suicidal intent. Patients should be offered interventions individually tailored according to their specific problems.

Suicide in female nurses in England and Wales.

BACKGROUND Female nurses appear to have an increased risk of suicide but the reasons are unknown. METHOD We have concluded a study of nurse suicides (N = 106) in England and Wales, including a psychological autopsy study (N = 42) and case-control comparison with living nurses (N = 84). RESULTS Nearly three-quarters of the nurse suicides had previous contact with psychiatric services and almost half had been psychiatric in-patients in the past. There were particularly marked differences between the cases and controls for current psychiatric disorder (90.5% v. 7.1%, OR = 68.5), personality disorder (38.1% v. 12%, OR = 32), and history of deliberate self-harm (71.4% v. 2.4%, OR = 58.5). Family background and social factors (especially concerning interpersonal relationships) also distinguished the two groups. Smoking and serious alcohol abuse were much more frequent in the suicides. There was some indication that while many of the suicides were in contact with psychiatric services, care may not have been optimal in some cases. CONCLUSIONS The most important strategies for suicide prevention in nurses are in prevention, detection and management of psychiatric disorders. In assessing suicide risk a history of DSH and the presence of comorbid psychiatric and personality disorders are particularly important.

Deliberate Self-Harm Patients with Alcohol Disorders: Characteristics, Treatment, and Outcome

Deliberate self-harm (DSH) patients with alcohol problems present a considerable challenge for clinical services. In a study of a sample of 150 DSH patients who were representative of all such patients seen at a general hospital during the study period, 40 patients with an ICD-10 diagnosis of alcohol dependence or harmful use of alcohol were compared with the remainder of the sample. The treatment of the patients with alcohol disorders before and after the episode of DSH and the outcome 12-20 months later were also investigated. Compared with other DSH patients, those with an alcohol diagnosis were older and more often male, living alone, unemployed, sick, disabled, or with a past history of DSH. They also had higher scores on measures of anger, aggression, and impulsivity. Comorbid psychiatric disorder was present in 37 (92.5%) patients, this being depression in three-quarters of those cases. Fourteen (35.0%) patients were receiving treatment from the psychiatric services prior to DSH, and 33 (82.5%) were subsequently offered treatment. Of the patients who were followed up, 37.9% remained in contact with psychiatric services, 55.2% showed poor compliance with treatment and 44.8% reported a further episode of DSH. All patients presenting after DSH need to be carefully screened for alcohol disorders and for comorbid psychiatric diagnoses. Treatment of DSH patients with alcohol disorders should include the treatment of any comorbid depressive illness.

Economic recession and suicidal behaviour: Possible mechanisms and ameliorating factors

Background: A growing body of research evidence from countries around the world indicates that economic recession is associated with increases in suicide, particularly in males of working age. Aims: To explore contributory and ameliorating factors associated with economic recession and suicide and thereby stimulate further research in this area and encourage policy makers to consider how best to reduce the impact of recession on mental health and suicidal behaviour. Method: We conducted a selective review of the worldwide literature focusing on possible risk factors, mechanisms and preventative strategies for suicidal behaviour linked to economic recession. Results: A model of how recession might affect suicide rates is presented. A major and often prolonged effect of recession is on unemployment and job insecurity. Other important effects include those exerted by financial loss, bankruptcy and home repossession. It is proposed these factors may lead directly or indirectly to mental health problems such as depression, anxiety and binge drinking and then to suicidal behaviour. Countries with active labour market programmes and sustained welfare spending during recessions have less marked increases in suicide rates than those that cut spending on welfare and job-search initiatives for the unemployed. Other measures likely to help include targeted interventions for unemployed people, membership of social organisations and responsible media reporting. Good primary care and mental health services are needed to cope with increased demand in times of economic recession but some governments have in fact reduced healthcare spending as an austerity measure. Conclusion: The research evidence linking recession, unemployment and suicide is substantial, but the evidence for the other mechanisms we have investigated is much more tentative. We describe the limitations of the existing body of research as well as make suggestions for future research into the effects of economic recession on suicidal behaviour.

A survey of the off-label use of mood stabilizers in a large psychiatric hospital

The term ‘off-label’ prescribing refers to the use of a drug outside the terms of its Marketing Authorization, including prescribing for an unlicensed indication. The aims of the study were to determine the frequency of off-label prescriptions for mood stabilizers (lithium and antiepileptics) among inpatients of a large psychiatric hospital, the nature of the off-label clinical indications in use and whether patients had been informed about the off-label usage. A cross-sectional survey of inpatients aged 18-65 years at St Andrew’s Hospital, Northampton, UK and interviews with consultant psychiatrists about off-label usage of mood stabilizers were carried out. Of the 249 patients studied, 75 (30.1%) were receiving one or more mood stabilizers, of which 71 (94.7%) were off-label. The most frequently cited off-label indications for mood stabilizers were: prophylaxis of mood swings (48 cases), treatment of aggression (31), manic symptoms (10), antipsychotic augmentation in treatment-resistant schizophrenia (7) and post-traumatic stress disorder (6). Lithium was prescribed infrequently. The reasons for this are discussed. Although in most instances the psychiatrist was aware the drug was being used off-label, in less than one-third of cases had the patient been informed of this, partly because of anticipated difficulties in their understanding the off-label concept, but also because of concerns that this information could adversely affect compliance. The off-label prescription of mood stabilizers is very common in psychiatry and such usage benefits patients. When prescribing off-label, psychiatrists should consider the evidence that the drug is likely to be effective for the unlicensed indication. Where there is limited evidence of benefit, a trial of the drug, with clinical monitoring, may be indicated. Patients should be fully informed about their medication, and this includes information that the prescription is off-label. Pharmacists can assist this process. The off-label concept may be difficult for some patients to understand.

Prescription errors in psychiatry – a multi-centre study

Medication errors are an important cause of patient morbidity and mortality, of which there have been few reports in psychiatry, especially in the UK. Our aim was to examine the nature, frequency and potential severity of prescribing errors in UK mental health units in a prospective, 1 week survey of errors detected by pharmacy staff in nine NHS trusts. Pharmacists checked 22036 prescription items. In total, 523 errors meeting the study definition were detected (2.4% of prescription items checked). Prescription writing errors (77.4%) were most common, while decision-making errors accounted for 22.6% of errors. In 280 (53.5%) cases the prescribed drug had been administered before the error was detected. Most errors were of doubtful or minor importance but 22 (4.3%) were deemed likely to result in serious adverse effects or death. The error detection rate varied fourfold between trusts. Prescribing errors are fairly common in psychiatry. A small proportion of errors have the potential for serious harm. Pharmacy staff have an important role to play in their management.