E. Isometsä

Mental disorders and comorbidity in attempted suicide

The present study examined the prevalence and comorbidity of mental disorders according to DSM‐III‐R among male and female suicide attempters. A systematic sample of 114 patients from consecutive cases of attempted suicide referred to a general hospital in Helsinki between 1 January and 31 July 1990 was interviewed. In 98% of the cases at least one Axis I diagnosis was made. Depressive syndromes were more common among females (85%) than males (64%), and alcohol dependence was more common among males (64%) than females (21%). A high proportion of suicide attempters (82%) suffered from comorbid mental disorders. Comorbidity appears to play an important role in parasuicide.

Hopelessness, impulsiveness and intent among suicide attempters with major depression, alcohol dependence, or both.

The present study examined differences in hopelessness, impulsiveness and suicide intent between suicide attempters with either major depression or alcohol dependence, comorbid major depression and alcohol dependence, and those without these disorders. A sample of 114 patients from consecutive cases of attempted suicide referred to a general hospital in Helsinki was interviewed and diagnosed according to DSM‐III‐R. Suicide intent was measured by the Beck Suicide Intent Scale (SIS) and hopelessness was assessed by the Beck Hopelessness Scale (HS). Impulsiveness of the suicide attempt was measured by two items of the SIS. Suicide attempters with major depression without comorbid alcohol dependence had higher suicide intent and lower impulsiveness than attempters with non‐depressive alcohol dependence. Suicide attempts may differ between subjects with major depression, alcoholism or both disorders in terms of impulsiveness and suicide intent.

Differences between urban and rural suicides

As part of a nation‐wide psychological autopsy we examined the differences in DSM‐III‐R mental disorders, recent life events and other characteristics between urban (n=143) and rural (n=85) completed suicides in a random sample of 229 cases from the National Suicide Prevention Project in Finland for the period 1987‐1988. Psychoactive substance use disorders (48% vs. 34%), cluster B personality disorders (24% vs. 9%) and psychiatric comorbidity (66% vs. 42%) were found more commonly among urban than rural suicides. Urban suicides were also more often reported to be preceded by a recent separation (25% vs. 8%), whereas rural suicide victims tended to have lacked a close companion of the opposite sex (36% vs. 18%) and to have had physical disorders (56% vs. 40%). Overall, urban and rural suicides may vary with regard to the prevalence of some mental disorders, their comorbidity, and physical disorders, as well as the preceding life situation. This variation may also imply the need for differences in strategies for suicide prevention in each setting.

A prospective latent analyses study of psychiatric comorbidity of DSM-IV bipolar I and II disorders

OBJECTIVEnTo test two hypotheses of psychiatric comorbidity in bipolar disorder (BD): (i) comorbid disorders are independent of BD course, or (ii) comorbid disorders associate with mood.nnnMETHODSnIn the Jorvi Bipolar Study (JoBS), 191 secondary-care outpatients and inpatients with DSM-IV bipolar I disorder (BD-I) or bipolar II disorder (BD-II) were evaluated with the Structured Clinical Interview for DSM-IV Disorders, with psychotic screen, plus symptom scales, at intake and at 6 and 18 months. Three evaluations of comorbidity were available for 144 subjects (65 BD-I, 79 BD-II; 76.6% of 188 living patients). Structural equation modeling (SEM) was used to examine correlations between mood symptoms and comorbidity. A latent change model (LCM) was used to examine intraindividual changes across time in depressive and anxiety symptoms. Current mood was modeled in terms of current illness phase, Beck Depression Inventory (BDI), Young Mania Rating Scale, and Hamilton Depression Rating Scale; comorbidity in terms of categorical DSM-IV anxiety disorder diagnosis, Beck Anxiety Inventory (BAI) score, and DSM-IV-based scales of substance use and eating disorders.nnnRESULTSnIn the SEM, depression and anxiety exhibited strong cross-sectional and autoregressive correlation; high levels of depression were associated with high concurrent anxiety, both persisting over time. Substance use disorders covaried with manic symptoms (r = 0.16-0.20, p < 0.05), and eating disorders with depressive symptoms (r = 0.15-0.32, p < 0.05). In the LCM, longitudinal intraindividual improvements in BDI were associated with similar BAI improvement (r = 0.42, p < 0.001).nnnCONCLUSIONSnDepression and anxiety covary strongly cross-sectionally and longitudinally in BD. Substance use disorders are moderately associated with manic symptoms, and eating disorders with depressive mood.

Socio-economic position and mental disorders in a working-age Finnish population: the health 2000 study

BACKGROUNDnMental disorders are more common in people with lower socio-economic position (SEP) but it is not known which specific SEP component is most strongly linked to poor mental health. We compared the strength of associations of three SEP components-occupation, income and education-with common mental disorders in a Finnish population.nnnMETHODSnCross-sectional analysis of a nationally representative sample of 4561 men and women aged 30-65 years. Mental disorders were assessed using the Composite International Diagnostic Interview resulting in 12-month DSM-IV diagnoses of depressive, anxiety and alcohol use disorders. Participants were classified as having low SEP if they worked in a manual occupation, lacked secondary-level education or had income below the Organisation for Economic Co-operation and Development (OECD) definition of relative poverty.nnnRESULTSnIn models comparing the simultaneous association of all three socio-economic indicators with mental disorders, low income was associated with increased risk for depressive disorder [odds ratio (OR)=1.73, 95% confidence interval (CI) =1.31-2.29] and anxiety disorder (OR=1.56, 95% CI 1.14-2.12). Manual occupational class was modestly associated with risk for alcohol use disorder (OR=1.44, 95% CI 1.06-1.95). Low income was the only socio-economic component associated with psychiatric comorbidity, that is, a combination of various disorders within the same individual (OR 2.26, 95% CI 1.52-3.37 for any combination).nnnCONCLUSIONnLow income seems to be a more important correlate of mental disorders than education or occupation in a high-income country such as Finland.

Treatment received by alcohol-dependent suicide attempters

The purpose of this study was to examine the clinical features of alcohol‐dependent suicide attempters and the treatment they received before and after the index attempt. A total of 47 subjects with current DSM‐III‐R alcohol dependence were identified from a systematic sample of 114 suicide attempters in Helsinki. All of them were comprehensively interviewed after the attempt, and the treatment they had received was established from psychiatric and other health‐care records and follow‐up interviews. Most had a history of psychiatric (83%) or substance abuse (83%) treatment. During the final month before the attempt, half of the subjects (51 %)) had been treated by health care services; 11% had received disulfiram‐treatment and 6% had received psychotherapy. Subjects complied with recommended aftercare more often when they had been actively referred. After 1 month, 64% were being treated by health care services. However, only 14% were receiving disulfiram‐treatment and 9% were receiving psychotherapy. These findings suggest that the quality and activity of treatment offered to suicide attempters with alcohol dependence should be improved.

Psychosocial factors and completed suicide in personality disorders

The aim of the present study was to investigate the relationships between personality disorders (PD) and various psychosocial factors in a random sample (n= 229) of suicides with psychological autopsy‐based DSM‐III‐R diagnoses representing the total 1‐year suicide population in Finland.

Inadequate dosaging in general practice of tricyclic vs. other antidepressants for depression

Several prescription database studies suggest major differences between antidepressants in the proportion of patients in general practice treated with doses likely to elicit a true drug response. However, in these studies it has been difficult to differentiate prescriptions for depression from those for other indications, or to distinguish lower starting doses from the final treatment doses. We investigated possible differences between types of antidepressant in the proportions of patients receiving adequate treatment doses for depression from the primary health care services of Helsinki. Doctors at 22 (71%) of the 31 health centres in Helsinki were surveyed with regard to their antidepressant prescriptions over a period of 2 working weeks. There were marked differences in dosaging adequacy between the various types of antidepressant prescribed for depression at final treatment doses. Overall, 71% of the prescriptions for the tricyclic antidepressants, but only 13% of those for the other antidepressants, mainly selective serotonin reuptake inhibitors, were for low doses that are generally considered to be ineffective (P > 0.001). These findings endorse the emerging perception that, in general practice, tricyclic antidepressants are usually prescribed for depression in too low doses, and that a greater reliance on other antidepressants would probably improve the effectiveness of treatment in primary health care.

Suicide and the use of antidepressants Drug treatment of depression is inadequate

EDITOR, - Goran Isacsson and colleagues suggest that therapeutic failure of antidepressant drugs may be a greater problem in people who commit suicide than toxicity in overdose as their results indicated no advantage of the newer, less toxic drugs; furthermore, their results confirmed that only a small minority of people who commit suicide have received antidepressant treatment before death despite the high prevalence of depression in the population.1 The notable problems in their otherwise impressive database were, however, that they had neither diagnostic information nor knowledge of the dosage used in the cases studied. As our work may contribute to these questions,2 we wish to confirm and extend their findings.nnIn the national suicide prevention project in Finland all suicides (n=1397) in Finland committed between 1 April 1987 and 31 March 1988 were comprehensively examined by the psychological necropsy method. Mental disorders were evaluated retrospectively, according to the criteria in the Diagnostic and Statistical Manual of Mental, Disorders, third edition, revised, in a diagnostic study of a random sample of 229 suicides.3 In this study 71 of the 229 people who had committed suicide were estimated to have had current unipolar major depression.nnFurther examination of these 71 people showed that only 22 out of 66 (33%) had received antidepressant treatment (the information concerning possible antidepressant treatment was insufficient in four cases and conflicting in one)2 - a finding similar to the proportion (30%) reported by Barraclough et al in West Sussex.4 Most notably, only two people had received antidepressants in adequate doses (doxepin 250 mg/day and mianserin 60 mg/day). None of the others had received more than an equivalent of 100 mg of a tricyclic antidepressant daily. Thus only 3% (2/66) of people with current major depression who committed suicide were receiving adequate antidepressant …

The treatment received by substance-dependent male and female suicide victims

Within a nation‐wide psychological autopsy study we investigated use of treatment services and recognition of substance abuse problems among male and female substance‐dependent suicide victims. Although during their final month half of the male subjects and two‐thirds of the female subjects contacted health care services, in only one‐sixth and one‐third of cases, respectively, were substance abuse problems currently recognized. During their final year, 37% of the males and 67% of the females received psychiatric care. This was associated with Axis‐I comorbid disorders among males, with lower socio‐economic status and abuse of prescribed drugs among females, and with previous suicide attempts among both sexes. Due to their high psychiatric morbidity and tendency to have contacts with psychiatric services, the recognition, treatment and follow‐up of subjects with substance use disorders in psychiatric care would appear to be of major importance for suicide prevention.