José Giner

Issues for DSM-V: Suicidal Behavior as a Separate Diagnosis on a Separate Axis

Suicidal behavior (death and attempts) is usually a complication of psychiatric conditions, most commonly mood disorders (1). However, it also occurs in schizophrenia, substance use disorders (particularly with alcohol), and personality and anxiety disorders, among others (1). About 10% of those who commit or attempt suicide have no identifiable psychiatric illness. However, our current nomenclature considers suicidal behavior a symptom of major depressive episode or borderline personality disorder.

Personality disorders and health problems distinguish suicide attempters from completers in a direct comparison.

BACKGROUND Whether suicide attempters and completers represent the same population evaluated at different points along a progression towards suicide death, overlapping populations, or completely different populations is a problem still unresolved. METHODS 446 Adult suicide attempters and knowledgeable collateral informants for 190 adult suicide probands were interviewed. Sociodemographic and clinical data was collected for both groups using semi-structured interviews and structured assessments. Univariate analyses and logistic regression models were conducted to explore the similarities and differences between suicide attempters and completers. RESULTS Univariate analyses yielded significant differences in sociodemographics, recent life events, impulsivity, suicide intent, and distribution of Axis I and II disorders. A logistic regression model aimed at distinguishing suicide completers from attempters properly classified 90% of subjects. The most significant variables that distinguished suicide from attempted suicide were the presence of narcissistic personality disorder (OR=21.4; 95% CI=6.8-67.7), health problems (OR=20.6; 95% CI=5.6-75.9), male sex (OR=9.6; 95% CI=4.42-20.9), and alcohol abuse (OR=5.5; 95% CI=2.3-14.2). LIMITATIONS Our study shares the limitations of studies comparing suicide attempters and completers, namely that information from attempters can be obtained from the subject himself, whereas the assessment of completers depends on information from close family or friends. Furthermore, different semi-structured instruments assessed Axis I and Axis II disorders in suicide attempters and completers. Finally, we have no data on inter-rater reliability data. CONCLUSIONS Suicide completers are more likely to be male and suffer from alcohol abuse, health problems (e.g. somatic illness), and narcissistic personality disorder. The findings emphasize the importance of implementing suicide prevention programs tailored to suicide attempters and completers.

Consenso español de salud física del paciente con depresión

Comorbidity between depression and physical illnesses is very common and has a significant impact on the health and management of the patient. With the support of the Sociedades Españolas de Psiquiatría y Psiquiatría Biológica, and Sociedad Española de Médicos de Atención Primaria (SEMERGEN) a consensus was prepared on physical health in patients with depression and is summarized in the present work. The literature review highlighted the high frequency of cardiovascular and endocrine-metabolic disorders in patients with depression such as diabetes and obesity, thus making the primary and secondary prevention recommendations for patients with cardiovascular or metabolic risk applicable to patients with depression. Comorbidity between depression and chronic pain is also frequent, and requires an integrated therapeutic approach. The presence of physical illness in patients with depression may condition, but not preclude, the pharmacological treatment; drug selection should take into account potential side-effect and drug-drug interactions. On the other hand, psychotherapy may contribute to the patients recovery. Overall, coordination between the primary care physician, the psychiatrist and other health professionals involved is essential for the management of patients with depression and concomitant physical illness.

Subjectivity in the Perception and Measurement of Quality of Life : Conceptualization and Development of the Seville Questionnaire

Quality of life (QoL) is a significant parameter in estimating the social and interpersonal impact of psychopathology, clinical course, and response to treatment in many mental illnesses, particularly schizophrenia. The clinician’s assessment and patient’s subjective report are essential ingredients of this process. We describe the development and structure of a QoL questionnaire based on the patient’s subjective understanding of the problems. Ninety areas identified by four groups of experts resulted in a 126-item questionnaire administered to 279 patients with a DSM-IV diagnosis of schizophrenia. A factorial approach led to 59 total items and two final scales (favorable and unfavorable), with three factors each. The Seville QoL Questionnaire (SQLQ) results can be presented as individual scores for each scale, or a total for both. Its psychometric properties have proven quite acceptable in reliability and validity, comparing favorably with other scales. SQLQ may prove to be a useful addition to QoL-measuring instruments.

The “Seroquel” Outcomes Study (SOS): Efficacy and tolerability of quetiapine in a long-term, naturalistic study of patients with schizophrenia

Objective. The “Seroquel” Outcomes Study (SOS) aimed to assess the efficacy and tolerability of quetiapine in patients with schizophrenia in the clinical practice setting. Methods. A 6-month, non-comparative, open-label study in adults with schizophrenia in a standard care setting in Spain. Outpatients received flexibly dosed quetiapine. Efficacy was evaluated using the Brief Psychiatry Rating Scale (BPRS) and the Clinical Global Impression (CGI) scale. BPRS response was defined as≥30% decrease from baseline. Tolerability was assessed using the Simpson–Angus Scale (SAS) and a modified Udvalg for Kliniske Undersogelser (UKU) side-effects scale. Results. A total of 2029 patients enrolled. Significant changes from baseline to Month 6 were recorded for BPRS total and subscale scores (P<0.001). Compared with doses of≥600 mg/day, doses of<400 mg/day were a strong predictor of a lower response rate (OR 0.62; 95% CI: 0.48, 0.82) and higher withdrawal rate (OR 3.3; 95% CI: 2.5, 4.4). Mean change in weight was minimal (+0.4 kg). Somnolence (26.7%), asthenia (12.5%), and constipation (9.8%) were the most common adverse events. Conclusion. Quetiapine was found to improve symptoms of schizophrenia, as indicated by a significant decrease in BPRS scores, and was well tolerated by patients in clinical practice.