Marco Innamorati

Suicidal behavior and alcohol abuse

Suicide is an escalating public health problem, and alcohol use has consistently been implicated in the precipitation of suicidal behavior. Alcohol abuse may lead to suicidality through disinhibition, impulsiveness and impaired judgment, but it may also be used as a means to ease the distress associated with committing an act of suicide. We reviewed evidence of the relationship between alcohol use and suicide through a search of MedLine and PsychInfo electronic databases. Multiple genetically-related intermediate phenotypes might influence the relationship between alcohol and suicide. Psychiatric disorders, including psychosis, mood disorders and anxiety disorders, as well as susceptibility to stress, might increase the risk of suicidal behavior, but may also have reciprocal influences with alcohol drinking patterns. Increased suicide risk may be heralded by social withdrawal, breakdown of social bonds, and social marginalization, which are common outcomes of untreated alcohol abuse and dependence. People with alcohol dependence or depression should be screened for other psychiatric symptoms and for suicidality. Programs for suicide prevention must take into account drinking habits and should reinforce healthy behavioral patterns.

Epidemiology of suicide in bipolar disorders: a systematic review of the literature.

Suicidal behavior is a major public health problem worldwide, and its prediction and prevention represent a challenge for everyone, including clinicians. The aim of the present paper is to provide a systematic review of the existing literature on the epidemiology of completed suicides in adult patients with bipolar disorder (BD).

Psychiatric comorbidity in patients with chronic daily headache and migraine: a selective overview including personality traits and suicide risk

Studies on the prevalence and impact of psychiatric disorders among headache patients have yielded findings that have clarified the relationship between migraine and major affective disorders, anxiety, illicit drug abuse, nicotine dependence, and suicide attempts. Studies in both clinical and community-based settings have demonstrated an association between migraine and a number of specific psychiatric disorders. In large-scale population-based studies, persons with migraine are from 2.2 to 4.0 times more likely to have depression. In longitudinal studies, the evidence supports a bidirectional relationship between migraine and depression, with each disorder increasing the risk of the other disorder. Although a strong association has been demonstrated consistently for migraine and major depression, especially for migraine with aura, there has been less systematic research on the links between migraine and bipolar disorder. This review will focus on the way in which psychiatric disorders decrease the quality of life and result in a worse prognosis, chronicity of the disease, and a worse response to treatment. Short-term pharmaceutical care intervention improves the patients’ mental health, but it does not significantly change the number and severity of headaches. The increase in self-efficacy and mental health associated with pharmaceutical care may be instrumental in improving the long-term pharmacotherapy of patients with migraine and headache.

The hypothalamic-pituitary-adrenal axis and serotonin abnormalities: A selective overview for the implications of suicide prevention.

Suicidal behavior and mood disorders are one of the world’s largest public health problems. The biological vulnerability for these problems includes genetic factors involved in the regulation of the serotonergic system and stress system. The hypothalamic-pituitary-adrenal (HPA) axis is a neuroendocrine system that regulates the body’s response to stress and has complex interactions with brain serotonergic, noradrenergic and dopaminergic systems. Corticotropin-releasing hormone and vasopressin act synergistically to stimulate the secretion of ACTH that stimulates the biosynthesis of corticosteroids such as cortisol from cholesterol. Cortisol is a major stress hormone and has effects on many tissues, including on mineralocorticoid receptors and glucocorticoid receptors in the brain. Glucocorticoids produce behavioral changes, and one important target of glucocorticoids is the hypothalamus, which is a major controlling center of the HPA axis. Stress plays a major role in the various pathophysiological processes associated with mood disorders and suicidal behavior. Serotonergic dysfunction is a well-established substrate for mood disorders and suicidal behavior. Corticosteroids may play an important role in the relationship between stress, mood changes and perhaps suicidal behavior by interacting with 5-HT1A receptors. Abnormalities in the HPA axis in response to increased levels of stress are found to be associated with a dysregulation in the serotonergic system, both in subjects with mood disorders and those who engage in suicidal behavior. HPA over-activity may be a good predictor of mood disorders and perhaps suicidal behavior via abnormalities in the serotonergic system.

Temperament and Personality Dimensions in Suicidal and Nonsuicidal Psychiatric Inpatients

Background: Suicide is a serious public health problem. In the international literature there is evidence to support the notion that certain temperaments and personality traits are often associated with suicidal behavior. Sampling and Methods: In this study, 150 psychiatric inpatients were investigated using the Temperament Evaluation of Memphis, Pisa, Paris and San Diego autoquestionnaire, the Minnesota Multiphasic Personality Inventory, 2nd edition (MMPI-2) and the Beck Hopelessness Scale and evaluated for suicide risk by means of the critical items of the Mini International Neuropsychiatric Interview. Results: Statistical analysis, including logistic regression analysis and multiple regression analysis, showed that suicide risk contributed to the prediction of hopelessness. Among the temperaments, only the hyperthymic temperament, as a protective factor, and the dysthymic/cyclothymic/anxious temperament contributed significantly to the prediction of hopelessness. Irritable temperament and social introversion were predictive factors for suicidal risk. Hopelessness and depression were associated with higher suicidal behavior and ideation, but, unexpectedly, depression as measured by the MMPI did not contribute significantly to the multiple regressions. Conclusions: The present study indicated that, although suicidal psychiatric patients have MMPI-2 profiles in the pathological range, they exhibit several differences from nonsuicidal patients. Patients at risk of suicide have specific temperaments as well as personality and defense mechanism profiles. They are more socially introverted, depressed and psychasthenic, and use hysterical and schizoid mechanisms more often. Generalizability of the findings was limited by the small sample size and the mix of bipolar disorder I, bipolar disorder II, major depressive disorder and psychotic disorder patients.

Suicide risk in first episode psychosis: a selective review of the current literature.

Many studies have confirmed that the risk of suicide in patients with first-episode psychosis (FEP) is high, and high rates of premature mortality, particularly from suicide, may occur in the early phases of schizophrenia. However, suicide rates are difficult to measure in FEP patients, even in carefully defined samples, and there is relatively little specific information about the risk of suicide at illness onset or retrospectively concerning the untreated psychotic period. This selected review of the literature investigates suicidal behaviour with particular regard to severe suicidality (plans and attempts) and risk factors associated with suicide in FEP patients. A search was performed to identify all papers and book chapters during the period 1965-2010, and approximately 100 studies met the inclusion criteria. Most of evidence suggests that risk of suicidal behaviour is relatively high in FEP patients. The research reports highlight the need for universal, comprehensive, public mental health interventions aimed, not only toward early detection, but also toward the rapid engagement in treatment of people with psychoses. These interventions should include an adequate assessment of suicidal behaviour in patients with FEP, and an examination of the efficacy of specific components of the interventions.

Life events as precipitants of suicide attempts among first-time suicide attempters, repeaters, and non-attempters

The aims of this study were to investigate risk factors for suicide attempts and propose a model explaining the associations among life events and suicide status. We assessed 263 subjects admitted following a suicide attempt to the Division of Psychiatry of the Department of Neurosciences of the University of Parma and compared them with 263 non-attempter clinical control subjects. Attempters reported significantly more adverse life events both in the last 6 months, and between the ages of 0-15 years than non-attempters. A multinomial logistic regression analysis with stepwise forward entry indicated that the best model to explain suicide status was one which included life events in the last 6 months, life events during age 0-15 years, and their interaction. First-time attempter status (vs. non-attempters) was more likely to be linked to life events in the last 6 months, the interaction between life events in the last 6 months and life events during age 0-15 years, and low social support. Those attempters with one or more prior attempts (repeat attempters) were more likely than non-attempters to be linked to the interaction between life events in the last 6 months and life events during age 0-15 years, and to higher rates of psychopharmacological treatment before the index admission. Guided by these findings, monitoring the impact of early-life and recent events in vulnerable individuals should be part of risk assessment and treatment.

Posttraumatic stress disorder and suicide risk among veterans: A literature review

Abstract Posttraumatic stress disorder (PTSD) is frequently associated with suicidal ideation and suicide attempts. Suicide is an important cause of death in veterans, and the risk for intentional death continues to be high many years after service. The aim of the present study was to investigate whether there is a relationship between PTSD and suicidal behavior among veterans. We also discussed the risk factors of suicide among war veterans with PTSD. A systematic review was conducted focusing on war-related PTSD and suicidal behavior. A total of 80 articles from peer-reviewed journals were identified, 34 were assessed for eligibility, and 16 were included. Having a history of PTSD is associated with higher rates of morbidity and mortality and increased the risk for suicidal behavior. The association between PTSD and suicidal behavior was confirmed by the presence of other risk factors and high rates of comorbidity. Current suicidal behavior should be adequately assessed in war veterans.

Completed suicide in schizophrenia: Evidence from a case-control study.

Suicide is the single major cause of death among patients with schizophrenia. Despite great efforts in the prevention of such deaths, suicide rates have remained alarming, pointing to the need for a better understanding of the phenomenon. The present sample comprised 20 male patients with schizophrenia who committed suicide and who were investigated retrospectively for a large number of characteristics. Controls were 20 living patients with schizophrenia. The results suggest that suicide attempts, hopelessness and self-devaluation were the three variables most strongly associated with completed suicide. However, a number of variables were identified which may constitute risk factors, some of which have not been identified in the past: agitation and motor restlessness (OR = 3.66; 95%CI = 0.95/14.02), self-devaluation (OR = 28.49; 95%CI = 3.15/257.40), hopelessness (OR = 51.00; 95%CI = 7.56-343.72), insomnia (OR = 12.66; 95%CI = 0.95/14.02), mental disintegration (OR = 3.66; 95%CI = 0.95/14.02), and suicide attempt (OR = 3.66; 95%CI = 1.40/114.41). Poor adherence to medications was also predictive of completed suicide in our sample of schizophrenia patients, primarily because the suicide victims showed very low adherence.

Periventricular white matter hyperintensities as predictors of suicide attempts in bipolar disorders and unipolar depression

The aim of this study was to evaluate whether deep white matter hyperintensities (DWMH) and periventricular white matter hyperintensities (PVH) are associated with suicidal behavior in patients with major affective disorders. Subjects were 99 consecutively admitted inpatients (42 men; 57 women; mean age: 46.5 years [SD=15.2; Min./Max.=19/79]) with a diagnosis of major affective disorder (bipolar disorder type I, bipolar disorder type-II and unipolar major depressive disorder). 44.4% of the participants had made at least one previous suicide attempt. T2-weighted brain magnetic resonance images were rated for the presence and extension of WMH using the modified Fazekas scale. Patients were interviewed for clinical data on average 5 days after admission. Bivariate analyses, corrected for multiple-testing, and logistic regression analysis were used to test the association between suicide attempts and clinical variables. Attempters and nonattempters differed only in the presence of PVH--the former were more likely to have PVH. The logistic regression indicated that the presence of PVH was robustly associated with suicidal behaviors after controlling for age (OR: 8.08). In conclusion, neuroimaging measures may be markers of risk for suicidal attempts in patients with major affective disorders.