Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki and Department of Psychiatry at Peijas Hospital, Health Care District of Helsinki and Uusimaa, Vantaa, Finland
Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland
Correspondence: Erkki T. Isometsä, Head of Mood Disorders Research, Department of Mental Health and Alcohol Research, National Public Health Institute, Mannerheimintie 166, FIN-00300 Helsinki, Finland. E-mail: erkki.isometsa{at}ktl.fi
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ABSTRACT |
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Aims To investigate risk factors for attempted suicide among psychiatric out- and in-patients with major depressive disorder in the city of Vantaa, Finland.
Method The Vantaa Depression Study included 269 patients with DSMIVmajor depressive disorder diagnosed using semistructured interviews and followed up at 6- and 18-month interviews with a life chart.
Results During the 18-month followup, 8% of the patients attempted suicide. The relative risk of an attempt was The relative risk of an attempt was 2.50 during partial remission and 7.54 during a major depressive episode, compared with full remission (P 0.001). Numerous factors were associated with this risk, but lacking a partner, previous suicide attempts and total time spent in major depressive episodes were the most robust predictors.
Conclusions Suicide attempts among patients with major depressive disorder are strongly associated with the presence and severity of depressive symptoms and predicted by lack of partner, previous suicide attempts and time spent in depression. Reducing the time spent depressed is a credible preventive measure.
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INTRODUCTION |
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METHOD |
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Screening, diagnostic evaluation and baseline measurements
In the first phase, all patients (n=806) at the Department of
Psychiatry of the Peijas Medical Care District were screened for a possible
new episode of DSMIV (American
Psychiatric Association, 1994) major depressive disorder between 1
February 1997 and 31 May 1998 (Melartin
et al, 2002). Patients with a positive screen were fully
informed about the study project and their participation was requested. Of the
703 eligible patients, 542 (77%) agreed and gave written informed consent.
In the second phase a researcher using SCAN 2.0 (Wing et al, 1990) interviewed the 542 consenting patients, 269 of whom were diagnosed with DSMIV major depressive disorder and were included in the study; the diagnostic reliability was excellent (k=0.86, 95% CI 0.581.0) (Melartin et al, 2002). The Structured Clinical Interview for DSMIIIR personality disorders (SCIDII; Spitzer et al, 1987) was used to assess diagnoses on Axis II. The cohort baseline measurements included the 17-item Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960), 21-item Beck Depression Inventory (Beck et al, 1961), Beck Anxiety Inventory (Beck et al, 1988), Beck Hopelessness Scale (Beck et al, 1974), Scale for Suicidal Ideation (Beck & Kovacs, 1979), Social and Occupational Functioning Assessment Scale of DSMIV (American Psychiatric Association, 1994: pp. 760761), Interview for Recent Life Events (Paykel, 1983), Interview Measure of Social Relationships (Brugha et al, 1987) and the Perceived Social Support Scale Revised (Blumenthal et al, 1987).
Follow-up
Of the 269 individuals with current major depressive disorder initially
included in the study, 198 were still alive at the end of the study period,
their depression had remained unipolar and they could be followed up
(Melartin et al,
2004). At baseline, the majority (154/198, 78%) were receiving
antidepressants at normal adult doses. The patients whose diagnosis switched
to bipolar disorder during the follow-up (13/269, 5%) were analysed
separately. The outcome of major depressive disorder and the comorbid
disorders was investigated at 6 and 18 months by repeated SCAN 2.0 and
SCIDII interviews, observer- and self-report scales and medical and
psychiatric records. A detailed life chart was created, with time after
baseline divided into three classes: state of full remission (none of the nine
criteria symptoms for major depressive episode), partial remission (one to
four symptoms); and major depressive episode (five or more symptoms). We used
two different definitions for duration of the index episode: the uninterrupted
duration of the episode in the state of major depression (time with full
criteria) and time to the first onset of state of full remission that lasted
at least 2 consecutive months (time to full remission)
(Melartin et al,
2004).
Occurrence of a suicide attempt before the baseline interview and during the follow-up was based on both the interview and psychiatric records. By definition, a suicide attempt had to involve at least some degree of intent to die; self-harm with no suicidal intention was not included. Patient-months were calculated based on the life chart. Information about the deaths among all the 269 patients during the follow-up was obtained from the official records of Statistics Finland.
For the validity of the results it is essential to verify that there were no more suicidal patients among those who did not complete the study than among those followed up. This did not seem to be the case. Patients who could not be followed up did not differ from the patients who were followed up, in terms of suicide attempts before the index episode (18% v. 14%), suicide attempt during the index episode (25% v. 23%) or suicidal ideation (38% v. 39%). However, they were somewhat younger, were more often living alone, had a higher score on the Eysenck Personality Inventory neuroticism scale (Eysenck & Eysenck, 1964) and more often had comorbid dysthymia (Melartin et al, 2004).
Statistical methods
Logistic regression models were created, classifying suicide attempt during
the follow-up as the dependent variable. The statistical methods included
non-parametric and parametric univariate analyses (the t-test,
2-test, Fishers exact test, analysis of variance
(ANOVA), the MannWhitney test and the KruskalWallis test) and
logistic regression models; the Statistical Package for the Social Sciences
software, version 11.0, was used.
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RESULTS |
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We found significant differences between those attempting suicide and those not attempting suicide (Table 1) in terms of: severity of index episode of depression; amount of suicidal ideation and anxiety; prevalence of personality disorder; prevalence of suicide attempts during the index episode; time to full remission and total time spent in a major depressive episode; and marital status (lack of partner). Patients with cluster B or borderline personality disorder had more attempts (MannWhitney test: Z=2.146, P=0.032, and Z=2.165, P=0.030, respectively).
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In the logistic regression model predicting suicide attempts during the follow-up (Table 2), the predetermined covariates comprised gender, age, marital status, HRSD score, alcohol dependence or misuse, Beck Anxiety Inventory score, personality disorder (any), cluster B personality disorder, suicide attempt during the index episode and time spent in major depressive episodes. After removing the non-significant variables, three factors were strongly associated with suicide attempt: months spent in major depressive episodes (OR=1.13), suicide attempt during the index episode (OR=5.62) and lack of partner (OR=5.10).
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Patients who switched to bipolar disorder (13/269, 5%) formed a particularly suicidal subgroup. They reported more suicidal ideation before the index episode (9 (69%) v. 97 (38%); Fishers exact test, P=0.039) and had more suicide attempts before the index episode (8 (62%) v. 56(22%); Fishers exact test, P=0.003) but this was nonsignificant during the follow-up (2 (22%) v. 16 (8%); Fishers exact test, P=0.17).
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DISCUSSION |
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To our knowledge, the present study is the first prospective investigation to employ a life chart to place the suicide attempts, allowing us to identify important disparities in risk between periods with different levels of depressive symptoms. We interpret these robust findings as evidence for the causal role of depression per se in the aetiology of suicide attempts. Given the high level of comorbidity with anxiety, substance use and personality disorders in the patient population (Melartin et al, 2002), all factors that are related independently to suicidal behaviour, the finding is far from self-evident.
Strengths, limitations and generalisability
The present study has some major methodological strengths. It involved a
relatively large (n=269) cohort of both out- and inpatients with
major depressive disorder, effectively representing all psychiatric patients
with a new episode of major depressive disorder in a Finnish city. Based on an
epidemiological survey, we have estimated
(Rytsälä et al,
2001) that two-thirds of all individuals with major depressive
disorder in the general population of the city of Vantaa seeking treatment
from psychiatrists are treated in the Peijas Medical Care District. The
patients were diagnosed carefully using structured interviews with excellent
reliability (=0.86) for the diagnosis of major depressive disorder,
plus information on all comorbid Axis I and II disorders at baseline and later
interviews. The total rate of losses to the study was low, because 87% of
participants could be interviewed at least once after baseline. However, owing
to deaths, diagnostic switch to bipolar disorder and patients who left the
study after 6 months, those included in the present report represent 74% of
the original 269 patients. These patients do not differ in terms of baseline
suicidal behaviour from those who could not be included. The study took place
during the era of current antidepressants (19971999) in a modern
community psychiatric setting; at baseline, 78% of the patients received
antidepressants at adequate levels in the acute phase, in compliance with the
American Psychiatric Associations Practice Guidelines. Methodological
details are discussed more fully in earlier reports
(Melartin et al,
2002; Sokero et al,
2003; Melartin et al,
2004). The most important limitation of the present study is that,
despite a large cohort of patients, the number of suicide attempts was
moderate and the number of patients attempting was small during the followup.
Although the main findings are statistically robust, some degree of type II
error may have occurred and some risk of spurious findings also exists.
Finally, the density of psychiatrists per population in Finland is among the
highest in Europe, and psychiatric settings treat about half of all
individuals seeking treatment for depression from healthcare providers
(Hämäläinen et al,
2004). Nevertheless, the characteristics of patients in the Vantaa
Depression Study do not differ in terms of comorbidity and symptom severity
from the few other studies that have reported them comprehensively
(Zimmerman et al,
2000; Tedlow et al,
2002), supporting the generalisation of our findings to other
settings.
Predictors of suicide attempt
Preceding the follow-up phase, 15% of the cohort had attempted suicide
during the index episode and 24% before that
(Sokero et al, 2003). The prevalence of those attempting suicide during the follow-up (8%) in our
study is similar to another report
(Bronisch & Hecht, 1992)
but lower than in two others with populations apparently at higher risk
(Duggan et al, 1991;
Oquendo et al, 2002).
Our univariate analysis findings are also in line with risk factor findings in
our own baseline analysis (Sokero et
al, 2003) and in the other studies. Marital status
(Bronisch & Hecht, 1992),
major depressive disorder (Bronisch &
Hecht, 1992; Oquendo et
al, 2002; Hansen et
al, 2003; Sokero et
al, 2003), anxiety
(Fawcett et al, 1990;
Sokero et al, 2003),
personality disorder (Paykel &
Dienelt, 1971; Hansen et
al, 2003; Sokero et
al, 2003) and suicidal behaviour
(Paykel & Dienelt, 1971;
Fawcett et al, 1990;
Bronisch & Hecht, 1992;
Nordström et al,
1995; Oquendo et al,
2002; Sokero et al,
2003) were all associated with suicide attempts. In contrast to
our cross-sectional findings (Sokero
et al, 2003), substance use disorder, age, chronic
physical illness and hopelessness did not, independently, predict suicide
attempts. Finally, the small group of patients who switched to bipolar
disorder during the follow-up appeared to be a particularly
suicidal subgroup. However, the number of cases was too small to
evaluate risk factors for their suicidal behaviour.
Clinical implications
The clinical implications of our findings are clear. Suicide attempts among
patients with major depressive disorder are strongly associated temporarily
with the presence of depressive symptoms and robustly predicted by lack of a
partner, previous suicide attempts and time spent depressed. Reducing the
duration of a depressed state is likely to be an effective preventive measure
for suicide attempts.
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Clinical Implications and Limitations |
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LIMITATIONS
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REFERENCES |
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Received for publication March 24, 2004. Revision received September 14, 2004. Accepted for publication September 30, 2004.
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