Suicidal Behaviour In Depression Completed suicide

How many depressed people commit suicide? An influential study by Guze and Robins (1970) estimated that the lifetime risk of a depressed person committing suicide was about 15%. This figure has been widely quoted since, but recently has been questioned. Bostwick and Pankratz (2000) argued that this figure is an overestimate because the studies analysed by Guze and Robins used only the most severe (that is, hospitalised) depressed patients and had fairly short follow-up periods. As the risk of suicide is greatest after discharge from hospital (Harris & Barraclough, 1997), projecting rates within a short, post-discharge follow-up to lifetime rates is likely to lead to overestimation, particularly when the figure is based on proportionate mortality prevalence—the number of deaths by suicide relative to the number of deaths in the sample. Bostwick and Pankratz (2000) reanalysed the data from the Guze and Robins review, as well as newer data, using case fatality prevalence (proportion of total sample that died by suicide) rather than proportionate mortality prevalence (proportion of deaths that were suicides). They also divided the new data by severity into patients that were hospitalised because of suicide concerns, inpatients who were not specifically hospitalised because of suicide risk, and outpatients. Their estimates of lifetime prevalence of suicide in affective disorder patients for the newer data were 8.6% for those hospitalised because of suicidal risk, 4.0% for those hospitalised without risk specified, and 2.2% for outpatients. For the non-affectively ill population, the risk was less than 0.5%. The data used by Guze and Robins reanalysed in this way yielded a lifetime risk of 4.8%.

Some studies have actually followed up patients and reported suicide rates over a longer period. In a very substantial study, Ostby et al. (2001) followed up over 39 000 unipolar, major depression patients and 15 000 bipolar patients who had been inpatients in Sweden between 1973 and 1975. The average follow-up period was 10 years. During the follow-up period, 5.2% of the unipolar group and 4.4% of the bipolar group committed suicide. Both groups had elevated general mortality rates, as indicated by standardised mortality ratios (SMRs). The SMR is the number of deaths from a particular cause divided by what would be expected in the population from that cause. Thus, an SMR of 2 means that the group had twice the number of deaths from that particular cause than would have been expected. Interestingly, most causes of death, including natural causes, were overrepresented in both patient groups. However, death by suicide was by far the most overrepresented. The SMRs for death by suicide were 20 in the unipolar group and 10 in the bipolar group. These SMRs are actually very similar to those reported by Harris and Barraclough (1997) in a meta-analysis of studies that had at least a 2-year follow-up and had lost fewer than 10% of patients at follow-up. These authors found a mean SMR of 20 for major depression, 15 for bipolar disorder, and 12 for dysthymia.

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