Mental disorders and suicide

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Virtually all mental disorders carry an increased risk of suicide, except for mental retardation and dementia. The suicide risk in functional mental disorders is double that in substance use disorders, which in turn carry double the risk of suicide compared to organic disorders. The greatest risk of suicide among all clinical states is in attempted suicide, which carries about 40 times the expected value (Tab|e 3). In anorexia nervosa and major depression the risk is about 20-fold, and in other mood disorders and psychoses about 10 to 15 times higher than expected. In anxiety, personality, and substance use disorders the suicide risk is at lower levels, but about five to 10 times higher than the expected value. In subtance disorders the risk is dependent on the type of disorder, being clearly lowest in alcohol, cannabis, and nicotine abusers.(23)

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Table 3 Rank order of suicide in mental disorders

Psychological autopsy studies have been used to construct an overall view of suicide by collecting all available relevant information on the victim's life preceding his or her death. In five psychological autopsy studies(2 2,26,27and 28 mental disorders of suicide victims have been assessed using DSM-III or DSM-IIIR diagnoses and large unselected samples. Although the range of figures for individual suicides is wide, the victim received at least one diagnosis on Axis I in 86 to 98 per cent of these suicides and at least one diagnosis on Axis II in 5 to 44 per cent. In all five studies depressive disorders and substance use disorders were frequent and comorbidity was common (Table.,!).



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Table 4 Major findings on mental disorders in five psychological autopsy studies(24,25,2 2 and 28) on completed suicides using DSM-III or DSM-IIIR criteria

In two recent European psychological autopsy studies(2 28) from Finland and Northern Ireland the distribution of the principal diagnoses was similar ( T,a.b..l,e,5). The most common psychiatric diagnoses in suicide were major depression (30-31 per cent) and alcohol dependence (17-24 per cent). All other single diagnoses formed less than 10 per cent of all suicides. As a principal diagnosis, major mood disorders together comprised 42 to 36 per cent and substance use disorders 19 to 30 per cent of all suicides. Comorbidity was a major finding in both samples. The most commonly observed comorbidity pattern in suicide has been substance use disorder with major depression.

The mortality risk for suicide in major depression is 20 times that expected, and 15- to 20-fold in all affective disorders. Every sixth death among depressive people treated as psychiatric patients is by suicide.(29) The risk of suicide varies across the subclasses of depression, and is related to the selection of suicidal patients for the various types of treatment. The risk is highest for depressive inpatients, even during the postdischarge period, and much lower among psychiatric outpatients, although clearly lowest for those treated for depression in primary care. (3°)

Depression of suicide victims seems to differ qualitatively from that of living controls; it seems to be more severe and accompanied more often by insomnia, anhedonia, self-neglect, and impaired memory. Moreover, suicide risk in follow-up is higher in depression associated with such symptoms as insomnia, anhedonia, diminished concentration, and anxiety. Of the various subjective qualities of depression, hopelessness or negative anticipation is most widely accepted as the best predictor of suicide. Inadequate and inefficient antidepressant treatment of depressed suicide victims has been a persistent finding in several studies. Less than half of suicide victims with major depression have been in contact with psychiatric care at the time of suicide. However, there is some evidence that good monitoring and maintenance treatment in high-risk groups of patients may be able to decrease their suicide rates. (3D

At the individual level, misuse of alcohol or drugs complicates the suicidal process. Alcohol and drugs, often combined, are a major risk or a precipitating factor for suicide. They may intensify the suicidal intent, offer a constantly available suicide method, worsen the somatic status of the victim and increase the risk of complications after the attempt. Alcohol impairs judgement and lowers the threshold to suicide. Alcohol is detected in about every third case at the moment of suicide/32) The lifetime risk of suicide has been estimated at 7 per cent for alcohol dependence, with only slight variation over the life. (33) The suicide rate in alcoholism is about six times higher than that in the general population. (23) In drug dependence or abuse it is 15 to 20 times higher than expected.(23 34) In some countries, the level of alcohol consumption seems to be associated directly with the suicide rate, especially among young males and adolescents. (35>

The suicide risk in schizophrenia appears to be almost 10 times higher than in the general population. (23> The lifetime risk of suicide in schizophrenia is estimated to be at least 4 per cent, and in selected follow-up studies has been as high as 10 to 13 per cent. (33) The great majority of schizophrenic patients commit suicide in the active phase of the disorder after having suffered depressive symptoms. Suicide in schizophrenia is thus less of a surprise; it is typically preceded by a previous attempt, and suicidal intent has been communicated at least as often as in non-schizophrenic suicides. (,36,> Undertreatment, comorbidity, treatment non-compliance, and a high frequency of non-responders are also common problems among schizophrenic suicide victims. Adequacy of comprehensive care is crucial for suicide prevention in schizophrenia, especially among actively psychotic patients with recent suicidal behaviour and depressive symptoms. (37>

Most of the suicide victims with personality disorder, especially with borderline personality disorder, have also comorbid depressive disorder or substance abuse. This kind of comorbidity is very frequent among the young suicide victims.(25,26>

Mental disorders, particularly depressive disorders, substance abuse, and antisocial behaviour have an important role in the adolescent suicides. The diagnostic distribution of mental disorders among them is surprisingly similar to that of the young and even middle-aged adults. (38>

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