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a) Mood disorders

Major depressive disorder and other depressive syndromes are the most commonly and most consistently identified axis I diagnoses in individuals who die by suicide (694, 695). For example, Robins et al. (60) found that among 134 persons who died by suicide, 98% were psychiatrically ill and most had depression or chronic alcoholism. Barraclough et al. (65), in a similar study, found that of 100 individuals who died by suicide, 93% were mentally ill and 85% had either depression or alcoholism. Henriksson et al. (59), using psychological autopsy methods to investigate current mental disorders among a random sample of 229 persons who died by suicide during a 1-year period in Finland, found that 93% of those persons had received at least one axis I diagnosis and that 59% had a depressive disorder.

In patients with bipolar disorder who die by suicide, the majority are experiencing either a depressive or mixed episode of illness (69, 72, 315). For example, Isometsa et al. (68) noted that among 31 patients with bipolar disorder identified in a group of 1,397 persons who died by suicide in Finland in a 12-month period, 79% died while in a major depressive episode and 11% while in a mixed state. In a study of more than 300 patients who were discontinued from lithium treatment, Baldessarini et al. (696) found that the majority of suicidal acts occurred either during a major depressive episode (73%) or during a dysphoric-mixed episode (16%).

In addition to being highly prevalent in individuals who die from suicide, mood disorders have long been associated with an increased risk for suicide. For example, in 1970, Guze and Robins (697) reviewed 17 studies that assessed the risk of suicide in individuals with primary affective disorders and calculated the frequency of suicide as a percentage of all deaths. High suicide rates were found, with the ultimate risk of suicide estimated to be about 15%, or approximately 30 times that seen in the general population. For major depression, review of the literature suggests that overall rates of suicide mortality range from 5% to 26% and are about twice as high for men as for women (694). However, these studies generally assessed severely ill patient populations and individuals early in the course of their illness, when suicide rates are known to be highest.

Several investigators have subsequently reexamined these estimates of lifetime suicide risk in individuals with mood disorders. For example, Inskip et al. (94), using cohort-based curve-fitting techniques and data from previous studies, estimated the lifetime risk for suicide in mood disorders to be 6%. In addition, Bostwick and Pankratz (77) used data from prior studies to calculate case fatality prevalences (the ratio of suicides to the total number of subjects) to determine suicide risks for three groups of patients with affective disorders—outpatients, inpatients, and suicidal inpatients. With this method, which provides a less biased estimate of risk, they found a gradation in suicide risk that varied with treatment setting as well as with hospitalization for suicidality. For example, in patients with mood disorders who were previously hospitalized for suicidality, the estimated lifetime prevalence of suicide was 8.6%, compared to a lifetime risk of 4% for those with a psychiatric hospitalization for any reason. For mixed inpatient/outpatient populations, the prevalence of suicide was 2.2%, whereas for the populations without affective illness, it was less than 0.5%. For individuals with major depressive disorder, Blair-West et al. (205) used age- and gender-stratified calculations to arrive at comparable estimates for lifetime suicide risk of 3.4%, with a lifetime risk for males more than six times than for females (6.8% versus 1.1%).

Harris and Barraclough (64), in their meta-analysis of suicide as an outcome in psychiatric illness, assessed relative suicide risk in mood disorder by calculating SMRs. Their analysis used data from published English-language studies that had mean or median follow-up periods of at least 2 years and that provided sufficient data to calculate ratios of observed to expected numbers of suicides. For patients with major depressive disorder, 23 studies that included a total of 351 suicides among more than 8,000 patients yielded an SMR of 20.35, or a 20-fold increase in risk. A key finding was that risk in patients with major depressive disorder was highest immediately after hospital discharge (698, 699). For patients with bipolar disorder, data from 15 studies including a total of 93 suicides among 3,700 subjects yielded an SMR for suicide of 15.05. Although patients with dysthymia also had an elevated SMR for suicide, of 12.12, the nine studies that contributed to this estimate were extremely heterogeneous in their findings and most had extremely small samples, which raises some question about the validity of this approximation.

Several studies have examined rates of suicide in longitudinal follow-up in individuals hospitalized for mood disorder. Hoyer et al. (75) used data from the Danish Psychiatric Case Register to determine SMRs for suicide among 54,103 patients (19,638 male and 34,465 female patients) who had an initial admission to a Danish psychiatric hospital between 1973 and 1993 and who received a mood disorder diagnosis. During the study period, 29% of the patients died, and of those, suicide occurred in 20%. Standardized mortalities for suicide were comparable for patients with ICD-8 diagnoses of unipolar major depression, psychotic reactive depression, and bipolar disorder, with SMRs of 19.33, 18.67, and 18.09, respectively. In contrast, the SMR for suicide in patients with neurotic depression was significantly less, at 10.51. In all diagnostic subgroups and regardless of age and gender, the risk of suicide was greatest during the first year after the initial admission, decreased over the subsequent 5 years, and then stabilized. Overall, the risk for suicide was comparable in men and women, except in patients with bipolar disorder, for whom the SMR for suicide was somewhat greater in women than in men (20.31 versus 18.09).

In a similarly designed study using data from a Swedish inpatient register, Osby et al. (73) obtained the date and cause of death for patients hospitalized between 1973 and 1995 with a diagnosis of bipolar disorder (N=15,386) or unipolar depressive disorder (N= 39,182). SMRs for suicide were found to be significantly increased in women and in patients with a unipolar depressive disorder diagnosis (15.0 for male bipolar disorder patients, 20.9 for male unipolar depressive disorder patients, 22.4 for female bipolar disorder patients, and 27.0 for female unipolar depressive disorder patients). Suicide mortality was more pronounced in younger individuals and with shorter intervals from the index hospitalization. Although SMRs decreased in all age groups with increasing time of follow-up, some suicide risk persisted even at long follow-up intervals.

Baxter and Appleby (188) used the Salford (U.K.) Psychiatric Case Register to identify 7,921 individuals who had received psychiatric or mental health care and determined their mortality rates (estimated as rate ratios) over a follow-up period of up to 18 years. Among individuals with affective disorders, there was a 12.2-fold elevation in observed suicide mortality in men, compared to expected mortality based on population rates. For women, the relative increase in suicide mortality was even greater, with a 16.3-fold elevation.

Angst et al. (74) followed a sample of 406 hospitalized patients with mood disorders (220 with bipolar disorder and 186 with unipolar depressive disorder) on a prospective basis for 22 years or more and found an overall standardized mortality rate for suicide of 18.04, comparable to the SMRs found in the Swedish and Danish longitudinal follow-up studies. Sixty-one percent of the sample had manifested psychotic symptoms at least once over their lifetime, suggesting that this was a particularly ill group of patients. The suicide rate was greatest near the age of illness onset; however, from ages 30 to 70 years, the rate was remarkably constant, suggesting a persistence of risk throughout the illness course. The suicide mortality in women was greater than that in men (SMR of 21.87 for women, compared to 13.49 for men), in part reflecting the greater rate of suicide for men in the general population. Patients with unipolar depressive disorder had a significantly higher rate of suicide than patients with bipolar I disorder or bipolar II disorder, with an SMR for suicide of 26.7, compared with 12.3 for bipolar disorder patients. The SMR for suicide did not differ significantly between bipolar I disorder patients and bipolar II disorder patients.

Some evidence suggests that in individuals with mood disorders, the rate of suicide may be increasing over time. For example, Harris and Barraclough (64) noted that the suicide risk for patients with major depression in cohorts treated before 1970 was increased by 17-fold in contrast to a 36-fold increase in risk for cohorts treated after 1970. In the study described earlier, Hoyer et al. (75) noted an increase in both the absolute and relative risks for suicide over the 20-year study time period, and they suggested that the increase may have been related to changes in the health care delivery system and the availability of psychiatric inpatient services. In addition, Baldessarini et al. (563) observed that the annualized rates of suicide and suicide attempts in patients with major affective disorders appear to have risen across the decades since 1970. This trend was sustained and statistically significant for both suicides and suicide attempts, as well as for treated and untreated samples considered separately. Although this apparent secular trend could reflect increased recruitment of more severely ill patients to more recent studies or increased reporting of suicidal behaviors, the percentage reduction of suicide risk with lithium treatment did not decline across the years, suggesting that the patient populations are in fact comparable and that the prevention of suicide in major affective disorders is becoming increasingly challenging (558). Furthermore, suicide attempts that do occur in individuals with major mood disorders may be more lethal than suicide attempts by individuals in the general population. The reported ratio of suicide attempts to deaths from suicide averages between 3:1 and 5:1 among persons with mood disorders, whereas in the general population the suicide attempt rate has been estimated to be about 10–20 times (average, 18 times) greater than the suicide rate, or about 0.3% per year (700).

For individuals with mood disorders, it is also important to note factors that are particularly associated with increased risk. Fawcett et al. (79, 313) determined time-related predictors of suicide in a sample of 954 psychiatric inpatients in the NIMH Collaborative Program on the Psychobiology of Depression, about one-third of whom had bipolar disorder and the rest of whom had other mood disorders. During the initial 10 years of follow-up, 34 patients died by suicide, an overall rate that was extremely low, at 0.36% per year. The first year of follow-up was the time of highest risk, with 38% of suicides occurring during that period. Within 1 year of admission, six factors were associated with suicide: panic attacks, severe psychic anxiety, diminished concentration, global insomnia, moderate alcohol abuse, and anhedonia. The three factors associated with suicide that occurred after 1 year were severe hopelessness, suicidal ideation, and history of previous suicide attempts. By 14 years, among individuals for whom follow-up information was available, 36 had died by suicide, 120 had attempted suicide, and 373 had no recorded suicide attempt (247). Analysis at that time point showed that patients who died by suicide and patients with suicide attempts shared core characteristics, including a history of previous suicide attempts, alcohol and substance abuse, impulsivity, and psychic turmoil within a cycling/mixed bipolar disorder. In contrast to suicide within 12 months of intake, which was predicted by clinical variables, suicide beyond 12 months was prospectively predicted by temperament attributes, such as higher levels of impulsivity and assertiveness. Stressful life events (701), executive dysfunction (702), and higher levels of depression (10, 78, 221, 222, 703) may also be associated with greater risk, as may an awareness of the discrepancies between a previously envisioned "normal" future and the patient's likely degree of future chronic disability (273).

In summary, mood disorders are consistently identified as conferring a significant increase in the risk for suicide as well as for suicide attempts. However, among individuals with mood disorders, a variety of factors commonly modify that risk and should be taken into consideration during the assessment and treatment planning processes. These factors include the specific mood disorder diagnosis and duration of illness, the type and severity of the mood episode, the prior history of treatment, the presence of comorbid diagnoses or specific psychiatric symptoms such as severe anxiety or agitation, and the occurrence of significant psychosocial stressors. It is important to note, however, that this increased risk of suicidal behaviors among individuals with mood disorders has been consistently shown to be modifiable with treatment (see Section VI.D, "Somatic Therapies").

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b) Schizophrenia

Schizophrenia has also been associated with an increase risk of suicide in multiple studies. Harris and Barraclough (172), for example, analyzed data from 38 studies that had follow-up periods of up to 60 years. Acknowledging that some heterogeneity in the diagnosis of schizophrenia across studies was likely as a result of changes in diagnostic criteria, the authors noted 1,176 suicides among more than 30,000 patients with schizophrenia, yielding an SMR for suicide in schizophrenia of 8.45. Baxter and Appleby (188), in a case registry study of long-term suicide risk in the United Kingdom, found an even higher 14-fold increase in rate ratios for suicide among individuals with schizophrenia. In contrast, using cohort-based curve-fitting techniques and data from 29 studies of mortality in schizophrenia, Inskip et al. (94) estimated the lifetime risk for suicide as 4%.

In addition to assessing suicide rates among patients with schizophrenia, longitudinal follow-up studies have also examined factors associated with increased risk of suicide. Black et al. (98) found that suicide occurred in 14 of 688 schizophrenia patients (2%) who were admitted to an Iowa psychiatric hospital over a 10-year period, with the majority of deaths occurring within 2 years of hospital discharge. Although women were found to be at relatively greater risk, the numbers of suicides significantly exceeded expected rates for both male and female patients. Nyman and Jonsson (101) found that suicide occurred in 10 of 110 (9%) young patients with schizophrenia who were hospitalized between 1964 and 1967 and followed for up to 17 years. In this group, suicide was associated with a more chronic course as well as with social and financial dependency. Dingman and McGlashan (103) longitudinally followed 163 Chestnut Lodge patients with a diagnosis of schizophrenia and noted that the 13 patients who died by suicide were predominantly male and had a later onset of illness, less chronic illness, better premorbid functioning, and a greater ability for abstract and conceptual thinking. At a later follow-up (mean=19 years), 6.4% of the Chestnut Lodge sample had died by suicide, and this group had exhibited fewer negative symptoms but more severe delusions and suspiciousness at index admission than those who did not die by suicide (93). A group of young psychotic patients who had not exhibited a chronic course was followed after discharge from an index hospitalization by Westermeyer et al. (83), who found that 36 patients died by suicide and 550 did not. Suicide occurred in about 9% of individuals with schizophrenia and was more likely during the early years of their illness, particularly within 6 years of initial hospitalization. At greater risk for suicide were unmarried white male patients with chronic symptoms, relatively high IQs, and a gradual onset of illness.

De Hert et al. (89) studied outcomes for 870 patients (536 men and 334 women) with schizophrenia (87%) or schizoaffective disorder (13%) after a mean duration of follow-up of 11.4 years. Sixty-three individuals died by suicide, yielding a suicide rate of 635 per 100,000 per year and an SMR for suicide of 39.7. The frequency of suicide in men was twice that in women, although the SMR and the age at the time of suicide did not differ significantly between the sexes. Of the suicides, 33 (52.4%) occurred while the patient was hospitalized (although only nine actually took place in the hospital) and 12 (19.1%) occurred during the first 6 months after discharge. When the patients who died by suicide were compared with an age- and sex-matched group of 63 patients from the remaining sample, a number of differences between the groups were observed. Those who died by suicide were more likely to have a family history of suicide, had had more and shorter hospitalizations and more past suicide attempts, and were more likely to have used a highly lethal method in prior suicide attempts. They also had higher total WAIS IQ scores and were more likely to have been psychotic or depressed or to have suffered a major loss in the 6 months before death or follow-up. Compared with control subjects, the patients who died by suicide were also less likely to have received community-based care and were less likely to have had a useful daily activity, remission of symptoms, or an early onset of prominent negative symptoms.

Among individuals with schizophrenia who die by suicide, a number of demographic factors seem to be present more often than in living control subjects. In a cohort of 9,156 patients with schizophrenia, Rossau and Mortensen (95) individually matched 10 control subjects to each of 508 individuals who were admitted to Danish hospitals between 1970 and 1987 and who later died by suicide. They found suicide risk to be particularly high during the first 5 days after discharge, with some excess suicides during temporary hospital leaves. Increases in risk were also associated with multiple psychiatric admissions during the previous year, previous suicide attempts, previous diagnosis of depression, male sex, and previous admissions to general hospitals for physical disorders. Breier and Astrachan (102) compared 20 schizophrenia patients who died by suicide with a randomly selected sex-matched group of nonsuicidal schizophrenia patients and a group of persons without schizophrenia who died by suicide. Patients with schizophrenia who died by suicide were more likely to be men and tended to be young, white, and never married. In contrast to the persons without schizophrenia who died by suicide, the schizophrenia patients who died by suicide tended not to show a temporal relationship of suicide with suicide attempts or stressful life events.

Among individuals who died by suicide, comparisons have also been made between those with schizophrenia and those with other diagnoses. Heila et al. (100) used psychological autopsy data for 1,397 individuals who died by suicide over a 1-year period in Finland and compared the 92 individuals with schizophrenia (7%) to the remainder of the sample. They found that suicide occurred at any point during the course of schizophrenia and over a large age range. In addition, among the individuals with schizophrenia, 71% had a history of suicide attempts, and, particularly in women, active illness and depressive symptoms were often observed immediately before the suicide. Significant life events, however, were seen less often before suicide in individuals with schizophrenia than in those with other diagnoses (46% and 83%, respectively).

Other studies have found suicidal ideation and suicide attempts to be common among individuals with schizophrenia. For example, in the Chestnut Lodge sample, over an average of 19 years of follow-up, 40% of the patients with schizophrenia spectrum disorders reported suicidal ideation since their initial hospitalization, and 23% reported at least one suicide attempt (93). Radomsky et al. (80) evaluated lifetime rates of suicidal behavior among 1,048 consecutively admitted psychiatric inpatients with DSM-III-R psychotic disorders. Of the 454 individuals with a diagnosis of schizophrenia, 27.3% reported at least one lifetime suicide attempt, with an additional 26.4% reporting suicidal ideation only. For the 159 patients with schizoaffective disorder, 42.8% and 27% reported suicide attempts and suicidal ideation, respectively. Roy et al. (117) found that 55% of a series of 127 consecutively admitted patients with chronic schizophrenia had previously made a suicide attempt. Harkavy-Friedman et al. (108), in a sample of 104 individuals with schizophrenia or schizoaffective disorder, found that 33% had made a suicide attempt, with 60% of those reporting multiple attempts. Attempts were often medically serious, requiring medical inpatient care in 57% of cases and emergency medical evaluation in an additional 11%, and were associated with strong suicidal intent (in the 76% of patients for whom this information was available). As with suicide in schizophrenia, initial suicide attempts tended to occur early during the course of the illness.

A number of specific factors appear to increase the likelihood of a suicide attempt among individuals with schizophrenia. For example, in the study by Roy et al. (117), those who had attempted suicide had significantly more psychiatric admissions and were more likely to have experienced a major depressive episode or received antidepressant treatment, compared with those who had not attempted suicide. Young et al. (704), in a longitudinal study of 96 individuals with recent-onset schizophrenia who were followed for a 1-year period, noted that depression was moderately correlated with concurrent suicidality but was not independently associated with future suicidality, whereas the presence of suicidal ideation even at low levels increased the risk for significant suicidal ideation or a suicide attempt during the subsequent 3 months. In their sample, Harkavy-Friedman et al. (108) found that suicide attempts were reported to be precipitated by depression (27%), loss of a significant other or other stressful life event (24%), being bothered by psychotic symptoms (11%), and responding to command hallucinations (4%). In a subsequent study of 100 individuals with schizophrenia, Harkavy-Friedman et al. (106) found that 8% of suicide attempts were associated with command auditory hallucinations for suicide and that individuals with previous suicide attempts were at particularly increased risk. In a prospective study of 333 patients with chronic schizophrenia (705), multivariate analysis suggested that current and lifetime suicide attempts and suicidal ideation were associated with hopelessness and possibly with greater levels of insight or higher cognitive functioning. Increased insight, specifically awareness of delusions and negative symptoms, has also been noted in individuals with schizophrenia who experience recurrent suicidal thoughts and behaviors (706).

In summary, an increase in the risks of suicide and suicide attempts is seen in individuals with schizophrenia and should be taken into consideration in the assessment and treatment planning process. Additional factors that modify risk include the duration of illness, the patient's insight into the illness's implications, the patient's history of treatment, and the presence of comorbid diagnoses or specific psychiatric symptoms, such as depression, hopelessness, or negative symptoms. As with mood disorders, however, increasing evidence also suggests that the risk of suicidal behaviors among individuals with schizophrenia can be modifiable with treatment (see Section VI.D, "Somatic Therapies").

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c) Anxiety disorders

Data on lifetime rates of suicide among patients with anxiety disorders are limited but suggest that these diagnoses are associated with an increase in suicide risk. At the same time, it is not clear whether anxiety disorders represent an independent risk factor for suicide or whether this increased risk is attributable to the presence of depressive disorders or substance use disorders, which commonly co-occur with anxiety disorders.

Among broadly defined groups of individuals with anxiety disorders, increased rates of suicide have been seen in several studies. Khan et al. (118) used the U.S. Food and Drug Administration (FDA) database to assess the risk of suicide among patients who were participating in recent clinical trials of antianxiety medications and had diagnoses of panic disorder, social phobia, generalized anxiety disorder, posttraumatic stress disorder, or obsessive-compulsive disorder. Among the 20,076 patients, 12 died by suicide, yielding a suicide risk among patients with anxiety disorders of 193 per 100,000 patients, or at least 10-fold higher than that in the general population. This finding is particularly striking since the patients were receiving treatment and since current suicidality is generally an exclusion criterion for clinical trials. Allgulander (119) also noted an increased risk of suicide in individuals with anxiety disorders. Data on 9,912 patients with anxiety neurosis in the Swedish National Psychiatric Case Register between 1973 and 1983 yielded SMRs for suicide before age 45 of 6.7 and 4.9 for men and women, respectively. Suicide risk was highest within 3 months of discharge and was two- to threefold less than the risk in individuals with depressive neurosis.

Several studies have examined characteristics of patients with panic attacks or panic disorder who have died by suicide. Henriksson et al. (707) used data on suicides in Finland in a 1-year period to examine the relationship between panic disorder and suicide. All of the 17 persons with a current diagnosis of panic disorder who died by suicide—1.22% of the 1,397 suicides in Finland in the 1-year period—also had another axis I disorder, most often major depression. A substance use disorder was found in one-half of these individuals, with almost one-half of those persons also receiving an axis II diagnosis. These results are in accord with those of a study by Barraclough et al. (65), which found a principal diagnosis of either alcoholism or depression in virtually all persons who died by suicide and who had had a panic attack in the week before death.

Two smaller follow-up studies of patients with panic disorder yielded similar conclusions. Noyes et al. (122) found that 4% (three of 74) of patients with panic disorder followed up after 7 years had died by suicide, with an additional 7% (five of 74) having made a serious suicide attempt. Comorbid diagnoses, particularly major depression and axis II disorders, were more likely to be present in those who died by suicide and in serious suicide attempters. Coryell et al. (123) found that 35 years after an index admission, approximately 20% of 113 patients with panic disorder had died by suicide and that alcoholism and secondary depression may have had a role in those deaths.

Rates of suicidal ideation and suicide attempts are also increased in individuals with anxiety disorders, but again, comorbid diagnoses may play a role in mediating this effect. In a random sample of 18,011 adults from five U.S. communities derived from the ECA study, Weissman et al. (125) found that the presence of suicidal ideation and suicide attempts varied. Levels were highest among subjects with a lifetime diagnosis of panic disorder, followed by those who had panic attacks but not panic disorder and those with other DSM-III disorders but not panic attacks or panic disorder; lower levels were found in individuals with no prior panic attacks or DSM-III diagnoses. Weissman et al. also found that 20% of the subjects with panic disorder and 12% of those with panic attacks had made suicide attempts. Furthermore, this increase in risk was not solely attributable to comorbid diagnoses, since the lifetime rate of suicide attempts for persons with uncomplicated panic disorder was consistently higher than that for persons with no psychiatric disorder (7% and 1%, respectively) (708). This conclusion contrasted with the findings of Hornig and McNally (137), who reanalyzed the ECA data with the effects of comorbid disorders and sociodemographic variables controlled in the aggregate rather than singly. Using both stepwise and backward logistic regression analyses, they did not find panic disorder to be associated with a significant increase in risk for suicide attempts beyond that predicted by the presence of other disorders.

Other investigators have assessed other populations to determine whether panic attacks or panic disorder is associated with increases in suicidal behaviors. Pilowsky et al. (130), in a study of 1,580 adolescents in an urban public school system, found that suicidal ideation was three times more likely and a history of suicide attempts twice as likely in individuals with panic attacks, even after the effects of demographic factors, major depression, and substance use were controlled. Fleet et al. (136) assessed 441 consecutive patients who presented to an emergency department with chest pain and who underwent a structured psychiatric interview. Of the total sample, 108 (25%) met the DSM-III-R criteria for panic disorder. The investigators found that more of those with panic disorder had experienced suicidal ideation during the preceding week than of those without panic disorder (25% and 5%, respectively), even after controlling for the effect of coexisting major depression. In addition, of the 44 patients (10% of the sample) who had experienced suicidal ideation during the preceding week, 60% met the DSM-III-R criteria for panic disorder (709). Thus, in both of these populations, panic attacks or panic disorder was a significant risk factor for suicidal ideation or suicide attempts, independent of comorbid disorders.

Other studies have assessed psychiatric outpatients with panic disorder and have demonstrated substantial variability in its effect on suicidality. Cox et al. (124), for example, used the suicide questions from the ECA study to assess 106 patients with panic disorder and found that 31% of the patients reported suicidal ideation and 18% reported a history of suicide attempts. Very few individuals with suicidal ideation reported actual suicide attempts within the preceding year. However, when suicide attempts did occur, they were predominantly in the context of depressed mood. In a sample of 100 outpatients with panic disorder, Lepine et al. (129) found that 42% had a prior suicide attempt. Suicide attempters were more likely to be female or unmarried, and 88% of the patients met the DSM-III-R criteria for at least one additional diagnosis, predominantly major depressive disorder (52%) or substance use disorder (31%). Warshaw et al. (127) followed 498 patients with panic disorder and found a 6% risk of suicidal behaviors over a 5-year period. Being married or having children were protective factors, whereas mood disorders, substance use, eating disorders, personality disorders, female sex, and a prior history of suicide attempts were associated with increased risk. In the absence of other risk factors, the risk of a suicide attempt in persons with panic disorder was minimal. King et al. (126) studied 346 depressed outpatients and found a significant difference in the frequency of suicide attempts in those with a history of panic attacks compared with those without such a history (26.9% and 16.8%, respectively). Paradoxically, however, depressed patients with a history of infrequent panic attacks had a higher incidence of suicide attempts than those with panic disorder (32.3% and 21.5%, respectively). Friedman et al. (710) assessed 293 patients with panic disorder, of whom 59 had comorbid borderline personality disorder. A past history of suicide attempts was reported by 25% of the patients with comorbid borderline personality disorder and by 2% of those without that comorbidity. In contrast, Beck et al. (128) found that none of the 73 patients with primary panic disorder in a study of 900 consecutive psychiatric outpatients reported having made a prior suicide attempt.

Other anxiety disorders, although less well studied, may also influence suicide attempts or suicidal ideation. For example, in recent clinical trials of new antianxiety medications that included patients with a broad range of diagnoses, the risk of suicide attempts was increased relative to the general population, with attempts occurring in 28 of 20,076 patients, for an annualized risk of 1,350 per 100,000 patients (118). Cox et al. (124) found that of 41 outpatients with a diagnosis of social phobia, 14 (34%) had experienced suicidal ideation and two (5%) had made a suicide attempt within the prior year, although five (12%) had at least one lifetime suicide attempt. Oquendo et al. (131) assessed 156 inpatients with a diagnosis of major depressive episode and found that those with comorbid posttraumatic stress disorder were more likely to have attempted suicide, a finding that was more prominent in women than in men and that was independent of the presence of borderline personality disorder. Schaffer et al. (132) retrospectively reviewed the assessments of 533 patients with major depression and found that suicidal ideation was present in 57.8%. Suicidal ideation was more likely to be present in the 43.2% of the sample that had a lifetime anxiety disorder, and this association was independent of either age or severity of depressive symptoms. In contrast, in a study of 272 inpatients with at least one major depressive episode, Placidi et al. (220) found that rates of panic disorder did not differ between the 143 patients who had attempted suicide and the 129 patients who had not. In fact, agitation, psychic anxiety, and hypochondriasis were more severe in the nonattempter group, and these effects were independent of severity of aggression and impulsivity. However, rates of comorbid borderline personality disorder were much greater in those who attempted suicide, which may have contributed to these findings.

Even subsyndromal anxiety symptoms may contribute to an increase in risk. For example, Marshall et al. (135) found that rates of suicidal ideation increased linearly and significantly with an increasing number of subthreshold symptoms of posttraumatic stress disorder. They reported that for the 2,608 of 9,358 individuals who were screened in 1997 as part of National Anxiety Disorders Screening Day and who reported at least one symptom of posttraumatic stress disorder of at least 1 month's duration, the risk of suicidal ideation was increased, even after controlling for the effect of comorbid major depressive disorder.

Anxiety disorders may be overrepresented among individuals with suicidal ideation or suicide attempts. Pirkis et al. (383) analyzed data from 10,641 respondents in the Australian National Survey of Mental Health and Wellbeing and found that the relative risk of anxiety disorder was increased 3.5-fold in individuals with suicidal ideation in the prior year and increased sevenfold in those with a suicide attempt in the prior year.

Thus, available evidence suggests that anxiety disorders, particularly panic disorder, may be associated with increased rates of suicidal ideation, suicide attempts, and suicide. It remains unclear whether panic attacks and panic disorder represent independent risk factors for suicide or whether elevations in suicidality associated with these disorders are simply a reflection of comorbidity with other disorders such as depression, substance use disorders, or personality disorders. Nonetheless, individuals with anxiety disorders warrant explicit evaluation and follow-up for comorbid diagnoses and for suicide risk. Psychiatrists should also be alert for masked anxiety symptoms and for anxiety disorders that are misdiagnosed as physical illnesses.

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d) Eating disorders

Studies point to eating disorders in general as a risk factor for death and as a likely risk factor for suicide. For example, Harris and Barraclough (64) calculated SMRs for suicide using data from 15 studies and found a 23.1-fold increase in risk in patients with eating disorders. Herzog et al. (138), in an 11-year longitudinal study of 246 women with eating disorders, noted a crude mortality rate of 5.1% and an SMR for death by any cause of 9.6. Three of the women died by suicide, yielding a significantly elevated SMR for suicide of 58.1.

The risk associated with specific eating disorders is less clear. Eckert et al. (139), in a similar longitudinal study, examined the clinical course and outcome of anorexia nervosa in 76 severely ill females. Although none of the deaths were attributed to suicide, by the time of 10-year follow-up, five subjects (6.6%) had died, yielding an almost 13-fold increase in mortality.

Coren and Hewitt (140) extracted data from all death certificates in the United States registered with the National Center for Health Statistics from 1986 through 1990. Of 5.5 million females who died in that period, 571 had anorexia nervosa listed as an underlying cause or accompanying condition of death. Of these, 1.4% died by suicide, compared to 4.1% of a matched control sample, suggesting that the risk of suicide in persons with anorexia nervosa is, if anything, lower than that in control subjects. However, substantial underreporting bias may be present, since personnel recording information on death certificates may not recognize anorexia as a contributory comorbid condition.

Eating disorders, particularly bulimia nervosa, have also been associated with an increased rate of suicide attempts, and, conversely, suicide attempters may have an increased rate of abnormal eating behaviors. Kent et al. (141) compared 48 women who were referred for psychiatric assessment after an act of deliberate self-poisoning with 50 control subjects who were evaluated in a hospital emergency department after a minor accidental injury. Even after controlling for the effect of differences in rates of depression, the investigators found that disordered eating behaviors were significantly more prevalent in the self-poisoning group. Compared to the general community, for whom surveys suggest rates of bulimia nervosa of 1%–2%, four subjects (8%) in the self-poisoning group met the diagnostic criteria for bulimia nervosa. Thus, awareness of eating disorders may be important in evaluating patients after a suicide attempt.

By the same token, suicide attempts may be more likely in women with eating disorders. Using anonymous survey data gathered from 3,630 girls in grades 6 through 12 in the upper Midwest, Thompson et al. (142) found that eating disturbances and aggressive behavior were significantly associated with substance use and with attempted suicide. In addition, adolescents reporting disturbed eating behaviors were three times more likely to report suicidal behaviors than were other respondents.

In summary, individuals with eating disorders may be at increased risk for suicidal behaviors. Anorexia nervosa seems more likely to be a potential risk factor for suicide, whereas bingeing, purging, and bulimia may be more likely to be associated with suicide attempts. The role of comorbid diagnoses in increasing the risk of suicidal behaviors remains unclear. Also unclear is whether the self-imposed morbidity and mortality associated with severe caloric restriction or bingeing and purging should be viewed as a self-injurious or suicidal behavior. Regardless, clinicians conducting suicide risk assessment should be attentive to the presence of eating disorders and especially the co-occurrence of eating disorders with other psychiatric disorders or symptoms such as depression or deliberate self-harm.

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e) ADHD

The relationship between ADHD and suicidal behavior is unclear, with some but not all studies indicating an association between the diagnosis of ADHD and suicide attempts or suicide. To identify psychiatric risk factors for adolescent suicide, Brent et al. (145) used psychological autopsy data to match 67 adolescents who died by suicide to community control subjects. At the time of death, 89.6% of those who died by suicide had a psychiatric disorder, with major depression, bipolar disorder–mixed episode, substance use disorder, and conduct disorder seen at increased rates relative to the rates for the community control subjects. In contrast, the rate of ADHD in those who died by suicide was 13.4% and did not differ from the rate in the control subjects (145). Similarly, in a case-control study of adolescent suicide attempters, ADHD was actually less likely in those who attempted suicide than in the control subjects (146).

In a group of subjects between ages 17 and 28 years, Murphy et al. (144) compared 60 subjects with ADHD, combined type, to 36 subjects with ADHD, predominantly inattentive type, and to 64 community control subjects. A higher proportion of the group with ADHD, combined type (15%), reported attempting suicide, compared with the group with ADHD, predominantly inattentive type (2.8%), and the control group (0%). Compared to the control group, both ADHD groups had greater amounts of psychological distress, received more prescriptions for psychiatric medication and more types of psychiatric services, and had a higher prevalence of alcohol/cannabis use disorders and learning disorders. The groups did not differ in comorbidity of conduct disorder, major depressive disorder, or anxiety disorders. Patients with the combined type of ADHD are clinically more likely to present with distractible and impulsive behavior, whereas patients with the predominantly inattentive type of ADHD are more likely to present with problems of staring, daydreaming, confusion, passivity, withdrawal, and sluggishness or hypoactivity. These differences in clinical features may account for the differences in the numbers of suicide attempts in the two subgroups.

Nasser and Overholser (143) examined the lethality of suicidal behavior in 60 hospitalized adolescent inpatients who had recently attempted suicide. The subjects were divided into three equal groups on the basis of the qualities of their suicidal acts (nonlethal, low-lethal, and high-lethal). The groups did not differ significantly in terms of hopelessness, depression, substance abuse, and self-esteem or in diagnoses of major depression, adjustment disorder, substance abuse, and bipolar disorder. However, the group of high-lethal attempters included four individuals with a diagnosis of major depressive episode and comorbid ADHD. Thus, it may be the comorbidity of ADHD with other disorders that increases the relative lethality of suicide attempts.

In summary, evidence for an independent association between ADHD and risk for suicide or attempted suicide appears weak. Individuals with ADHD, combined type, seem to be at greater risk than those with ADHD, predominantly inattentive type, perhaps because of an increased level of impulsivity. In addition, there may be a relationship between ADHD and suicide risk that relates to comorbidity with conduct disorder, substance abuse, and/or depressive disorder. Given the frequent occurrence of ADHD in patients with other psychiatric disorders, it is important for psychiatrists to be aware that comorbid ADHD may augment the risk of suicidal behaviors.

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f) Alcohol use disorders

The presence of an alcohol use disorder increases suicide risk. Estimates based on computerized curve fitting of data from 27 studies have suggested a 7% lifetime risk of suicide in individuals with alcohol dependence (94). Other approximations of lifetime suicide risk have ranged from 3.4% to as high as 15% (148, 157) but vary by country and depend on the definition of alcoholism used. In fact, the vast majority of studies have not used the DSM-IV criteria for alcohol use disorders, making comparisons across studies difficult. As a result, descriptions of studies in this document will use the diagnostic terms employed by the study authors.

Harris and Barraclough (64) used data from 32 publications, including findings for more than 45,000 individuals with follow-up periods for up to 30 years, to calculate an SMR for suicide of 5.86 among persons with alcohol abuse or dependence. The overall suicide rate for women with alcohol abuse or dependence was about 20 times the expected rate, whereas the rate for men was only about four times the expected rate. Beck et al. (227) also found a risk of suicide in alcoholics that was about fivefold greater than in nonalcoholics in a sample of 413 patients hospitalized for a suicide attempt and prospectively followed for 5–10 years. They also noted that the timing of suicides was spread throughout the follow-up, with no particular period of increased risk.

The association between alcohol use disorders and suicide is also demonstrated by psychological autopsy studies, which show alcohol use disorders to be common among individuals who die by suicide. For example, Henriksson et al. (59), in a random sample of 229 Finnish suicide deaths during a 1-year period, found that alcohol dependence was present in 43% of cases. In the United States, Conner et al. (150) found that 39% of 141 individuals who died by suicide over a 2.5-year period had had a history of alcohol use disorder.

Significant rates of alcohol use were also seen in a sample of youth suicides that included older adolescents. Brent et al. (151) examined death certificates and coroners' reports for all suicides, undetermined causes of death, and questionable accidents for 10- to 19-year-old residents of Allegheny County, Pennsylvania, from 1960 to 1983. Altogether, 159 definite suicides and 38 likely suicides were noted, but the suicide rate increased markedly over the study period, particularly among white males ages 15–19 years. During the study period there was also a 3.6-fold increase in the percentage of suicides with detectable blood alcohol levels (12.9% in 1968–1972, compared to 46.0% in 1978–1983). In addition, the rate of suicide by firearms increased much faster than that by other methods (2.5-fold and 1.7-fold, respectively), and persons who died by suicide with firearms were almost five times more likely to have been drinking than individuals who used other suicide methods.

A number of factors have been specifically observed with suicide in individuals with alcohol use disorders (153). Murphy et al. (152), in a study of 50 alcoholics who died by suicide, found that 26% had experienced interpersonal loss within 6 weeks of their death. These findings were comparable to those in a prior group of 31 alcoholics who died by suicides, one-third of whom had experienced the loss of a close interpersonal relationship within 6 weeks of the suicide. An earlier study by Murphy and Robins (156) also found a high proportion of recent interpersonal disruptions, as did a study of suicides in San Diego by Rich et al. (67). To identify other factors associated with increased risk for suicide among alcoholics, a subsequent study by Murphy et al. (149) pooled these two similar groups of alcoholics who died by suicide and compared them to two control samples of white male alcoholics, one from a psychiatric patient population and one from the ECA community-based population. Clinical features that were significantly more frequent among those who died by suicide than among the control subjects included current alcohol use, poor social support, serious physical illness, unemployment, living alone, and having made a suicidal communication. Eighty-three percent of the alcoholics who died by suicide had four or more of the seven risk factors.

Pirkola et al. (154) also examined factors associated with increased likelihood of suicide among alcohol misusers. They found that alcohol misusers who died by suicide (N=349) were more likely to be young, male, and divorced or separated, compared with individuals who did not misuse alcohol in the several months preceding their suicide (N=648). Alcohol misusers were also more likely to be intoxicated with alcohol at the time of death or to have died from an overdose of medications. Those with alcohol misuse had also experienced more adverse life events close to the time of their suicide despite having better psychosocial adjustment earlier in their lifetime. For example, alcoholics who died by suicide had more often worked but were also more likely to be recently unemployed.

A number of studies have identified comorbid disorders as being common among individuals with alcohol use disorders who die by suicide. In a series of 1,312 alcoholics admitted to a Swedish psychiatric hospital between 1949 and 1969 and followed through 1980, Berglund (157) found that alcoholics who died by suicide had a higher rate of depressive and dysphoric symptoms than alcoholics who died of other causes or who were alive at the end of the follow-up period. Murphy et al. (152) also found that concurrent depression was present in most but not all of their sample of alcoholics who died by suicide, suggesting that depression was neither a necessary nor a sufficient precondition for suicide. In a later study, Murphy et al. (149) found that major depressive episodes were significantly more frequent among alcoholics who died by suicide than among alcoholic control subjects and also found that 58% of the alcoholics who died by suicide had comorbid major depression.

Shaffer et al. (159) compared 120 individuals under age 20 who died by suicide to 147 age-, sex-, and ethnicity-matched community control subjects and found that 59% of the subjects who died by suicide and 23% of the control subjects met the DSM-III criteria for a psychiatric diagnosis based on information obtained from the subject's parents. When information from multiple informants was obtained, 91% of the subjects who died by suicide met the criteria for a DSM-III psychiatric diagnosis. In addition, with increasing age, there was an increased prevalence of a psychiatric diagnosis in general and of a substance and/or alcohol use disorder in particular. Previous suicide attempts and mood disorders were risk factors for suicide in both male and female subjects, whereas substance and/or alcohol abuse occurred exclusively in males and was present in 62% of 18- to 19-year-old subjects who died by suicide.

Even in individuals whose alcohol use disorder has remitted, suicide risk may still be increased but is likely to be influenced by comorbid disorders. Conner et al. (150) analyzed data from a community sample of 141 individuals who died by suicide and found that 39% (N=55) had a history of alcohol misuse. Compared with those who were actively using alcohol, those with remitted alcohol use disorders were predominantly younger individuals with psychotic disorders or older individuals with major depression.

In addition to being associated with an increased risk of suicide, alcohol use disorder is associated with a greater likelihood of suicide attempts. For example, Petronis et al. (163) analyzed data from 13,673 participants in the ECA survey and found that active alcoholism was associated with an 18-fold increase in the relative odds of making a suicide attempt. Gomberg (162) compared 301 women admitted to 21 alcohol treatment facilities to an equal number of age-matched nonalcoholic women from the community. Alcoholic women were far more likely to have attempted suicide (40%, compared with 8.8% of nonalcoholic women), and suicide attempts were particularly likely among alcoholic women under age 40. Alcoholic women who had attempted suicide were more likely to have used other drugs, and they reported significantly more tension, explosiveness, indecisiveness, fearfulness/anxiety, and difficulty concentrating and getting up in the morning.

Among alcoholics, differences also have been noted between those who attempt suicide and those who do not. Roy et al. (165), for example, performed a case-control study to determine the differences between alcoholic suicide attempters and alcoholic nonattempters. Of the 298 alcoholic patients studied, 19% had attempted suicide. Compared with the nonattempters, the attempters were significantly more likely to be female, to be young, and to have a lower economic status. They also were more likely to have first- or second-degree relatives who abused alcohol, to consume a greater amount of alcohol when drinking, and to have begun heavy drinking and experienced the onset of alcohol-related problems at an earlier age.

In addition, comorbid diagnoses are frequently identified among alcoholics who attempt suicide. Roy et al. (165), for example, found the most common comorbid psychiatric diagnoses among alcoholic suicide attempters to be major depression, antisocial personality disorder, substance abuse, panic disorder, and generalized anxiety disorder. Hesselbrock et al. (166), in a sample of 321 inpatients (231 men, 90 women) in alcoholism treatment centers, found that suicide attempters typically had multiple psychiatric diagnoses (e.g., depression, antisocial personality disorder, and substance abuse) and more severe psychiatric symptoms than nonattempters. Two-thirds of alcoholics who attempted suicide had a lifetime diagnosis of major depressive disorder, and most reported symptoms of depression within 2 weeks of the interview. Alcoholic suicide attempters tended to have a parental history of alcoholism, to have begun abusing alcohol at an early age, and to have abused other substances in addition to alcohol.

Preuss et al. (167), using data for 3,190 alcohol-dependent individuals from the Collaborative Study on the Genetics of Alcoholism, found that alcohol-dependent individuals with a history of suicide attempts were more likely to be dependant on other substances and more likely to have other psychiatric disorders. In addition, subjects with suicide attempts had a more severe course of alcohol dependence and more first-degree relatives with suicide attempts. In a subsequent study that followed 1,237 alcohol-dependent subjects over 5 years, Preuss et al. (168) found that the 56 alcohol-dependent subjects with suicide attempts during the follow-up period were more likely to have a diagnosis of a substance-induced psychiatric disorder or be dependent on other drugs. Furthermore, among 371 alcohol-dependent individuals who had made a suicide attempt and also had had an episode of depression, the 145 individuals (39.1%) with alcohol-independent mood disturbance had a greater number of prior suicide attempts and were more likely to have an independent panic disorder but reported a less severe history of alcohol dependence and were less likely to have been drinking during their most severe attempt (169). These findings suggest that in taking a clinical history in suicide attempters it is useful to identify comorbid depression but also to determine whether depressive episodes are alcohol induced or not.

That the presence of prior attempts is predictive of future attempts also highlights a need for taking a thorough history of past suicidal behaviors. Preuss et al. (168) followed 1,237 alcohol-dependent subjects over 5 years and found that the 56 alcohol-dependent subjects with suicide attempts during the follow-up period were more likely to have made prior attempts than subjects with no suicide attempts. Persons with comorbid major depression and alcohol use have higher rates of suicidal symptoms than those with either alone. Cornelius et al. (170) compared 107 patients with both major depression and alcohol dependence to 497 nondepressed alcoholics and 5,625 nonalcoholic patients with major depression assessed at the same psychiatric facility using a semistructured initial evaluation form. Depressed alcoholics had a significantly greater degree of suicidality, as reflected by a global measure that included wishes for death, suicidal ideation, and suicidal behaviors. They also differed significantly from the nonalcoholic depressed patients in having lower self-esteem and greater impulsivity and functional impairment.

In a subsequent study, Cornelius et al. (171) found that among psychiatrically hospitalized alcoholics with major depression, almost 40% had made a suicide attempt in the week before admission, with 70% having made a suicide attempt at some point in their lifetime. There was a significant association between recent suicidal behavior and recent heavy drinking, with most subjects also reporting drinking more heavily than usual on the day of their suicide attempt. In addition, these suicide attempts were usually impulsive. Suicidal ideation, however, was not increased by more recent heavy alcohol use, suggesting that alcohol increases suicidal attempts by increasing the likelihood of acting on suicidal ideation.

In summary, alcohol use disorders are associated with increased risks of suicide and suicide attempts. Conversely, rates of alcohol use disorders are elevated among those who die by suicide as well as among suicide attempters. The common occurrence of comorbid psychiatric symptoms and diagnoses suggests a need for thorough assessment and treatment of such complicating factors in users of alcohol. Also, the frequent presence of psychosocial stressors including unemployment and interpersonal losses should also be taken into consideration in the assessment and treatment planning process.

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g) Other substance use disorders

As with disorders of alcohol use, other substance use disorders may be associated with an increased risk of suicide. Harris and Barraclough (172) noted that the SMRs for suicide varied widely across studies and that calculations were often confounded by the subjects' simultaneous use of multiple substances and by the difficulties in distinguishing accidental overdoses from suicide. Nonetheless, their meta-analysis of published literature found that substance use disorders were associated with a substantial increase in suicide risk. The SMRs for suicide were 14.0 for those with opioid abuse or dependence; 20.3 for those with sedative, hypnotic, or anxiolytic abuse or dependence; and 19.2 for individuals with mixed substance abuse or dependence.

Among individuals with substance use disorders, suicide may be more likely in the presence of comorbid diagnoses such as mood disorders. For example, in a study comparing 67 adolescents who died by suicide to 67 demographically matched community control subjects, Brent et al. (145) found that substance abuse conferred more significant risk when it was comorbid with affective illness than when it was present alone (odds ratio of 17.0 and 3.3, respectively). Lesage et al. (174) compared 75 male subjects ages 18–35 years who died by suicide to a group of 75 demographically matched living control subjects and found significantly greater rates of DSM-III-R psychoactive substance dependence among the subjects who died by suicide (22.7% versus 2.7%). They also found that comorbid major depression or borderline personality disorder was common among those with substance dependence who died by suicide.

In psychological autopsy studies, diagnoses of substance use disorders are particularly common among individuals under age 30 who die by suicide. For example, Fowler et al. (173) studied a subset of 128 individuals from the San Diego Suicide Study (67) who were under 30 years old and found that 53% had a diagnosis of substance abuse. Of this group, about one-half had an additional psychiatric diagnosis such as atypical depression, atypical psychosis, or adjustment disorder with depression. Despite the young age of the study sample, substance abuse was typically a chronic condition that had been present for an average of 9 years. Abuse of multiple substances was the norm, with marijuana, alcohol, and cocaine being the most frequently abused substances. Other data from the San Diego Suicide Study sample as a whole (110) showed that most substance users abused alcohol as well as other substances, with relatively small numbers of "pure" alcoholics or "pure" substance users. They also noted that interpersonal conflicts or loss occurred more frequently near the time of death for substance abusers with and without depression than for persons with mood disorders alone.

Although the majority of persons with substance use disorders who die by suicide are male, it is important to recognize that men and women with substance use disorders may differ in their characteristics and their risk for suicide. Pirkola et al. (175) used data from a nationwide psychological autopsy study in Finland to study the characteristics of a sample of 172 men and 57 women who died by suicide and had a DSM-III-R diagnosis of psychoactive substance dependence. They found that women were more likely than men to have abused or been dependent on prescribed medication. In addition, women were more likely than men to have a substance use disorder preceded by a comorbid axis I disorder (45% and 18%, respectively). Borderline personality disorder, previous suicide attempts, and suicidal communications were more common in women age 40 years or younger. In addition, alcohol-dependent women died at a younger age than women with nonalcohol substance dependence and also died at a younger age than men with either alcohol dependence or nonalcohol substance dependence.

Available evidence suggests that suicide attempts are common in substance users and that substance use disorders are associated with an increased risk of suicide attempts. Borges et al. (176) used data from the U.S. National Comorbidity Survey, a nationally representative sample of 8,098 persons age 15–54 years that was carried out in 1990–1992, to examine whether retrospectively reported substance use, abuse, and dependence are predictors of the onset of suicidal behavior. After controlling for the effects of sociodemographic factors and comorbid psychiatric disorders, the investigators found that subsequent suicide attempts were predicted by use of alcohol, heroin, or inhalants. Current substance use, rather than a history of use, increased the likelihood of suicidal behavior, with the number of substances used being more important than the types of substances used. In addition, among those with suicidal ideation, current substance use, abuse, and dependence were significant risk factors for unplanned suicide attempts.

Rossow and Lauritzen (178) assessed the self-reported prevalences of nonfatal overdoses and suicide attempts in 2,051 individuals who were being treated for substance abuse. Almost one-half (45.5%) reported having had one or more life-threatening overdoses, and nearly one-third (32.7%) reported one or more suicide attempts. Suicide attempts were more often reported among those who had overdosed, and the number of life-threatening overdoses and number of suicide attempts were positively and moderately associated. Individuals who had exhibited both life-threatening behaviors also showed higher rates of HIV risk-taking behaviors, poor social functioning, and use of multiple substances. Suicide attempters also had more symptoms of depression and anxiety as measured by the Global Assessment Scale. Thus, there is substantial covariation between suicide attempts and drug overdoses in individuals with substance use disorders that is also associated with other risk-taking behaviors and poor social integration.

Individuals with substance use disorders also have an increased likelihood of making a suicide attempt, compared to control subjects. Beautrais et al. (177) compared 302 individuals who had made medically serious suicide attempts to 1,028 control subjects who were randomly selected from local electoral rolls. Overall, those who had made a serious suicide attempt had high rates of substance use disorders (odds ratio=2.6). Furthermore, of those with a serious suicide attempt, 16.2% met the DSM-III-R criteria for cannabis abuse/dependence at the time of the attempt, compared with 1.9% of the control subjects (181). Mann et al. (31), in a study of 347 consecutive admissions to a university psychiatric hospital, found that the 184 patients who had made a prior suicide attempt had a greater likelihood of past substance use disorder or alcoholism. Johnsson and Fridell (179) assessed 125 substance abusers 5 years after hospitalization for detoxification and short-term rehabilitation. Although seven patients were dead at the time of follow-up, none of the deaths were from suicide. Of 92 interviewed subjects, nearly one-half the group (45%) reported having attempted suicide at some point in their lives, with about 50% of that group having attempted suicide with prescribed psychotropic drugs such as antidepressants or sedatives. Only a few of the suicide attempts were made by using the individual's primary substance of abuse. The most common reasons given for suicide attempts were the loss of a person whom they loved and feelings of loneliness. Compared to those who had never made a suicide attempt, the suicide attempters were more likely to have had childhood psychiatric hospitalizations or experienced loss of significant others in childhood. They also were more likely to experience depressive moods or other psychiatric comorbidity.

The combination of cocaine use plus alcohol use also appears to increase the risk of suicide attempts. Cornelius et al. (711) found that of 41 consecutively admitted depressed alcoholic inpatients, 16 had made a suicide attempt and 10 had used cocaine during the week before their hospitalization. The proportion of patients making a suicide attempt in the week before admission was greater in those who had used cocaine than in those who had not (70% and 32%, respectively). Suicidal ideation was also more prevalent in the depressed alcoholics who also used cocaine. Roy (180) studied the characteristics of cocaine-dependent patients in a substance abuse treatment center and compared the 130 individuals who had never attempted suicide with the 84 individuals who had made prior suicide attempts (a mean of 2.1 prior attempts). Compared with nonattempters, attempters were more likely to be female and to have a lifetime history of alcohol dependence (58.3%, compared with 34.6% for nonattempters) and a family history of suicidal behavior (25%, compared with 5.4% for nonattempters). Attempters also had significantly higher childhood trauma scores for emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect than the nonattempters; however, these scores were not corrected for the differences in the gender ratios in the two groups. Thus, suicide attempts are common among individuals seeking treatment for cocaine dependence, and factors that seem to augment risk are similar to those for other groups of suicide attempters.

In summary, studies indicate that substance use is a significant risk factor for suicide attempts and suicide. This is particularly true in younger individuals, leading some researchers to hypothesize that increasing suicide rates among youths may be related to increasing rates of substance use. Individuals with chronic substance use disorders, those who have experienced life-threatening nonsuicidal overdoses, and those who abuse multiple substances, including alcohol, may be at even greater risk. Moreover, substance use disorders may complicate mood disorders (182), increasing susceptibility to treatment-resistant illness and psychological impairment, and on that basis may contribute to an elevated risk for suicide and for suicide attempts. As a result, it is important to evaluate individuals with suicidality in the context of substance use for the presence of comorbid mood disorders as well as other comorbid psychiatric diagnoses. The evaluation should also be aimed toward identifying patterns of recent substance use and psychosocial factors such as recent interpersonal loss or history of childhood trauma that may also affect the likelihood of suicidal behaviors among substance users.

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h) Personality disorders

Although personality disorders are often comorbid with substance use disorders and with other psychiatric diagnoses, they also appear to confer an independent risk for suicide. In addition, among individuals with personality disorders, the rate of suicide may be equivalent to rates in individuals with other major psychiatric syndromes. For example, in a meta-analysis of 14 case-control samples and nine longitudinal samples of patients with personality disorders, Linehan et al. (184) found rates of suicide that were between 4% and 8%. For patients with borderline personality disorder, studies have shown suicide rates ranging from 3% to 9% (183). Harris and Barraclough (64) also found suicide risk to be increased, calculating an SMR for suicide of 7.08 among individuals with personality disorder. However, the majority of patients included in their analysis were male and from a Veterans Administration study, raising questions about the representativeness of the population. Baxter and Appleby (188), in a large case registry study of long-term suicide risk in the United Kingdom, found even higher risks for suicide among individuals with personality disorder diagnoses, with a 12.8-fold elevation of risk in men and a 20.9-fold elevation of risk in women with personality disorders.

In a longitudinal follow-up study of individuals with personality disorders, Stone et al. (185) found that 18 of the 196 patients who were able to be located had died by suicide by 16.5 years. Compared to a suicide rate of 8.5% for the borderline personality group as a whole, those with alcohol problems had a twofold increase in the rate (19%), with a 38% rate of suicide among women who had a combination of alcoholism, major affective disorder, and borderline personality disorder. Other factors that appeared to contribute to suicide in individuals with borderline personality disorder were continuing alcohol abuse, impulsivity, and a history of parental brutality, specifically sexual molestation.

Psychological autopsy studies also show significant rates of personality disorder diagnoses among individuals who die by suicide. Duberstein and Conwell (186) reviewed case-based and cohort studies on suicide in individuals with personality disorders and found that approximately 30%–40% of suicides occur in individuals with personality disorders, with increased risk conferred by the presence of borderline, antisocial, and possibly avoidant and schizoid personality disorder diagnoses.

In a random sample of all persons who died by suicide in Finland within a 1-year period, Isometsa et al. (187) found that 29% of the subjects (N=67) had an axis II disorder. All individuals with a personality disorder also had at least one axis I diagnosis, which in 95% included a depressive syndrome, a substance use disorder, or both. Individuals with cluster B personality disorders were more likely to have substance use disorders and to have had a previous suicide attempt and were less likely to have had a health care contact during their final 3 months of life. In the same group of subjects, Heikkinen et al. (190) examined data on recent life events for 56 subjects with personality disorder who died by suicide and matched those subjects to control subjects who did not have a personality disorder diagnosis. Those with a personality disorder were more likely to have experienced one or more stressful life events in the last 3 months of life as well as in the week preceding the suicide. Specifically, of those with a personality disorder, 70% had a significant event in the week before suicide, with job problems, family discord, unemployment, and financial difficulty reported most commonly. Thus, these findings suggest that individuals with personality disorders who die from suicide have high rates of comorbid depression and substance use as well as high rates of significant life stressors that precede suicide.

The increased risk of suicide with personality disorders seems to be a particular factor that contributes to risk in young adults. Lesage et al. (174) compared 75 young men who died by suicide to a demographically matched group of men in the community and found that the 6-month prevalence of borderline personality disorder was substantially increased among those who died by suicide (28.0% versus 4.0%). In a study of adolescents and young adults who had been admitted to a regional poisoning treatment center because of deliberate self-poisoning or self-injury, Hawton et al. (384) compared 62 individuals who died by suicide or possible suicide to 124 matched control subjects and found that an increased risk of death was associated with the presence of a personality disorder (odds ratio=2.1).

Suicide attempts may also be more likely to occur in individuals with personality disorders than in those with other diagnoses. In a review of the topic, Linehan et al. (184) noted that suicide attempts are estimated to occur in 40%–90% of individuals with personality disorders. Soloff et al. (193) examined data for 84 patients who met the DSM-III-R criteria for borderline personality disorder and found that 61 patients (72.6%) had a lifetime history of suicide attempts, with an average of more than three attempts per patient. Risk factors for suicide attempts in patients with borderline personality disorder included older age, prior suicide attempts, antisocial personality, impulsive actions, and a depressed mood, but not comorbid mood disorder or substance use disorder. Ahrens and Haug (194), in a case-control study of 226 patients with a personality disorder who were admitted to a psychiatric hospital, found that patients with a personality disorder (including, but not limited to, borderline personality disorder) were more likely than other hospitalized patients to have had a suicide attempt immediately before admission, with persistent clinically relevant suicidal behavior within the first 24 hours after admission (39% versus 24%). Furthermore, in patients with a personality disorder, suicidality was not related to the presence of a specific mood disorder, since only 3% of the patients with personality disorder met the criteria for a major affective syndrome. However, the rates of reported suicide attempts in individuals with personality disorder diagnoses varied with the treatment setting. Pirkis et al. (198), in a study of suicide attempts by psychiatric patients under active treatment, observed a rate of suicide attempts in acute inpatients that was 10-fold greater than those for individuals in community-based and for individuals in long-stay inpatient care (22.7 attempts per 1,000 episode-days, compared with 2.3 and 2.1 attempts per 1,000 episode-days, respectively).

Conversely, among individuals who attempt suicide, personality disorders are commonly observed. Mann et al. (31), in a study of 347 consecutive patients who were admitted to a university psychiatric hospital, found that comorbid borderline personality disorder was more common among the 184 patients who had attempted suicide than among those with no prior suicide attempts. Beautrais et al. (177) compared 302 consecutive individuals who made serious suicide attempts with 1,028 randomly selected comparison subjects. Multiple logistic regression showed that those who made suicide attempts had a high rate of conduct disorder or antisocial personality disorder (odds ratio=3.7, 95% confidence interval=2.1–6.5). Thus, both borderline personality disorder and antisocial personality disorder appear to occur more frequently among suicide attempters. In a study of consecutive patients who had attempted suicide, Suominen et al. (191) compared 65 patients who did not have a personality disorder diagnosis to 46 patients who received a diagnosis of personality disorder. Of those with a diagnosis, 74% had a cluster B personality disorder and 46% had a diagnosis of borderline personality disorder. Individuals with a personality disorder were more likely to have attempted suicide in the past (78%, compared to 57% of those without a personality disorder diagnosis) and were more likely to have had psychiatric treatment in their lifetime (85% versus 57%); however, those with and without personality disorders did not differ in their degree of intent, hopelessness, somatic severity, or impulsiveness. Personality disorders were associated with a high degree of comorbidity, with comorbid alcohol dependence being particularly common and associated with greater difficulty in pursuing follow-up.

A number of additional factors may act as contributors to risk for suicide attempts among individuals with personality disorders. Brodsky et al. (196) analyzed data for 214 inpatients with a diagnosis of borderline personality disorder according to a structured clinical interview and examined the relationship between the specific DSM-IV criteria for borderline personality disorder and measures of suicidal behavior. After excluding self-destructive behavior and controlling for the effects of lifetime diagnoses of depressive disorder and substance abuse, they found that impulsivity was the only characteristic of borderline personality disorder that was associated with a higher number of suicide attempts. In addition, the number of previous suicide attempts was associated with having a history of substance abuse.

Comorbid mood disorders are also common among suicide attempters with personality disorder diagnoses. For example, Van Gastel et al. (192), in a study of 338 depressed psychiatric inpatients, found significantly more suicide attempts and more suicidal ideation among those with a comorbid personality disorder diagnosis than among depressed inpatients without a personality disorder. In addition, Oquendo et al. (131) found that among 156 inpatients with a diagnosis of a major depressive episode, having a history of suicide attempts was independently related to the presence of a cluster B personality disorder and to PTSD.

Corbitt et al. (195) also examined the effects of comorbid borderline personality disorder in 102 individuals with mood disorders and found that the 30 patients with major depressive disorder and comorbid borderline personality disorder were just as likely to have made a highly lethal suicide attempt as the 72 patients with major depressive disorder alone. However, those with comorbid borderline personality disorder were more likely to have a history of multiple serious suicide attempts, and past suicidal behavior was better predicted by the number of personality disorder symptoms than by the number of depressive symptoms. Thus, they suggested that the severity as well as the presence of comorbid cluster B personality disorder symptoms should be ascertained in assessing the risk of suicide attempts in patients with major depressive disorder.

Soloff et al. (197) compared the characteristics of suicide attempts in 77 inpatients with major depressive episodes to suicide attempts in 81 patients with borderline personality disorder, 49 of whom had a concomitant major depressive episode. Compared to patients with borderline personality disorder alone, all of the depressed patients had more severe observer-rated depression and lower levels of functioning. Patients with borderline personality disorder had higher rates of impulsivity, regardless of whether depression was also present. However, the diagnostic groups did not differ in their subjective intent to die, their degree of objective planning for death, the violence of the suicide method, or the degree of physical damage in the attempt as measured by the Beck Suicide Intent Scale.

In summary, individuals with personality disorders, and particularly those with a diagnosis of borderline personality disorder or antisocial personality disorder, have increased risks for suicide and for suicide attempts. These risks appear to be further augmented by the presence of comorbid disorders such as major depression, PTSD, and substance use disorders. The severity of symptoms such as impulsivity may also play a role in increasing risk, suggesting that such factors should be identified and addressed in the assessment and treatment of individuals with personality disorders.

References

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