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Suicide attempts: differences between unipolar and bipolar patients and among groups with different lethality risk

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Suicide attempts: differences between unipolar and bipolar patients and among groups with different lethality risk
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  Brief report  Suicide attempts: differences between unipolar and bipolar patientsand among groups with different lethality risk  Michele Raja*, Antonella Azzoni Servizio Psichiatrico di Diagnosi e Cura, Dipartimento di Salute Mentale, Ospedale Santo Spirito, Via Prisciano 26, 00136 Rome, Italy Received 29 September 2003; received in revised form 2 February 2004; accepted 3 February 2004 Abstract  Background  : The present naturalistic study aimed to distinguish between suicide attempts (SAs) of bipolar and unipolar  patients, and among SAs characterized by different lethality risk.  Methods : The records of 2395 consecutive admissions to our  psychiatric intensive care unit (PICU) were assessed for presence of suicide attempt (SA). Cases of SAwere rated for symptomseverity with the brief psychiatric rating scale (BPRS), the scale for the assessment of positive symptoms (SAPS), the scale for the assessment of negative symptoms (SANS), the mini mental state examination (MMSE), the global assessment of functioning scale (GAF) and the clinical global impression (CGI). An srcinal questionnaire was administered to exploreclinical aspects related with suicidal behavior.  Results : Among 2395 admissions, 80 (3.3%) had attempted suicide. Fifty-threecases (66.2%) suffered from a mood episode, including 22 (27.5%) with unipolar depression and 31 (38.7%) with bipolar depression (types I and II combined) or mixed state, while 27 (33.8%) cases received other diagnoses. Forty-eight (60%) caseshad attempted suicide prior to the index episode. Ten cases (12.5%) had a relative who attempted or committed suicide. Thirty-nine cases (48.7%) described their SA as impulsive. Twenty cases (25.0%) reported alcohol ingestion before SA. In comparisonwith women, men used more violent methods. Cases characterized by a non-lethal risk SA had higher BPRS psychotic cluster and SAPS scores than cases with either low or high lethal risk SA. Bipolar cases were over-represented in the high lethality risk group. BPRS anxiety–depressive cluster score was higher in unipolar than in bipolar cases.  Limitations : The sample may not berepresentative of all patients with SA. The questionnaire has not been standardized for use in psychiatric populations. Conclusions : The higher proportion of high lethal risk SA in bipolar cases suggests that the risk of completed suicide is higher in bipolar disorder than in unipolar depression. The risk of lethality in SAwas not associated with the intensity of symptoms of anxiety and depression. D  2004 Elsevier B.V. All rights reserved.  Keywords:  Suicide; Suicide attempt; Unipolar depression; Bipolar disorder  1. Introduction The lifetime prevalence of a suicidal attempt (SA)is high in the general population: 4.3% in the epide-miologic catchment area (Moscicki et al., 1988) and4.6% in the National Comorbidity Survey (Kessler et al., 1999). A SA indicates a severe risk of prematuredeath, and suicide is the main cause of excess deaths(Ostamo and Lonnqvist, 2001). Over 90% of suicidevictims suffer from psychiatric disorders (Henrikssonet al., 1993). 0165-0327/$ - see front matter   D  2004 Elsevier B.V. All rights reserved.doi:10.1016/j.jad.2004.02.001* Corresponding author. Tel./fax: +39-06-589-8721.  E-mail address:  michele.raja@fastwebnet.it (M. Raja).www.elsevier.com/locate/jadJournal of Affective Disorders 82 (2004) 437–442  It is important to distinguish the different aspects of suicidal behavior because literature on the subject may refer to suicidal ideation or purpose, to any SAor self-injurious behavior, to potentially lethalattempts or to completed suicides. The characteristicsof each of these groups are substantially different (Lecrubier, 2001).The aim of the present study was to describe aseries of suicide attempts (SAs) admitted to the psychiatric intensive care unit (PICU). We focusedour study on distinguishing among SAs characterized by different lethality risk, and between bipolar andunipolar patients. 2. Method The records of 2395 consecutive admissions (Jan-uary 1997–October 2002) to the PICU were assessedfor presence of SA. The following data were ascer-tained for each patient: sex, age, years of education,social class, and age at the onset of the disorder.Clinical condition was assessed by use of the brief  psychiatric rating scale (BPRS), the scale for theassessment of positive symptoms (SAPS), the scalefor the assessment of negative symptoms (SANS), themini mental state examination (MMSE), the globalassessment of functioning scale (GAF) and the clinicalglobal impression (CGI). For purposes of data analy-sis, we combined the BPRS symptom scales into four summary scores: (1) psychotic cluster (items: concep-tual disorganization, grandiosity, hallucinatory behav-ior, and unusual thought content); (2) withdrawal– retardation cluster (items: motor retardation, emotionalwithdrawal, and blunted affect); (3) hostility–suspi-ciousness cluster (items: hostility, suspiciousness, anduncooperativeness); (4) anxiety–depression cluster (items: anxiety, depression, and guilt). After obtainingconsent, subjects were given a questionnaire com- posed of 22 questions exploring previous SAs, impul-sivity of current SA, communication of suicidalintention to others before current SA, history of SAsor suicides in 1st and 2nd degree relatives, alcohol or substance ingestion before current SA, religious belief,and the emotional state at the time of the interview.Considering degree of lethal intent, objective planning, medical damage, and degree of violenceof suicide methods, we divided the SAs in threegroups characterized by absent, low, or high lethalrisk, and performed an analysis to find out possibledifferences among them. With the same purpose, wedistinguished unipolar and bipolar cases. We con-ducted statistical analysis by means of   t  -test for continuous variables, with Bonferroni correctionwhen called-for, and  v 2 -test for categorical variables.  P  <0.05 was considered statistically significant. 3. Results In the considered period, 80 SAs were foundamong 2395 admitted cases (3.3%). The mean Table 1Differences between men and women suicide attemptersTotal Men Women  v 2 (or Fisher)  P  (1) Age (years) 47.7( F 17.0)42.3( F 17.6)50.7( F 16.1)0.034*(2)  Method of SA Drowning ( n ) 3 3 0 0.04*Fall by a height ( n ) 5 2 3 1Drug overdose ( n ) 41 13 28 0.690Poison ( n ) 2 0 2 0.539Gas ( n ) 5 0 5 0.156Electrocution ( n ) 1 0 1 1Hanging or strangling ( n )8 6 2 0.019*Cutting ( n ) 15 4 11 0.557(3) PreviousSA ( n )48 14 34 0.271(4) Impulsivecurrent SA ( n )39 13 26 0.944(5) Familialsuicidality ( n )10 2 8 0.480(6) Alcoholingestion beforecurrent SA ( n )20 8 12 0.576(7) Religious ( n ) 63 21 42 0.985(8)  At the time of interview, reported sense of   Remorse ( n ) 40 15 25 0.756Guilt ( n ) 46 20 26 0.083Shame ( n ) 41 16 25 0.156Joy ( n ) 6 5 1 0.019*Surprise of beingalive ( n )49 16 33 0.820Relief for beingalive ( n )55 22 33 0.305SA, suicide attempt; *, statistically significant.  M. Raja, A. Azzoni / Journal of Affective Disorders 82 (2004) 437–442 438  interval between the SA and the administration of the questionnaire was 9.0 ( F 12.1) days. Fifty-threecases suffered from a mood episode (66.2%), in-cluding 22 with unipolar depression (27.5%) and 31with bipolar depression (types I and II combined) or mixed state (38.7%), while 27 cases received other diagnoses (33.8%). A total of 48 cases (60.0%) hadattempted suicide prior to the index episode of SA.Ten cases (12.5%) had a relative who had displayedsuicidal behavior. SA was performed by poisoningwith chemicals or gas (  N  =48), cutting (  N  =15),hanging or strangulation (  N  =8), jumping from aheight (  N   = 5), drowning (  N   = 3), electrocution(  N  =1). Thirty-nine cases (48.78%) described their SA as impulsive. Twenty cases (25.0%) reportedalcohol ingestion before the SA. Thirty-eight cases(47.5%) had disclosed their suicidal ideation to physicians, relatives, or friends before their SA. At the time of interview, patients expressed: relief (68.8%) or surprise (61.3%) to be alive, guilt (57.5%), shame (51.3%), remorse (50.0%), and joy(7.5%). 3.1. Differences between men and women In the considered period, 28 men and 52 womenwere admitted for a SA out of 1067 admitted men(2.6%) and 1328 admitted women (3.9%). The differ-ence was not statistically significant. The differ ences between men and women are shown in Table 1. 3.2. Differences among the groups with different lethal risk  The differences among the three groups are shownin Tables 2 and 3. Men tended to be over-represented Table 2Differences among suicide attemptersSeriousness of SA Absent lethal risk group: 15 casesLow lethal risk group: 18 casesHigh lethal risk group: 47 cases  P Variable Male sex ( n ) 4 3 21 0.08Previous SA ( n ) 9 11 28 0.994Impulsive current SA ( n ) 6 8 25 0.617Suicidal familiarity ( n ) 1 3 3 0.380Diagnosis (unipolar/bipolar/ other diagnoses) ( n )5/3/7 8/3/7 9/25/13 0.029*Age (years) 41.5 ( F 15.7) 52.2 ( F 19.0) 48.0 ( F 16.3) 0.196(variance analysis)GAF (current, total score, mean) 20.7 ( F 5.8) 17.1 ( F 5.2) 10.6 ( F 5.7) 0.000*, Bonferroni:1 vs. 3<0.05,2 vs. 3<0.05GAF (best in the last year,total score mean)50.9 ( F 12.6) 52.3 ( F 13.9) 55.5 ( F 12.7) 0.422BPRS (total score, mean) 57.3 ( F 12.4) 57.1 ( F 12.6) 53.0 ( F 10.6) 0.284BPRS psychotic cluster (mean) 9.3 ( F 5.2) 6.9 ( F 4.0) 6.3 ( F 3.3) 0.040*, Bonferroni:1 vs. 3<0.05BPRS withdrawal–retardationcluster (mean)8.1 ( F 4.9) 9.3 ( F 4.1) 7.2 ( F 3.8) 0.185BPRS hostility–agitationcluster (mean)6 ( F 2.7) 6.7 ( F 2.8) 5.5 ( F 2.8) 0.302BPRS anxiety–depressioncluster (mean)12.9 ( F 3.8) 12.6 ( F 3.6) 11.4 ( F 4.1) 0.331SAPS (total score, mean) 31.3 ( F 29.9) 18.9 ( F 16.1) 14.3 ( F 14.8) 0.013*, Bonferroni:1 vs. 3<0.05SANS (total score, mean) 46.9 ( F 24.8) 52.4 ( F 21.7) 40.5 ( F 19.5) 0.121MMSE (total score, mean) 27.8 ( F 1.5) 25.9 ( F 3.0) 26.9 ( F 2.7) 0.115SA, suicide attempt suicide; *, statistically significant.  M. Raja, A. Azzoni / Journal of Affective Disorders 82 (2004) 437–442  439  in the high lethal risk group. Obviously, the GAFcurrent score was lower in the high lethal risk group,since a severe SA is an important criterion to give a patient a low GAF score. Unexpectedly, cases with nolethal risk SA received BPRS psychotic cluster andSAPS scores higher than cases with low or high lethalrisk SA, i.e. they were affected by more severe psychotic symptoms. Bipolar cases were over-repre-sented in the high lethal risk group. 3.3. Differences between bipolar and unipolar cases The seriousness of SA was higher in bipolar cases(see Table 2). Not only current GAF score [12.3( F 5.5) vs. 16.0 ( F 7.1);  t  =2.118; df=50;  P  =0.039] but also last year GAF best score [52.6 ( F 10.2) vs.61.0 ( F 15.0);  t  =2.380; df=49;  P  =0.021] waslower in bipolar cases in comparison with unipolar cases. BPRS anxiety–depressive cluster score washigher in unipolar than in bipolar cases [14.1 ( F 3.4)vs. 11.9 ( F 3.7);  t  =2.191; df=50;  P  =0.033]. Noother significant difference was found between bipo-lar and unipolar cases. 4. Discussion 4.1. Methodological considerations The strengths of the study include: (1) the largesample of serious SAs considered; (2) the possibilityof studying the patients intensively, just after their SA. There are also some problems with our methodthat need to be acknowledged, however. (1) As in allnon-epidemiological studies, the sample may not berepresentative for all patients with SA. (2) Some dataon suicidal behavior were gathered with a question-naire that has not been standardized in psychiatric populations. 4.2. Epidemiological and clinical data Although acute suicidality is the justification for many admissions (Sederer and Summergrad, 1993), the proportion of admissions to our PICU for SA waslow (3.3% of the total), similar to that (2.8%) reportedin the study of  Pajonk et al. (2002). The high  percentage of SAs with a mood diagnosis was similar to that reported by Bala´zs et al. (2003).Most cases had not disclosed their suicidal ideation prior to their SA, underscoring the difficulty of pre-venting SAs. It has been suggested that the lack of willingness for self-disclosure might differentiate theserious from the mild SAs (Apter et al., 2001). How- ever,wedidnotfindanydifferenceonthispointamongthe groups characterized by different lethality risk.In relatives of people who have committed or attempted suicide, a high prevalence of suicidal behavior has been reported, with rates ranging from 14% (Murphy and Wetzel, 1982) to 17% (Gould et  al., 1996), to 40% (Runeson, 1998). The rate of  familial SA (12.8%) reported in this sample is probably underestimated. We did not systematicallyinvestigated this point with patients’ relatives andother informants.In accordance with previous studies, many cases(60%) had previously attempted suicide. Both suicidalideation and SA are predictive of completed suicide(Robins and Kulbok, 1988). Patients with a prior history of SA have a 5- to 6-fold increased risk of trying again. The risk is highest in the 3 monthsfollowing a first attempt  (Hyman, 1994). Therefore, intensive treatment of cases discharged after a SA ismandatory.In this sample, most SAs (60%) were by poisoning.Some methods (hanging or jumping from a height)may be underrepresented, since these methods areassociated with a higher rate of completed suicide or with hospitalization in surgical/orthopedic wards. Table 3Differences among the groups with mild, moderate and severeseriousness of SASeriousnessof SAAbsent lethalrisk group:15 casesLow lethalrisk group:18 casesHigh lethalrisk group:47 cases v 2 ,  P  (2)  Method of SA Drowning 0 0 3 0.335Fall by a height 0 0 5 0.154Drug overdose 9 14 18 0.013*Poison 1 1 0 0.227Gas 0 0 5 0.154Electrocution 0 0 1 0.701Hanging or strangling0 0 8 0.044*Cutting 5 3 7 0.272SA, suicide attempt; *, statistically significant.  M. Raja, A. Azzoni / Journal of Affective Disorders 82 (2004) 437–442 440  The lower scores of BPRS psychotic cluster andSAPS in SAs with higher lethal risk suggest that the absence  of psychotic symptoms in patients with other suicidal risk factors may be related to higher lethalityof the SA. The weight of evidence in the literaturesuggests that the presence of psychot ic symptomsdoes not increase the risk of suicide (Angst et al.,1998; Black et al., 1988; Coryell and Tsuang, 1982;Dilsaver et al., 1994) or SA (Grunebaum et al., 2001). Suicide attempters without psychotic symptoms could be more able to carry out their tragic purpose. Theseresults are consistent with the higher rate of completedsuicide observed in bipolar II patients in comparisonnot only with unipolar but also with bipolar I patientswho are often affected by psychotic symptoms(Rihmer and Kiss, 2002). Nearly half of cases reported their SA as ‘‘impul-sive’’. Furthermore, 1/4 of cases drank alcohol beforeSA, further lessening self-control. In previous studies,objective planning was correlated with lethal intent,suicidal ideation, and medical damage (Mieczkowskiet al., 1993), and with completed suicide (Beck et al.,1974). In the present study, a similar percentage of impulsive SA was observed in the groups with differ-ent lethal risk. However, as Soloff et al. (2000) note,objective planning is not necessarily inconsistent withimpulsive SA. One may act on sudden impulse tocomplete a long planned suicide. 4.3. Differences between men and women In accordance with previous studies (Hjemeland et al., 2002), the present results suggest that men andwomen engaging in SA may be more similar thandifferent. The only differences found in the present study were: (1) older age in women, (2) more frequent use of violent methods in men, and (3) more frequent report of joy as current feeling at the interview in men.The use of more violent methods of SA in menobserved in our study is consistent with the resultsof previous studies (Kucharska-Pietura et al., 2000;Pajonk et al., 2002) and may account for the higher number of committed suicides in men. 4.4. Differences between bipolar and unipolar cases It is uncertain whether the risk of suicide is higher in unipolar or bipolar patients with studies reportinghigher risk in unipolar patients (Angst  et al., 1998;Black et al., 1987), in bipolar patients (Axelsson andLagerkvist-Briggs, 1992; Dunner et al., 1976; Perrisand D’Elia, 1966; Rihmer and Kiss, 2002; Roy,1993), or no significant difference between the twogroups (Martin et al., 1985; Nasser and Overholser,1999). The present non-epidemiological study doesnot allow for accurate assessment of SA rates, how-ever, the higher proportion of high lethal risk SAs in bipolar cases suggests that the risk of completedsuicide is higher in bipolar disorder. Acknowledgements The authors wish to thank Dr. Albert Matthew for his advices and for the revision of the English text. References Angst, J., Sellaro, R., Angst, F., 1998. Long-term outcome andmortality of treated versus untreated bipolar and depressed patients: a preliminary report. Int. J. Psychiatry Clin. Pract. 2,115–119.Apter, A., Horesh, N., Gothelf, D., Graffi, H., Lepkifker, E., 2001.Relationship between self-disclosure and serious suicidal beha-vior. Compr. Psychiatry 42, 70–75.Axelsson, R., Lagerkvist-Briggs, M., 1992. Factors predicting sui-cide in psychotic patients. Eur. Arch. Psychiatry Clin. Neurosci.241, 259–266.Bala´zs, J., Lecubrier, Y., Csisze`r, N., Koszta´k, J., Bitter, I., 2003.Prevalence and comorbidity of affective disorders in personsmaking suicide attempts in Hungary: importance of the first depressive episodes and of bipolar II diagnoses. J. Affect. Dis-ord. 76, 113–119.Beck, A.T., Schuyler, D., Herman, I., 1974. Development of suicidal intent scales. In: Beck, A.T., Resnick, H.L.P., Let-tiem, D.B. (Eds.), The Prediction of Suicide. Charles Press, pp. 45–56.Black, D.W., Winokur, G., Nasrallah, A., 1987. Suicide in subtypesof major affective disorder: a comparison with general popula-tion suicide mortality. Arch. Gen. Psychiatry 44, 878–880.Black, D.W., Winokur, G., Nasrallah, A., 1988. Effect of psychosison suicide risk in 1593 patients with unipolar and bipolar affec-tive disorders. Am. J. Psychiatry 145, 849–852.Coryell, W., Tsuang, M.T., 1982. Primary unipolar depression andthe prognostic importance of delusions. Arch. Gen. Psychiatry39, 1181–1184.Dilsaver, S.C., Chen, Y.W., Swann, A.C., Shoaib, A.M., Krajewski,K.J., 1994. Suicidality in patients with pure and depressivemania. Am. J. Psychiatry 151, 1312–1315.Dunner, D.L., Gershon, E.S., Goodwin, F.K., 1976. Heritable fac-  M. Raja, A. Azzoni / Journal of Affective Disorders 82 (2004) 437–442  441
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