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Suicide — New Data on Causes and Cures

Careful assessment of suicidal thoughts and acts, awareness of traits associated with suicide, and vigorous treatment with medication and psychotherapy are essential for suicidal patients.

Suicide is one of the most feared events in psychiatric treatment. This year, several studies have expanded our knowledge of risk factors and neurobiological underpinnings of suicide and of promising treatment approaches in suicidal patients.

Three studies examined suicide risk in people after recent psychiatric hospitalizations or suicide attempts. In 75,401 psychiatric discharges, the risks for readmission for self-injurious behavior were greatest in patients initially admitted for self-harm or diagnosed with depression, anxiety disorder, personality disorder, or substance misuse. Among 39,685 patients hospitalized for attempted suicide, women with any mood disorder and men with schizophrenia had the greatest risks for subsequent completed suicide. Other researchers flagged several risk factors for suicide after psychiatric discharge, including history of self-harm, ongoing suicidal ideation, patient-initiated discharge, mood disorder, psychiatric comorbidity, and less intensive follow-up care. These risks seem to be highest soon after discharge, making close psychiatric follow-up imperative during this period.

That anxiety or impulsivity worsens suicide risk in patients with mood disorders has been reported previously. This year, researchers confirmed that comorbid disorders associated with anxiety, agitation, or poor impulse control increase the likelihood that suicidal thoughts in patients would progress to plans or attempts. Eating disorders (bulimia nervosa, anorexia nervosa, and eating disorders not otherwise specified) pose additional risks for suicide, although some of these risks might be explained by impulsivity, substance use, or mood or anxiety disorders associated with the eating disorder.

The pathophysiology of suicide transcends that of any particular diagnosis. Researchers this year examined suicide as a complex behavior influenced by multiple synaptic systems (beyond the extensively studied decreases in serotonin neurotransmission), the functioning of which can be permanently altered by experience. A history of severe childhood abuse or neglect in suicide completers was associated with less hippocampal expression of the glucocorticoid receptor gene NR3C1 via greater methylation of its promoter. This finding was remarkably consistent with an earlier study in infant rats that showed similar changes in a rat NR3C1 homologue that were produced by early adversity. A less-responsive glucocorticoid receptor could reduce inhibition of the hypothalamic-pituitary-adrenal stress response system, which eventually would increase arousal and interfere with effective brain function. Another neurobiological dimension of suicide appears to be hypermethylation of the promoter of an astrocyte tropomyosin-related kinase B gene, possibly leading to decreased kinase coordination of signaling in systems that regulate aggression, impulsivity, and arousal.

In the past decade, warnings increased about the risk for suicidality in children treated with antidepressants. In response, primary care physicians not only reduced their prescriptions of antidepressants, but also diagnosed depression less frequently (decreases of 44% in children, 37% in young adults, and 29% in adults). Meanwhile, the progressive decline in suicide rates in all age groups reversed. Yet, compelling data indicated that appropriately prescribed antidepressants reduce suicide risk. The latest report from the TADS investigators showed low rates of suicidality in adolescents taking fluoxetine and similar risks for new suicidal thinking or attempts among fluoxetine, cognitive-behavioral therapy, or combination-treatment groups. In another study, spontaneous self-reports by depressed adolescents of suicidal and nonsuicidal self-injury revealed much less of this behavior than did systematic structured inquiries. Physicians and families have remained reluctant to use antidepressants despite evidence that they reduce suicide rates. However, concerns about suicidality with SSRIs have not translated into clinical inquiries about suicidal ideation or behaviors.

Antidepressants alone are insufficient to eliminate suicidal and other self-destructive behaviors, especially in patients with disorders other than depression. Dialectical behavior therapy (DBT) and newer therapies (such as guideline-directed psychotherapy) have been found effective for reducing suicidality and other symptoms in patients with borderline personality disorder and might help patients with other diagnoses, as outlined in the accompanying "year-in-review" essay, "Treatments for Borderline Personality Disorder".

Many suicides occur in the context of alcohol use, but would restricting access to alcohol do any good? In Slovenia in the 1990s, both alcohol consumption and suicide rates were among the highest in Europe. Following the implementation of a minimum drinking age and restrictions in the general availability of alcohol, the suicide rate fell by 10% in men (fewer suicides in women had involved alcohol).

Independent of diagnosis, the most important risk factors for suicidality appear to be impulsivity, high levels of arousal and aggression, and past suicidal behavior. Future research may lead to treatments that target specific neurobiological dimensions of suicide. Clinicians can try to minimize their patients' risks, for example by close postdischarge follow-up in patients hospitalized for suicidality and by encouraging patients to avoid alcohol. Antidepressants reduce suicidality in depressed patients regardless of age and despite the 2003 Food and Drug Administration's warning, which might have overstated suicidality risks with antidepressant use. Combining antidepressants and psychotherapy increases response rates in depressed adolescents and can mitigate increases in suicidal thinking that might occur shortly after starting antidepressants. Structured psychotherapy targeting specific dimensions of psychopathology and the clinician–patient relationship now joins DBT as an evidence-based therapy for suicidality. To manage suicidality in any patient, clinicians need to ask about it in detail rather than wait for patients' spontaneous reports.

— Steven Dubovsky, MD

Published in Journal Watch Psychiatry January 4, 2010

Reader Remarks:

Review and add to remarks on this article

• suicidality
  Nancy C Brough, 6 Jan 2010 3:35 PM EST
  I believe the differences in patient outcomes and suicidality may be due to specialty-specific skill in assessment and pharmacologic treatment.... [more]

2011 Year in Review