Effect of Attitude Toward Suicide on Suicidal Behavior: Based on the Korea National Suicide Survey

Objective@#Suicide is a complex phenomenon; therefore, it should be approached in light of sociocultural perspectives and the general attitude toward suicide. This study aimed to extract factors from the Attitude Toward Suicide Scale (ATTS) and investigate the relationship between attitudes toward suicide and suicidal behavior (i.e., suicidal idea, plan, and attempt) by using a representative sample of Korean adults. @*Methods@#Three thousand Koreans aged 19 to 75 years were surveyed cross-sectionally in 2013 and 2018. The data collected were subjected to exploratory factor analysis. Extracted attitude factors were compared using a suicidal behavior continuum. Univariate and multivariate logistic models were constructed to compare the association between attitude factors and suicidal behaviors. @*Results@#Among the participants, 477 (15.9%) experienced suicidal idea only, 85 (2.8%) had a suicidal plan without attempt, and 58 (1.9%) attempted suicide. Four meaningful factors were extracted from the factor analysis: “permissiveness,” “unjustified behavior,” “preventability/readiness to help,” and “loneliness.” “Permissiveness,” “unjustified behavior,” and “loneliness” factors showed significant trends across the suicidal behavior continuum. Permissive attitude toward suicide increased the odds of suicidal idea, suicidal plan, and suicide attempt (adjusted odds ratio [aOR]=1.49, 95% confidence interval [CI]=1.25–1.79; aOR=2.79, 95% CI=1.84–4.25; aOR=2.67, 95% CI=1.65–4.33), while attitude toward suicide as unjustified behavior decreased the odds of suicidal ideation and attempt (aOR=0.79, 95% CI=0.67–0.94; aOR=0.64, 95% CI=0.42–0.99). @*Conclusion@#A significant association was found between attitude toward suicide and suicidal behaviors. Attitude toward suicide is a modifiable factor that can be used to develop prevention policies.

Early Trauma and Relationships among Recent Stress, Depressive Symptoms, Anxiety Symptoms, and Suicidal Ideation in Korean Women

Background@#Evidence continues to accumulate that the presence or absence of early trauma (ET) implies unique characteristics in the relationships between suicidal ideation and its risk factors. We examined the relationships among recent stress, depressive symptoms, anxiety symptoms, and suicidal ideation in Korean suicidal women with or without such a history. @*Methods@#Using data on suicidal adult females, 217 victims and 134 non-victims of ET, from the Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior, we performed structural equation modeling to investigate the contribution of recent stress, depressive symptoms, and anxiety symptoms on suicidal ideation within each group according to the presence or absence of a history of ET. @*Results@#Structural equation modeling with anxiety and depressive symptoms as potential mediators showed a good fit. Recent stress had a direct effect on both depressive symptoms and anxiety symptoms in both groups. Only anxiety symptoms for victims of ET (standardized regression weight, 0.281; P = 0.005) and depressive symptoms for non-victims of ET (standardized regression weight, 0.326; P = 0.003) were full mediators that increased suicidal ideation. Thus, stress contributed to suicidal ideation by increasing the level of anxiety and depressive symptoms for victims and non-victims, respectively. @*Conclusion@#Tailored strategies to reduce suicidal ideation should be implemented according to group type, victims or non-victims of ET. Beyond educating suicidal women in stressmanagement techniques, it would be effective to decrease anxiety symptoms for those with a history of ET and decrease depressive symptoms for those without such a history.

Self-Transcendence Mediates the Relationship between Early Trauma and Fatal Methods of Suicide Attempts

Background@#Early trauma is known to be a risk factor of suicide-related behavior. On the other hand, people who attempt suicide using a fatal method are reported to be more likely to complete suicide. In this study, we assumed that early trauma affects an individual's temperament and character and thereby increases the risk of a fatal method of suicide attempts. @*Methods@#We analyzed 92 people with a history of previous suicide attempts. We compared the Temperament and Character Inventory-Revised scores between the groups with and without early trauma, and between the groups with and without a history of suicide attempt using fatal methods through an analysis of covariance with age, sex, and presence of a psychiatric history as covariates. A mediation analysis was conducted of the relationship between early trauma and fatal methods of suicide attempt with self-transcendence as a mediator. @*Results@#Higher self-transcendence was reported in the fatal group (27.71 ± 13.78 vs. 20.97 ± 12.27, P = 0.010) and the early trauma group (28.05 ± 14.30 vs. 19.43 ± 10.73, P = 0.001), respectively. The mediation model showed that self-transcendence mediates the relationship between early trauma and fatal methods of suicide attempt. The 95% confidence intervals for the direct and indirect effect were (−0.559, 1.390) and (0.026, 0.947), respectively. @*Conclusion@#Self-transcendence may mediate the relationship between early trauma and fatal methods of suicide attempt. Self-transcendence may be associated with unhealthy defenses and suicidal behavior for self-punishment and may constitute a marker of higher suicide risk.

Early Trauma and Relationships among Recent Stress, Depressive Symptoms, Anxiety Symptoms, and Suicidal Ideation in Korean Women

Background@#Evidence continues to accumulate that the presence or absence of early trauma (ET) implies unique characteristics in the relationships between suicidal ideation and its risk factors. We examined the relationships among recent stress, depressive symptoms, anxiety symptoms, and suicidal ideation in Korean suicidal women with or without such a history. @*Methods@#Using data on suicidal adult females, 217 victims and 134 non-victims of ET, from the Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior, we performed structural equation modeling to investigate the contribution of recent stress, depressive symptoms, and anxiety symptoms on suicidal ideation within each group according to the presence or absence of a history of ET. @*Results@#Structural equation modeling with anxiety and depressive symptoms as potential mediators showed a good fit. Recent stress had a direct effect on both depressive symptoms and anxiety symptoms in both groups. Only anxiety symptoms for victims of ET (standardized regression weight, 0.281; P = 0.005) and depressive symptoms for non-victims of ET (standardized regression weight, 0.326; P = 0.003) were full mediators that increased suicidal ideation. Thus, stress contributed to suicidal ideation by increasing the level of anxiety and depressive symptoms for victims and non-victims, respectively. @*Conclusion@#Tailored strategies to reduce suicidal ideation should be implemented according to group type, victims or non-victims of ET. Beyond educating suicidal women in stressmanagement techniques, it would be effective to decrease anxiety symptoms for those with a history of ET and decrease depressive symptoms for those without such a history.

Self-Transcendence Mediates the Relationship between Early Trauma and Fatal Methods of Suicide Attempts

Background@#Early trauma is known to be a risk factor of suicide-related behavior. On the other hand, people who attempt suicide using a fatal method are reported to be more likely to complete suicide. In this study, we assumed that early trauma affects an individual's temperament and character and thereby increases the risk of a fatal method of suicide attempts. @*Methods@#We analyzed 92 people with a history of previous suicide attempts. We compared the Temperament and Character Inventory-Revised scores between the groups with and without early trauma, and between the groups with and without a history of suicide attempt using fatal methods through an analysis of covariance with age, sex, and presence of a psychiatric history as covariates. A mediation analysis was conducted of the relationship between early trauma and fatal methods of suicide attempt with self-transcendence as a mediator. @*Results@#Higher self-transcendence was reported in the fatal group (27.71 ± 13.78 vs. 20.97 ± 12.27, P = 0.010) and the early trauma group (28.05 ± 14.30 vs. 19.43 ± 10.73, P = 0.001), respectively. The mediation model showed that self-transcendence mediates the relationship between early trauma and fatal methods of suicide attempt. The 95% confidence intervals for the direct and indirect effect were (−0.559, 1.390) and (0.026, 0.947), respectively. @*Conclusion@#Self-transcendence may mediate the relationship between early trauma and fatal methods of suicide attempt. Self-transcendence may be associated with unhealthy defenses and suicidal behavior for self-punishment and may constitute a marker of higher suicide risk.

Comparison of Suicide Risk by Mental Illness: a Retrospective Review of 14-Year Electronic Medical Records

Background@#Korea is one of the countries with the highest rate of suicide, while suicidality is known to be closely related to mental illnesses. The study aimed to evaluate the suicide rates in psychiatric patients, to compare it to that of the general population, and to investigate the differences among psychiatric diagnoses and comorbidities. @*Methods@#Medical records and mortality statistics of psychiatric patients at Seoul National University Hospital from 2003 to 2017 were reviewed. The standardized mortality ratio (SMR) for suicide was calculated to compare the psychiatric patients with the general population. The diagnosis-specific standardized mortality rate and hazard ratio (HR) were adjusted by age, sex, and psychiatric comorbidity (i.e., personality disorder and/or pain disorder). @*Results@#A total of 40,692 survivors or non-suicidal deaths and 597 suicidal death were included. The suicide rate among psychiatric patients was 5.13-fold higher than that of the general population. Psychotic disorder had the highest SMR (13.03; 95% confidence interval [CI], 11.23–15.03), followed by bipolar disorder (10.26; 95% CI, 7.97–13.00) and substancerelated disorder (6.78; 95% CI, 4.14–10.47). In survival analysis, psychotic disorder had the highest HR (4.16; 95% CI, 2.86–6.05), which was further increased with younger age, male sex, and comorbidity of personality disorder. @*Conclusion@#All psychiatric patients are at a higher risk of suicide compared to the general population, and the risk is highest for those diagnosed with psychotic disorder.

Comparison of Suicide Risk by Mental Illness: a Retrospective Review of 14-Year Electronic Medical Records

Background@#Korea is one of the countries with the highest rate of suicide, while suicidality is known to be closely related to mental illnesses. The study aimed to evaluate the suicide rates in psychiatric patients, to compare it to that of the general population, and to investigate the differences among psychiatric diagnoses and comorbidities. @*Methods@#Medical records and mortality statistics of psychiatric patients at Seoul National University Hospital from 2003 to 2017 were reviewed. The standardized mortality ratio (SMR) for suicide was calculated to compare the psychiatric patients with the general population. The diagnosis-specific standardized mortality rate and hazard ratio (HR) were adjusted by age, sex, and psychiatric comorbidity (i.e., personality disorder and/or pain disorder). @*Results@#A total of 40,692 survivors or non-suicidal deaths and 597 suicidal death were included. The suicide rate among psychiatric patients was 5.13-fold higher than that of the general population. Psychotic disorder had the highest SMR (13.03; 95% confidence interval [CI], 11.23–15.03), followed by bipolar disorder (10.26; 95% CI, 7.97–13.00) and substancerelated disorder (6.78; 95% CI, 4.14–10.47). In survival analysis, psychotic disorder had the highest HR (4.16; 95% CI, 2.86–6.05), which was further increased with younger age, male sex, and comorbidity of personality disorder. @*Conclusion@#All psychiatric patients are at a higher risk of suicide compared to the general population, and the risk is highest for those diagnosed with psychotic disorder.

Comparison of Serum Uric Acid in Major Depressive Disorder and Bipolar Disorder: a Retrospective Chart Review Study

Background@#Uric acid (UA) has been suggested as a possible biomarker of bipolar disorder (BD) in recent studies. We aimed to provide a clearer comparison of UA levels between BD and major depressive disorder (MDD). @*Methods@#We retrospectively reviewed the medical chart records of psychiatric inpatients aged 19–60 years, whose main discharge diagnoses were either MDD or BD, with an admission between January 1, 2015 and December 31, 2018 at Seoul National University Hospital. Data such as sex, age, body mass index (BMI), medication usage, and serum UA levels were extracted. Patients with medical conditions or on medications that could influence UA levels were excluded. Age, sex, BMI, and psychiatric drug usage were considered in the comparison of serum UA between MDD and BD patients. @*Results@#Our sample consisted of 142 MDD patients and 234 BD patients. The BD patients had significantly higher serum UA levels compared to the MDD patients, without accounting for other confounding variables (5.75 ± 1.56 mg/dL vs. 5.29 ± 1.59 mg/dL, P = 0.006). T-test comparisons between psychiatric medication users and non-users revealed that mood stabilizers and antipsychotics may be relevant confounding factors in our sample analysis. The likelihood of BD diagnosis was significantly correlated with higher UA levels (odds ratio, 1.410; 95% confidence interval, 1.150–1.728; P = 0.001) when accounting for sex, age, and BMI in the logistic regression analysis. Also, accounting for mood stabilizers or antipsychotics, the likelihood of BD diagnosis was still significantly correlated with higher UA levels. @*Conclusion@#Our study confirms that BD patients are significantly more likely to show higher serum UA levels than MDD patients. The high UA levels in BD point to purinergic dysfunction as an underlying mechanism that distinguishes BD from MDD. Further research is recommended to determine whether UA is a trait or a state marker and whether UA correlates with the symptoms and severity of BD.

The Epidemiology of Antidepressant Prescriptions in South Korea from the Viewpoint of Medical Providers: A Nationwide Register-Based Study

Antidepressants are widely used to treat depression in Korea, however, only a few studies have focused on the provider of the treatment. The aim of the study is to compare the differences between patients who were prescribed antidepressants by psychiatrists and those who were prescribed antidepressants by non-psychiatrists in South Korea. Patients with a diagnosis of depressive disorder who had been newly prescribed antidepressants in 2012 were selected from the Health Insurance Review and Assessment Service database. They were classified into two groups depending on whether they received the antidepressant prescription from a psychiatrist or non-psychiatrist. Sociodemographic, clinical, and depression related cost has been investigated. Treatment resistant depression, which is defined as a failure of two antidepressant regimens to alleviate symptoms, was also investigated. Prescription adequacy was assessed based on whether a regimen was maintained for at least 4 weeks. Among the 834694 patients with pharmaceutically treated depression (PTD) examined in this study, 326122 (39.1%) were treated by psychiatrists. Patients who were treated by psychiatrists were younger and had more psychiatric comorbidities than those treated by non-psychiatrists. They had longer PTD duration (229.3 days vs. 103.0 days, p < 0.05) and a larger proportion of treatment resistant depression (9.3% of PTD) when compared to those patients treated by non-psychiatrists. The patients treated by psychiatrists had a smaller proportion of inadequate antidepressant use compared to those patients in the non-psychiatrist group (44.5% vs. 65.1%, p < 0.05). The costs related to depression corrected with PTD duration were higher in the nonpsychiatrist group (32214 won vs. 56001 won, p < 0.05). Patients who receive antidepressants from psychiatrists are patients with more severe, treatment-resistant depression. Psychiatrists prescribe antidepressants more adequately and cost-effectively than non-psychiatrists.

High-Dose Zolpidem Dependence and Detoxification from Withdrawal Symptoms Using Diazepam / 신경정신의학

Zolpidem is a nonbenzodiazepine hypnotic for the treatment of insomnia, and known as a relatively-safe medication. However, there have been several case reports of zolpidem abuse aand dependence these days. Even though some withdrawal symptoms like seizures can occur, there has not been any standard detoxification method until now. A high dose of zolpidem has similar pharmacological properties as the rest of the benzodiazepines, even though the usual dose of zolpidem has a selectivity to the type 1 benzodiazepine receptors. We report a rare case of high-dose addiction and successful detoxification by cross-titration with diazepam.