Do Suicide Attempts of Mood Disorder Patients Directly Increase the Risk for a Reattempt?

Background: Preceding suicide attempts strongly predict future suicidal acts. However, whether attempting suicide per se increases the risk remains undetermined. We longitudinally investigated among patients with mood disorders whether after a suicide attempt future attempts occur during milder depressive states, indicating a possible lowered threshold for acting. Methods: We used 5-year follow-up data from 581 patients of the Jorvi Bipolar Study, Vantaa Depression Study, and Vantaa Primary Care Depression Study cohorts. Lifetime suicide attempts were investigated at baseline and during the follow-up. At follow-up interviews, life-chart data on the course of the mood disorder were generated and suicide attempts timed. By using individual-level data and multilevel modeling, we investigated at each incident attempt the association between the lifetime ordinal number of the attempt and the major depressive episode (MDE) status (full MDE, partial remission, or remission). Results: A total of 197 suicide attempts occurred among 90 patients, most during MDEs. When the dependencies between observations and individual liabilities were modeled, no association was found between the number of past suicide attempts at the time of each attempt and partial remissions. No association between adjusted inter-suicide attempt times and the number of past attempts emerged during follow-up. No indication for direct risk-increasing effects was found. Conclusion: Among mood disorder patients, repeated suicide attempts do not tend to occur during milder depressive states than in the preceding attempts. Previous suicide attempts may indicate underlying diathesis, future risk being principally set by the course of the disorder itself.

Comorbid alcohol use disorder in psychiatric MDD patients: A five-year prospective study.

BACKGROUND: Comorbid alcohol use disorder (AUD) is common among patients with major depressive disorder (MDD), and often complicates presentation and treatment. However, there is a scarcity of clinical studies investigating the characteristics and outcome of psychiatric MDD patients with AUD. METHODS: In the Vantaa Depression Study (VDS), a five-year prospective study of psychiatric out- and inpatients (N = 269) with MDD, we investigated the clinical features of MDD, comorbid Axis I and II disorders, psychosocial factors, and long-term outcome of patients with or without AUD. RESULTS: Depressed patients with comorbid AUD at baseline (n = 66/269, 24.5%) were more often male (OR=3.57, [95% CI 1.72 - 7.41], p = 0.001), had more suicidal ideation (OR=1.06 [1.02 - 1.11], p = 0.008), comorbid panic disorders (OR=3.44 [1.47 - 8.06], p = 0.004), symptoms of any personality disorder (OR=1.04 [1.00 - 1.08], p = 0.038), and more often smoked daily (OR=2.79 [1.32 - 5.88], p = 0.007) than those without. At five years, 13.9% (25/180) still had AUD. More specifically, alcohol abuse was associated with suicide attempts, and dependence with suicidal ideation, and Cluster B personality disorder. Patients with AUD spent more time depressed and had more suicide attempts during follow-up. LIMITATIONS: We did not investigate other substance use disorders. The AUD diagnoses were based on DSM-IV criteria. CONCLUSIONS: Psychiatric MDD patients with comorbid alcohol use disorders have characteristics consistent with the epidemiology of AUDs in the general population. They are more often males and smoke, and have more comorbid mental disorders and suicidal behavior. Prospectively they spend more time depressed, thus having worse outcomes than patients without AUDs.

Role of Hopelessness in Suicidal Ideation Among Patients With Depressive Disorders.

OBJECTIVE: The cognitive theory of suicide postulates that hopelessness is an essential precondition for suicidal ideation in patients with depressive disorder . However, the explanatory power and predictive value of hopelessness for suicidal ideation remain uncertain. METHODS: From 1997 to 2007, patients with depressive disorder who were cohorts from the Vantaa Depression Studies (n = 406) completed the Scale for Suicide Ideation (SSI), Beck Hopelessness Scale (BHS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Perceived Social Support Scale-Revised (PSSS-R), and Eysenck Personality Inventory-Q (EPI-Q) at baseline, 6 and 18 months, and 5 years. We conducted a mixed-effects generalized linear regression and clustered receiver-operating characteristics analysis to test how well BDI and BHS predict severe suicidal ideation within and between patients. RESULTS: BHS predicted clinically significant suicidal ideation (odds ratio [OR] = 2.8), explaining 13.1% of between-patient and and 3.5% of within-patient variance of SSI. Adjusting for the fixed effect of BDI removed a substantial part of the effect of BHS on SSI (adjusted OR = 1.38, P = .018). BAI moderated the effect of BHS on SSI, whereas EPI-Q and PSSS-R did not. BDI detected suicidal ideation more accurately (area under the receiver-operating characteristics curve [AUC] = 0.846) than BHS (AUC = 0.754). CONCLUSIONS: In patients with depressive disorder, hopelessness explains suicidal ideation, but largely because it covaries with depressive symptoms. The role of hopelessness as a central determinant of suicidal ideation in depression may have been overestimated. Symptoms of anxiety moderate the association between hopelessness and suicidal ideation. Severity of depressive symptoms may predict suicidal ideation more accurately than hopelessness.

The Relationship Between Smoking and Suicidal Behavior in Psychiatric Patients with Major Depressive Disorder.

Smoking is frequently associated with suicidal behavior, but also with confounding other risk factors. We investigated whether smoking independently predicts suicidal ideation, attempts (SAs), or modifies risk of SAs during major depressive episodes (MDEs). In the Vantaa Depression Study (VDS), a 5-year prospective study of psychiatric patients (N = 269) with major depressive disorder (MDD), we investigated the association of suicidal ideation and smoking, and smoking as an independent risk factor for SAs in 2-level analyses of risk during MDEs. Smoking was not significantly associated with suicidal ideation, nor SAs after controlling for confounding factors, and no evidence of a significant effect during MDEs was found. Smoking was neither significantly associated with suicidal ideation, nor predicted suicide attempts.

Depression and smoking: a 5-year prospective study of patients with major depressive disorder.

BACKGROUND: Major depressive disorder (MDD) and smoking are major public health problems and epidemiologically strongly associated. However, the relationship between smoking and depression and whether this is influenced by common confounding factors remain unclear, in part due to limited longitudinal data on covariation. METHODS: In the Vantaa Depression Study, psychiatric out- and inpatients with DSM-IV MDD and aged 20-59 years at were followed from baseline to 6 months, 18 months, and 5 years. We investigated course of depression, smoking, and comorbid alcohol-use disorders among the 214 patients (79.6% of 269) participating at least three time points; differences between smoking versus nonsmoking patients, and covariation of MDD, smoking, and alcohol-use disorders. RESULTS: Overall, 31.3% of the patients smoked regularly, 41.1% intermittently, and 27.6% never. Smokers were younger, had more alcohol-use disorders and Cluster B and C personality disorder symptoms, a higher frequency of lifetime suicide attempts, higher neuroticism, smaller social networks, and lower perceived social support than never smokers. Smoking and depression had limited longitudinal covariation. Depression, smoking, and alcohol-use disorders all exhibited strong autoregressive tendencies. CONCLUSIONS: Among adult psychiatric MDD patients, smoking is strongly associated with substance-use and personality disorders, which may confound research on the impact of smoking. Rather than depression or smoking covarying or predicting each other, depression, smoking, and alcohol-use disorders each have strong autoregressive tendencies. These findings are more consistent with common factors causing their association than either of the conditions strongly predisposing to the other.

P2RX7 gene is associated consistently with mood disorders and predicts clinical outcome in three clinical cohorts.

We investigated the effect of nine candidate genes on risk for mood disorders, hypothesizing that predisposing gene variants not only elevate the risk for mood disorders but also result in clinically significant differences in the clinical course of mood disorders. We genotyped 178 DSM-IV bipolar I and II and 272 major depressive disorder patients from three independent clinical cohorts carefully diagnosed with semistructured interviews and prospectively followed up with life charts for a median of 60 (range 6-83) months. Healthy control subjects (n = 1322) were obtained from the population-based national Health 2000 Study. We analyzed 62 genotyped variants within the selected genes (BDNF, NTRK2, SLC6A4, TPH2, P2RX7, DAOA, COMT, DISC1, and MAOA) against the presence of mood disorder, and in post-hoc analyses, specifically against bipolar disorder or major depressive disorder. Estimates for time ill were based on life charts. The P2RX7 gene variants rs208294 and rs2230912 significantly elevated the risk for a familial mood disorder (OR = 1.35, P = 0.0013, permuted P = 0.06, and OR = 1.44, P = 0.0031, permuted P = 0.17, respectively). The results were consistent in all three cohorts. The same risk alleles predicted more time ill in all cohorts (OR 1.3, 95% CI 1.1-1.6, P = 0.0069 and OR 1.7, 95% CI 1.3-2.3, P = 0.0002 with rs208294 and rs2230912, respectively), so that homozygous carriers spent 12 and 24% more time ill. P2RX7 and its risk alleles predisposed to mood disorders consistently in three independent clinical cohorts. The same risk alleles resulted in clinically significant differences in outcome of patients with major depressive and bipolar disorder.

Family history of psychiatric disorders and the outcome of psychiatric patients with DSM-IV major depressive disorder.

BACKGROUND: Major Depressive Disorder (MDD) is often comorbid with other heritable disorders. The correlates of a family history (FH) of mood disorders but not of comorbid disorders among MDD patients have been investigated. Since bipolar disorder (BD) is highly heritable, latent BD may bias findings. METHODS: The Vantaa Depression Study included 269 psychiatric out- and in-patients with DSM-IV MDD, diagnosed with semistructured interviews and followed-up for 5 years with a life-chart. The FH of mood, psychotic disorders, and alcoholism among first-degree relatives of 183 patients was investigated. RESULTS: Three fourths (74.9%) of patients reported a FH of some major mental disorder; 60.7% of mood disorder, 36.6% alcoholism, and 10.9% psychotic disorder. In multivariate regression models, a FH of mood disorder was associated with high neuroticism (OR 1.08 [1.02-1.15], p=0.014); a FH of alcoholism with alcohol dependence, number of cluster B personality disorder symptoms, and dysthymia (OR 2.27 [1.01-5.08], p=0.047; OR=1.11 [1.01-1.23], p=0.030; and OR 4.35 [1.51-12.5], p=0.007), and a FH of psychotic disorder with more time spent with depressive symptoms (OR 1.03 [1.00-1.05], p=0.043). However, after excluding those who later switched to BD, several of the associations abated or lost significance. LIMITATIONS: Family history was ascertained only by an interview of the proband. CONCLUSIONS: The majority of MDD patients have a positive FH besides mood also of other disorders. A mood disorder FH may correlate with higher neuroticism, alcoholism FH with alcoholism or personality disorders. FH studies of MDD should take into account the impact of patients switching to BD.

Treatment attitudes and adherence of psychiatric patients with major depressive disorder: a five-year prospective study.

BACKGROUND: The prevalence, long-term temporal consistency and factors influencing negative attitudes and poor treatment adherence among psychiatric patients with major depressive disorder (MDD) are not well known. METHODS: In the Vantaa Depression Study (VDS), a prospective 5-year study of psychiatric patients with DSM-IV MDD, 238 (88.5%) patients' attitudes towards and adherence to both antidepressants and psychotherapeutic treatments at baseline, 6 months, 18 months and 5 years was investigated. RESULTS: Throughout the follow-up, most patients reported positive attitudes towards pharmacotherapy and psychosocial treatments, and good adherence. While attitudes became more critical over time, adherence to psychosocial treatment improved, but remained unchanged for pharmacotherapy. Employment predicted positive attitude (OR=1.97, 95% CI 1.01-3.83, P=0.046), and larger social network good adherence (OR=1.11, 95% CI 1.00-1.23, P=0.042) to pharmacotherapy at the last follow-up. Cluster B personality disorder symptoms predicted negative attitude (OR=0.82, 95% CI 0.70-0.96, P=0.012) and poor adherence (OR=0.83, 95% CI 0.72-0.95, P=0.007), but cluster C symptoms positive attitude (OR=1.30, 95% CI 1.09-1.54, P=0.003), and living alone good adherence (OR=3.13, 95% CI 1.10-9.09, P=0.032) to psychosocial treatment. LIMITATIONS: Patients may exaggerate their adherence to treatments. Attrition from follow-up may occur due to undetected negative change in treatment attitude or adherence. CONCLUSIONS: Among psychiatric MDD patients in long-term follow-up, treatment attitudes and adherence to pharmaco- and psychotherapy were and remained mostly positive. They were significantly predicted by personality features and social support. Attention to adherence of those with cluster B personality disorders, or poor social support, may be needed.

Incidence and predictors of suicide attempts in DSM-IV major depressive disorder: a five-year prospective study.

OBJECTIVE: Prospective long-term studies of risk factors for suicide attempts among patients with major depressive disorder have not investigated the course of illness and state at the time of the act. Therefore, the importance of state factors, particularly time spent in risk states, for overall risk remains unknown. METHOD: In the Vantaa Depression Study, a longitudinal 5-year evaluation of psychiatric patients with major depressive disorder, prospective information on 249 patients (92.6%) was available. Time spent in depressive states and the timing of suicide attempts were investigated with life charts. RESULTS: During the follow-up assessment period, there were 106 suicide attempts per 1,018 patient-years. The incidence rate per 1,000 patient-years during major depressive episodes was 21-fold (N=332 [95% confidence interval [CI]=258.6-419.2]), and it was fourfold during partial remission (N=62 [95% CI=34.6-92.4]) compared with full remission (N=16 [95% CI=11.2-40.2]). In the Cox proportional hazards model, suicide attempts were predicted by the months spent in a major depressive episode (hazard ratio=7.74 [95% CI=3.40-17.6]) or in partial remission (hazard ratio=4.20 [95% CI=1.71-10.3]), history of suicide attempts (hazard ratio=4.39 [95% CI=1.78-10.8]), age (hazard ratio=0.94 [95% CI=0.91-0.98]), lack of a partner (hazard ratio=2.33 [95% CI=0.97-5.56]), and low perceived social support (hazard ratio=3.57 [95% CI=1.09-11.1]). The adjusted population attributable fraction of the time spent depressed for suicide attempts was 78%. CONCLUSIONS: Among patients with major depressive disorder, incidence of suicide attempts varies markedly depending on the level of depression, being highest during major depressive episodes. Although previous attempts and poor social support also indicate risk, the time spent depressed is likely the major factor determining overall long-term risk.

Predictors for switch from unipolar major depressive disorder to bipolar disorder type I or II: a 5-year prospective study.

OBJECTIVE: In this naturalistic study, we investigated the rate, time course, and predictors of a diagnostic switch from unipolar major depressive disorder (MDD) to bipolar disorder type I or II during a 5-year follow-up. METHOD: The Vantaa Depression Study included at baseline 269 psychiatric outpatients (82.9%) and inpatients (17.1%) with DSM-IV MDD, diagnosed using structured and semi-structured interviews and followed up at 6 months, 18 months, and 5 years between February 1, 1997 and April 30, 2004. Information on 248 MDD patients (92.2%) was available for analyses of the risk of diagnostic switch. Cox proportional hazards models were used. RESULTS: Twenty-two subjects (8.9%) with previous unipolar MDD switched to bipolar disorder type II and 7 (2.8%) to type I. Median time for switch to bipolar type I was significantly shorter than to type II. In Cox proportional hazards analyses, severity of MDD (hazard ratio [HR] = 1.08, 95% CI = 1.00 to 1.15, p = .036), obsessive-compulsive disorder (OCD) (HR = 5.00, 95% CI = 2.04 to 12.5, p < .001), social phobia (HR = 2.33, 95% CI = 1.00 to 5.26, p = .050), and large number of cluster B personality disorder symptoms (HR = 1.10, 95% CI = 1.02 to 1.20, p = .022) predicted switch. CONCLUSION: Among outpatients with MDD in secondary level psychiatric settings, diagnostic switch to bipolar disorder usually refers to type II rather than type I. The few switching to bipolar type I do so relatively early. Predictors for diagnostic switch include not only features of mood disorder, such as severity, but may also include some features of psychiatric comorbidity, such as concurrent social phobia, OCD, and symptoms of cluster B personality disorders.

Maintenance pharmacotherapy for recurrent major depressive disorder: 5-year follow-up study.

Practice guidelines endorse maintenance antidepressant treatment for recurrent major depressive disorder. In the Vantaa Depression Study, we followed 218 psychiatric patients with major depressive disorder for up to 5 years with a life-chart. Of these patients, 86 (39.4%) had more than three lifetime episodes and an indication for maintenance pharmacotherapy. However, of these, only 57% received treatment and only for 16% of the time indicated. Good adherence to pharmacotherapy in the acute phase independently predicted maintenance treatment. The tertiary preventive impact of maintenance treatment may remain limited, as many patients with major depressive disorder either do not receive it, or receive it for too short a period.

Long-term outcome of major depressive disorder in psychiatric patients is variable.

OBJECTIVE: The prevailing view of outcome of major depressive disorder (MDD), based on mostly inpatient cohorts sampled from tertiary centers, emphasizes chronicity and frequent recurrences. We investigated the long-term outcome of a regionally representative psychiatric MDD cohort comprising mainly outpatients. METHOD: The Vantaa Depression Study included 163 patients with DSM-IV MDD (71.5% of those eligible) diagnosed using structured and semistructured interviews and followed up at 6 months, 18 months, and 5 years with a life chart between February 1, 1997, and April 30, 2004. The effects of comorbid disorders and other predictors on outcome were comprehensively investigated. RESULTS: Over the 5-year follow-up, 98.8% of patients achieved a symptom state below major depressive episode (MDE) criteria, and 88.4% reached full remission, with the median time to full remission being 11.0 months. Nearly one third (29.3%) had no recurrences, whereas 30.0% experienced 1, 12.9% experienced 2, and 27.9% experienced 3 or more recurrences. Preceding dysthymic disorder (p = .028), cluster C personality disorder (p = .041), and longer MDE duration prior to entry (p = .011) were the most significant predictors of longer time in achieving full remission. Severity of MDD and comorbidity, especially social phobia, predicted probability of, shorter time to, and number of recurrences. CONCLUSION: Previous literature on mostly inpatient MDD may have, by generalizing from patients with the most severe psychopathology, overemphasized chronicity of MDD. The long-term outcome of MDD in psychiatric care is variable, with about one tenth of patients having poor, one third having intermediate, and one half having favorable outcomes. In addition to known predictors, cluster C personality disorders and social phobia warrant further attention as predictors of MDD outcome among outpatients.