Lack of association between testosterone and suicide attempts.

OBJECTIVE: To determine whether testosterone levels differ in male suicide attempters versus healthy controls and to explore the associations between testosterone levels and time of blood collection, and between testosterone levels and characteristics of suicide attempts. METHOD: A sample of 112 male suicide attempters was studied. Thirty-seven male blood donors were recruited as controls. RESULTS: The mean testosterone levels were 5.1 ± 2.9 ng/ml in male attempters and 4.6 ± 1.6 ng/ml in controls. Group differences in testosterone levels were not significant when we studied the interaction with time of extraction (F = 0.37; d.f. = 2; p = 0.70) or when matched by age and time of extraction (t = -0.74; d.f. = 26; p = 0.47). When partial correlations were performed correcting for the effect of time of extraction, significant partial correlations were found in testosterone levels with history of aggressive behavior and lethality of the attempt. CONCLUSIONS: When circadian variation and age were considered, we found no support for the putative role of testosterone as a biological marker of suicidal behavior. Further research should consider: (1) testosterone and neurosteroids; (2) serial determinations with a minimal time gap between the attempt and the blood extraction; (3) controls within the same time periods, and (4) other variables that may affect testosterone levels, such as body mass index, physical activity and sleep disturbances.

Suicide attempts among women during low estradiol/low progesterone states.

The relationship between the menstrual cycle and risk for suicidal behaviors is not clear. The aim of this study is to determine whether perimenstrual phases in fertile women are associated with acute risk for suicide attempt and explore whether risk is elevated during low estradiol/low progesterone states. Women (N=431) recruited within 24h of a suicide attempt were assessed for psychopathology, suicidal behavior and LH, FSH, estradiol and progesterone blood levels. Among fertile women (N=281/431), suicide attempts were more likely to occur during menses (26%, 72/281 observed vs. 15%, 43/281 expected attempts; p<0.001). Compared to women whose attempts occurred during other phases, women who attempted suicide during low estradiol/low progesterone states (menstrual phase, amenorrhea and menopause) reported severe suicide intent, a measure that may be predictive of eventual suicide death. Suicide attempts among women are more likely when estrogen and progesterone levels are low and attempts made under these conditions are associated with greater severity. Low gonadal hormone levels may constitute a key factor in the neurobiological basis of suicidal behavior among women, suggesting a novel, testable hypothesis regarding the underpinnings of suicidal acts.

Nucleotide variation in central nervous system genes among male suicide attempters.

Despite marked morbidity and mortality associated with suicidal behavior, accurate identification of individuals at risk remains elusive. The goal of this study is to identify a model based on single nucleotide polymorphisms (SNPs) that discriminates between suicide attempters and non-attempters using data mining strategies. We examined functional SNPs (n = 840) of 312 brain function and development genes using data mining techniques. Two hundred seventy-seven male psychiatric patients aged 18 years or older were recruited at a University hospital psychiatric emergency room or psychiatric short stay unit. The main outcome measure was history of suicide attempts. Three SNPs of three genes (rs10944288, HTR1E; hCV8953491, GABRP; and rs707216, ACTN2) correctly classified 67% of male suicide attempters and non-attempters (0.50 sensitivity, 0.82 specificity, positive likelihood ratio = 2.80, negative likelihood ratio = 1.64). The OR for the combined three SNPs was 4.60 (95% CI: 1.31-16.10). The model's accuracy suggests that in the future similar methodologies may generate simple genetic tests with diagnostic utility in identification of suicide attempters. This strategy may uncover new pathophysiological pathways regarding the neurobiology of suicidal acts.

Low serum cholesterol may be associated with suicide attempt history.

OBJECTIVE: This case-control study used both healthy blood donors and psychiatric inpatients as controls and controlled for gender, age, low body mass index, alcohol and nicotine use, and aggressive and impulsive behaviors to examine the association between low serum cholesterol levels and suicide attempts. METHOD: At a Spanish general hospital, the recruitment included 417 patients with suicide attempt history (138 men and 279 women), 155 psychiatric inpatient controls without suicide history (68 men and 87 women), and 358 healthy controls (220 men and 138 women). All participants were aged 18 years or older. To study the association between low serum cholesterol levels (fasting < 160 mg/dL) and suicide attempts, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated in univariate analyses. Logistic regression models adjusted ORs for confounding variables in male, female, and total samples. The study was conducted from January 1996 to December 1997. RESULTS: The ORs in the total sample (for psychiatric and healthy controls respectively) were 1.8 (95% CI = 1.2 to 2.9, p = .007) and 1.9 (95% CI = 1.4 to 2.6, p < .001) for the univariate analyses, and 1.6 (95% CI = 0.95 to 2.6, p = .08) and 1.6 (95% CI = 1.0 to 2.4, p = .04) after variable adjustment. In women, the adjusted OR was 1.8 (95% CI = 0.90 to 3.5, p = .09) for psychiatric controls. In men, the adjusted OR was 2.0 (95% CI = 0.99 to 4.1, p = .05) for healthy controls. All ORs were in the hypothesized direction but some subsamples appeared too small to reach significance. CONCLUSION: This study, somewhat limited by the small sample size, suggests that low cholesterol may be associated with suicide attempts. Low cholesterol level in suicide attempts may be more important from a pathophysiologic than from a diagnostic point of view.

Acute atropine intoxication with psychiatric symptoms by herbal infusion of Pulmonaria officinalis (Lungwort)e

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Background and objectives: Lungwort infusion is a preparation extracted from Pulmonaria officinal is which is occasionally used as a folk remedy for the common cold. The current report aims to describe acute atropine intoxications with delirium caused by Lungwort infusion in several members of the same family. Methods: Description of three case reports. Search of literature through Medline. Results: Three generations of a same family presented acute and moderately severe atropine intoxications after drinking an infusion prepared with Pulmonaria officinalis. Conclusions: Despite the lack of scientific evidence for its clinical use, medicinal plants continue being widely used. In spite of severe adverse effects reported, the general thought is that herbal remedies are harmless. To our knowledge, this is the first report of acute atropine intoxications with psychiatric symptoms secondary to Pulmonaria officinalis in several members of a family. We suspect that the lungwort infusion may have been contaminated with some other substance with atropinic properties (AU)

Low plasma cholesterol levels in suicidal males: a gender- and body mass index-matched case-control study of suicide attempters and nonattempters.

Findings from animal and human studies suggest an association between low cholesterol levels and suicidal behaviors. The purpose of this case-control study was to test whether cholesterol levels in suicide attempters are lower than in controls without suicide attempt history matched by gender, age, and body mass index (BMI). Suicide attempters (n=177: 68 men and 109 women) and controls (177 blood donors) were assessed. Serum cholesterol levels were significantly lower in suicide attempters than in controls. After gender stratification, the difference remained significant in men, but not in women.

Suicidal behavior in schizophrenia and depression: a comparison.

The aim of this study was to compare the frequencies and suicide attempt characteristics in patients with schizophrenia (N = 25) and major depression in absence of schizophrenia (N = 107). There were no significant differences in attempt methods, but attempters with schizophrenia reported a lower number of life events influencing the attempt (2.0 vs. 2.6), less influence of life events on the attempt (42% vs. 83%) and lower GAF scores (36 vs. 50). Schizophrenia was not associated with higher impulsivity scores but with significantly more lethal attempts (40% vs. 29%) and with a trend toward (p = 0.08) higher scores in aggressive behavior history.

Suicide attempts and impulsivity.

Impulsivity in suicidal behavior can describe the attempt (state) or the attempter (trait). There are no studies simultaneously measuring attempt impulsivity and attempter impulsivity in representative samples of suicide attempts. A one-year study of 278 suicide attempts in a general hospital tested the continuous versus dichotomous relationship between attempter impulsivity (Barratt Impulsiveness Scale) and attempt impulsivity (low scores in the planning subscale of Beck's Suicidal Intent Scale). Attempter impulsivity was not a good predictor of attempt impulsivity independently of how both dimensions were measured (continuous or dichotomous ways). Impulsive attempts were associated with low lethality and lack of depression. Opportunities for prevention of suicide attempts in major depression and some personality traits may exist but require attentive monitoring of suicidal ideation and intent.

Premenstrual symptoms and luteal suicide attempts.

OBJECTIVE: If premenstrual symptoms (PMS) are temporally and specifically associated with suicidal attempts, suicide attempts in women with PMS should occur more frequently in the luteal phase. METHOD: In a general hospital, 125 fertile female suicide attempters (and 83 blood donors as controls) with regular menstrual cycles were prospectively studied. A retrospective DSM-IV diagnosis of Premenstrual Dysphoric Disorder (PMDD) was made. RESULTS: Attempts during the luteal phase were not more frequent in females with PMDD (34%,23/68) than in those without PMDD (35%, 20/57). The sample had enough power to detect medium and large effect sizes. As expected, there was a significantly higher frequency of PMDD in suicide attempters than in the controls (54% vs 6%; Fisher's exact test, p < or = 0.001). CONCLUSION: This study was limited by the use of retrospective PMDD diagnosis but suggests that PMDD may not be associated with suicidal acts during the luteal phase,when PMS are present.

Variables associated with hospitalization decisions by emergency psychiatrists after a patient's suicide attempt.

OBJECTIVE: This study explored the factors psychiatrists considered in deciding on hospitalization for a large sample of suicide attempters in the emergency department of a general hospital in Madrid, Spain, between 1996 and 1998. METHODS: Psychiatrists assessed 509 patients who had attempted suicide; 196 of these (39 percent) were hospitalized in the psychiatric unit, and 313 (61 percent) were discharged from the emergency department. The assessment included Beck's Suicidal Intent Scale (SIS) and a checklist of 47 clinical variables. RESULTS: Of the 32 clinical variables significantly associated with hospitalization that were introduced in a logistic regression model, 11 remained significant. Six variables were associated with an increased odds of hospitalization: intention to repeat the attempt, plan to use a lethal method, low psychosocial functioning before the suicide attempt, previous psychiatric hospitalization, a suicide attempt in the past year, and planning that nobody would try to save their life after they had attempted suicide. Five variables decreased the odds: a realistic perspective on the future after the attempt, relief that the attempt was not effective, availability of a method to kill oneself (that was not used), belief that the attempt would influence others, and family support. Models based on the SIS total score and individual SIS items had lower specificity and sensitivity. CONCLUSIONS: Psychiatrists appear to rely on patients' self-report in deciding on hospitalization rather than focus on demographic, diagnostic, or psychosocial issues. If the findings of this study were replicated in other hospital settings, the implication would be that the guidelines for assessing suicide attempts need to encourage thorough and detailed assessment of the attempt and the future plans.

Lack of association between the serotonin transporter promoter gene polymorphism and impulsivity or aggressive behavior among suicide attempters and healthy volunteers.

The association between a polymorphism in the promoter area of the serotonin transporter (17q11.1-q12) with impulsivity and history of aggressive behavior was studied in a Spanish general hospital. Subjects comprised 216 suicide attempters (152 women and 64 men) and 223 control blood donors (124 women and 99 men). They were classified as S individuals (s/s or s/l) with low expression of the serotonin transporter, and L individuals (l/l) with high expression. The genotype was not associated with high levels of impulsivity (measured with the Barratt Impulsiveness Scale) or history of aggressive behavior (measured with the Brown-Goodwin scale). This lack of association did not appear to be explained by lack of statistical power. High scores on the Barratt Impulsiveness Scale (BIS) and the Brown-Goodwin Aggressive Behavior Scale were associated with being an attempter, male gender and borderline personality disorder. While our Spanish suicide attempters and published US suicide attempters have similar BIS scores, our Spanish suicide attempters have significantly lower aggressive behavior scores. If cross-cultural differences in aggressive behavior scores are definitively established, country norms for aggressive behavior scales will need to be developed to compare genetic studies in different countries.

Lack of association between polymorphic variations in the alpha 3 subunit GABA receptor gene (GABRA3) and suicide attempts.

This is the first case-control study exploring the association between suicide attempts and the polymorphic variations of the alpha 3 subunit gamma-aminobutyric acid (GABA) receptor gene (GABRA3) located in chromosome X. In a Spanish general hospital, 184 suicide attempters (127 women and 57 men) and 275 control blood donors (109 women and 166 men) were recruited. The four frequent variants (A1, A2, A3 and A4) of GABRA3 were studied. There were no significant differences in the total or by-gender frequencies of the four alleles. In females, there were no significant differences in the genotypes. This study can rule out even small size effects in the total sample and suggests a lack of association between GABRA3 polymorphism and suicide attempt, in the Spanish population.

Association between the menses and suicide attempts: a replication study.

OBJECTIVE: In our prior (first) study, suicide attempts were associated with the menses. The main hypothesis of this replication (second) study is that the proportion of suicide attempters during the menses is significantly higher than the expected probability in the general population. METHODS: Using the same methodology and setting, this replication naturalistic study included 120 fertile female suicide attempters with regular menstrual cycles during a 1-year period in the emergency room of a general hospital in Madrid, Spain, serving a catchment area of 500,000 people. RESULTS: The significant increase in probability of attempting suicide during the menses for the first study was 1.61; for the second study, 1.72; and for both studies combined, 1.68 (95% confidence interval, 1.27-2.09). Thus, using the combined results, the probability of attempting suicide during the menses was 1.68 times higher than the overall probability of attempting suicide for any fertile women. In the catchment area, the population rate of fertile women arriving at the hospital after a suicide attempt was 166 per 100,000. The probability for women during the menses arriving at the hospital after a suicide attempt was significantly higher, 279 per 100,000 (1.68 x 166 per 100,000). The 95% confidence interval was 211 to 347 per 100,000. CONCLUSIONS: Despite inherent limitations, this naturalistic study replicates a small but significant increase of suicide attempts during the menses.

A pilot study on a gene-hormone interaction in female suicide attempts.

This one-year naturalistic study included all suicide attempters in a catchment area. In the first published set of analyses, an association between menses and suicide attempts was replicated. According to the polymorphism of the serotonin transporter promoter area, the subjects can be classified as S individuals (s/s or s/l) or L individuals (l/l). In the second published set of analyses, L females appeared protected from suicide attempts since they were underrepresented among female (and not male) attempters. This new, unpublished third set of analyses tested for an interaction between the same polymorphism and low hormonal activity (during menses and menopause). In fertile female attempters, the proportion of L women in the menses (41%, 7/17) was significantly higher than expected in the population (15.5 %) and almost significantly higher than in S female attempters (22%,19/87). L females were also overrepresented in postmenopausal attempters. Despite sample size limitations, this gene-hormone interaction needs to be further investigated in female suicide attempters.

How safe are psychiatric medications after a voluntary overdose?

PURPOSE: This study assessed psychiatric medications and their potential lethality in a representative sample of suicide attempts. MATERIALS AND METHODS: During 1996-98, 563 suicide attempts were studied in a general hospital in Madrid (Spain). Medication overdose was used in 456 suicide attempts (81%). The ratio between dose taken and maximum prescription dose recommended was used to evaluate the medication toxicity. RESULTS: Benzodiazepines were the drugs most often used in self-poisoning (65% of overdoses), followed by new antidepressants (11%), tricyclic antidepressants (TCAs) (10%), and antipsychotics (8%). An overdose with any of the three latter psychiatric medications was significantly more frequent in patients prescribed those medications. The overdoses for TCA were potentially lethal in 47% of the cases. However, all patients who overdosed on psychiatric medications recovered well and were discharged without any sequelae. DISCUSSION: This study suggests that psychiatric medications, particularly benzodiazepines, new antidepressants and antipsychotics, are relatively safe when they are used for self-poisoning. If patients with mental illnesses are under treated, there is a clear and documented higher risk for suicide. CONCLUSION: It is better to prescribe psychiatric medications, particularly the new ones, rather than withhold them due to an exaggerated fear of a lethal overdose

A gender-specific association between the serotonin transporter gene and suicide attempts.

This pilot study tested the gender-specificity of the association between suicide attempts and a polymorphism in the promoter area of the serotonin transporter with two allelic variants, a long (1) variant and a short (s) variant. In a Spanish general hospital, 180 suicide attempters (121 women and 59 men) and 212 control blood donors (93 women and 119 men) were recruited. Subjects were classified as S individuals (s/s or s/l) with low expression of the serotonin transporter, and L individuals (l/l) with high expression. S individuals were significantly overrepresented (or L, underrepresented) in female attempters when compared with female controls and male attempters. Lethality appeared to have a significant influence on the effects of the genotype in suicide since S females were overrepresented among non-lethal female attempters. Further studies are needed to replicate that the serotonin genotype polymorphism may influence suicide attempts only in females.

Nuevas perspectivas en formación médica continuada: el empleo de las nuevas tecnologías de telecomunicaciones / New perspectives in Continous Medical Education (CME): use of new telecommunication technologies

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