Executive functioning in depressed patients with suicidal ideation.

OBJECTIVE: Suicidal thinking has been associated with cognitive rigidity, however, not all depressed patients contemplate suicide. Therefore, we hypothesized that compared with depressed subjects without suicidal ideation, depressed individuals with suicidal ideation would display poorer performance on measures of executive functioning that involve mental flexibility. METHOD: In-patients with a current major depressive episode who had no current suicidal ideation (n=28) were compared with those who had current suicidal ideation (n=5) on measures of executive functioning and two neurocognitive tests that predominantly assess non-frontal regions. RESULTS: Compared with non-suicidal depressed patients, depressed suicidal patients performed significantly worse on several measures of executive functioning after controlling for age, IQ, severity of depression and prior suicide attempts. The two groups performed similarly on tests that predominantly assess non-frontal regions. CONCLUSION: Depressed individuals contemplating suicide have cognitive rigidity, which does not appear to be a global brain dysfunction. Suicidal mental states may result from dysfunctional executive decision-making that is associated with the frontal lobe.

Gate questions in psychiatric interviewing: the case of suicide assessment.

Gate questions are commonly used to shorten structured interviews, by not probing negative responses with more detailed questions. This study quantified cases of aborted suicide attempts that would have been missed, if we had skipped detailed questions following a gate. To accomplish this, we interviewed a random sample of 135 adult psychiatric inpatients concerning their past suicidal behavior. Using our structured interview, subjects were asked a general question about aborted suicide attempts, and then asked method-specific questions regardless of their response to the general "gate" question. Of the seventy subjects who were found to have histories of aborted attempts, 44.3% answered "no" to the gate question. Comparing these "false negative" subjects to "true positives," who had answered "yes" to the gate question and reported bona fide aborted attempts yielded no significant associations with demographics, psychiatric diagnoses, or reported histories of actual suicide attempts. Thus, a large number of subjects with aborted attempts would have been missed if a negative response to the gate question had not been probed. Clinical and reasearch implications generally, as well as implications for suicide assessment, are discussed.

Childhood trauma as a correlate of lifetime opiate use in psychiatric patients.

Associations have been reported between childhood sexual and/or physical abuse and adult substance abuse in general. This study investigated the relationship between childhood abuse and opiate use in particular among 763 consecutively admitted psychiatric inpatients. Patients were interviewed about demographic information, alcohol and drug use, and history of interpersonal violence. Opiate users were 2.7 times more likely to have a history of childhood sexual and/or physical abuse than nonopiate users, after controlling for diagnostic and sociodemographic variables. Opiate use was higher among those reporting physical abuse alone (24.1%) or both physical and sexual abuse (27%) than among those reporting sexual abuse alone (8.8%). Implications of these findings are discussed.

Human immunodeficiency virus among trauma patients in New York City.

STUDY OBJECTIVE: To determine the HIV seroprevalence rates in relation to the demographic characteristics of victims, cause of death, and toxicology findings in a sample of victims of violence and accidents who presented to emergency departments before death. METHODS: This descriptive survey of a complete 3-year sample of homicides and accidents was conducted in 5 boroughs of New York City (population 7,322,564). Persons 15 years of age and older injured by intentional violence or accidents (excluding drug overdoses, falls from short heights, and suicides) who presented to hospitals, died, and were sent to the medical examiner were included. Standard methods were used to test plasma and serum samples for HIV and cocaine or its metabolite. Chi2 Tests compared HIV seroprevalence across groups according to demographic characteristics and toxicology findings. Logistic regression analysis was done for those variables found to be significant with chi2 tests. All statistical tests were conducted with 2-tailed alpha levels of .05. RESULTS: Among the 1,242 subjects in the sample, 90 (7.2%) had positive findings. Male patients (8%) had higher rates than female patients (3.4%). HIV rates were highest among patients 35 to 44 years of age (20.8%), followed by the 45- to 54-year age group (9.6%) and 25- to 34-year age group (8.1%). Victims of homicide (8.2%) and accidents other than motor vehicle crashes (10.5%) had higher rates than victims of motor vehicle crashes (4%). Patients with positive results for cocaine (16.3%) were more likely than those with negative result (5.8%) to be HIV positive. There were no statistically significant differences by race, except that no Asians were HIV positive. Logistic regression analysis found that only age and positive cocaine results, not sex and race, were related to increased risk of HIV infection. CONCLUSION: We found the rate of HIV infection among victims of fatal trauma was significant, especially in those with evidence of cocaine use. The HIV infection rate approximates the high end of the range of HIV rates found in studies before 1990. It further emphasizes the need for use of universal precautions in the care of trauma patients.

Ambient temperature and mortality from unintentional cocaine overdose.

CONTEXT: Hot weather taxes cardiovascular function and is associated with increased deaths from heart disease. Cocaine can cause hypertension, tachycardia, coronary vasospasm, arrhythmias, and increased core temperature. OBJECTIVE: To determine the association between mortality from cocaine overdose and hot weather. SETTING: New York, NY. DESIGN: Retrospective review of medical examiner cases from 1990 through 1995. SUBJECTS: All fatal unintentional cocaine overdoses from 1990 through 1992 (n = 1382) and all hyperthermia deaths of cocaine users (n = 10) were used to identify a maximum daily temperature threshold above which mortality from cocaine intoxication increased. The study population consisted of all fatal unintentional cocaine overdoses from 1993 through 1995 (n = 2008) and 4 contemporaneous comparison groups that included fatal unintentional opiate overdoses (n = 793), all other fatal unintentional overdoses (n = 85), and a subset of homicides (n = 4638) and fatalities from motor vehicle crashes (n = 815). MAIN OUTCOME MEASURES: The number of overdose deaths and the proportion of homicides and traffic fatalities with a positive cocaine toxicology test result on days with a maximum temperature above or below the temperature threshold. RESULTS: A threshold temperature of 31.1 degrees C (88 degrees F) was identified, above which the mean daily number of fatal cocaine overdoses increased steadily. On days with a maximum daily temperature of 31.1 degrees C (88 degrees F) or higher ("hot days"), the mean daily number of cocaine overdose deaths was 2.34 (SD = 1.68), which was 33% higher than the mean on days with a maximum temperature of less than 31.1 degrees C (88 degrees F) (mean = 1.76 [SD=1.37] (P<.001). In contrast, the mean number of opiate overdose deaths per day was 0.81 (SD = 0.94) on hot days and 0.71 (SD = 0.86) on other days (P=.28). For other drug overdose deaths, the mean number of deaths per day was 0.08 (SD = 0.28) on hot days and 0.08 (SD = 0.28) on other days (P=.69). Among homicides, the proportion with a positive cocaine toxicology test result was 18.9% on hot days and 19.5% on other days (P=.69), and among traffic fatalities, the proportions with positive cocaine toxicology test results were 9.5% on hot days and 10.3% on other days (P=.91). CONCLUSIONS: High ambient temperature is associated with a significant increase in mortality from cocaine overdose. Based on our comparison groups, the increase is not explained by changes in cocaine use among the general population. Although cocaine use is dangerous on all days, it appears to be even more dangerous on hot days.

Aborted suicide attempts: a new classification of suicidal behavior.

OBJECTIVE: With the goal of ultimately finding early suicide predictors, the authors undertook a study of aborted suicide attempts. They defined such an attempt as an event in which an individual comes close to attempting suicide but does not complete the act and thus sustains no injury. METHODS: The authors interviewed a random sample of 135 adult psychiatric inpatients concerning their past suicidal behavior. Using standardized scales, they assessed suicidal intent for aborted suicide attempts and actual suicide attempts, as well as degree of injury for actual attempts. RESULTS: Over half of the 135 subjects reported making at least one aborted suicide attempt. Aside from younger age, no demographic characteristics were associated with aborted attempts. Aborted attempts were reported more often in subjects with a diagnosis of borderline personality disorder than in subjects with other diagnoses. Intent scores for aborted attempts were comparable to those for actual suicide attempts. Subjects who had made an aborted attempt were nearly twice as likely to have made an actual suicide attempt as subjects with no aborted attempts. Among subjects with both aborted and actual attempts, the first aborted attempt preceded the first actual attempt approximately half the time. CONCLUSIONS: Aborted suicide attempts were reported commonly by psychiatric inpatients, had a similar level of intent as actual attempts, and were highly associated with actual attempts. Thus, clinicians should specifically ask patients about aborted attempts as a part of the suicide history. Further study is needed to examine the association between aborted suicide attempts and suicide.

HIV seroprevalence among suicide victims in New York City, 1991-1993.

OBJECTIVE: The authors sought to determine the HIV seroprevalence among suicide victims in New York City. METHOD: All suicides of city residents from 1991 through 1993 were studied. The crude proportion of all suicide victims who were HIV positive and the proportion adjusted to the age, gender, and racial/ethnic characteristics of the New York City population were determined. The demographically adjusted proportion was then contrasted with HIV seroprevalence estimates for the New York City general population. HIV-seropositive suicide victims were assessed for pathological findings suggestive of HIV-related illnesses. RESULTS: The crude proportion of all suicide victims who were HIV seropositive was 0.088, and the demographically adjusted proportion was 0.049. Over 90% of all HIV-positive suicide victims were aged 25 to 54 years, and almost 90% were men. Among black and Hispanic men aged 35 to 54 years who committed suicide, the proportion who were HIV seropositive was 0.252--the highest seropositive rate of any demographic group. More than two-thirds of HIV-seropositive suicide victims had no HIV-related pathology or AIDS-indicator conditions at autopsy. CONCLUSIONS: The demographically adjusted proportion of suicide victims who were HIV positive (approximately 0.038 to 0.059), contrasted with the HIV seroprevalence estimates for the New York City general population (approximately 0.014 to 0.032), the absence of HIV-related pathology among suicide victims, and the likelihood that many HIV-positive individuals had other risk factors for suicide, such as substance abuse, suggests that a positive HIV serostatus is associated, at most, with a modest elevation in suicide risk.

HIV seroprevalence rates among homicide victims in New York City: 1991-1993.

This study assessed HIV seroprevalence in homicide victims killed in New York City in 1991-1993, using data from the Office of Chief Medical Examiner. Among 5852 homicide victims there were 344 (5.9%) victims who were HIV positive. Females were just as likely as males to be HIV positive. For females, the highest rates were in the 25-34 year (11.7%) and 35-44 year (12.6%) age categories. For males the highest rates were in the 35-44 year (13.7%) and 45-54 year (11.5%) age categories. Other than there being no HIV positive Asian victims, there were no differences in HIV rates among racial/ethnic groups. The highest rates of HIV infection for homicide victims were among those using both opiates and cocaine (males: 23.0%; females: 27.3%). Women, not men, using cocaine alone had a high HIV positive rate (18.4%). Victims not using these drugs had rates of HIV around 2%. The authors believe that the high risk of HIV among homicide victims, may be due to the use of cocaine and associated risky use of needles and risky sex practices.

HIV infection among victims of accidental fatal drug overdoses in New York City.

AIMS: To determine the factors associated with HIV seroprevalence rates for victims of drug overdoses. DESIGN: Descriptive epidemiologic survey of a complete 3-year sample of accidental fatal drug overdoses. SETTING: New York City (population 7,322,564). PARTICIPANTS: All people over 15 years of age (n = 2159) who died of accidental fatal drug overdoses during 1991-93. MEASUREMENTS: Using medical examiner data and logistic regression analyses were conducted to examine the association between HIV seroprevalence and gender, race, age and type of drug overdose. FINDINGS: There were 646 (29.9%) victims who were HIV positive. Women (37.5%) were more likely than men (27.9%) to be HIV positive. African-Americans (39.4%) had a higher rate of HIV infection than Latinos (27.5%), whites (19.2%) or Asians (8.3%). Victims residing in communities with higher levels of poverty had higher rates of HIV infection but poverty did not account for the high rates of HIV infection among African-Americans. The highest rates of HIV infection were found among victims aged 35-44 years (38.8%) and 45-54 years (33.7%). Dying from an opiate overdose was associated with a 2.4 times increase in the likelihood of being HIV positive. CONCLUSION: If opiate abuse continues to rise in the United States, HIV infection will increase in the next few years. Women who abuse drugs participate in risky sexual practices and are more likely than men to develop HIV infection from receptive sex as well as sharing of needles. Harm reduction programs should address risky sex as well as needle programs. There should be further study of why African-Americans who died of drug overdoses have the highest rates of HIV infection.

Poverty and fatal accidental drug overdoses of cocaine and opiates in New York City: an ecological study.

This ecological study examines the association of the poverty status of urban communities in New York City with their mortality rates of accidental drug overdoses. Mean annual age-adjusted rates of drug overdoses involving cocaine, opiates, or both (n = 1,684) were calculated for each of 59 residential community districts in New York City for 1990-1992. A linear regression analysis was performed to test the association of the mortality rate with the poverty status of the district as measured by the proportion of the district living below the 1989 U.S. poverty line. Poverty status accounted for 69% of the variance in the drug overdose mortality rates of communities (p < .001). This study suggests that mortality rates of overdoses involving cocaine and optiates are significantly associated with the poverty status of communities in New York City.

A prospective study of violence by psychiatric patients after hospital discharge.

OBJECTIVE: The study assessed the frequency of violence by patients two weeks after discharge from a psychiatric hospital and identified characteristics of patients with an increased risk of violence after discharge. METHODS: A structured form was used to interview patients aged 18 to 59 years in a private university psychiatric hospital. Patients provided self-reports of past violence, and violence while in the hospital was assessed by routine nurse ratings. Patients were telephoned two weeks after discharge to assess violence since discharge. RESULTS: Sixteen of 430 patients who were interviewed by telephone two weeks after discharge reported violence against persons since their discharge. Patients who were violent in the month before admission were nine times more likely to be violent in the two weeks after discharge, compared with patients who were not violent just before admission. Patients with a personality disorder were four times more likely than patients without a personality disorder to be violent after discharge. The targets of violence were often family members or other intimates and often the same persons attacked before hospitalization. CONCLUSIONS: Patients who were violent just before admission were more likely to be violent after discharge and to attack the same persons they had attacked in the past. Clinicians should routinely evaluate past violence and work with the patient and potential targets of violence to prevent future violence.

Violence by patients admitted to a private psychiatric hospital.

OBJECTIVE: The authors determined the rates and patterns of violence toward persons by psychiatric patients before admission to the inpatient service of the Payne Whitney Clinic and determined which factors were associated with a greater risk of violence. METHOD: During hospitalization, 763 patients were interviewed by a research assistant using a structured interview instrument. The interviewer inquired about demographic and socioeconomic information and about history of violence and alcohol and drug use. RESULTS: Having physically attacked another person in the month before admission was equally likely among male (13.6%) and female (14.7%) patients. The patterns of violence were similar for men and women in terms of target, severity of injuries, use of a weapon, and place of occurrence. Univariate analyses showed that only youth was associated with violence for male patients, while youth, low socioeconomic status, substance abuse, and axis II pathology were associated with a greater risk of violence for female patients. Logistic regression analyses showed that recent cocaine use was significantly associated with violence by female patients when age, socioeconomic status, and axis II pathology were controlled for. For male patients, recent heroin use was related to a greater risk of violence. CONCLUSIONS: The frequency of violence by female patients was 150% higher than it was in a study at the Payne Whitney Clinic a decade ago. The frequency of violence by male patients was 50% higher than it was a decade ago. In the current study, substance abuse was associated with greater risk of violence by patients.

Lower risk of suicide during pregnancy.

OBJECTIVE: The authors determined the risk of suicide during pregnancy. METHOD: The autopsy reports of all female residents of New York City, 10-44 years old, who committed suicide from 1990 to 1993 were assessed for pregnancy. These data were compared with age-adjusted and race-adjusted standardized mortality ratios for women, which were calculated by using population data from the 1990 U.S. Census as well as data obtained from the New York City Health Department on the number of live births, spontaneous abortions, and induced abortions. RESULTS: The standardized mortality ratio for suicide during pregnancy was 0.33; that is, the number of suicides of pregnant women was only one-third of that expected. CONCLUSIONS: Despite the mood swings and stresses associated with pregnancy and impending childbirth, pregnant women have a significantly lower risk of suicide than women of childbearing age who are not pregnant.

The prevalence of aborted suicide attempts among psychiatric in-patients.

We report the prevalence of aborted suicide attempts in which the essential characteristics are (i) intent to kill oneself (ii) a change of mind before making an actual suicide attempt and (iii) the absence of physical injury. The lifetime history of aborted suicide attempts was assessed by semi-structured interview of 733 patients, aged 18-59 years, who were consecutively admitted to a psychiatric hospital. In the study group, 46% of subjects had made a suicide attempt and 29% had made at least one aborted attempt during their lifetime. Subjects who had made aborted attempts were more likely to have made actual attempts. Approximately 11% of the subjects in the study group had a history of aborted attempts of potential high lethality, such as going to a height in order to jump, or holding a gun to the head. There were no major demographic differences between those with and without a history of aborted attempts. However, among those with no prior history of actual attempts, subjects with depression and a family history of suicide were more than twice as likely as those without such a history to have made an aborted attempt. Aborted suicide attempts are a common suicidal behaviour among psychiatric in-patients. Whether they predict actual attempts or suicide warrants prospective investigation.

Introduction to the special section on the contribution of psychotherapy and pharmacotherapy research to national mental health care.

This special section represents a coordinated publication of the Journal of Consulting and Clinical Psychology and the Archives of General Psychiatry. These 2 journals have typically focused on somewhat different areas of research and have been read by different audiences. In an effort to achieve cross-fertilization of the disciplines of psychiatry and clinical psychology, this coordinated publication provides a current view of research both in psychopharmacology and psychotherapy as applied to major depression, anxiety disorders, alcohol abuse, and drug abuse. To further the aims of informing the diverse readership in areas to which they are often not exposed in the separate journals, the Journal of Consulting and Clinical Psychology is publishing in this section, articles that address biomedical and psychopharmacological research, and the Archives of General Psychiatry is publishing a coordinated set of articles on psychotherapy and behavior therapy. Collectively, the series contained in these 2 journals is designed both to foster knowledge and to enhance communication among psychiatrists and psychologists.