Did manic-depressive patients who committed suicide receive prophylactic or continuation treatment at the time?

Ninety-two Danish manic-depressive patients with a first psychiatric admission between 1969 and 1983, who committed suicide before 1 July 1986, were considered. Information on any prophylactic or continuation treatment at the time of the suicide was obtained. In 64 of the patients, every precaution seems to have been taken: 28 patients committed suicide during ongoing treatment; 10 while not receiving prophylactic treatment (not indicated); 7 while not in prophylactic treatment because the patients refused or did not tolerate such; and 19 while in prophylactic treatment with antidepressants (10), or lithium (6), or both (3), in usually adequate dosage. In 28 of the patients, suicide might have been obviated. Guidelines for improvement of suicide prevention in manic-depressive illness are presented.

Cardiovascular death and manic-depressive psychosis.

In order to study if tricyclic antidepressant drugs (TCA) in therapeutic doses increase the risk of death due to cardiovascular causes, the relative mortality from cardiovascular diseases was studied in two large groups of first hospitalized manic-depressive patients, one from the TCA era, the other from the period just before the introduction of TCA. Both groups were selected from the Danish Psychiatric Central Register and followed for an average of 4.5 years. Among 2662 manic-depressive men hospitalized between 1969 and 1976, the relative cardiovascular mortality was 1.53 compared to the general population. Among 1133 such cases admitted between 1950 and 1956, the rate was 1.87. Our findings do not support the hypothesis that TCA contribute to the cardiovascular mortality in manic-depressives and even support suggestions that TCA treatment may lower the risk of death by cardiovascular disease, suicide, and other non-cancer causes.

Excess mortality of bipolar and unipolar manic-depressive patients.

To compare mortality in bipolar and unipolar manic-depressive patients, 2168 manic-depressive first admissions reported to the Danish Psychiatric Central Register were divided into a bipolar group (19%), i.e., patients with at least one admission for mania during an average observation period of six years, and a unipolar group. When compared with the general population, the total group had an increased mortality by suicide and accidents in both sexes and by non-violent causes in men. The bipolar group had a higher non-violent mortality than the unipolar group, but the violent mortality was not different. Statistical problems introduced by patients switching from the unipolar to the bipolar group during the period of observation are discussed.

Admission pattern and diagnostic stability among unipolar and bipolar manic-depressive patients.

The instability of the diagnoses in a psychiatric register causes practical problems when groups of probands with specific diagnoses are selected for further studies. A cohort of 3,062 first admissions with at least one manic-depressive admission was followed for 5-7 years. 623 had at least one admission for mania and were considered bipolar. The percentage of patients who changed their diagnoses was highest at first readmission; at each later readmission about 10% of the bipolars and 25% of the unipolars changed from manic-depressive psychosis and a similar number changed from other diagnoses to manic-depressive psychosis. Compared with the diagnostic distribution of all register cases, reactive psychoses were more frequent than expected as former diagnoses and schizophrenia as later diagnosis. Neuroses and character deviations were frequent alternative diagnoses among unipolars, not among bipolars. The consequences of different selection criteria for the composition of proband groups are discussed.

The 24-hour pattern of serum TSH in patients with endogenous depression.

The 24-h pattern of serum thyrotropin (TSH) has been studied using hourly blood-sampling in four patients with severe endogenous depression. All patients showed a pattern similar to that of normal subjects, with lowest levels of serum TSH between 0900 and 2000 h and highest levels between 2100 and 0800 h. A phaseshift of the TSH rhythm can therefore not account for our previous finding of a significant negative correlation between severity of endogenous depression and night increase in serum TSH measured as the difference between the values at 2400 and 1400 h.

Long-stay patients in Danish psychiatric hospitals.

The numbers of long-stay patients in Danish psychiatric hospitals were studied, based on information from the Danish cumulative psychiatric register and from the census studies of patients in Danish psychiatric hospitals, performed at 5-year intervals since 1957. In 1977, 2079 (20%) of the in-patient population which had been admitted before 1957 were still in hospitals. This 'old long-stay' group has diminished exponentially, with an annual reduction of 7%. During the period 1972--6, the number of patients who, on any given day, had been in-patients or attending as day-patients for more than 1 but less than 2 years (the 'new long-stay') varied between 847 and 1089: an average of 20 per 100 000 total population. The ratio of in-patients to day-patients was approximately 4:1. Based on the decline of the 1972 cohort during the period 1972--7, and assuming a constant 'influx' of new long-stay patients and a constant exponential decline of the cohorts, the number of new long-stay patients, including day-patients, at equilibrium was estimated to be about 4300 or 85 per 100 000 total population. About 31% will be schizophrenics and about 43% will be patients with organic disorders. Ninety-four per cent of the number at equilibrium will be reached after 16 years for the diagnostic group with the slowest decline, schizophrenia. On 1 April 1976, 3106 long-stay patients were present, accumulated since 1 April 1972. Nineteen per cent of these patients were in day-hospitals. This type of institution was used especially for younger patients with schizophrenia and reactive disorders.

Disturbed circadian variation of serum thyrotropin in patients with endogenous depression.

The relationship between the degree of depression and the circadian variation of serum TSH, T3 and T4 was investigated in 19 endogenously depressed patients. The difference between the hormone concentrations at 2 p.m. and at 12 p.m. was taken as an estimate of the magnitude of circadian variation. It was found that the circadian variation in serum TSH was inversely related to the degree of endogenous depression. This was mainly due to a diminution or absence of the night increase of TSH in severely depressed patients. A circadian variation of serum free T3 was found in the less depressed patients whereas no diurnal change was found in serum free T4. In severely depressed patients there were no significant diurnal changes in free thyroid hormone concentrations. The results indicate a hypothalamic dysfunction in manic-depressive psychosis.

Fifteen years later. A comparison of patients in Danish psychiatric institutions in 1957, 1962, 1967, and 1972.

The census study in 1972, including all Danish psychiatric institutions, was the fourth in a series, the first being performed in 1957. In the 15-year period from 1957 to 1972 the total number of hospitalized psychiatric patients, including day-patients, has been almost unchanged, about 240-260 per 100,000 population. There have, however, been marked changes within the resident population. The hospital prevalence of schizophrenia has gradually decreased from 132 to 97 per 100,000 males and from 140 to 86 per 100,000 females. The decrease concerns all age groups over 35 years and is especially pronounced in females aged 35-54. In young males there has been a remarkable increase during the last 5-year period. In 1957 the schizophrenic patients constituted 62% of the male and 57% of the female patients, compared with 43% and 30%, respectively, of the patients in 1972. The downward trend which was practically linear during the first two 5-year periods slowed down during the third period but was still quite marked for the middle-aged and old groups. The patients with organic disorders (especially senile and cerebrovascular psychoses) and with reactive conditions have increased in absolute numbers as well as in rates per 100,000 population.

Incidence of depressive syndromes in a Danish county. The Aarhus County investigation.

On the basis of a material from a cumulative registration of the psychiatric morbidity in a geographically delimited population group - the County of Aarhus with approximately 175,000 inhabitants over the age of 15 years - the frequency of depressive syndromes in psychiatric and other medical services was investigated. The material fulfils the following criteria: During the calendar years 1960 to 1964, the patients 1) were residents in the County of Aarhus, 2) had attained the age of 15 years or more, 3) had contacted at least one of the services which systematically sent information to the psychiatric register; and 4) based on an evaluation of all available data, had a main diagnosis of manic-depressive psychosis, psychogenic depression or neurotic depression. An average yearly registration rate of 1.30 per 1,000 men and 3.28 per 1,000 women was found (males: manic-depressive psychosis 0.60, psychogenic depression 0.23 and neurotic depression 0.47; females: manic-depressive psychosis 1.00, psychogenic depression 0.88 and neurotic depression 1.40). The three diagnostic groups show differences in age distribution, geographical pattern and distribution by marital status.