Clinical characteristics in schizophrenia patients with or without suicide attempts and non-suicidal self-harm--a cross-sectional study.

BACKGROUND: To investigate whether schizophrenia patients with both suicide attempts and non-suicidal self-harm have earlier age of onset of psychotic and depressive symptoms and higher levels of clinical symptoms compared to patients with only suicide attempts or without suicide attempt. METHODS: Using a cross-sectional design, 251 patients (18-61 years old, 58% men) with schizophrenia treated at hospitals in Oslo and Innlandet Hospital Trust, Norway, were assessed with a comprehensive clinical research protocol and divided into three groups based on their history of suicide attempts and non-suicidal self-harm. RESULTS: Suicide attempts were present in 88 patients (35%); 52 had suicide attempts only (29%) and 36 had both suicide attempts and non-suicidal self-harm (14%). When compared with nonattempters and those with suicide attempts without non-suicidal self-harm, patients with both suicide attempts and non-suicidal self-harm were more frequently women, younger at the onset of psychotic symptoms, had longer duration of untreated psychosis, and had higher levels of current impulsivity/aggression and depression. Patients with both suicide attempts and non-suicidal self-harm were more likely to repeat suicide attempts than patients with suicide attempts only. CONCLUSIONS: Patients with both suicide attempts and non-suicidal self-harm had different illness history and clinical characteristics compared to patients with only suicide attempts or patients without suicidal behavior. Our study suggests that patients with both suicide attempts and non-suicidal self-harm represent a distinct subgroup among patients with schizophrenia and suicidal behavior with their early onset of psychotic symptoms, high rate of repeated suicidal behavior and significant treatment delay.

Suicide attempts are associated with worse quality of life in patients with bipolar disorder type I.

BACKGROUND: The association between suicidal behavior and quality of life (QoL) in bipolar disorder (BD) is poorly understood. Worse QoL has been associated with suicide attempts and suicidal ideation in schizophrenic patients, but this relationship has not been investigated in BD. This study tested whether a history of suicide attempts was associated with poor QoL in a well-characterized sample of patients with BD, as has been observed in other psychiatric disorders and in the general population. METHODS: One hundred eight patients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BD type I (44 with previous suicide attempts, 64 without previous suicide attempts) were studied. Quality of life was assessed using the World Health Organization's Quality of Life Instrument-Short Version. Depressive and manic symptoms were assessed using the Hamilton Depression Rating Scale-17 items and the Young Mania Rating Scale. RESULTS: Patients with BD and previous suicide attempts had significantly lower scores in all the 4 domains of the World Health Organization's Quality of Life Instrument-Short Version scale than did patients with BD but no previous suicide attempts (physical domain P = .001; psychological domain P < .0001; social domain P = .001, and environmental domain P = .039). In the euthymic subgroup (n = 70), patients with previous suicide attempts had significantly lower scores only in the psychological and social domains (P = .020 and P = .004). LIMITATIONS: This was a cross-sectional study, and no causal associations can be assumed. CONCLUSIONS: Patients with BD and a history of previous suicide attempts seem to have a worse QoL than did patients who never attempted suicide. Poorer QoL might be a marker of poor copying skills and inadequate social support and be a risk factor for suicidal behavior in BD. Alternatively, poorer QoL and suicidal behavior might be different expressions of more severe BD.

Depression, aggression, and suicidal ideation in first graders: a school-based cross-sectional study.

OBJECTIVE: This study explored the clinical characteristics and risk factors of suicidal ideation in a sample of first graders from South Korea. Children's depression and aggression and maternal depression were examined as possible risk factors. METHODS: This study is a school-based, cross-sectional study of 5 elementary schools in Gunpo City, South Korea. Participants were 707 first graders (mean age, 6.54 years) and their mothers. We assessed children's depressive and aggressive symptoms using the Behavior Assessment System for Children-2 (BASC-2) and maternal depression using the Beck Depression Inventory (BDI). Two items from BASC-2 and 1 item from BDI identified children's and maternal suicidal ideation. RESULTS: Twenty-seven (3.8%) children evidenced suicidal ideation. Children with suicidal ideation had higher mean scores of depression domain (10.11 ± 5.34 vs 4.57 ± 3.44, P < .0001) and aggression domain (7.78 ± 3.84 vs 3.80 ± 2.85, P < .0001) on BASC-2 and maternal depression (9.78 ± 6.45 vs 7.28 ± 5.38, P = .02) on BDI. In regression analysis, children's depression (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.07-1.32; P = .001) and aggression (OR, 1.24; 95% CI, 1.08-1.41; P = .002) contributed significantly to children's suicidal ideation, whereas maternal depression was not significantly related to children's suicidal ideation (OR, 0.99; 95% CI, 0.92-1.06; P = .75). CONCLUSIONS: This study demonstrated that even first graders had a considerable prevalence of suicidal ideation and that depression and aggression were associated with suicidal ideation in young children.

Family history of affective illness in schizophrenia patients: symptoms and cognition.

This study examined the relationship between having a family history of affective disorder and neuropsychological functioning and PANSS symptoms in schizophrenia patients falling into four exclusive family history groups (affective spectrum disorders, schizophrenia spectrum disorders, both, or neither). Schizophrenia patients with a family history of affective illness had the best performance on IQ tests and executive function measures. Symptoms showed fewer family history group differences. Schizophrenia patients with a family history of affective disorder may be a distinct subtype in the group of schizophrenias and may be biologically more similar to patients with serious affective disorder.

Childhood trauma and prodromal symptoms among individuals at clinical high risk for psychosis.

INTRODUCTION: Numerous studies point to an association between childhood trauma and the later development of psychotic illness. However, little is known about the prevalence of childhood trauma and its relationship to attenuated positive and other symptoms in individuals at heightened clinical risk for psychosis. METHOD: Thirty clinical high-risk patients (83% male, 43% Caucasian, and with a mean age of 19) were ascertained from the New York metropolitan area and evaluated for prodromal and affective symptoms, and queried regarding experiences of childhood trauma and abuse. RESULTS: Ninety-seven percent endorsed at least one general trauma experience, 83% reported physical abuse, 67% emotional abuse, and 27% sexual abuse. As hypothesized, total trauma exposure was positively associated with severity of attenuated positive symptoms (in particular grandiosity), an effect primarily accounted for by ethnic minority participants, who reported greater exposure to trauma. Trauma exposure was related to affective symptoms only in the Caucasian subgroup. CONCLUSIONS: Childhood trauma was commonly self-reported, especially among clinical high-risk patients from ethnic minorities, for whom trauma was related to positive symptoms. Future areas of research include an evaluation of potential mechanisms for this relationship, including neuroendocrine and subcortical dopaminergic function.

Suicidal behavior in schizophrenia: a test of the demoralization hypothesis.

This study examined Drake's model that individuals with schizophrenia with good premorbid adjustment and insight into their illness are more vulnerable to becoming demoralized and therefore suicidal. One hundred sixty-four patients with schizophrenia (N = 115) or schizoaffective disorder (N = 49) were assessed for depressive symptoms and DSM-III-R depression, premorbid functioning, insight and suicidal behavior using The Diagnostic Interview for Genetic Studies and the Premorbid Adjustment Scale. Premorbid adjustment, insight and past MDE did not discriminate attempters from nonattempters, contrary to the model. However, consistent with the model, the interaction between good premorbid adjustment and insight predicted severity of depressive symptoms, and the psychological symptoms of depression significantly differentiated attempters from nonattempters, whereas the somatic symptoms did not. This study provides support for some aspects of the demoralization model.

Are BPI and BPII suicide attempters distinct neuropsychologically?

UNLABELLED: It is not clear if bipolar disorder I (BPI) and bipolar disorder II (BPII) represent the same disorder on a continuum of severity or two distinct syndromes. Neuropsychological functioning is a means of understanding similarities and differences between diagnostic groups. OBJECTIVE: To compare the neuropsychological functioning of depressed suicide attempters with BPI or BPII and healthy controls. METHODS: Fifty-one individuals with bipolar disorder (BPI n=32, BPII n=19) and a history of suicide attempt were compared with 58 healthy controls with respect to neuropsychological functioning in the following domains: motor functioning, psychomotor performance, attention, memory, working memory, impulsiveness and language fluency. RESULTS: Participants with BPI and BPII performed significantly more poorly than healthy controls on tests of Digit Symbol Test of psychomotor functioning, the N Back Test of working memory and the Go-No-Go Test of impulsiveness. Participants with BPI were significantly worse than controls but not those with BPII on the Test of Verbal Fluency. Participants with BPII performed significantly worse than either controls or those with BPI on the Simple Reaction Time Motor Test and the Stroop Test of attention. CONCLUSION: While participants with both BPI and BPII performed more poorly than healthy controls, individuals with BPII also performed more poorly than those with BPI on some tests suggesting that they may have a unique syndrome. The findings have implications for assessment and treatment in bipolar disorder.

Association of serotonin 5-HT2A receptor binding and the T102C polymorphism in depressed and healthy Caucasian subjects.

Serotonin 5-HT2A receptor (5-HT2A) binding is reported to be altered in individuals with suicidal behavior, mood disorders, and aggressive-impulsive traits. Genetic association with major depression, suicidal behavior, and aggressive-impulsive traits has not been established. This study examines the possible association of the 5-HT2A gene C102T polymorphism with the receptor binding kinetics, and clinical overt phenotypes. The study population included 63 healthy volunteers and 152 subjects with mood disorders, 56 of whom had a history of suicide attempts. All were Caucasian. Platelet 5-HT2A binding kinetics (Bmax and KD) were assayed and adjusted for seasonal variation. All subjects were genotyped for the T102C polymorphism. Clinical phenotype was determined by structured clinical interview. The TT genotype was associated with higher Bmax in all subjects (F=3.53, df=2,211; p=0.03), controlling for diagnosis. Bonferroni-adjusted post hoc testing showed higher binding in the TT compared with TC genotype in the control group (F=7.56, df=2,60, p=0.001), but not in the mood-disordered subjects. No difference was found in genotype and allele distribution between the mood-disordered subjects, with and without suicide attempt history, and controls. Bmax was not related to a diagnosis of mood disorders. The TT genotype appears associated with higher platelet 5-HT2A Bmax in the healthy population, but this genotypic effect appears absent in mood disorders and unrelated to psychopathology.

Suicide attempts in schizophrenia: the role of command auditory hallucinations for suicide.

BACKGROUND: We examined the presence of command auditory hallucinations for suicide (CAHS) in a sample of individuals with schizophrenia or schizoaffective disorder. We examined the relationship between CAHS and demographic and clinical variables. We also investigated the relationship between CAHS and suicide attempts. METHOD: 100 individuals with DSM-IV schizophrenia or schizoaffective disorder hospitalized on an inpatient research unit participated. Information was gathered using the Diagnostic Interview for Genetic Studies and the Harkavy Asnis Suicide Scale. Data were gathered from 1995 to 2001. RESULTS: CAHS were frequent in this sample (22%), as were suicide attempts (33%). Eight percent of the entire sample (36% of those who experienced CAHS) made at least 1 suicide attempt in response to the hallucinations. The presence of CAHS was not related to demographic or clinical measures assessed. The frequency of CAHS was not statistically different for suicide attempters (30%) and nonattempters (18%). However, 80% (8/10) of attempters with CAHS reported at least 1 attempt in response to CAHS. Three of 6 repeat attempters who made at least 1 suicide attempt in response to CAHS also made other attempts that were not in response to CAHS. The presence of CAHS was not associated with a history of depression or substance abuse/dependence. CONCLUSION: The presence of CAHS does not directly predict suicide attempts. However, individuals who are already at risk for suicidal behavior (e.g., past attempters) may be at increased risk for a suicide attempt when experiencing CAHS.

Visual backward-masking deficits in schizophrenia: relationship to visual pathway function and symptomatology.

Patients with schizophrenia have information processing deficits which can be measured using visual backward-masking (VBM) tasks. There are two types of visual pathways: transient and sustained. The former is more sensitive to low spatial frequency (LSF) and the latter to high spatial frequency (HSF) stimuli. It has been hypothesized that the VBM deficit in schizophrenia is due to an overactive transient channel response to the mask. To examine this hypothesis, patients with schizophrenia and comparison volunteers were tested on a traditional backward-masking task as well as on tasks that altered the mask to bias stimulation toward transient (LSF) or sustained (HSF) channels. Medication effects and relationship to symptomatology were also examined. Patients with schizophrenia showed a significant deficit on the traditional backward-masking task and were also significantly impaired on the LSF- and HSF-masking tasks, though a differential deficit was not found on the latter two tasks. A U-shaped function, indicative of masking by interruption, was found on the LSF- and HSF-masking tasks. Masking performance was not altered when the same patients were tested on and off medication, and performance was related to positive and negative symptoms. In conclusion, the finding of a deficit in patients with schizophrenia on tasks producing a U-shaped function suggests that an aberrant transient response to the mask is producing increased interruption of the sustained response to the target.

Suicidal behavior in schizophrenia and schizoaffective disorder: examining the role of depression.

Understanding the relationship between depression and suicidal behavior among individuals with schizophrenia and schizoaffective disorder can aid assessment and treatment. In this study, 86 individuals with schizophrenia and schizoaffective disorder were assessed for past and current suicidal behavior, depression, hopelessness, and reasons for living. Thirty-four percent reported a history of suicide attempts. Suicidal behavior typically occurred 4.5 years after the onset of psychosis and 7.5 years after the onset of the first major depressive episode for those who had a history of major depression. Depression was frequent among both attempters and non-attempters, but only half of the attempters reported a suicide attempt during an episode of major depression. And almost half of those with depression never made a suicide attempt despite a long history of illness. Although depression is a potential stressor for triggering suicidal behavior in a vulnerable subset of individuals with schizophrenia, schizophrenia research must identify other risk factors for suicidal behavior. Clinicians should remember that even without a depressive episode there is still a significant risk for suicidal behavior in schizophrenia.

Assessing depression in youth at clinical high risk for psychosis: a comparison of three measures.

Depressive symptoms are prevalent among individuals at clinical high-risk (CHR) for psychosis. Prior studies have used the Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HDRS), and the "dysphoric mood" item of the Scale of Prodromal Symptoms (SOPS) to assess depressive symptoms in CHR samples. We compared the psychometric properties of these instruments in a CHR cohort, to support the selection of appropriate depressive symptoms measures in future studies and in clinical settings. Internal consistency was assessed using Cronbach's alpha. Construct validity was assessed through correlations with SOPS items that were expected or not expected to be related to depressive symptoms. Criterion validity was assessed by comparing scores between patients with and without a major depressive disorder diagnosis. We hypothesized based on the schizophrenia literature that the BDI would have superior internal consistency and discriminant validity compared to the HDRS, and that all three measures would show convergent validity and criterion validity. The BDI demonstrated superior internal consistency and construct validity in this at-risk sample. The BDI and HDRS differentiated patients with major depressive disorder, but SOPS dysphoria did not. This has implications for the choice of depression measures in future CHR studies and for the interpretation of past findings.

Catatonic schizophrenia: a cohort prospective study.

BACKGROUND: In the 20th century, catatonia was usually deemed a subtype of schizophrenia. Recently, the nature and classification of catatonia are being reconsidered. This study is the first to describe catatonia using prospectively collected data and to examine how catatonic schizophrenia differs from, or resembles, other types of schizophrenia. METHODS: Data were analyzed in a cohort of 90,079 offspring followed from birth till ages 29-41 years. Proportional hazards models were used, calculating time to first psychiatric hospital admission, to compare risk factors for catatonic schizophrenia vs "other schizophrenia." RESULTS: Of 568 cases of schizophrenia, 43 (7.6%) had catatonic schizophrenia. The sexes were equally at risk for catatonic schizophrenia in contrast to other schizophrenia, for which the incidence was higher in males (1.70, 1.42-2.03, P < .0001). Advancing paternal age had no influence on the risk of catatonic schizophrenia in contrast to other schizophrenia, in which the risk to offspring of fathers age 35+ was 1.27 (1.03-1.57, P = .03) compared with those of younger fathers. Those with catatonic schizophrenia were somewhat more likely to have older mothers (aged 35+) (relative risk = 2.14, 0.85-5.54) while maternal age was not related to other schizophrenia. Both were equally affected by parental history of schizophrenia. Patients with catatonia were significantly more likely to attempt suicide (P = .006). CONCLUSION: Patients with catatonic schizophrenia show a somewhat different profile of risk factors from those with other types of schizophrenia in this cohort and are more likely to attempt suicide. This lends some support to the hypothesis that catatonic schizophrenia may have a distinct etiology.

Obsessive compulsive symptoms in individuals at clinical risk for psychosis: association with depressive symptoms and suicidal ideation.

Obsessive-compulsive symptoms, particularly aggressive obsessions, are prevalent in schizophrenia patients and associated with other symptom severity, suicidal ideation and functional impairment. In a psychosis-risk cohort, obsessive-compulsive diagnosis and symptoms were assessed in terms of prevalence and content, and for associations with clinical measures. Obsessive-compulsive symptoms were prevalent in the CHR cohort, as was suicidal ideation. The presence and severity of aggressive obsessions were associated with depression, suicidal ideation and social impairment. The high prevalence of aggressive obsessions and associated suicidal ideation in a clinical high risk cohort, and their relationship to depression, is relevant for risk assessment and treatment strategies.

Self-harm in patients with schizophrenia spectrum disorders.

This study describes the prevalence, clinical characteristics, and gender profile of self-harm in a cross-sectional sample of 388 patients with schizophrenia spectrum disorders. All patients were interviewed and assessed with respect to lifetime self-harm and relevant clinical variables. An overall of 49% of the patients reported self-harm which was associated with female gender, having had a depressive episode, younger age at psychosis onset, alcohol abuse or dependence, current suicidality, awareness of illness, and low adherence to prescribed medication. Higher awareness of having a mental disorder was associated with self-harm in men only, while emotional dysregulation was associated with self-harm in women only. We conclude that while self-harm in patients with schizophrenia spectrum disorders is highly prevalent in both genders, risk factors in men and women differ in several important ways.

A neurophysiological deficit in early visual processing in schizophrenia patients with auditory hallucinations.

Existing 67-channel event-related potentials, obtained during recognition and working memory paradigms with words or faces, were used to examine early visual processing in schizophrenia patients prone to auditory hallucinations (AH, n = 26) or not (NH, n = 49) and healthy controls (HC, n = 46). Current source density (CSD) transforms revealed distinct, strongly left- (words) or right-lateralized (faces; N170) inferior-temporal N1 sinks (150 ms) in each group. N1 was quantified by temporal PCA of peak-adjusted CSDs. For words and faces in both paradigms, N1 was substantially reduced in AH compared with NH and HC, who did not differ from each other. The difference in N1 between AH and NH was not due to overall symptom severity or performance accuracy, with both groups showing comparable memory deficits. Our findings extend prior reports of reduced auditory N1 in AH, suggesting a broader early perceptual integration deficit that is not limited to the auditory modality.

Predictors of treatment utilization in major depression.

Suicide attempters with major depression are at risk for repeat attempts and often do not utilize treatment. Identifying predictors of treatment non-utilization could inform interventions to motivate treatment use and reduce suicide risk in major depression. Two hundred and seventy three participants with a major depressive episode as part of a major depressive disorder or bipolar disorder, were assessed for socio-demographic and clinical characteristics at baseline and again 1 year later to identify predictors of treatment utilization. Treatment utilization rate was high 1 year after initial evaluation (72.5%). Severity of baseline depression, baseline treatment status, and education were associated with treatment utilization at 1 year. Interventions focused on increasing knowledge about depression and treatment efficacy may improve treatment adherence when treating depression.

Mental health and extracurricular education in Korean first graders: a school-based cross-sectional study.

OBJECTIVE: This study explores the results of mental health screening in Korean first graders in association with the amount of time the children spent in extracurricular education. METHOD: The study included a community sample of 761 boys and girls, with a mean age of 6.6 years, collected from 5 elementary schools in Gunpo-si, South Korea, in July 2007. Primary caregivers completed a questionnaire that included information on demographic characteristics, the amount of time the children spent in extracurricular education and other activities, and an adapted form of the Behavior Assessment System for Children, Second Edition (BASC-2) to screen for mental health problems. RESULTS: These first graders spent a mean of a little over 2 hours each day in extracurricular education. Extracurricular education demonstrated positive correlations with 4 BASC-2 domains, including hyperactivity (r = 0.092, P < .05), aggression (r = 0.073, P < .05), conduct problems (r = 0.073, P < .05) and depression (r = 0.137, P < .01). A positive linear relationship between depression and extracurricular education was also evident in regression analyses (F = 2.25, R(2) = 0.022, P = .001). The relationship held true even when controlling for time spent with parents, time spent with friends, and time spent asleep. Post hoc analyses revealed that children receiving more than 4 hours of extracurricular education per day showed a sharp increase in depressive symptoms as well as a decrease in the amount of time spent with caregivers. CONCLUSIONS: Results of this study demonstrate that excessive amounts of time spent in extracurricular education (greater than 4 hours per day) may be associated with depression in school-aged children. These findings have relevance for mental health screening and educational policy.

Heterogeneity of auditory verbal working memory in schizophrenia.

The heterogeneity of schizophrenia remains an obstacle for understanding its pathophysiology. Studies using a tone discrimination screening test to classify patients have found evidence for 2 subgroups having either a specific deficit in verbal working memory (WM) or deficits in both verbal and nonverbal memory. This study aimed to (a) replicate in larger samples differences between these subgroups in auditory verbal WM; (b) evaluate their performance on tests of explicit memory and sustained attention; (c) determine the relation of verbal WM deficits to auditory hallucinations and other symptoms; and (d) examine medication effects. The verbal WM and tone discrimination performance did not differ between medicated (n = 45) and unmedicated (n = 38) patients. Patients with schizophrenia who passed the tone screening test (discriminators; n = 60) were compared with those who did not (nondiscriminators; n = 23) and healthy controls (n = 47). The discriminator subgroup showed poorer verbal WM than did controls and a deficit in verbal but not visual memory on the Wechsler Memory Scale-Revised (Wechsler, 1987), whereas the nondiscriminator subgroup showed overall poorer performance on both verbal and nonverbal tests and a marked deficit in sustained attention. Verbal WM deficits in discriminators were correlated with auditory hallucinations but not with negative symptoms. The results are consistent with a verbal memory deficit in a subgroup of schizophrenia having intact auditory perception, which may stem from dysfunction of language-related cortical regions, and a more generalized cognitive deficit in a subgroup having auditory perceptual and attentional dysfunction.