Effectiveness of a nationwide aftercare program for suicide attempters.

BACKGROUND: The effectiveness of large-scale interventions to prevent suicide among persons who previously attempted suicide remains to be determined. The National Suicide Surveillance System (NSSS), launched in Taiwan in 2006, is a structured nationwide intervention program for people who survived their suicide attempts. This naturalistic study examined its effectiveness using data from the first 3 years of its operation. Method Effectiveness of the NSSS aftercare services was examined using a logistic/proportional odds mixture model, with eventual suicide as the outcome of interest. As well, we examined time until death for those who died and factors associated with eventual suicide. RESULTS: Receipt of aftercare services was associated with reduced risk for subsequent suicide; for service recipients who eventually killed themselves, there was a prolonged duration between the index and fatal attempts. Elderly attempters were particularly prone to a shorter duration between the index and fatal attempts. Male gender, the lethality potential of the index attempt, and a history of having had a mental disorder also were associated with higher risk. CONCLUSIONS: The structured aftercare program of the NSSS appears to decrease suicides and to delay time to death for those who remained susceptible to suicide.

Predicting self- and other-directed violence among discharged psychiatric patients: the roles of anger and psychopathic traits.

BACKGROUND: We examined the extent to which trait anger and psychopathic traits predicted post-discharge self-directed violence (SDV) and other-directed violence (ODV) among psychiatric patients. METHOD: Participants were 851 psychiatric patients sampled from in-patient hospitals for the MacArthur Violence Risk Assessment Study (MVRAS). Participants were administered baseline interviews at the hospital and five follow-up interviews in the community at approximately 10-week intervals. Psychopathy and trait anger were assessed with the Psychopathy Checklist: Screening Version (PSC:SV) and the Novaco Anger Scale (NAS) respectively. SDV was assessed during follow-ups with participants and ODV was assessed during interviews with participants and collateral informants. Psychopathy facets and anger were entered in logistic regression models to predict membership in one of four groups indicating violence status during follow-up: (1) SDV, (2) ODV, (3) co-occurring violence (COV), and (4) no violence. RESULTS: Anger predicted membership in all three violence groups relative to a non-violent reference group. In unadjusted models, all psychopathy facets predicted ODV and COV during follow-up. In adjusted models, interpersonal and antisocial traits of psychopathy predicted membership in the ODV group whereas only antisocial traits predicted membership in the COV group. CONCLUSIONS: Although our results provide evidence for a broad role for trait anger in predicting SDV and ODV among discharged psychiatric patients, they suggest that unique patterns of psychopathic traits differentially predict violence toward self and others. The measurement of anger and facets of psychopathy during discharge planning for psychiatric patients may provide clinicians with information regarding risk for specific types of violence.

Suicidal thoughts and behaviors in older adults in rural China: a preliminary study.

BACKGROUND: One purpose of this study was to examine the feasibility of conducting epidemiological survey on suicidal thoughts and behaviors (hereafter "suicidal thoughts/behaviors"; i.e., any suicidal ideation, serious ideation, planning, and attempts) among older adults in rural China. Another purpose was to investigate among older people in rural China the prevalence of suicidal thoughts/behaviors, as well as their sociodemographic and clinical correlates. METHODS: A randomly selected sample of 263 subjects, 50 years or older, was recruited in a remote rural area of Southwestern China (Mianyang Region, Sichuan Province) and interviewed using structured instruments. Basic sociodemographic and clinical data were collected. RESULTS: There was no refusal among approached subjects, and subjects were willing to answer questions on suicidal thoughts/behaviors. The lifetime prevalence of suicidal ideation, serious ideation, planning, and attempt was 28.9% (23.4%-34.4%), 19.7% (14.9%-24.6%), 11.4% (7.5%-15.3%), and 5.3% (2.6%-8.1%), respectively. The corresponding 12-month prevalence was 8.8% (5.3%-12.2%), 5.3% (2.6%-8.1%), 2.7% (0.7%-4.6%), and 0%, respectively. The 2-week prevalence was 3.4% (1.2%-5.6%), 2.3% (0.5%-4.1%), 2.3% (0.5%-4.1%), and 0%, respectively. Correlates of suicidal thoughts/behaviors of this group are similar to findings from other community studies, such as female gender, unmarried status, major medical conditions, insomnia, financial difficulties and lower education, depressive symptoms, recent stressful life events, greater life dissatisfaction. CONCLUSIONS: Our findings suggest that larger scale epidemiological survey of suicidal thoughts/behaviors on older adults in rural China would be feasible. Suicidal thoughts/behaviors are common among older people in rural China, as seen in this preliminary study, which points to the need for further larger scale investigations.

Pseudodementia. Current concepts and future directions.

The literature describing pseudodementia was reviewed and a definition for this neuropsychiatric syndrome is formulated. It is defined as an intellectual impairment in patients with a primary psychiatric disorder, in which the features of intellectual abnormality resemble, at least in part, those of a neuropathologically induced cognitive deficit. This neuropsychological impairment is reversible, and there is no apparent primary neuropathological process that leads to the genesis of this disturbance. Data from published reports and preliminary findings presented here suggest that intellectual impairment of patients with pseudodementia resembles subcortical dementia in many of its features.

Huntington's dementia. Clinical and neuropsychological features.

The neuropsychiatric syndrome of Huntington's disease is outlined in this report with an emphasis on the cognitive deficits that lend themselves to future neurobehavioral research. Eighteen patients without disabling cognitive or psychiatric symptoms were evaluated for a period of 3 to 15 weeks, with assessment of their cognitive disorder, psychiatric, and neurological symptoms. Neuropsychological examination included repeated mental status examination, the Wechsler Adult Intelligence Scale (WAIS), and, for some, parietal lobe testing. In addition to suffering from a loss of finely detailed memories, patients demonstrated impaired organizing, sequencing, planning, and recalling of information on request. On the WAIS, mean verbal and performance scores were not significantly different. Neuropsychological findings suggested that the Huntington's disease pattern of cognitive impairment is not initially diffuse and homogeneous, but characterized by a relative sparing of several higher cortical functions. Many patients had increased irritability and labile affect. The similarity of Huntington's disease to frontal lobe syndromes is also discussed.

Screening for depression in elderly primary care patients. A comparison of the Center for Epidemiologic Studies-Depression Scale and the Geriatric Depression Scale.

BACKGROUND: Later-life depressive disorders are a major public health problem in primary care settings. A validated screening instrument might aid in the recognition of depression. However, available findings from younger patients may not generalize to older persons, and existing studies of screening instruments in older patient samples have suffered substantial methodological limitations. METHODS: One hundred thirty patients 60 years or older attending 3 primary care internists' practices participated in the study. Two screening scales were used: the Center for Epidemiologic Studies-Depression Scale (CES-D) and the Geriatric Depression Scale (GDS). The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. Third Edition, Revised, was used to establish "gold standard" diagnoses including major and minor depressive disorders. Receiver operating curve analysis was used to determine each scale's operating characteristics. RESULTS: Both the CES-D and the GDS had excellent properties in screening for major depression. The optimum cutoff point for the CES-D was 21, yielding a sensitivity of 92% and a specificity of 87%. The optimum cutoff point for the GDS was 10, yielding a sensitivity of 100% and a specificity of 84%. A shorter version of the GDS had a sensitivity of 92% and a specificity of 81% using a cutoff point of 5. All scales lost accuracy when used to detect minor depression or the presence of any depressive diagnosis. CONCLUSIONS: The CES-D and the GDS have excellent properties for use as screening instruments for major depression in older primary care patients. Because the GDS's yes or no format may ease administration, primary care clinicians should consider its routine use in their practices.

Adrenal weight and morphology in victims of completed suicide.

Several lines of evidence have implicated hypothalamic-pituitary-adrenal (HPA) axis dysfunction in major depression and suicidal behavior. In the present study, the weight and morphology of postmortem adrenal glands were compared between suicide victims and sudden death, nonpsychiatric controls. The mean adrenal weight of the combined left and right glands was significantly higher in the suicide group; this difference was accounted for specifically by increases in left adrenal weight of suicides compared with the control group. There was a positive correlation between adrenal weight and total cortical thickness in both left and right glands, providing direct evidence that increased adrenal weight in suicide victims is due to cortical hypertrophy. The finding of left-right adrenal weight asymmetry in suicides is consistent with the hypothesis of abnormal lateralized input from higher control centers of the HPA axis.

Sleep in Gilles de la Tourette syndrome.

The sleep of six Tourette patients (drug-free and while taking haloperidol was compared with that of nine normal volunteers. The untreated patients had 30% less delta sleep, which returned to values indistinguishable from those of volunteers when they received haloperidol.

Psychiatric syndromes in Huntington's disease.

Thirty patients with Huntington's disease, a genetically transmitted neuropsychiatric disorder that can be diagnosed reliably, were evaluated systematically for psychopathology, followed for extended periods, and treated with psychopharmacological medications when necessary. DSM-III criteria were used for establishing syndromic diagnoses. Twenty-four individuals demonstrated substantial behavioral abnormalities, including affective and schizophrenic syndromes, changes of personality, and disorders that could not be classified adequately. Pharmacotherapy was modestly beneficial in some cases. Consideration of the array of behavioral disturbances encountered in this pathogenetically unified disorder suggests that a dimensional approach to symptom classification might prove more useful heuristically than present typological methods.

Depressive episodes in patients with multiple sclerosis.

Thirty multiple sclerosis patients were assessed: 15 with predominantly cerebral involvement of their demyelinating disease and 15 with predominantly spinal cord and cerebellar involvement. The groups were matched with regard to age, duration of illness, and Kurtzke disability scores. Assessment included neuropsychological testing, the Beck Depression Inventory, and a psychiatric interview patterned after the Schedule for Affective Disorders and Schizophrenia. A group of normal volunteers served as controls for the neuropsychological testing. There were significantly more major depressive episodes in the cerebral group, as assessed by the patients' histories and by interview, and there was a trend toward more depressive symptoms in this group, as measured by the Beck inventory.

Cognitive function and the dexamethasone suppression test in depression.

Twenty patients with major depressive disorder defined by the Research Diagnostic Criteria were given a range of neuropsychological tests and evaluated with the dexamethasone suppression test (DST). No correlation was found between results on the DST and cognitive impairment.

The trial use of clozapine for abnormal involuntary movement disorders.

Twelve patients with abnormal involuntary movement disorders were treated with clozapine in a double-blind, placebo-controlled trial. The cohort consisted of individuals with Gilles de la Tourette's syndrome, Huntington's disease, and atypical persistent dyskinesia that was drug induced. Two subjects were dropped from the protocol due to complications. Two patients with Huntington's disease showed a marked decrease in movements; other individuals obtained no significant therapeutic benefits. Seven of the 10 patients completing the trial experienced moderate or marked side effects.

Manic syndrome in AIDS.

A manic syndrome in eight patients with AIDS is described. On the basis of clinical, neuropsychological, laboratory, magnetic resonance imaging, and epidemiological evidence, the authors suggest that the manic syndrome was secondary to HIV infection. The patients also developed concomitant cognitive impairment.

Depression and self-reported functional status in older primary care patients.

OBJECTIVE: The authors' goal was to examine whether depression is associated with overreporting of functional disability. METHOD: The subjects were 304 patients 60 years old or older who were recruited from primary care settings. Measures included examiner ratings of depression diagnosis and medical burden and self-reported and examiner-rated functional assessments. Multiple regression techniques were used to determine the independent association of depression with self-reported function after examiner-rated function was added to the analysis as a covariate. RESULTS: Depression diagnosis was associated with poorer self-reported role functioning, whether the patient attributed the disability to physical or emotional causes. Depression was not independently associated with poorer self-reported physical functioning. CONCLUSIONS: Clinicians and researchers should recognize that depression can confound the self-reporting and attribution of functional disability.

Depressive symptoms, medical illness, and functional status in depressed psychiatric inpatients.

OBJECTIVE: There is evidence that both psychiatric (especially affective) and medical illnesses contribute to physical disability. However, the differential contributions of specific psychiatric disorders and of medical pathology to functional status in psychiatric populations have not been studied. The authors therefore examined the contributions of depressive symptoms and medical illness to functional disability in depressed inpatients. METHOD: This prospective investigation included 109 psychiatric inpatients with DSM-III-R major depression. Regression techniques were used to examine the contribution of demographic variables (age, sex, education), depressive symptom severity (Hamilton Rating Scale for Depression score), psychiatric function (Global Assessment of Functioning Scale score), organ system pathology (Cumulative Illness Rating Scale score), and medical disability (Karnofsky Performance Status Scale score) to overall functional status (Instrumental Activities of Daily Living and Physical Self-Maintenance scores). These relationships were also examined in older and younger subgroups. RESULTS: Greater age, female sex, and illness factors all contributed to poorer functional status. Of the illness factors, psychiatric pathology contributed more to low functional status than did medical illness. The predictive power came specifically from the functionally based measures of psychiatric and medical illness; a quantitative measure of symptoms (Hamilton depression scale) or organ pathology (Cumulative Illness Rating Scale) did not significantly predict overall functional status. CONCLUSIONS: Clinicians and researchers should recognize that symptomatic and functional assessments tap related but different domains and that both psychiatric and medical illnesses contribute to overall disability.

Medical illness burden, trait neuroticism, and depression in older primary care patients.

OBJECTIVE: The authors tested the hypotheses that medical illness burden is independently associated with depression and that this association is moderated by neuroticism. METHOD: Multiple regression techniques were used to determine the independent associations of medical burden and neuroticism with depression in a group of 196 subjects, 60 years of age and older, recruited from primary care settings. RESULTS: Medical burden and neuroticism were independently associated with major depression, depressive symptoms, and psychiatric dysfunction. CONCLUSIONS: These findings support models in which medical disorders may contribute directly to depression. At the same time, the role of neuroticism in later-life depression warrants further study.

Relationships of age and axis I diagnoses in victims of completed suicide: a psychological autopsy study.

OBJECTIVE: Psychiatric illness is a potent risk factor for suicide, rates of which differ markedly with age. The purpose of this study was to examine whether the psychiatric diagnoses of suicide victims vary predictably with age. METHOD: DSM-III-R axis I diagnoses of 141 persons aged 21 to 92 years who had completed suicide were established by the psychological autopsy method. Multiple logistic regression analyses were used to determine whether age, gender, or their interaction predicted the presence of specific disorders. RESULTS: One or more axis I conditions were diagnosable in 90.1% of the suicide victims. Substance use disorders were most frequent, followed by mood disorders and primary psychotic illness. Younger age at death was a significant predictor of substance abuse or dependence and primary psychoses, while older age predicted major mood disorders. Comorbidity of substance use and mood disorders was common. Among victims with substance abuse or dependence, older age at death predicted major depression; among victims with mood disorders, younger age at death predicted comorbid substance abuse or dependence. CONCLUSIONS: The distribution of psychiatric illnesses in suicide victims differs across the life course. Age-related patterns of addictive and psychotic disorders echo their prevalence in the general population. In contrast, the relationship between age and mood disorders among suicide victims is distinctly different from that of the general population. These findings suggest that risk for suicide increases with age in individuals with major affective illness. Depressed elderly men are particular targets for suicide prevention strategies.

Cerebrovascular risk factors and 1-year depression outcome in older primary care patients.

OBJECTIVE: A model in which cerebrovascular disease contributes to the pathogenesis of depression in later life was the basis of the authors' hypothesis that cerebrovascular risk factors at intake are independently associated with depression at 1-year follow-up. METHOD: The subjects were 247 patients aged 60 years or older in primary care practices. The study measures were completed at intake and 1-year follow-up. Multiple regression techniques were used to determine the independent association of initial cerebrovascular risk factors with depressive symptoms and diagnoses at 1 year. RESULTS: The authors found that the severity of initial cumulative cerebrovascular risk factors was significantly independently associated with 1-year depressive symptoms and diagnoses, but not after also controlling for overall medical burden. CONCLUSIONS: The results lend some support to the cerebrovascular model of depression.

Assessing the competence of persons with Alzheimer's disease in providing informed consent for participation in research.

OBJECTIVE: The capacity of persons with Alzheimer's disease or other neuropsychiatric disorders for giving consent to participate in research has come under increasing scrutiny. While instruments for measuring abilities related to capacity have been developed, how they should be used to categorize subjects as capable or incapable is not clear. A criterion validation study was carried out to help address this question. METHOD: The authors measured the ability of 37 subjects with mild-to-moderate Alzheimer's disease and 15 elderly comparison subjects to provide consent for participation in a hypothetical clinical trial. Using the judgment of three experts as the criterion standard, the authors performed a receiver operator characteristic analysis for the capacity ability measures from the MacArthur Competence Assessment Tool-Clinical Research VERSION: The results were compared with categorizations of capacity status that were based on normative values. RESULTS: While most comparison subjects scored perfectly on all measures of the competence assessment tool, the majority of the group with Alzheimer's disease showed significant decision-making impairment. Thresholds based on normative values resulted in 84% (N=31) of the Alzheimer's disease subjects being rated as incapable on at least one ability; thresholds based on expert judgment resulted in 62% (N=23) failing to meet cutoff scores on at least one ability. CONCLUSIONS: Even relatively mild Alzheimer's disease significantly impairs consent-giving capacity. But differentiating capable from incapable subjects remains an issue despite the aid of standardized tools. More research is needed to understand the relationship between subject factors (performance on ability measures) and categorical judgments about their capacity.

Gilles de la Tourette's syndrome. A review of clinical and research studies and consideration of future directions for investigation.

Tourette syndrome (TS) is a complex neurobehavioral disorder that has recently become a topic for clinical, genetic, neurochemical, and therapeutic research. Substantial progress has been made defining the clinical features of the disorder, establishing its familial nature, and documenting its response to pharmacotherapeutic intervention. Despite these advances, significant problems remain. The separation between TS and other syndromes is imprecise, and there are no uniformly accepted criteria for measuring response to treatment. Although family studies are promising, no mechanism of genetic transmission has been defined and the number of available revealing kindred for future DNA linkage studies is small. Clinical neurochemical investigations have been hampered by poor design and small subject samples; detailed postmortem neurochemical and pathological studies of brains from patients with TS have not been undertaken thus far. Careful application of newer research technologies combined with appropriately chosen subjects with TS may add to our understanding of the physiologic, anatomic, and genetic factors that contribute to this intriguing disorder. Future postmortem central nervous system studies will be essential.