Incidence of melancholic depression by age of onset and gender in the Lundby population, 1947-1997.

Whether melancholic depression is a distinct syndrome or not has long been debated. There are few studies providing information about the epidemiology of melancholic depression. In this study, we investigate the incidence rates, overall as well as by gender and age of onset of melancholic depression according to Taylor and Fink and corresponding DSM-IV disorders: major depressive disorder (MDD) with melancholic specifier, MDD with psychotic features, MDD with postpartum debut and bipolar depression in the Lundby population. Incidence rates with 95% confidence intervals were calculated. The incidence rate of melancholic depression was 0.48 (CI 0.36-0.61) per 1000 person-years under risk. The rates of the corresponding DSM-IV disorders were as follows: MDD with melancholic specifier 0.38 (CI 0.27-0.49), MDD with psychotic features 0.13 (CI 0.07-0.21), MDD with postpartum debut 0.02 (CI 0.00-0.06) and bipolar depression 0.04 (CI 0.01-0.10). Females had a significantly higher incidence rate, with a peak in age group 40-49, in melancholic depression according to Taylor and Fink and MDD with melancholic specifier. There was no gender difference in incidence rates of MDD with psychotic features or bipolar depression. The diagnoses were set in retrospect and the number of subjects with MDD with postpartum debut and bipolar depression was low. Incidence of melancholia was low in the Lundby Study. There was a female preponderance to become melancholically depressed in line with research on undifferentiated depression.

As good as it gets: an empirical study on mentally-ill patients and their stay at a general hospital in Sweden, 1896-1905.

General hospital care and treatment of mentally ill patients in a Swedish town was studied in records for 503 patients, 1896-1905. Restraint was extremely rare; 65% left the hospital as healthy or improved. Non-psychotic and alcoholic patients spent fewer days in hospital than patients with psychosis or dementia. There was no evidence of a social status bias. For 36% of the patients a certificate for mental hospital care was issued, with additional information. The cause of illness was stated as unknown for 42% of these patients; adverse circumstances were recorded for 18%. Heredity for mental illness was found in 50% of the patients, particularly in those with mania. Patients with a higher social status were underrepresented.

Mental illness in Sweden (1896-1905) reflected through case records from a local general hospital.

Mental illness in a hospital in a medium-sized town in Sweden was studied. Consecutive case records from 1896 to 1905, and also from 2011, were selected. In the historical sample, neurasthenia was the most common diagnosis, followed by affective disorders and alcohol abuse. ICD-10 diagnoses corresponded well with the historical diagnoses. Melancholia resembled modern criteria for depression. Mania, insania simplex and paranoia indicated more severe illness. Abuse was more common among men and hysteria among women. Those with a medical certificate for mental hospital care were very ill and showed no gender difference. There were no diagnoses for abuse, but 17% had a high level of alcohol consumption. The pattern of signs and symptoms displayed by patients does not appear to change with time.

Taking care of oneself by regaining control - a key to continue living four to five decades after a suicide attempt in severe depression.

BACKGROUND: Depression is a strong risk factor for suicide and suicide attempt. Several studies have examined the pathway to suicide attempt, but few studies have considered aspects important for overcoming being suicidal. The aim of the present study was to examine personal strategies to continue living after a suicide attempt. METHODS: A qualitative grounded theory approach was used. Thirteen former inpatients diagnosed with severe depression (1956-1969) participated in a follow-up 42-56 years after their last suicide attempt, which occurred between the ages of 21 and 45. They were interviewed on one occasion between June 2013 and January 2014, using semi-structured interviews. RESULTS: The pathway to a suicide attempt was defined as 'being trapped in an overwhelming situation'. Three categories described the recovery process: 'coming under professional care', 'experiencing relief in the personal situation', and 'making a decision to continue living'. These categories emerged in a core category, labelled 'taking care of oneself by regaining control'. Overcoming being suicidal occurred regardless of recovering from depression. CONCLUSION: In the very long-term course following a suicide attempt, the process of recovery is multi-dimensional and fluctuating, and includes appropriate treatment, connecting with others, decision making, and overcoming existential issues.

Interactive Voice Response with Feedback Intervention in Outpatient Treatment of Substance Use Problems in Adolescents and Young Adults: A Randomized Controlled Trial.

PURPOSE: Substance use disorders and problematic substance use are common problems in adolescence and young adulthood. Brief personalized feedback has been suggested for treatment of alcohol and drug problems and poor mental health. This repeated measurement randomized controlled trial examines the effect of an interactive voice response (IVR) system for assessing stress, depression, anxiety and substance use. METHODS: The IVR system was used twice weekly over 3 months after treatment initiation, with or without addition of a personalized feedback intervention on stress and mental health symptoms. Both IVR assessment only (control group) and IVR assessment including feedback (intervention group) were provided as an add-on to treatment-as-usual procedures (TAU) in outpatient treatment of substance use problems in adolescents and young adults (N = 73). RESULTS: By using a mixed models approach, differences in change scores were analyzed over the three-month assessment period. Compared to the control group, the intervention group demonstrated significantly greater improvement in the Arnetz and Hasson stress score (AHSS, p = 0.019), the total Symptoms Checklist 8 score (SCL-8D, p = 0.037), the SCL-8D anxiety sub-score (p = 0.017), and on a summarized feedback score (p = 0.026), but not on the depression subscale. There were no differences in global substance use scores between the intervention group (feedback on mental health symptoms) and the control group. CONCLUSION: In conclusion, IVR may be useful for follow-up and repeated interventions as an add-on to regular treatment, and personalized feedback could potentially improve mental health in adolescents and young adults with problematic substance use.

Mortality, causes of death and risk factors for death among primary amphetamine users in the Swedish criminal justice system.

This study examined mortality and predictors of death in 1,396 primary amphetamine users (85% males) who were interviewed with the Addiction Severity Index in the Swedish criminal justice system during 2000-2006 and followed through 2008. Forty-nine clients deceased (standardized mortality ratio 4.1 [3.0-5.4]), at least 84% of deaths were violent or drug-related (12% suicides), and Cox regression analysis indicated that death was associated with frequent use of sedatives and less frequent use of amphetamine. No female deaths were observed; death and male gender were associated in binary analysis. Implications for diagnostics and treatment are discussed.

Is melancholia a distinct syndrome? Recurrence, chronicity, and severity give evidence in the 50 year follow-up of the Lundby Study.

Introduction: Whether melancholia is a distinct syndrome has long been debated. One aspect of a valid syndrome is whether it allows for determination of a prognosis. The aim of this study is to investigate the course of melancholic depression versus non-melancholic depression with a focus on: (i) time to and probability of recovery from the first depressive episode, (ii) time to and risk of the first recurrence, (iii) rate of recurrence, (iv) time with depression or antidepressant medication, and (v) suicide risk. Methods: The Lundby Study is a longitudinal community study on mental health that followed a geographically defined population (N = 3,563) for up to 50 years, 1947-1997. Subjects with first onset depression were assessed as melancholic (N = 46) or non-melancholic (N = 381) using the DSM-IV melancholic specifier. These diagnoses were made in retrospect using all available information from semi-structured interviews by psychiatrists, key informants, registers, and patient records. Results: We found no significant difference between melancholic- and non-melancholic depression in time to and probability of recovery from the first depressive episode. The time to first recurrence was shorter in melancholic than in non-melancholic depression and the risk of first recurrence for the melancholic group was 2.77 (95% confidence interval [CI] 1.83-4.20) times the risk in the non-melancholic group. The median rate of recurrence was higher in the melancholic group, at 0.19 recurrences per year at risk (interquartile range [IQR] 0.08-0.47), compared to the non-melancholic group, at 0.10 recurrences per year at risk (IQR 0.05-0.21) (p < 0.03). The median percentage of time being depressed or on antidepressant medication was higher in the melancholic group, 17% (IQR 3-20%), compared to the non-melancholic group, 8% (IQR 7-33%) (p < 0.001). The risk of suicide was higher in the melancholic group, hazard ratio 4.13 (95% CI 1.49-11.48, p < 0.01). Discussion: To conclude, melancholic depression had a more recurrent, chronic, and severe course with a higher suicide risk than did non-melancholic depression in the Lundby population. Although our use of retrospective diagnosis might limit interpretation of results, the findings indicate that melancholia may be useful in determining prognosis and may be a valid psychopathological syndrome.

Substance Use, Hospitalizations, and Co-Occurring Disorders among Patients Transferred from a Needle Exchange Program to Opioid Maintenance Treatment.

Opioid use disorders (OUD) is a relapsing condition with high mortality. Opioid maintenance treatment (OMT) reduces heroin use, and overall morbidity and mortality. The prevalence of psychiatric and substance use disorders, potential baseline predictors for psychiatric hospitalization, and psychiatric diagnoses at follow-up were investigated and may give hints about possible preventative strategies. The medical records for 71 patients were reviewed 36 months following referral to OMT from a needle exchange program (NEP). Their psychiatric diagnoses and hospitalizations were identified. Their baseline characteristics were assessed for potential differences between hospitalized versus non-hospitalized patients and between patients with and without psychiatric diagnoses in a longitudinal observational study without controls. A regression analysis was performed to identify predictors for hospitalization when controlling for OMT status. Sixty-five percent of the patients were hospitalized at least once with a psychiatric diagnosis. Substance-related reasons were prevalent, and detoxification occurred among 59% of patients, with sedative- hypnotics (benzodiazepines, zopiclone, zolpidem, and pregabalin) being the substance used by 52% of patients. Baseline use of these drugs and/or buprenorphine predicted for hospitalization when controlling for OMT status. During the follow-up period, 72% of patients met the criteria for a psychiatric diagnosis other than OUD. The prevalence of non-substance use disorders overlapping with SUD was 41%, and that overlapping with anxiety disorder was 27% of all participants. Increased attention to psychiatric co-occurring disorders in the treatment of OUD is required and the importance of addressing sedative-hypnotics use when initiating OMT is highlighted.

Repetition of suicide attempts across episodes of severe depression. Behavioural sensitisation found in suicide group but not in controls.

BACKGROUND: Those who die by suicide and suffer from depression are known to have made more suicide attempts during their life-span as compared to other people with depression. A behavioural sensitisation or kindling model has been proposed for suicidal behaviour, in accordance with a sensitisation model of depressive episodes. The aim of the present study was to test such a model by investigating the distribution of initial and repeated suicide attempts across the depressive episodes in suicides and controls with a unipolar severe depression. METHOD: A blind record evaluation was performed of 80 suicide victims and controls admitted to the Department of Psychiatry between 1956 and 1969 and monitored to 2010. The occurrence of initial and repeated suicide attempts by order of the depressive episodes was compared for suicides and controls. RESULTS: The risk of a first suicide attempt decreased throughout the later episodes of depression in both the suicide group (p < .000) and control group (p < .000). The frequencies of repetition early in the course were actually higher in the control group (p < .007). After that, the risk decreased in the control group, while the frequencies remained proportional in the suicide group. At the same time, there was a significantly greater decreased risk of repeated attempts during later episodes in the control group as compared to the suicide group (p < .000). The differences were found despite a similar number of episodes in suicides and controls. CONCLUSION: Repeated suicide attempts in the later episodes of depression appear to be a risk factor for suicide in severe depression. This finding is compatible with a behavioural sensitisation of attempts across the depressive episodes, which seemed to be independent of a corresponding kindling of depression.

Repetition and severity of suicide attempts across the life cycle: a comparison by age group between suicide victims and controls with severe depression.

BACKGROUND: Suicide attempts have been shown to be less common in older age groups, with repeated attempts generally being more common in younger age groups and severe attempts in older age groups. Consistently, most studies have shown an increased suicide risk after attempts in older age. However, little is known about the predictive value of age on repeated and severe suicide attempts for accomplished suicide. The aim of the present study was to investigate the reduced incidence for initial, repeated, or severe suicide attempts with age in suicide victims and controls by gender. METHODS: The records of 100 suicide victims and matched controls with severe depression admitted to the Department of Psychiatry, Lund University Hospital, Sweden between 1956 and 1969, were evaluated and the subjects were monitored up to 2006. The occurrence of suicide attempts (first, repeated, or severe, by age group) was analysed for suicide victims and controls, with gender taken into consideration. RESULTS: There was a reduced risk for an initial suicide attempt by older age in females (suicide victims and controls) and male controls (but not suicide victims). The risk for repeated suicide attempts appeared to be reduced in the older age groups in female controls as compared to female suicide victims. The risk for severe suicide attempts seemed reduced in the older age groups in female suicide victims. This risk was also reduced in male controls and in male controls compared to male suicide victims. CONCLUSION: In the older age groups repeated attempts appeared to be predictive for suicide in women and severe attempts predictive in men.

Number of addictive substances used related to increased risk of unnatural death: a combined medico-legal and case-record study.

BACKGROUND: Substance use disorders have repeatedly been found to lead to premature death, i.e. drug-related death by disease, fatal intoxications, or trauma (accidents, suicide, undetermined suicide, and homicide). The present study examined the relationship between multi-drug substance use and natural and unnatural death. METHODS: All consecutive, autopsied patients who had been in contact with the Addiction Centre in Malmö University Hospital from 1993 to 1997 inclusive were investigated. Drug abuse was investigated blindly in the case records and related to the cause of death in 387 subjects. RESULTS: Every substance apart from alcohol used previously in life added to the risk of unnatural death in a linear way. There were independent increased risks of fatal heroin overdoses or undetermined suicide. Death by suicide and violent death were unrelated to additional abuse. CONCLUSION: The number of drugs used was related to an increased risk of unnatural death by undetermined suicide (mainly fatal intoxications) and heroin overdose.

From Substance Use Disorders in Life to Autopsy Findings: A Combined Case-Record and Medico-Legal Study.

Objectives: Several studies have shown mortality and suicide risk in substance use disorders, and autopsy findings with respect to the used substances. However, there seems to be a gap in the knowledge about substances misused in life and at death at the within-person level. Methods: All consecutive, autopsied patients during 1993 to 1997, who had been in contact with the Addiction Centre in Malmö from 1968, were investigated (365 subjects). Drug misuse in the long-term course noted in case records was related to autopsy findings. Self-inflicted death (suicide/undetermined suicide/accidental overdose) was compared with natural death. Results: Benzodiazepine misuse was associated with a high risk of autopsy findings of the substance in suicide and death of undetermined intent. It was also associated among non-misusers, but less so. An alcohol level above 1‰ was found more often in self-inflicted death. Prescription opioids at autopsy were mainly found in self-inflicted death among non-misusers. Heroin misuse was related to overdose. Central nervous system stimulants (CNS-S) and cannabis were rarely found in self-inflicted death among previous misusers. The overlap between depression in life and antidepressants at death was low. Conclusions: Benzodiazepines and alcohol seem to disinhibit suicidal tendencies. Suicide risk among users of cannabis and CNS-S may be related to other risk factors than acute use. Implications for suicide prevention are discussed.

Risk factors for recurrence in depression in the Lundby population, 1947-1997.

BACKGROUND: Depression is a common disorder in both men and women, and the recurrence rate is high. The aim of this study was to identify risk factors for recurrence in depression in the Lundby Study. METHODS: The Lundby Study is a community-based longitudinal study with focus on mental health. The study started in 1947 and three follow-ups have been carried out since, the last one in 1997. The population consists of 3563 subjects. Data from 508 subjects afflicted by depression was gathered. Premorbid factors (gender, socioeconomic status, marital status, personality and heredity) and factors related to the first depressive episode (age, degree of impairment and melancholic depression) were investigated regarding their influence on the risk for recurrence in depression. Multiple logistic regression was used in the calculations. RESULTS: Risk factors associated with recurrent depression were melancholic depression at first onset (OR 3.52 [95% CI 1.62-7.66, p < 0.001]), young age as compared to old age at first onset (OR 0.51 [95% CI 0.28-0.92, p = 0.03]) and a premorbid nervous/tense personality (OR 1.77 [95% CI 1.22-2.56, p < 0.01]). Demographic factors, including gender, had no effect on the odds of recurrence. LIMITATIONS: The Lundby Study spans over 50 years, making the results vulnerable to changes in diagnostic regimes and recall bias. CONCLUSION: Melancholia at onset, regardless of severity of symptoms, had the greatest impact on the risk of recurrence in depression in the Lundby Study. Information about risk factors for recurrence in depression are useful in offering effective preventive measures in the form of psychotropic drugs and psychotherapy, and deciding the length of follow-up.

Aspects of Additional Psychiatric Disorders in Severe Depression/Melancholia: A Comparison between Suicides and Controls and General Pattern.

OBJECTIVE: Additional and comorbid diagnoses are common among suicide victims with major depressive disorder (MDD) and have been shown to increase the suicide risk. The aim of the present study was first, to investigate whether patients with severe depression/melancholia who had died by suicide showed more additional psychiatric disorders than a matched control group. Second, general rates of comorbid and additional diagnoses in the total group of patients were estimated and compared with literature on MDD. METHOD: A blind record evaluation was performed on 100 suicide victims with severe depression/melancholia (MDD with melancholic and/or psychotic features: MDD-M/P) and matched controls admitted to the Department of Psychiatry, Lund, Sweden between 1956 and 1969 and monitored to 2010. Diagnoses in addition to severe depression were noted. RESULTS: Less than half of both the suicides and controls had just one psychiatric disorder (47% in the suicide and 46% in the control group). The average number of diagnoses was 1.80 and 1.82, respectively. Additional diagnoses were not related to an increased suicide risk. Anxiety was the most common diagnosis. Occurrence of suspected schizophrenia/schizotypal or additional obsessive-compulsive symptoms were more common than expected, but alcohol use disorders did not appear very frequent. CONCLUSIONS: The known increased risk of suicide in MDD with comorbid/additional diagnoses does not seem to apply to persons with MDD-M/P (major depressive disorder-depression/Melancholia). Some diagnoses, such as schizophrenia/schizotypal disorders, were more frequent than expected, which is discussed, and a genetic overlap with MDD-M/P is proposed.

First and Subsequent Lifetime Alcoholism and Mental Disorders in Suicide Victims With Reference to a Community Sample-the Lundby Study 1947-1997.

Background: Suicide victims have been found to frequently suffer from mental disorders, often more than one, and comorbidity has also been found to be a risk factor for suicide. The aim of the present study was to determine the first disorder and possible subsequent disorders in suicide victims during their lifetimes and to compare their development with the development of mental and alcohol use disorders (AUDs) in a community sample. Methods: The Lundby Study is a prospective longitudinal study of mental health in a general population comprising 3,563 subjects, including 68 suicide victims, followed by four field investigations from 1947 to 1997; mortality was monitored up to 2011. Results: AUD was most common as a first diagnosis (26/68, 38.2%) among suicide victims, followed by "depression" (20/68, 29.4%) and "anxiety" (7/68, 10.3%). A predominance of AUD as a first diagnosis was found in the male group, whereas "depression" was the most common first diagnosis in the female group. However, there were very few females with AUD in the Lundby Study. In the whole population, it was more common for someone who started with an AUD to develop a subsequent mental disorder than the other way around. The same was true for AUD in relation to depression. Conclusions: AUD was the most common first mental disorder among male suicide victims and could thus be considered a starting point in the suicidal process. We propose that in addition to detecting and treating depression, it is important to detect and treat AUD vigorously and to be alert for subsequent symptoms of depressive and other mental disorders in suicide prevention efforts.

Health Related Quality of Life in Individuals Transferred from a Needle Exchange Program and Starting Opioid Agonist Treatment.

BACKGROUND: Opioid agonist treatment (OAT), for the treatment of heroin dependence, has been reported to improve overall health and lower mortality. Drug use and retention in treatment have often been used as measures of treatment success. More recently, however, researchers have suggested that measurements of quality of life should be an outcome in substance use treatment evaluations. In a recent randomized controlled trial we demonstrated high rates of successful rapid referral from a needle exchange program (NEP) to OAT. The aim of this study was to see whether an improvement in health related quality of life (HRQoL) could be seen at 3-month follow-up after starting OAT and whether it was associated with any baseline characteristics. We also wanted to compare our sample to a sample from the general population with regard to HRQoL. METHODS: This was a 3-month follow-up of 71 patients who started OAT. Measurements of HRQoL with EQ-5D (an instrument developed by the EuroQol group) were made at baseline and at three months. RESULTS: Mean EQ-5D VAS (visual analogue scale) for the study sample at baseline was 47.3, which was lower than a Swedish reference population reporting 83.3. Individuals reporting being prescribed a drug for a psychiatric condition had significantly lower EQ-5D index values. Improvement in EQ-5D index score was significantly less for individuals reporting previous overdoses (-0.10, p=0.025). Individuals reporting previous suicide attempts had significantly lower EQ-5D VAS score at baseline. A significant increase of the EQ-5D VAS difference over time was found with a mean difference of 10.94 (p=0.008) for the total sample. CONCLUSION: To our knowledge this is the first time HRQoL as an outcome is reported in a population transferred from a NEP to OAT. Our results indicate that OAT can result in increased HRQoL, even with this type of rapid low-threshold referral.

Remission from Alcohol Use Disorder among Males in the Lundby Cohort during 1947-1997.

BACKGROUND: Alcohol use disorders are a major health problem, often with a chronic course. Studies on remission from alcohol use disorders are sparse. OBJECTIVE: The aim of this study was to analyse the rate of remission from AUD and the possible influence of other mental disorders and sociodemographic factors on the remission in the Lundby Cohort. METHOD: Remission from AUD was studied for 312 male subjects in the Lundby Cohort, which was followed for 50 years. Cox regression analyses were used to study the possible influence of sociodemographic variables and other mental disorders on AUD remission. RESULTS: In all, 64/312 (21%) subjects achieved remission during the study period. The presence of a severe mental disorder, such as delirium tremens and organic disorders, was related to remission. Blue-collar workers had higher rates of remission than white-collar workers. There was indication that treatment improved the prognosis. CONCLUSIONS: The overall remission rate was low, but treatment may improve the prognosis. Severe mental disorders, such as delirium tremens and organic disorders as well as being blue-collar rather than white-collar worker, were related to remission.

Heroin addicts reporting previous heroin overdoses also report suicide attempts.

Nonfatal heroin overdoses and suicide attempts are both common among heroin addicts, but there is limited knowledge about the association between them. The sample in the present study consisted of 149 regular heroin users in Malmö, Sweden. Out of these 98 had taken an unintentional heroin overdose at some time and 51 had made at least one attempt to commit suicide (but not using heroin). Suicide attempts were significantly more common among those who had taken unintentional overdoses as compared with those who had never taken any overdose (p < 0.01). The more overdoses, the greater the risk of suicide attempt.

Violent and nonviolent methods of suicide: different patterns may be found in men and women with severe depression.

The objective of this study was to investigate violent and nonviolent suicidal acts in men and women with severe depression. The records of 98 suicide victims, who had been admitted to the Department of Psychiatry, Lund University Hospital, Sweden between 1956 and 1969, were evaluated and the subjects were monitored up to 1998. The female group displayed a significant linear trend for nonviolent completed suicide after one suicide attempt, and even more significantly, after repeated attempts. A switch from only nonviolent suicide attempts to completed violent suicide was significantly more common in men than in women. These different progressions may contribute to the expected finding that men used violent methods for completed suicide more often than women.

Clinical Prediction of Suicide and Undetermined Death: A Pseudo-Prospective Clinical and Medico-Legal Study of Substance Abusers.

This study examines aspects of prediction of suicide and death of undetermined intent. We investigated all consecutive, autopsied patients between 1993 and 1997 who had been in contact with the Addiction Centre in Malmö from 1968 onwards. The staff was asked, shortly after autopsy but before they knew of the manner of death, if they thought the patient had committed suicide. The case records were blindly evaluated, and toxicological autopsy findings for alcohol in blood samples investigated. The specificity of prediction was 83% and significantly more often correct than the sensitivity, which was only 45% for suicide and for suicide/death of undetermined intent (93% versus 39%). Suicidal communication was more often considered non-serious before death of undetermined intent than before suicide. The former could be predicted by ideation but not by suicide attempt reported in case records, unlike suicide, which was predicted by both. The undetermined group also showed higher levels of alcohol in the blood at autopsy. We concluded that more serious clinical investigation of suicidal feelings, which may be hidden and not taken seriously, and treatment of alcohol use disorders with active follow-up appear urgent in the efforts to prevent suicide.