Psycho-social correlates of suicidal behaviour.

Although suicidal behaviour is quite rare in the absence of current major mental disorders, the majority of these patients do not complete or attempt suicide. Therefore, as the scientific literature shows, other (psychological and social) suicide risk factors also play a contributory role. In this paper we will shortly review the clinically significant psychological and social correlates of suicidal behaviour that can help clinicians in recognising and managing suicide risk.

Depression and suicide - the role of underlying bipolarity.

The risk of suicidal behaviour in mood disorders is an inherent severity of the depressive episode. Suicidal behaviour in patients with mood disorders is both state and severity dependent, which means that suicidality markedly decreases or vanishes after clinical recovery. However, since the majority of mood disorder patients never commit or attempt suicide, special clinical characteristics of the illness, as well as some personality, familial and psycho-social factors should also play a contributory role. This paper discusses the clinically explorable suicide risk factors in patients with major mood disorders, with particular regard to the underlying bipolarity. Successful acute and longterm pharmacotherapy - supplemented by psycho-social interventions - markedly reduces the risk of attempted and completed suicide, even in this high-risk population. Keywords: major depressive disorder; bipolar disorders.

[Assessing suicide risk using the Brief Suicide Questionnaire - preliminary results]. / Az öngyilkossági veszély felmérése a Rövid Szuicid Kérdoív segítségével ­ elozetes eredmények.

The authors tested the clinical applicability of a self-developed, 6-item, clinician-rated questionnaire evaluating suicide risk in suicidal and non-suicidal psychiatric inpatients and healthy controls. Results have shown that the questionnaires able to detect marked suicide risk in psychiatric inpatients with a high sensitivity and specificity which indicates its usefulness and good applicability in clinical practice.

[Antidepressant-resistant depression and the bipolar spectrum -- diagnostic and therapeutic considerations]. / Antidepresszívum-rezisztens depresszióés a bipoláris spektrum kapcsolata -- diagnosztikaiés terápiás szempontok.

According to the results of epidemiological studies mood disorders with unipolar (major and minor depressive disorder; dysthymia) or bipolar features are among the most prevalent psychiatric disorders. These disorders with their frequent comorbidities (alcohol and/or drug use disorders, smoking, suicide, cardiovascular disorders) pose great public health challenge and cause substantial individual and familar burdens as well. Since SSRIs and other new antidepressant agents entered the market the possibilities to treat depression improved substantially but 25-35 percent of major depressives do not respond even to the second antidepressant trial but the rate of patients who are resistant after the third and fourth adequate antidepressant trial are around only 15-25 and 10 percent, respectively. Pharmacotherapy-resistant depression is a multicausal phenomenon. Along with its well-known risk-factors investigations of the past decade have revealed that unrecognised or hidden (subsyndromal or subthreshold) bipolarity is one of the most frequent causes of treatment resistance. In the case of bipolar depression (either as a part of syndromal bipolar I or II disorder or a subsyndromal manifestation) antidepressant monotherapy should be avoided and, instead of it, the administration of a mood stabilizer (primarily lithium and lamotrigine) or some atypical antipsychotics (preferably quetiapine) are recommended. If antidepressant is inevitably necessary in bipolar depression, we should use it always in combination with mood stabilizers or atypical antipsychotics.

[The role of childhood abuse in adult suicidal behaviour]. / A gyermekkori abúzusok szerepe a felnöttkori szuicid magatartás kialakulásában.

In our present study we have analysed the influence of childhood abuse on affective temperament-types and Gotland Male Depression Scale scores in 150 nonviolent suicide attempters. Our findings confirm previous Hungarian and international data concerning the connection of suicidal behaviour and psychiatric disorders, undesirable psychosocial circumstances and negative life events. Moreover, our study provides new results regarding the strong association of the affective temperament types, male type of depression, seriously traumatic early life events and furthermore their predisposing role in connection with suicidal behaviour. Suicide attempters, experiencing physical and/or sexual abuse in their childhood showed significantly higher total scores (p<0.05) on cyclothymic and irritable temperament subscales. The Gotland Male Depressive syndrome was equally very common and equally serious both in males and females who made a nonviolent suicide attempt. However, regardless of gender, it was significantly more severe (p<0.01) among those who were victims of both physical and sexual childhood abuse.

A study of affective temperaments in Hungary: internal consistency and concurrent validity of the TEMPS-A against the TCI and NEO-PI-R.

BACKGROUND: TEMPS-A (Temperament Evaluation of the Memphis, Pisa, Paris and San Diego - Autoquestionnaire) is a new self-assessed temperament 110-item scale with depressive (D), cyclothymic (C), hyperthymic (H), irritable (I) and anxious (A) subscales. To date, it has been translated into 25 languages, and validated in 10. The present Hungarian version provides the most complete external validation across the Beck Depression Scale (BDI), Profile of Mood States (POMS), the BarOn Emotional Quotient Inventory (BarOn EQ-i), Temperament and Character Inventory (TCI), and the NEO Personality Inventory - Revised (NEO-PI-R). We were particularly interested in concurrent validation against the TCI and the NEO-PI-R, the most important of the new personality instruments. METHODS: 1132 clinically-well subjects (27% male) from the general population and university students (16-81 years) were administered the above scales and instruments. The data were tested with standard psychometric batteries. RESULTS: Factor analysis revealed 5 factors approximating the original D, C, I, H, and A subscales, which in their superfactor confirmed an Emotional (D, C, I, A) vs. Hyperthymic structure. Except for the D (a=0.65), the Cronbach alpha for the remainder temperaments ranged from 0.75-0.81. Dominant temperaments ranged from the I (2.7%) to the C (4.2%); the highest prevalence was observed among men with C=6% and H=5.4%. The BDI and POMS correlated significantly with the relevant subscales, as did the BarOn. Of the many significant possible correlations with the TCI, the most noteworthy were novelty seeking and harm avoidance with D, A, C, as well as C, and persistence with H. As for the NEO-PI-R, we were struck by the positive correlation of openness with C, and conscientiousness negatively with C; most other positive correlations such as neuroticism with all temperaments but the hyperthymic were expected and strongly supportive of concurrent validity. LIMITATIONS: Higher educational background of the subjects studied relative to that of the general population of Hungary. The distribution of the data may have in some instances deviated somewhat from the underlying assumptions for the standard psychometric tests for normality. We did not conduct test-retest reliability. CONCLUSIONS: The factorial structure of the TEMPS-A shows good reliability and internal consistency. Although the superstructure is reminiscent of neuroticism-extraversion, within it are embedded discernible classical affective temperaments. A provocative finding is the high prevalence of cyclothymia in Hungarian males (6%), which is rather unique when compared with the other 10 countries studied to date. This finding, coupled with high male hyperthymia (5.4%), may explain the high lifetime prevalence of bipolar disorders reported from Hungary. Inter alia, our psychometric data along with the foregoing epidemiologic considerations, are very much in line with the cyclothymic-bipolar spectrum model proposed by the senior author [Akiskal, H.S., Djenderedjian, A.H., Rosenthal, R.H., Khani, M.K., 1977. Cyclothymic disorder: validating criteria for inclusion in the bipolar affective group. Am. J. Psychiatry 134, 1227-1233].

The importance of depressive mixed states in suicidal behaviour.

Research indicates that depressive mixed state (DMX) constitutes a very important suicide risk factor within the major affective episode. eral recently published studies demonstrated that DMX is present in one third of unipolar- and in two thirds of bipolar II major depressives, and substantially increases the risk of suicidal behaviour. Because of its nature and characteristics, this condition should be considered as part of the bipolar spectrum. The recognition and better understanding of DMX also have important implications for the recognition and prevention of suicide. The aim of this manuscript is to review the relationship between suicide attempt/completed suicide and depressive mixed state (DMX) (major depression plus 3 or more co-occurring intra-depressive non-euphoric hypomanic symptoms, which highly correspond to the well-recognised "agitated depression"). Our review establishes three important key points related to the role of depressive mixed states in suicidal behaviour: 1. In the majority of suicides, a current major mood episode is present; 2. DMX and agitated depression present a risk factor for suicidal behaviour; 3. DMX and agitated depression should be considered as bipolar spectrum. These should be taken into consideration in clinical and diagnostic work with affective disorder patients.

The close link between suicide attempts and mixed (bipolar) depression: implications for suicide prevention.

BACKGROUND: Previous reports have shown a significant relationship between suicide ideation and mixed depression. The aim of this study was to explore the prevalence and clinical characteristics of mixed depression among non-violent suicide attempters. METHODS: Using a structured interview (modified Mini International Neuropsychiatric Interview) and assessing all the symptoms of 16 psychiatric diagnoses, the authors examined 100 consecutive nonviolent suicide attempters (aged 18-65) within 24 h after their attempts. Mixed depression was defined as a major depressive episode (MDE)/dysthymic disorder plus 3 or more co-occurring hypomanic symptoms, according to the definition validated by Akiskal and Benazzi [Akiskal, H.S., Benazzi, F., 2003a. Delineating depressive mixed states: Their therapeutic significance. Clin. Approaches Bipolar Disord. 2, 41-47, Akiskal, H.S., Benazzi, F., 2003b. Family history validation of the bipolar nature of depressive mixed states. J. Affect. Disord. 73, 113-122.]. RESULTS: Current mixed depression was present in 63.0% in the total sample, and in 70.8% among the 89 depressive suicide attempters. Irritability, distractibility and psychomotor agitation were present in more than 90% of the subjects with mixed depression. The rate of mixed depression was significantly higher among bipolar than non-bipolar depressive suicide attempters (90% vs. 62%). Patients with mixed depression had the following concurrent disorders: bipolar disorders 41.0%, panic disorder 30.0%, generalized anxiety disorder 89.0%, alcohol abuse/dependence 56.0%, and substance abuse 27.0%. Mixed depression versus non-mixed depression had the following significant associations (odds ratio=OR): females 2.4, bipolar II disorder 9.3, generalized anxiety disorder 41.3, irritability 101.6 and psychomotor agitation 61.1. LIMITATIONS: The study didn't include suicide attempters with very high risk of fatality. CONCLUSIONS: The important new finding of this study is the very high prevalence of mixed depression among depressed suicide attempters. The rates of mixed depression among bipolar and non-bipolar depressive suicide attempters were much higher than previously reported among nonsuicidal bipolar II and unipolar depressive outpatients, suggesting that suicide attempters come mainly from mixed depressives with predominantly bipolar II base. Irritability and psychomotor agitation were the strongest predictors of suicide attempt. From a public health standpoint, our data highlight the necessity of detecting and treating mixed (bipolar) depression in the prevention of suicidal behaviour.

[Creativity and mental illness]. / Kreativitás és pszichiátriai betegségek.

It has been known for a long time that people with salient social and artistic creativity suffer more frequently from psychiatric illnesses than the average population. In their review paper, the authors assess the Hungarian and international scientific literature regarding the association of creativity and psychopathology. They conclude that contrary to the concept prevailing in the first part of the 20th century about the strong association between schizophrenia and creativity, the results of empirical research now unambiguously suggest that prominent social and artistic creativity is associated primarily with affective, and more specifically with bipolar affective illnesses. In addition, we already know that as regards the development of creativity, it is not the given affective (depressive, manic, hypomanic) episode which is important, but the hyperthymic or cyclothymic temperament structure which also predisposes for affective illness.

[Affective temperaments: psychometric properties of the Hungarian TEMPS-A]. / Az affektív temperamentum: a TEMPS-A kérdöívvel szerzett hazai tapasztalatok.

The study examines the psychometric properties of the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) based on 717 (438 females and 279 males) healthy subjects in a Hungarian normative sample. The questionnaire is a self-report 110-item tool that postulates five affective temperaments: depressive, cyclothymic, irritable, hyperthymic, and anxious. Most of the TEMPS-A scales have excellent internal consistencies (0.78-0.84), except for the Depressive Temperament Scale, which had a Cronbach's alfa coefficient of 0.63. The item-analyses have identified a few deficient items which do not fit into the scale. In line with the literary data, women had higher mean scores on the depressive, cyclothymic, and anxious subscales, whereas men scored higher on the cyclothymic subscale. Cut-offs for each temperament were based on z-scores higher than + 2S.D. Dominant nervous-anxious (4.3%), depressive (3.8%), cyclothymic (3.2%), and irritable (3.2%) temperaments were the most common in this normative population, whereas dominant hyperthymic (1.8%) temperament was relatively uncommon. Factor analyses of the TEMPS-A items yielded considerable overlap between depressive and cognitive anxiety traits. The strongest correlation was observed between the anxious and the depressive temperament subscales in line with some international findings (r=0.62**). To test construct validity, we administered the Beck Depression Inventory, Profile of Mood States (shortened version) and the Cloninger Temperaments and Character Inventory, which all supported the validity of TEMPS-A subscales. Based on the results obtained with the Hungarian normative sample, the TEMPS-A is a reliable and valid instrument in personality psychology, and further refinement on clinical samples opens new and interesting research avenues.

Possible effect of gender and season on the length of hospitalisation in unipolar major depressives.

BACKGROUND: Seasonal variation as well as gender differences of several phenomena of affective disorders are a common topic of interest. METHODS: The authors analysed the possible effect of season and gender on the length of hospital stay in 529 in-patients with unipolar major depressive episode. RESULTS: Age and menopausal status alone did not influence the length of hospitalisation but there was a statistical tendency (only for females) for the shortest hospital stay in summer, that reached significance in females younger than 50 years. CONCLUSIONS: The results suggest a possible seasonal and gender effect on recovery from major depression. LIMITATIONS: Retrospective nature of the study, lack of systematic assessment of clinical response and no data collection about marital status and living conditions, that also can influence the time of discharge.

Parkinson's disease and depression.

The prevalence of depression in Parkinson's disease is around 40%, but, unfortunately, such depression is frequently unrecognized and untreated. However, recognition and appropriate treatment of depression in patients with Parkinson's disease is essential for clinical practice. This review focuses on the epidemiology, pathophysiology and treatment of depression associated with Parkinson's disease.

Suicide prevention strategies--a brief review.

Since suicide is a very complex, multicausal human behaviour, its prevention should also be complex. The prediction of suicide is very difficult at the level of the general population, but it is much easier among patients with certain mental disorders, because most persons who kill themselves have diagnosable and treatable psychiatric disorders. This article reviews the most important biological and non-biological suicide prevention strategies.

Suicidal and violent behaviour in mood disorders: A major public health problem. A review for the clinician.

Abstract Suicide attempt, and particularly completed suicide are relatively rare events in the community, but they are very common among psychiatric patients. Since over 90% of suicide victims suffer from (mostly untreated) current major mental disorders (particularly from major depressive episode), psychiatric risk factors are the clinically most useful predictors, especially if psychosocial and demographic risk factors are also pesent. Violent behaviours associated with mood disorders constitute a related yet independently also important aspect of this illness, and assessment and management of violence is a key component of everyday psychiatric practice. While most people with current mental disorder are not violent, violence is more common among seriously mentally ill individuals than in healthy persons. This is particularly true for untreated schizophrenics and untreated patients with major mood disorders, first of all in the cases of comorbid substance use disorders, mainly among those with current mania or postpartum depression. Although specific clinical studies are lacking, it is very lilely that successful acute and long-tem treatment of mood disorders can reduce the risk of violent behaviour in this patient population.

Current research on affective temperaments.

PURPOSE OF REVIEW: The aim of this review is to highlight the relationship between affective temperaments and clinical mood disorders and to summarize the earlier and most recent studies on affective temperaments in both clinical and nonclinical populations. RECENT FINDINGS: Current research findings show that specific affective temperament types (depressive, cyclothymic, hyperthymic, irritable and anxious) are the subsyndromal (trait-related) manifestations and commonly the antecedents of minor and major mood disorders. Up to 20% of the population has some kind of marked affective temperaments; depressive, cyclothymic and anxious temperament is more frequent in women, whereas hyperthymic and irritable temperaments predominate among men. Molecular genetic studies show a strong involvement of the central serotonergic (depressive, cyclothymic, irritable and anxious temperaments) and dopaminergic (hyperthymic temperament) regulation, suggesting that the genetic potential of major mood episodes lies in these temperaments. SUMMARY: Premorbid affective temperament types have an important role in the clinical evolution of minor and major mood episodes including the direction of the polarity and the symptom formation of acute mood episodes. They can also significantly affect the long-term course and outcome including suicidality and other forms of self-destructive behaviours such as substance use and eating disorders.

Affective temperaments, as measured by TEMPS-A, among nonviolent suicide attempters.

BACKGROUND: The aim of this study was to investigate the role of affective temperaments in suicidal behavior. METHOD: Using the standardized Hungarian version of the full-scale 110-item version of the TEMPS-A autoquestionnaire we compared the affective temperament-profiles of 150 consecutively investigated nonviolent suicide attempters (106 females and 44 males) and 302 age, sex and education matched normal controls (216 females and 86 males). RESULTS: Compared to controls, both female and male suicide attempters scored significantly higher in the four of the five affective temperaments, containing more or less depressive component (depressive, cyclothymic, irritable and anxious). On the other hand, however, no significant difference between the suicide attempters and controls was found for the hyperthymic temperament. Significantly higher rate of suicide attempters (90.0%) than controls (21.5%) have had some kind of dominant (mean score+2SD or above) affective temperament. Compared to controls, depressive, cyclothymic, irritable and anxious temperaments were significantly more frequent and hyperthymic temperament was nonsignificantly less common among suicide attempters. CONCLUSIONS: The findings support the strong relationship between depression and suicidal behavior even on temperamental level, and suggest that hyperthymic temperament does not have predisposing role for suicidal behavior at least in the case of nonviolent suicide attempters. LIMITATION: As only nonviolent suicide attempters were studied, our findings should pertain only for this patient-population.

Psychiatric characteristics of 100 nonviolent suicide attempters in Hungary.

BACKGROUND: Previous international and Hungarian studies have shown that around 90% of persons making suicide attempts had at least one current mental disorder. The aim of this study was to investigate the current prevalence of DSM-IV Axis I psychiatric diagnoses among nonviolent suicide attempters in Budapest, Hungary. METHODS: Using a structured interview (Mini International Neuropsychiatric Interview) determining DSM-IV Axis I diagnoses, the authors examined 100 consecutively contacted nonviolent suicide attempters (68 females and 32 males), aged between 14 and 66 (mean: 36.3 years). RESULTS: A total of 64% of the subjects were repeated attempters, and the most common method was drug overdose (96%), in 21% of cases in combination with alcohol ingestion. A total of 92% of the attempters had at least one current DSM-IV Axis I psychiatric diagnosis. In 87% it was depressive disorder (59% unipolar major depression, 14% bipolar II depression and 12% bipolar I depression, 2% dysthymic disorder), in 46% anxiety disorders, in 27% substance-use disorder and in 2% psychotic disorder. Sixty percent of the attempters received two or more current Axis I diagnoses (35% depressive + anxiety disorder only, 15% depressive + substance-related disorder only, and 10% depressive + anxiety + substance-related disorder). LIMITATIONS: Nonviolent suicide attempters are not representative of all persons with attempted suicide and subthreshold Axis I diagnoses were not investigated. CONCLUSION: This study supports previous international and Hungarian findings on the high prevalence and comorbidity of Axis I mental disorders among persons with recent nonviolent suicide attempt.