Treatment engagement: a neglected aspect in the psychiatric care of suicidal patients.

OBJECTIVE: Suicide remains a serious health problem in the United States and worldwide. Despite changing distributions in sex, race-ethnicity, and age and considerable efforts to reduce the incidence rate, the number of suicides has remained relatively stable. The transition from emergency services to outpatient services is a crucial but often neglected step in treating suicidal individuals. Up to 50% of attempters refuse recommended treatment, and up to 60% drop out after only one session. This point of intervention is crucial for patients at elevated risk of suicide to reduce imminent danger and to increase the chances that patients will follow up on recommended treatment. METHODS: PubMed, MEDLINE, and PsycINFO databases were searched for empirical investigations of treatment engagement of suicide attempters. Keywords searched included treatment, intervention, engagement, adherence, compliance, utilization, participation, and suicide attempt. Mapped terms were also included. Thirteen articles were selected. RESULTS: Studies that have examined the effectiveness of postdischarge contact with suicide attempters (phone, letter, and in-person visits) to increase treatment adherence have found some immediate effects after substantial contact that were not sustained. Simple referrals to outpatient care were not effective. Family group interventions for adolescents have improved adherence, as have brief interventions in the emergency department. CONCLUSIONS: Despite greater public awareness of suicide, heightened prevention effort, and increased efficacy of treatment interventions, success in reducing suicidal behavior has been limited. Developing brief interventions for use in emergency settings that can reduce suicide risk and enhance treatment follow-up has been a neglected aspect of suicide prevention and may help to reduce suicidal behavior.

The role of depression in the differential effect of childhood parental divorce on male and female adult offspring suicide attempt risk.

In previous studies by our group, we found that female offspring of parental divorce and parental remarriage are more susceptible to suicide attempt than male offspring. In this study, we examine whether these findings remain even after controlling for offspring depression. The sample consists of respondents from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions. Multivariable regressions controlled for offspring depression, parental depression, age, race/ethnicity, income, and marital status. Our previous findings that female offspring of parental divorce and parental remarriage are more likely to report a lifetime suicide attempt than male offspring remained even after controlling for offspring depression. Findings suggest that focusing on engaging female offspring who demonstrate symptoms of depression is not sufficient to reduce suicide attempt risk in this group as many at risk individuals will remain unrecognized.

Parental divorce, parental depression, and gender differences in adult offspring suicide attempt.

Research suggests parental divorce during childhood increases risk of suicide attempt for male but not female offspring. The negative impact on offspring associated with parental divorce may be better explained by parental psychopathology, such as depression. We examined whether adult offspring of parental divorce experience elevated risk of suicide attempt, controlling for parental history of depression, and whether the risk varies by the gender of the offspring. Using the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the sample consists of respondents who experienced parental divorce (N = 4895). Multivariable regressions controlled for age, race/ethnicity, income, marital status, and parental history of depression. Females living with their fathers were significantly more likely to report lifetime suicide attempts than females living with their mothers, even after controlling for parental depression. Findings suggest that childhood/adolescent parental divorce may have a stronger impact on suicide attempt risk in female offspring than previously recognized.

Clinical pitfalls in the diagnosis of ataque de nervios: a case study.

Ataque de nervios (attack of nerves) is an idiom of distress generally thought of in relation to Caribbean Hispanics. The following case study discusses the presentation of ataque de nervios in a Colombian female. This case study provides insight into a different presentation of ataque de nervios in a new population that clinicians should be aware of in order to ensure accurate diagnosis. Ataque de nervios is a distinct syndrome that does not fully correspond with any single DSM-IV diagnosis. However, there is overlap between symptoms in this condition and those in conventional clinical diagnoses. Common problems in deriving an accurate differential diagnosis are discussed. Implications for treatment are also reviewed, with an emphasis on a comprehensive approach to treatment that supports the client's norms and values.

Religion and suicide.

Religion impacts suicidality. One's degree of religiosity can potentially serve as a protective factor against suicidal behavior. To accurately assess risk of suicide, it is imperative to understand the role of religion in suicidality. PsycINFO and MEDLINE databases were searched for published articles on religion and suicide between 1980 and 2008. Epidemiological data on suicidality across four religions, and the influence of religion on suicidality are presented. Practice guidelines are presented for incorporating religiosity into suicide risk assessment. Suicide rates and risk and protective factors for suicide vary across religions. It is essential to assess for degree of religious commitment and involvement to accurately identify suicide risk.

Objections to suicide among depressed patients with alcohol use disorders.

BACKGROUND: Understanding how alcohol misuse interacts with beliefs that protect individuals against suicide can help to enhance suicide prevention strategies. One measure of suicide non-acceptability is the Moral Objections to Suicide (MOS) subscale of the Reasons for Living Inventory (RFLI). METHOD: 521 mood disordered patients with and without alcohol use disorders (AUD) were administered a battery of clinical measures including the Scale for Suicidal Ideation and the Reasons for Living Inventory. A multivariate analysis of covariance (MANCOVA) was conducted, examining the effects of alcohol use history on the five RFLI subscales and suicidal ideation, while controlling for differences in age, education, marital status and sex. RESULTS: RFL scores were no different between groups, except in one respect: patients with AUD had fewer moral objections to suicide. Higher suicidal ideation was associated with lower MOS scores. Prior suicidal behavior was associated with lower MOS, and higher current suicidal ideation. However, AUD history was not associated with suicidal ideation. CONCLUSION: Patients with AUDs had fewer objections to suicide, even though their level of current suicidal ideation was similar to those without AUD, suggesting that attitudes about the acceptability of suicide may be conceptually distinguished from suicidal ideation, and may be differentially associated with risk for suicidal behavior. These findings suggest that alcohol use and suicidal behavior predict current attitudes toward suicide, however causal mechanisms are not clearly understood.

Moral objections to suicide and suicidal ideation among mood disordered Whites, Blacks, and Hispanics.

UNLABELLED: Understanding the beliefs that protect individuals against suicide can help to enhance suicide prevention strategies. One measure of suicide non-acceptability is the moral objections to suicide (MOS) sub-scale of the reasons for living inventory (RFLI). This study examined the MOS and suicidal ideation of White, Black, and Hispanic individuals with mood disorders. We expected minority individuals to have stronger objections to suicide. METHOD: Eight hundred and four, White (588), Black (122) and Hispanic (94) participants with DSM-IV diagnoses of MDD or bipolar disorder were administered the scale for suicide ideation, the reasons for living inventory and several measures of clinical distress. RESULTS: Higher suicidal ideation was modestly correlated with lower MOS scores overall (r=0.15, p=0.001). Among Blacks however the relationship was inverted: despite having higher suicidal ideation than Whites or Hispanics, Blacks reported the least accepting attitudes toward suicide. CONCLUSION: These results suggest that attitudes regarding the acceptability of suicide may be independent of suicidal ideation.

Childhood or adolescent parental divorce/separation, parental history of alcohol problems, and offspring lifetime alcohol dependence.

BACKGROUND: This study examined whether the experiences of childhood or adolescent parental divorce/separation and parental alcohol problems affected the likelihood of offspring DSM-IV lifetime alcohol dependence, controlling for parental history of drug, depression, and antisocial behavior problems. METHOD: Data were drawn from the 2001-2002 National Epidemiological Survey on Alcohol and Related Conditions (NESARC), a nationally representative United States survey of 43,093 civilian non-institutionalized participants aged 18 and older, interviewed in person. Logistic regression models were used to calculate the main and interaction effects of childhood or adolescent parental divorce/separation and parental history of alcohol problems on offspring lifetime alcohol dependence, after adjusting for parental history of drug, depression, and antisocial behavior problems. RESULTS: Childhood or adolescent parental divorce/separation and parental history of alcohol problems were significantly related to offspring lifetime alcohol dependence, after adjusting for parental history of drug, depression, and antisocial behavior problems. Experiencing parental divorce/separation during childhood, even in the absence of parental history of alcohol problems, remained a significant predictor of lifetime alcohol dependence. Experiencing both childhood or adolescent parental divorce/separation and parental alcohol problems had a significantly stronger impact on the risk for DSM-IV alcohol dependence than the risk incurred by either parental risk factor alone. CONCLUSIONS: Further research is needed to better identify the factors that increase the risk for lifetime alcohol dependence among those who experience childhood or adolescent parental divorce/separation.

Depressed patients with co-occurring alcohol use disorders: a unique patient population.

OBJECTIVE: Alcohol use and depressive disorders are frequently comorbid. Few studies have assessed the impact of comorbid alcohol use disorders (AUDs) on clinical aspects of major depression. We compared depressed subjects with and without co-occurring AUDs with respect to demographic and clinical parameters. METHOD: 505 individuals participated. 318 subjects had DSM-IV major depressive disorder (MDD) without a history of any alcohol or substance abuse/dependence (MDD only), and 187 individuals had MDD and a history of alcohol abuse/dependence (MDD/AUD). Demographic, clinical, and psychiatric history measures of patients in the 2 groups were examined and compared. The study was conducted from January 1990 to June 2005. RESULTS: MDD/AUD patients were younger at their first psychiatric hospitalization (p = .014), their first major depressive episode (p = .041), and their first suicide attempt (p = .001). They reported more previous major depressive episodes (p = .001), suicide attempts (p = .001), and recent life events (p = .001); and had higher lifetime aggression (p < .001), impulsivity (p < .001), and hostility (p < .001) scores. MDD/AUD patients were also more likely to report tobacco smoking (p < .001), a lifetime history of abuse (p = .004), and a history of AUD among first-degree relatives (p < .001) compared to MDD only patients. MDD/AUD individuals also had higher childhood (p < .001), adolescent (p < .001), and adult (p < .001) aggression scores and reported more behavioral problems during their childhood compared to their counterparts. Logistic regression analysis demonstrates that the number of previous depressive episodes, lifetime aggression, and smoking drive the difference between the groups. CONCLUSIONS: Our findings suggest that comorbid MDD/AUD may result from worse antecedents and lead to early onset, more comorbidity, and a more severe course of illness.

The role of moral objections to suicide in the assessment of suicidal patients.

BACKGROUND: Moral and religious objections to suicide (MOS) are reported to be associated with less suicidal behavior in depressed patients, and are proposed to act as a protective factor against suicidal behavior. It is unclear whether MOS are a protective factor against suicide attempt per se, or if this effect is mediated through other variables. METHOD: Depressed inpatients (n=265) reporting low or high MOS were compared on history of suicidal behaviour, demographic and clinical characteristics. RESULTS: Patients with low MOS had significantly more lifetime suicide attempts, were more often without religious affiliation, had greater depression severity, hopelessness and trait impulsivity, less anxiety and fewer reasons for living. Logistic regression revealed that lower MOS was independently associated with suicide attempt. CONCLUSIONS: Moral and religious objections to suicide may serve as a protective factor against suicidal acts given their unique association with less suicidal behavior in depressed inpatients.

Perceived reasons for living at index hospitalization and future suicide attempt.

It is unclear why certain individuals choose not to engage in suicidal behavior. Although important, protective factors against suicidal behavior have seldom been studied. The Reasons for Living Inventory is a measure of putative protective factors that is inversely related to a history of suicide attempts, but its predictive utility remains relatively untested. This study sought to determine whether the Reasons for Living Inventory predicts future suicide attempts over a 2-year period. Depressed inpatients were assessed for reasons for living and were followed for 2 years. Follow-up interviews took place at 3 months, 1 year, and 2 years after discharge from the index hospitalization. Survival analysis indicates a high score on the Reasons for Living Inventory predicted fewer future suicide attempts within a 2-year period in women but not in men. Perceived reasons for living serve as protective factors against suicide attempt in women and not in men.