The European Psychiatric Association (EPA) guidance on suicide treatment and prevention.

UNLABELLED: Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. SUICIDAL CRISIS: Acute intervention should start immediately in order to keep the patient alive. DIAGNOSIS: An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential. TREATMENT: Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. Treatment with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. Treatment with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. TREATMENT TEAM: Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. FAMILY: The suicidal person independently of age should always be motivated to involve family in the treatment. SOCIAL SUPPORT: Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks. SAFETY: A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. TRAINING OF PERSONNEL: Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.

[Development of the Risk Assessment Suicidality Scale (RASS): a population-based study].

Suicide and suicide attempts are significant and costly public health problems. In order to prevent suicidal and other self-injurious behavior, research on the multiple factors involved in these behaviors with comprehensive and user-friendly instruments is necessary. The aim of the current study was to construct a self-report instrument with emphasis on the items which describe suicide-related behavior itself rather than strongly related clinical features on the basis of a general population study. Twelve items comprising a new scale were applied to 734 subjects from the general population (40.6% males and 59.4% females) aged 40.8 +/- 11.5, along with the STAI and the CES-D. The scoring method was developed on the basis of frequency table of responses to the individual scale items. The factor analysis returned 3 factors explaining 59.19% of total variance (Intention, Life, and History). The Cronbach's alpha was 0.85 for the Intention, 0.69 for the Life and 0.52 for the History subscale. The RASS is a reliable and valid instrument which might prove valuable in the assessment of suicidal risk in the general population as well as in mental patients.

[Predicting risk of suicide in bipolar and unipolar depression: correlation between temperament and personality]. / Prädiktion des Suizidrisikos bei bipolar und unipolar depressiven Patienten: Wechselwirkung von Temperament und Persönlichkeit.

OBJECTIVE: The aim of this study was to evaluate the roles of personality and affective temperament traits in the prediction of suicide risk in mood disorders. METHODS: The participants were 147 psychiatric inpatients with bipolar disorders I and II and major depressive disorder. Patients undertook the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego self-rating questionnaire, the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), and the Beck Hopelessness Scale. RESULTS: Sixty-four subjects were diagnosed with increased suicidal risk based on the Mini International Neuropsychiatric Interview (MINI). Logistic regression analysis resulted in two models predictive of MINI-based suicidal risk: irritable temperament and the MMPI-2 scale. Multiple regression analysis further indicated that higher hyperthymic values are protective against hopelessness, while MINI-based suicidal intent is a predictor of hopelessness. CONCLUSIONS: Personality and affective temperament traits may have a role in the prediction of suicide.

Circulating endothelial progenitor cells and depression: a possible novel link between heart and soul.

Although depression is known to be an independent risk factor for cardiovascular disorders, the mechanisms behind this connection are not well understood. However, the reduction in the number of endothelial progenitor cells (EPCs) in patients with cardiovascular risk factors has led us to hypothesize that depression influences the number of EPCs. EPCs labeled with CD34, CD133 and vascular endothelial growth factor receptor-2 (VEGFR2) antibodies were counted by flow cytometry in the peripheral blood (PB) of 33 patients with a current episode of major depression and of 16 control subjects. Mature (CD34+/VEGFR2+) and immature (CD133+/VEGFR2+) EPC counts were decreased in patients (vs controls; P<0.01 for both comparisons), and there was a significant inverse relationship between EPC levels and the severity of depressive symptoms (P<0.01 for both EPC phenotypes). Additionally, we assayed the plasma levels of VEGF, C-reactive protein (CRP) and tumor necrosis factor (TNF)-alpha and observed significantly elevated TNF-alpha concentrations in patients (vs controls; P<0.05) and, moreover, a significant inverse correlation between TNF-alpha and EPC levels (P<0.05). Moreover, by means of a quantitative RT-PCR approach, we measured CD34, CD133 and VEGFR2 mRNA levels of PB samples and found a net trend toward a decrease in all the investigated EPC-specific mRNA levels in patients as compared with controls. However, statistical significance was reached only for VEGFR2 and CD133 levels (P<0.01 for both markers). This is the first paper that demonstrates evidence of decreased numbers of circulating EPCs in patients with a current episode of major depression.

Towards a genetically validated new affective temperament scale: a delineation of the temperament phenotype of 5-HTTLPR using the TEMPS-A.

BACKGROUND: Although it has been described that affective temperaments are associated with the 5-HTTLPR, less attention was paid to the association between this polymorphism and subscales and items related to each affective temperament. The aim of our study was to investigate the association of affective temperament subscales and individual items with the s allele of the 5-HTTLPR. METHOD: 138 psychiatrically healthy women completed the TEMPS-A questionnaire and were genotyped for 5-HTTLPR. Scores of subjects on the temperament scales, subscales and items in the three genotype and the two phenotype groups were compared using ANOVA. We selected items with significantly different mean scores between the three genotype groups and the two phenotype groups separately and performed item analysis. RESULTS: Subjects in the different 5-HTTLPR genotype and phenotype groups have significantly different score on scales measuring depressive, cyclothymic, irritable and anxious temperaments, and several subscales composing these temperamental scales. Subjects in the three genotype groups scored significantly different on 11 items, 8 of these remained in a derived genotype scale after item analysis. Subjects in the two phenotype groups had significantly different scores on 12 items, 9 of them were retained in a derived phenotype scale after item analysis. LIMITATIONS: Our sample was relatively small and included only women. CONCLUSIONS: Our data provide support for the association of affective temperaments with the s allele. Although the cyclothymic temperament shows the strongest association, all temperaments within the depressive superfactor have a similar share in this association. The newly derived 5-HTTLPR Phenotype Scale shows strong association with 5-HTTLPR genotype and phenotype, therefore this scale should be further investigated in relation to psychiatric disorders, as well as psychological traits and temperaments.

Cigarette smoking and psychiatric disorders in Hungary.

Data from the United States and from several European countries show that patients with major mood disorders, schizophrenia and social phobia smoke at significantly higher rates than the general population. However, there are no published results on this field from Central Europe, including Hungary. In the present study, the rate of current and lifetime smoking of the consecutively screened outpatients with DSM-IV unipolar major depression (n=92), bipolar disorder (n=60), schizophrenia (n=80), schizoaffective disorder (n=42) and panic disorder without major depression (n=60) were assessed and the data were compared to the controls (n=5503), representative for the general population of Hungary. The results showed that, compared to controls, the rates of current and lifetime smoking were significantly higher among patients with unipolar major depression, bipolar disorder, schizophrenia and schizoaffective disorder, but not among patients with panic disorder without major depression. The findings support previous findings from other countries on the strong relationship between cigarette smoking and major mood and schizophrenic spectrum disorders.

Gender differences in panic disorder symptoms and illicit drug use among young people in Hungary.

The authors have investigated the frequency of illicit drug use, and spontaneous and drug-provoked panic disorder symptoms in Hungarian youths. A semi-structured self-reporting questionnaire (with questions about drug usage and the persistence of some DSM-IV panic disorder symptoms) was filled out in discos/nightclubs, secondary schools and universities. Almost 17% of the total sample (n = 1298) reported on illicit drug-use at least once in their life, and this rate was significantly higher among males. Regardless of the illegal drug use 14.6% of the total sample reported on four or more DSM-IV symptoms of panic disorder, and this rate was significantly higher among females. Analyzing the panic disorder symptoms only among drug-users (n = 219), the frequency of persons with four or more anxiety symptoms was 14.1% before drug use, and it increased to 30.6% during the period of drug use (P < 0.001). The findings support previous results showing (i) higher prevalence of anxiety symptoms among females; (ii) higher rate of illicit drug use among males; and (iii) a possible anxiety-provoking effect of illicit drugs.

Gender differences in major depressive disorder in a Hungarian community survey.

INTRODUCTION: The aim of this study was to investigate the characteristics of Major Depressive Disorder (MDD) in males and females in a sample of the Hungarian adult population. METHOD: 2953 randomly selected subjects between 18 and 64 years old were interviewed using the Hungarian version of the Diagnostic Interview Schedule (DIS), which generated DSM-III-R diagnoses. RESULTS: The lifetime and period prevalences of MDD were more than twice as high in women than in men. The gender difference appeared in early adolescence and continued up until the age of 50. An increased risk for anxiety disorders was found in patients with MDD, irrespective of gender, and in the majority of cases (65%) the anxiety symptoms preceded the onset of MDD. Depressed women tended to have more symptoms and a more marked tendency for recurrence than men. The preponderance of females was twice as high in MDD with comorbid anxiety than in MDD without it, in spite of the fact that the likelihood of the coexistence of MDD and anxiety disorders did not differ by gender. CONCLUSION: The higher MDD prevalence rate in women might be the consequence of a higher rate of pre-existing anxiety disorder(s).

Can better recognition and treatment of depression reduce suicide rates? A brief review.

Depression, the major cause of suicide, is prevalent but an under-detected, underdiagnosed and, under-treated illness and it is particularly true for depressed suicide victims. However, several studies consistently show that successful treatment of depression not only relieves depressive symptoms, but also decreases and makes suicidality vanish. If the rate of treated depressions in the population increases gradually, at a given point it will appear in the decline of the suicide rates. Although absolute evidence is lacking at present, recent reports from some European countries strongly suggest that increasing utilisation of antidepressants is one of the most important contributing factors in the decrease in suicide rates.

Anxiety disorders comorbidity in bipolar I, bipolar II and unipolar major depression: results from a population-based study in Hungary.

BACKGROUND: The aim of this study was to analyze the lifetime comorbidity between DSM-III-R anxiety disorders in separate subgroups of patients with major depression, bipolar II and bipolar I disorder in a community sample of a Hungarian population. METHODS: Randomly selected subjects (aged between 18 and 64 years, N=2953) were interviewed by the Diagnostic Interview Schedule (DIS) which generated DSM-III-R diagnoses. RESULTS: The prevalence of generalized anxiety disorder, agoraphobia and simple phobia was the highest among bipolar II patients (20.8, 37.5 and 16.7%, respectively), social phobia was most prevalent in (nonbipolar) major depression (17.6%), while the rate of panic disorder was the same in the (nonbipolar) major depressive and bipolar II subgroups (12.4 and 12.5%, respectively). Bipolar I patients showed a relatively low rate of comorbidity. CONCLUSIONS: The findings support previous results on the particularly high rate of lifetime comorbidity between anxiety disorders and unipolar major depression and particularly bipolar II illness. LIMITATIONS: Underestimation of the prevalence of bipolar II disorder by the diagnostic methodology used, resulting in a small number of bipolar II cases, lack of analysis of data by gender, no data on obsessive-compulsive disorder.

Suicide attempts in the Hungarian adult population. Their relation with DIS/DSM-III-R affective and anxiety disorders.

Prevalence of suicide attempts and their relationship with DIS anxiety and affective disorder diagnoses were investigated in a Hungarian adult community sample. Despite the high suicide mortality rate, the rate of suicide attempts was similar to that reported in other studies using similar methods. Suicide attempts occurred more frequently among women and previously married persons. Although the presence of any lifetime anxiety and/or affective disorder increased the rate of reported suicide attempts, the effect of co-morbidity, recurrence and chronicity might be considered significant predictors. The highest odds of an attempt were related to the diagnoses of dysthymic or bipolar disorders. Agitation was the only depressive symptom, which increased the odds of a suicide attempt.

Sensitivity and specificity of DSM-IV atypical features for bipolar II disorder diagnosis.

The aim of the study was to find the sensitivity and the specificity of DSM-IV atypical features (mood reactivity, weight gain, appetite increase, hypersomnia, leaden paralysis, interpersonal rejection sensitivity) for the diagnosis of bipolar II disorder. Consecutive 557 unipolar (54.9%) and bipolar II (45.0%) major depressive episode (MDE) outpatients were interviewed with the Structured Clinical Interview for DSM-IV and the Global Assessment of Functioning Scale. Bipolar II was diagnosed broadly, with a minimum duration of hypomania of at least some days, instead of the 4 days required by DSM-IV. MDE with atypical features was significantly more common in bipolar II patients. For the diagnosis of bipolar II disorder, MDE with atypical features, sensitivity was 0.45, and specificity was 0. 74. Among individual atypical features, hypersomnia had the best combination of sensitivity (0.35) and specificity (0.81). Combinations of two and three features did not improve sensitivity and specificity. As the diagnosis of past hypomania may not be very reliable from a patient's interview, atypical features may be an important marker of bipolar II disorder.

Bipolar II disorder and suicidal behavior.

Despite the fact that the nosologic position of bipolar II disorder continues to be debated, several lines of research indicate that it is a distinct nosologic category that should be separated from both bipolar I and unipolar major depression. This review of the authors' and others' work demonstrates that the lifetime risk of suicide attempts is highest in bipolar II and lowest in unipolar patients, whereas risk is intermediate in bipolar I patients. Moreover, two reports show that bipolar II patients are over represented among suicide victims. Clinicians must take great care in not missing this diagnosis, which, when untreated, has ominous prognostic implications.

Decreasing tendency of seasonality in suicide may indicate lowering rate of depressive suicides in the population.

The seasonality of suicide is well known and a repeatedly demonstrated phenomenon. The authors analyzed the seasonality of 148 suicide events on Gotland between 1981 and 1996. A marked and significant seasonality with a spring and summer peak was found between 1981 and 1989, when the prescription of antidepressants was relatively low and stable. However, this seasonality disappeared in the period between 1990 and 1996, when prescription of antidepressants increased dramatically, indicating that more and more depressed patients were pharmacologically treated. As the seasonality of suicide in the population is the reflection of the seasonal nature of depressive suicides, the result suggests that a decreasing tendency of seasonality in suicide may indicate the lowering rate of depressive suicides in the given population.

The prevalence of major depressive and bipolar disorders in Hungary. Results from a national epidemiologic survey.

In order to estimate the prevalence of affective disorders in Hungary a sample of the Hungarian adult population (18-64 years) selected at random was interviewed using the Diagnostic Interview Schedule (DIS) which generated DSM-III-R diagnoses. The lifetime rate for Major Depressive Disorder (MDD) was 15.1%, and for Bipolar Disorders (BD) 5.1%. The female-to-male ratio was 2.7 for MDD and nearly equal for BD. The 1-year and 1-month period prevalence rates were 7.1% and 2.6% for MDD and 0.9% and 0.5% for manic episodes. A higher rate of divorced or separated persons was found among individuals with a lifetime diagnosis of MDD. Besides these, the lifetime diagnosis of BD coexisted with higher rates of the never-married state. The highest hazard rate for the development of BD or MDD was in the range 15-19 years but in MDD another peak was also found in the range 45-50 years. The first peak was characteristic of the recurrent, and the other one of the single form of MDD. Insomnia, loss of energy, decreased interest, concentration problems were the most common symptoms during the depressive episode, independent of polarity. Higher rates of lifetime diagnosis of dysthymia and all kinds of anxiety disorder were revealed among persons with MDD. BD was associated with GAD (Generalized Anxiety Disorder), and panic disorder more often than chance.