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| Risk Factors
> Mental Disorders |
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Depression
Depression is the most common mental health disorder in psychiatric practice, and is present in about 10% of the population at any given time. Depression is still the leading mental health disorder associated with suicide, and is present in up to 60% of completed suicides. Several studies of completed suicides where relatives and health professional have been interviewed (psychological autopsy studies) indicate that an identifiable mental illness is present in between 80-90% of completed suicides. Co-occurring alcohol abuse on top of depression is reported in about 75% of suicides. In younger suicides, recent research has suggested that adjustment disorder with depressed mood may be a common trigger. Major depression with psychotic features is a particular depressive subtype at increased risk for suicide, although there is some uncertainty in the research literature as to whether delusional ideas during depression influence suicidal behavior.
Bipolar Disorder
Although Bipolar disorder affects about 1-2% of the population, sufferers from this condition are at particular increased risk of suicide. Suicidal behavior generally tends to occur early in the course of illness (usually within the first few years) and is most often associated with mixed symptoms or dysphoric mania (mania with depressive symptoms). The lifetime suicide rate in Bipolar Disorder is about 10%; however, the rate of suicide attempts is even greater, 25-50% of patients will make a suicide attempt at some point during their illness. Recent studies suggest that the risk of suicidal behavior may be diminished by adherence to medication regimens with preventive mood-stabilizing agents such as lithium. Co-morbid alcohol use increases risk as with other disorders.
Schizophrenia
Schizophrenia is a relatively rare clinical condition affecting about 1 % of the population. Patients with this condition are at increased risk of suicide, about 15% of patients die by suicide. Patients are particularly at risk if they have mood swings as a component to their illness, if they abuse alcohol or if they experience voices instructing them to kill themselves. A chronic course of illness with a pattern of frequent relapses and hospitalizations also increases the risk of suicide as it may frequently lead to demoralization and hopelessness in affected individuals.
Alcohol Disorders
Alcohol abuse and dependence is highly associated with suicidal behavior including suicide, and as many as 30% of completed suicides will have a primary psychiatric diagnosis of an alcohol disorder. As mentioned under risk factors above, alcohol may act in the acute state as a trigger or as an enduring trait modulating an individual’s threshold for suicidal acts including suicide, or frequently contributing to both the trigger and threshold effect. Acute alcohol intake releases many brain neurotransmitters some of which stimulate pleasure / euphoria (dopamine), and others involved in the regulation of mood and restraint (serotonin). Following the neurotransmitter release however there can be a transient neurotransmitter depletion state leading to the opposite emotional feelings including dysphoria and disinhibition which represent high risk periods for individuals already predisposed to suicidal acts. It is possible that the young developing brain may be more sensitive to these acute neurochemical and consequent behavioral effects. Chronic alcohol causes neurotoxicity to several important brain regions involved in regulation of mood and restraint, rendering the individual chronically vulnerable to acting (or failing to suppress) suicidal impulses during times of stress.
Other Substance Abuse Disorders
Several other recreational substances are thought to have similar brain effects to alcohol thus contributing to increased risk of suicide. These include cocaine, amphetamines and hallucinogenic drugs. Cannabis may also cause lowering of mood, disinhibition and paranoid thinking which can increase suicide risk.
Borderline Personality Disorder
This is a particularly emotionally disabling personality disorder characterized by mood swings (affective instability), interpersonal conflict, self-destructive and suicidal urges and impulses, impulsivity in general and identity issues. The disorder seems to be much more common in females and self-destructive behavior and suicidal behavior is common. The risk of suicide is about 10% in this population. Other personality disorders are also associated with increased risk for suicidal acts including suicide including antisocial personality disorder and narcissistic personality disorder.
Organic Mental Disorders
Certain organic disorders are associated with increased suicide risk. These include Huntington’s Chorea, Alzheimer’s Disease in its early stages, and also in patients who have suffered traumatic brain injury.
Panic and Anxiety Disorders
Some research suggests that Panic Disorder may increase suicide risk, but the effect is likely to be modest and may be a concern if co-existing with other risk factors noted above.
Anorexia Nervosa and Body Dysmorphic Disorders
Post-traumatic Stress Disorder (PTSD) Research evidence is accumulating to suggest that severe PTSD is associated with increased suicide risk, and this is particularly seen in combat veterans, but may be evidenced in other PTSD conditions.
Medical Disorders and Medication
Patients with chronic medical illness such as severe pain syndromes, chronic dialysis, etc are at increased risk for suicide, with hopelessness and despair being the modulating factor. Some patients with terminal illnesses such as cancer may be at increased risk of suicide, although studies suggest that the risk is greatest in those who develop a depressive reaction. Although in theory any medication may induce an alteration in mood there are a couple of medications, which carry a specific warning regarding increased suicide risk. The most important of these is steroid preparations, which in a select few cases may induce a steroid-induced altered mood state with profound depression and suicidal urges. The other compound that carries a specific suicide risk warning is the drug Accutane. Accutane is a Vitamin A preparation that has been highly successful in the treatment of acne, typically prescribed to adolescent males. While the suicide rate per million prescriptions is no greater for patients taking this drug than in age matched control groups in the general population, isolated cases of rapidly altered mood and subsequent suicide have been reported in sufficient quantity worldwide for the manufacturers to insert a suicide risk warning. This is more than likely an idiosyncratic reaction, and it is possibly dose-dependent. The devastating consequences of this adverse reaction however guarantee that research will continue to try to understand the mechanism that may underlie this syndrome. The overwhelming research evidence to date would suggest that antidepressant pharmacotherapy is safe and effective in the treatment of depression. No formal studies have been conducted to date to assess whether antidepressant medications reduce suicide rates, but indirect evidence suggests that they may, in a dose-dependent manner. A small group of scientists and patient advocates have asserted that antidepressants may increase suicide risk, and cite isolated cases in support of their assertion. It is possible that paradoxical idiosyncratic reactions similar to Accutane description above may occur with antidepressant medication, but it has received insufficient study to date.
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