Mood disorders

All types of mood disorders have been associated with suicide. These include bipolar affective disorder, depressive episode, recurrent depressive disorder and persistent mood disorders (e.g. cyclothymia and dysthymia), which form categories F31-F34 in ICD-10. Suicide is therefore a significant risk in unrecognized and untreated depression. Depression has a high prevalence in the general population and is not recognized by many as a disease. It is

estimated that 30% of patients seen by a physician are suffering from depression. Roughly 60% of those who do seek treatment initially contact a general practitioner. It is a special challenge for the physician to work with both physical disease and psychological disorders simultaneously.

• Tiredness

• Sadness

• Lack of concentration

• Anxiety

• Irritability

• Sleep disturbances

• Pain in different parts of the body.

These symptoms should alert the physician to the presence of depression and lead to an assessment of the suicide risk. Specific clinical features associated with increased risk of suicide in depression are:

• Persistent insomnia

• Self-neglect

• Severe illness (particularly psychotic depression)

Collaborating with the psychiatrist and ensuring that adequate and appropriate treatment is given is a crucial function of the physician.  In typical depressive episodes, the individual usually suffers from:

• Depressed mood (sadness)

• Loss of interest and enjoyment

• Reduced energy (fatiguability and diminished activity)

• Impaired memory

• Agitation

• Panic attacks.

The following factors increase the risk of suicide in people with depression:

• Age below 25 years in men

• Early phase of the illness

• Abuse of alcohol

• Depressed phase of a bipolar disorder

• Mixed (manic-depressive) state

• Psychotic mania.

Depression is an important factor in suicide among both adolescents and the elderly but those with late onset of depression are at a higher risk.

Epidemiological data suggest that antidepressants reduce suicide risk among the depressed. The full therapeutic dose of medication should be continued for several months. In the elderly it may be necessary to continue treatment for two years after recovery. Patients on regular lithium maintenance therapy have been found to have lower suicide risk.

Alcoholism

Alcoholism (both alcohol abuse and dependence on alcohol) is a frequent diagnosis in those who have committed suicide, particularly in young people. There are biological, psychological and social explanations for the correlation between suicide and alcoholism. Specific factors associated with increased suicide risk among alcoholics are :

• Early onset of alcoholism

• Long history of drinking

• High level of dependence

• Depressed mood

• Poor physical health

• Poor work performance

• Family history of alcoholism

• Recent disruption or loss of a major interpersonal relationship.

Schizophrenia

Suicide is the largest single cause of premature death among schizophrenics. Specific risk factors for suicide are:

• Young unemployed male

• Recurrent relapses

• Fear of deterioration, especially in those of high intellectual ability

• Positive symptoms of suspiciousness and delusions

• Depressive symptoms.

Suicide risk is highest at the following times:

• Early stages of the illness

• Early relapse

• Early recovery.

Suicide risk decreases with increasing duration of the illness.

Personality disorders

Recent studies on young people who committed suicide have shown a high prevalence (20-50%) of personality disorder. The personality disorders that are more frequently associated with suicide are borderline personality and antisocial personality disorders. Histrionic and narcissistic personality disorders and certain psychological traits such as impulsivity and aggression, have also been associated with suicide.

Anxiety Disorders

Among anxiety disorders, panic disorder has been most frequently associated with suicide, followed by obsessive-compulsive disorder (OCD). Somatoform disorder and eating disorders (anorexia nervosa and bulimia) are also related to suicidal behaviour.