Affective disorders and suicide risk: a reexamination.

OBJECTIVE In 1970, Guze and Robins published a meta-analysis of suicide in patients with affective illness that inferred a lifetime risk of 15%. Since then, this figure has been generalized to all depressive disorders and cited uncritically in many papers and textbooks. The authors argue for an alternative estimate of suicide risk and question the generalizability of the Guze and Robins estimate. METHOD The authors sorted studies obtained through a literature search that included data pertaining to suicide occurrence in affective illness into one of three groups: outpatients, inpatients, or suicidal inpatients. Suicide risks were calculated meta-analytically for these three groups, as well as for two previously published collections. RESULTS There was a hierarchy in suicide risk among patients with affective disorders. The estimate of the lifetime prevalence of suicide in those ever hospitalized for suicidality was 8.6%. For affective disorder patients hospitalized without specification of suicidality, the lifetime risk of suicide was 4.0%. The lifetime suicide prevalence for mixed inpatient/outpatient populations was 2.2%, and for the nonaffectively ill population, it was less than 0.5%. CONCLUSIONS The percentage of subjects dead due to suicide (case fatality prevalence) is a more appropriate estimate of suicide risk than the percentage of the dead who died by suicide (proportionate mortality prevalence). More important, it is well established that patients with affective disorders suffer a higher risk of suicide relative to the general population. However, no risk factor, including classification of diagnostic subtype, has been reliably shown to predict suicide. This article demonstrates a hierarchy of risk based on the intensity of the treatment setting. Given that patients with a hospitalization history, particularly when suicidal, have a much elevated suicide prevalence over both psychiatric outpatients and nonpatients, the clinical decision to hospitalize in and of itself appears to be a useful indicator of increased suicide risk.

[1]  C. Odoroff,et al.  The mortality experience of a population with psychiatric illness. , 1969, The American journal of psychiatry.

[2]  P. Allebeck,et al.  Psychiatric Diagnoses as Predictors of Suicide , 1990, British Journal of Psychiatry.

[3]  F. Braceland,et al.  PROGNOSIS IN MENTAL DISEASE , 1937 .

[4]  J. Lanke,et al.  Suicide rates in the Lundby study: mental illness as a risk factor for suicide. , 1981, Neuropsychobiology.

[5]  Å. Stenstedt A study in manic-depressive psychosis; clinical, social and genetic investigations. , 1952, Acta psychiatrica et neurologica Scandinavica.

[6]  B. Barraclough Suicide Prevention, Recurrent Affective Disorder and Lithium , 1972, British Journal of Psychiatry.

[7]  K. Dahlgren Attempted suicides-35 years afterward. , 1977, Suicide & life-threatening behavior.

[8]  P. Huston,et al.  Involutional psychosis; course when untreated and when treated with electric shock. , 1948, Archives of neurology and psychiatry.

[9]  A. Pokorny A follow-up study of 618 suicidal patients. , 1966, The American journal of psychiatry.

[10]  T. Helgason EPIDEMIOLOGY OF MENTAL DISORDERS IN ICELAND. A PSYCHIATRIC AND DEMOGRAPHIC INVESTIGATION OF 5395 ICELANDERS. , 1964, Acta psychiatrica Scandinavica.

[11]  D. Avery,et al.  Mortality in depressed patients treated with electroconvulsive therapy and antidepressants. , 1976, Archives of general psychiatry.

[12]  G. Simon,et al.  Suicide mortality among patients treated for depression in an insured population. , 1998, American journal of epidemiology.

[13]  J. Sweeney,et al.  Major depression and the risk of attempted suicide. , 1995, Journal of affective disorders.

[14]  T. Bronisch The relationship between suicidality and depression , 1996 .

[15]  M. Tsuang,et al.  Excess mortality in schizophrenia and affective disorders. Do suicides and accidental deaths solely account for this excess? , 1978, Archives of general psychiatry.

[16]  B. Barraclough,et al.  Lifetime risk of suicide for affective disorder, alcoholism and schizophrenia , 1998, British Journal of Psychiatry.

[17]  G. Andrews,et al.  Diagnosis, Personality and the Long-term Outcome of Depression , 1990, British Journal of Psychiatry.

[18]  S. Guze,et al.  Suicide and Primary Affective Disorders , 1970, British Journal of Psychiatry.

[19]  A C Sims,et al.  Importance of a high tracing-rate in long-term medical follow-up studies. , 1973, Lancet.

[20]  A. Beck,et al.  Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation. , 1985, The American journal of psychiatry.

[21]  T. Rennie PROGNOSIS IN MANIC-DEPRESSIVE PSYCHOSES , 1942 .

[22]  A. Sims,et al.  The Pattern of Mortality in Severe Neuroses , 1978, British Journal of Psychiatry.

[23]  D. Black,et al.  Suicide in subtypes of major affective disorder. A comparison with general population suicide mortality. , 1987, Archives of general psychiatry.

[24]  M. Speechley,et al.  The adequacy of suicide statistics for use in epidemiology and public health. , 1991, Canadian journal of public health = Revue canadienne de sante publique.

[25]  C. Barkley,et al.  Future Imperfect: the Long-Term Outcome of Depression , 1994, British Journal of Psychiatry.

[26]  M. Vaeth,et al.  Excess mortality of bipolar and unipolar manic-depressive patients. , 1986, Journal of affective disorders.

[27]  D. Black,et al.  Is Death from Natural Causes Still Excessive in Psychiatric Patients?: A Follow-up of 1593 Patients with Major Affective Disorder , 1987, The Journal of nervous and mental disease.

[28]  R. Bland,et al.  Suicide risk varies by subtype of affective disorder , 1991, Acta psychiatrica Scandinavica.

[29]  J. Copeland Psychotic and neurotic depression: discriminant function analysis and five-year outcome , 1983, Psychological Medicine.

[30]  H. Babigian,et al.  Epidemiological considerations of psychotic depression. , 1972, Archives of general psychiatry.

[31]  J A Motto,et al.  Development of a clinical instrument to estimate suicide risk. , 1985, The American journal of psychiatry.

[32]  B. O'Shea,et al.  Excess mortality among psychiatric patients. , 1985, JAMA.

[33]  J. Egeland,et al.  Suicide and family loading for affective disorders. , 1985, JAMA.

[34]  F. Goodwin,et al.  Heritable factors in the severity of affective illness. , 1976, Biological psychiatry.

[35]  F. A. Whitlock,et al.  Depression and cancer: a follow-up study , 1979, Psychological Medicine.

[36]  M. Tansella,et al.  Mortality Among Patients with Psychiatric Illness a Ten-Year Case Register Study in an Area with a Community-based System of Care , 1995, British Journal of Psychiatry.

[37]  C. Duggan,et al.  Do different subtypes of hospitalized depressives have different long-term outcomes? , 1991, Archives of general psychiatry.

[38]  Y. Davenport,et al.  Follow-up of 53 Bipolar Manic-Depressive Patients , 1974, British Journal of Psychiatry.

[39]  A. Sims Mortality in neurosis. , 1973, Lancet.

[40]  A. Pokorny Prediction of suicide in psychiatric patients. Report of a prospective study. , 1983, Archives of general psychiatry.

[41]  J. Haug,et al.  THE COURSE OF MANIC‐DEPRESSIVE PSYCHOSIS A follow up investigation of 215 patients , 1968, Acta psychiatrica Scandinavica.

[42]  K. Jamison,et al.  Effect of Lithium Maintenance on. Suicidal Behavior in Major Mood Disorders a , 1997, Annals of the New York Academy of Sciences.

[43]  P. Diggle,et al.  Analysis of Longitudinal Data , 2003 .

[44]  R. Sharma,et al.  Mortality in affective disorder. , 1994, Journal of affective disorders.

[45]  E S Shneidman,et al.  Suicide as psychache. , 1993, The Journal of nervous and mental disease.

[46]  A. Beck,et al.  Prediction of Suicide , 1975 .

[47]  F. Keller,et al.  Hopelessness and the tendency to commit suicide in the course of depressive disorders. , 1993, Crisis.

[48]  P. Kragh‐Sørensen,et al.  Mortality in major affective disorder: relationship to subtype of depression , 1993, Acta psychiatrica Scandinavica.

[49]  K. Jamison Suicide and Bipolar Disorders a , 1986, Annals of the New York Academy of Sciences.

[50]  G. Blair-West,et al.  Down‐rating lifetime suicide risk in major depression , 1997, Acta psychiatrica Scandinavica.

[51]  I. James,et al.  SUICIDE FOLLOWING DISCHARGE FROM PSYCHIATRIC HOSPITAL. , 1964, Archives of general psychiatry.

[52]  S. Mützell Survival after Attempted Suicide in Sweden. A follow-up after 20 years , 1997 .

[53]  P. Vestergaard,et al.  Five-year mortality in lithium-treated manic-depressive patients. , 1991, Journal of affective disorders.

[54]  E. Robins,et al.  Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides. , 1959, American journal of public health and the nation's health.

[55]  J. Morrison Suicide in a psychiatric practice population. , 1982, The Journal of clinical psychiatry.

[56]  R A Steer,et al.  Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients. , 1999, Suicide & life-threatening behavior.

[57]  C. Astrup,et al.  A follow-up of 270 patients with acute affective psychoses. , 1959, Acta psychiatrica Scandinavica. Supplementum.

[58]  G. Andrews,et al.  The Long-Term Outcome of Depressive Illness , 1988, British Journal of Psychiatry.

[59]  M. Berglund,et al.  Mortality in severe depression , 1987, Acta psychiatrica Scandinavica.

[60]  M. Rosén,et al.  Avoidable mortality among psychiatric patients , 1998, Social Psychiatry and Psychiatric Epidemiology.

[61]  E. Slater Zur Erbpathologie des manisch-depressiven Irreseins. Die Eltern und Kinder von Manisch-Depressiven , 1938 .

[62]  F. Post The Management and Nature of Depressive Illnesses in Late Life: A Follow-Through Study , 1972, British Journal of Psychiatry.

[63]  D. Hedeker,et al.  Clinical predictors of suicide in patients with major affective disorders: a controlled prospective study. , 1987, The American journal of psychiatry.

[64]  C. Watts The Incidence and Prognosis of Endogenous Depression , 1956, British medical journal.

[65]  Erwin N. Koranyi Fatalities in 2,070 Psychiatric Outpatients: Preventative Features , 1977 .

[66]  M. Åsberg,et al.  Attempted suicide predicts suicide risk in mood disorders , 1995, Acta psychiatrica Scandinavica.

[67]  E. Love,et al.  Suicide following an inpatient hospitalization for a suicide attempt: a Canadian follow-up study , 1998, Social Psychiatry and Psychiatric Epidemiology.

[68]  Lifetime risk of suicide in affective disorders , 1998, British Journal of Psychiatry.

[69]  G. Winokur,et al.  AFFECTIVE DISORDER. III: DIAGNOSTIC CORRELATES AND INCIDENCE OF SUICIDE , 1964, The Journal of nervous and mental disease.

[70]  B. Müller-Oerlinghausen,et al.  Effect of prophylactic treatment on suicide risk in patients with major affective disorders. Data from a randomized prospective trial. , 1996, Pharmacopsychiatry.

[71]  P. Grof,et al.  Length of Lithium Treatment Needed to Eliminate the High Mortality of Affective Disorders , 1993, British Journal of Psychiatry.

[72]  A. Beck,et al.  Clinical predictors of eventual suicide: a 5- to 10-year prospective study of suicide attempters. , 1989, Journal of affective disorders.

[73]  C. Perris,et al.  A study of bipolar (manic-depressive) and unipolar recurrent depressive psychoses. X. Mortality, suicide and life-cycles. , 1966, Acta psychiatrica Scandinavica. Supplementum.

[74]  J. Geddes,et al.  Period trends in rate of suicide in first 28 days after discharge from psychiatric hospital in Scotland, 1968-92 , 1995, BMJ.

[75]  R. Goldney,et al.  Suicide in Association with Psychiatric Hospitalisation , 1985, The Australian and New Zealand journal of psychiatry.

[76]  M. Tsuang,et al.  The Iowa 500: suicide in mania , depression, and schizophrenia. , 1975, The American journal of psychiatry.

[77]  R. Murray,et al.  The Long-Term Outcome of Maudsley Depressives , 1988, British Journal of Psychiatry.

[78]  S. Guze,et al.  Mortality in a follow-up of 500 psychiatric outpatients. II. Cause-specific mortality. , 1985, Archives of general psychiatry.

[79]  D. Hastings Follow-up results in psychiatric illness. , 1958, The American journal of psychiatry.

[80]  E. Ziskind,et al.  METRAZOL AND ELECTRIC CONVULSIVE THERAPY OF THE AFFECTIVE PSYCHOSES: A CONTROLLED SERIES OF OBSERVATIONS COVERING A PERIOD OF FIVE YEARS , 1945 .

[81]  R. Goldstein,et al.  The prediction of suicide. Sensitivity, specificity, and predictive value of a multivariate model applied to suicide among 1906 patients with affective disorders. , 1991, Archives of general psychiatry.

[82]  J. Fleiss Review papers : The statistical basis of meta-analysis , 1993 .

[83]  E. Stenager,et al.  Suicide and patients with neurologic diseases. Methodologic problems. , 1992, Archives of neurology.

[84]  C. Chapman,et al.  A Genetic Study of Bipolar Affective Disorder , 1975, British Journal of Psychiatry.

[85]  M. Tsuang,et al.  Communication of suicidal intent and suicide in unipolar depression. A forty year follow-up. , 1979, Journal of affective disorders.

[86]  P. Sainsbury,et al.  The accuracy of officially reported suicide statistics for purposes of epidemiological research. , 1982, Journal of epidemiology and community health.

[87]  B. Everitt,et al.  Analysis of longitudinal data , 1998, British Journal of Psychiatry.

[88]  A. Nilsson Mortality in Recurrent Mood Disorders during Periods on and off Lithium - A Complete Population Study in 362 Patients , 1995, Pharmacopsychiatry.

[89]  P. Huston,et al.  Manic-depressive psychosis; course when treated and untreated with electric shock. , 1948, Archives of neurology and psychiatry.

[90]  M. Tsuang Suicide in schizophrenics, manics, depressives, and surgical controls. A comparison with general population suicide mortality. , 1978, Archives of general psychiatry.

[91]  C. Seager Controlled trial of straight and modified electroplexy. , 1959, The Journal of mental science.

[92]  M. Goldacre,et al.  Suicide after discharge from psychiatric inpatient care , 1993, The Lancet.

[93]  M. Tohen,et al.  Lithium treatment and risk of suicidal behavior in bipolar disorder patients. , 1998, The Journal of clinical psychiatry.

[94]  D. Black,et al.  Prospective Studies of Suicide and Mortality in Psychiatric Patients , 1986, Annals of the New York Academy of Sciences.

[95]  C. Silverman The epidemiology of depression. A review. , 1968, The American journal of psychiatry.

[96]  M. Maes,et al.  The prediction of suicidal intent in depressed patients , 1997, Acta psychiatrica Scandinavica.

[97]  M. Berglund,et al.  Post‐diction of suicide in a group of depressive patients , 1988, Acta psychiatrica Scandinavica.

[98]  D. Black,et al.  Effect of psychosis on suicide risk in 1,593 patients with unipolar and bipolar affective disorders. , 1988, The American journal of psychiatry.

[99]  J. Bailar The promise and problems of meta-analysis. , 1997, The New England journal of medicine.