A new, major multi-national study illuminates the depression-related clinical behavior patterns that precede many suicide attempts.
Researchers believe the new insights may lead to changes in the care of patients affected with depression.
The statistics for suicide are frightening. According to the WHO, more than 800,000 people commit suicide every year, with perhaps 20 times that number attempting suicide. Suicide is one of the leading causes of death in the young (in the UK for example, it is the leading cause of death in men under 35).
In the BRIDGE-II-MIX study, researchers evaluated 2811 patients suffering from depression, of whom 628 had already attempted suicide. Each patient was interviewed by a psychiatrist as if it were a standard evaluation of a mentally-ill patient.
The parameters studied included previous suicide attempts, family history, current and previous treatment, patients’ clinical presentation, how they scored on the standard Global Assessment of Functioning scale, and other parameters.
Researchers paid particular attention to the characteristics and behaviors of those who had attempted suicide, comparing the actions to depressed patients who had not attempted suicide. By doing this comparison, they found that certain patterns recur before suicide attempts.
According to author Dr. Dina Popovic (Barcelona), “We found that ‘depressive mixed states’ often preceded suicide attempts. A depressive mixed state is where a patient is depressed, but also has symptoms of ‘excitation’, or mania. We found this significantly more in patients who had previously attempted suicide, than those who had not.
“In fact 40 percent of all the depressed patients who attempted suicide had a ‘mixed episode’ rather than just depression. All the patients who suffer from mixed depression are at much higher risk of suicide.
“We also found that the standard DSM criteria identified 12 percent of patients at showing mixed states, whereas our methods showed 40 percent of at-risk patients. This means that the standard methods are missing a lot of patients at risk of suicide.”
In a second analysis of the data, researchers found the risk of attempting suicide among depressed patients is 50 percent greater when they demonstrate:
- risky behavior (e.g. reckless driving, promiscuous behavior);
- psychomotor agitation (pacing around a room, wringing one’s hands, pulling off clothing, and putting it back on and other similar actions);
- impulsivity (acting on a whim, displaying behavior characterized by little or no forethought, reflection, or consideration of the consequences).
“In our opinion, assessing these symptoms in every depressed patient we see is extremely important, and has immense therapeutic implications,” says Dr. Popovic.
However, determination or discovery of the symptomatic behaviors is challenging as most of the actions will not be spontaneously referred by the patient.
Popovic says this means the clinician needs to inquire specifically about the behaviors, a task that is confounded by clinician’s unawareness of the importance of looking at these symptoms before deciding to treat depressed patients.
This is an important message for all clinicians, from the GPs who see depressed patients and may not pay enough attention to these symptoms — which are not always reported spontaneously by the patients — through to secondary and tertiary level clinicians, explains Popovic.
One good note is that clinicians working with bipolar patients in highly specialized tertiary centers are usually aware of the red flags, but the knowledge needs to extent to all levels.
“The strength of this study is that it’s not a clinical trial, with ideal patients — it’s a big study, from the real world.”