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1614
Method
Subjects
The study participants were 272 patients aged 1772 years who
were admitted to a university psychiatric hospital for the treatment of mood disorders. All patients gave written informed consent as approved by the Institutional Review Board.
Each patient had a history of at least one major depressive episode and met the DSM-III-R criteria for major depression or bipolar disorder. The patients had no active medical or neurological
problems or current alcohol or substance abuse.
Measures
DSM-III-R axis I and II disorders were diagnosed by using the
Structured Clinical Interview for DSM-III-R (SCID) for axis I (8)
and axis II (9) disorders. Psychiatric symptoms were rated with
the 24-item Hamilton Depression Rating Scale (10), the Brief Psychiatric Rating Scale (BPRS) (11), and the Beck Depression Inventory (12). The items for agitation, psychic anxiety, somatic anxiety,
and hypochondriasis from the Hamilton depression scale and the
items for anxiety, somatic concern, and tension from the BPRS
were used to measure the presence of anxiety symptoms. Lifetime
aggression and impulsivity were rated by using the Brown-Goodwin Aggression Inventory (13) and the Barratt Impulsivity Scale
(14), respectively.
A suicide attempt was defined as a self-destructive act carried
out with at least some intent to end ones life. The Scale for Suicidal Ideation (15) was used to measure suicidal ideation during
the 2 weeks before hospitalization. The subjects intent to die at
the time of the attempt was assessed by using the Suicide Intent
Scale (16). The lethality or medical damage inflicted by suicide attempts was measured with the Medical Damage Rating Scale (16).
The raters each had a masters or doctorate degree and had met
our previously reported criteria for reliability (7).
Am J Psychiatry 157:10, October 2000
Statistical Analyses
Chi-square analyses and Students t tests were used to contrast
attempters and nonattempters. Fishers exact test was used to
compare the rates of panic disorder and borderline personality
disorder diagnoses in the two groups when the expected counts
in some cells were not sufficiently high. A multivariate analysis of
variance for Hamilton depression scale anxiety symptoms and
BPRS anxiety symptoms by attempter status was performed. All
statistical tests were two-tailed.
Results
Of the total subjects, 143 (52.6%) had attempted suicide
and 129 (47.4%) had not. The two subgroups did not differ
on demographic characteristics (data available on request). The mean age of the entire study group was 35.2
years (SD=11.7); 42.6% were male (N=116), and 77.9%
were Caucasian (N=212).
One-third of the subjects (34.2%, N=93)more than
one-half of the attempter grouphad made multiple suicide attempts. At least one comorbid diagnosis was identified in 42.6% of the study group (N=116). The suicide attempters and nonattempters differed significantly in the
numbers with axis I and axis II comorbid disorders; both
were more common among the attempters (Table 1).
Panic disorder was present in 26 subjects (9.6%; four
men and 22 women). The attempters did not differ significantly from the nonattempters in lifetime rate of panic
disorder (Table 1).
The attempters scored higher on subjective depression
(Beck Depression Inventory) than the nonattempters, but
they did not differ in severity of objective depression
(Hamilton depression scale total) or general psychopathology (BPRS total) (Table 2).
The mean score for anxiety items on the Hamilton depression scale was higher in the nonattempter group, and
there were significant differences for agitation, psychic
anxiety, and hypochondriasis (Table 2). The BPRS mean
score for anxiety was also higher in the nonattempter
group, and there were significant differences for the somatic concern and anxiety items (Table 2). A Hotelling T2
test multivariate comparison of the attempters and nonattempters indicated significant differences between groups
for the Hamilton scale anxiety symptoms (F=2.78, df=4,
260, p=0.03), the BPRS anxiety symptoms (F=5.03, df=3,
255, p=0.002), and the Brown-Goodwin Aggression Scale
and Beck Depression Inventory scores (F=18.70, df=2, 202,
p=0.001). Thus, the mean scores for anxiety and the combination of aggressivity and subjective depression were
significantly different in the attempters and nonattempters (also see Table 2).
After adjustment for panic disorder and anxiety measures, a logistic regression of suicide attempter status on
aggressivity showed that aggressivity was still highly predictive of attempter status (likelihood ratio test: 2=28.71,
df=1, p<0.001). Using a likelihood ratio test based on a logistic regression, we found that panic disorder and anxiety
Am J Psychiatry 157:10, October 2000
Axis I
At least one axis I
comorbid diagnosis 73 51.0
Panic disorder
12 8.4
Axis II
At least one axis II
comorbid diagnosis 112 78.3
Cluster B personality
disorder
81 56.6
Borderline
personality disorder 68 47.6
a
No Suicide
Attempt
(N=129)
N
44
14
Analysisa
(df=1)
34.1
10.9
7.94
0.48
0.007
0.54
69
53.5
14.52
<0.001
29
22.5
33.99
<0.001
17
13.2
35.16
<0.001
Discussion
The major results of this study are that a lifetime history
of a suicide attempt in patients with a major depressive
episode is unrelated to a history of panic disorder and is
associated with less severe symptoms of agitation and
anxiety.
To our knowledge, only one previous study (17) compared the incidence of suicide attempts among depressed
patients with and without panic disorder. In that study
there was a higher frequency of suicide attempts in patients with infrequent panic attacks than in those with
panic disorder or with depression only. In 47% of the subjects the panic attacks began after the suicide attempt or
were not present at the moment of the attempt. Thus, that
study did not suggest that panic attacks directly increased
the risk of suicide attempt. Female gender and a history of
psychosis, but not panic attack history, significantly related to a history of suicidal behavior.
Other investigators (Table 4) studied patients with panic
disorder and patients with comorbid panic disorder, reporting an incidence of suicide attempts from 1% to 29%
in the patients with panic disorder alone (mean=9.6, me-
1615
Mean
Analysisa
No Suicide Attempt
SD
Mean
SD
df
6.1
15.4
13.6
16.7
46.9
22.0
4.8
16.5
13.2
6.05
2.79
3.01
234.60
191.66
223.34
<0.001
0.006
0.003
10.1
0.6
1.1
1.2
0.8
26.0
0.5
2.1
1.7
0.7
10.9
0.7
1.2
1.2
0.9
0.37
2.14
2.32
1.54
2.31
256.63
249.25
254.29
261.68
243.87
0.71
0.03
0.02
0.13
0.02
10.2
1.4
1.6
1.1
37.9
2.6
4.4
2.0
8.7
1.7
1.6
1.2
1.91
2.84
3.16
1.50
254.00
247.18
256.72
255.00
0.06
0.005
0.002
0.13
TABLE 3. Clinical Features of 272 Patients With Major Depression Who Did or Did Not Also Have Panic Disorder
Score
Panic Disorder
Analysisa
No Panic Disorder
Clinical Feature
Mean
SD
Mean
SD
df
18.8
53.3
26.8
6.1
15.0
11.3
19.1
49.8
24.6
6.0
16.4
13.9
0.30
0.92
0.30
28.21
21.29
23.80
0.77
0.37
0.75
26.8
0.4
2.2
2.4
1.2
10.5
0.7
1.1
1.3
1.2
26.2
0.4
1.9
1.5
0.5
10.6
0.6
1.1
1.2
0.8
0.25
0.07
1.08
3.11
2.56
29.30
28.32
29.24
28.66
26.26
0.80
0.94
0.29
0.004
0.02
36.6
3.0
4.7
2.0
11.2
13.5
9.1
2.1
1.7
1.2
10.4
6.7
36.8
2.3
4.0
1.9
14.6
16.2
9.7
1.5
1.6
1.2
11.4
5.5
0.09
1.71
2.05
0.11
1.53
1.35
30.11
26.81
29.27
29.06
29.37
12.46
0.93
0.10
0.05
0.91
0.14
0.20
dian=6.5) and from 2% to 71% in the patients with comorbid panic disorder (mean=19.1, median=12.0). The
variance of the values and the fact that the group with comorbid conditions had a median rate double that of the
group with panic disorder alone suggest that comorbidity
is an important factor in suicidal acts. The rate of suicide
attempts in panic disorder alone may still be higher than
in the general population.
Investigators in three studies (2, 21, 24) calculated the
incidence of suicide attempts in a population of comorbid
panic disorder patients, reporting rates of 42%, 19%, and
3%. The percentage of suicide attempters in our group of
patients with comorbid panic disorder was 53.3%. Such
different rates suggest that a major reason for variance in
suicidal behavior is related to factors other than comorbid
panic disorder. This conclusion is consistent with the report by Beck et al. (20) of a higher rate of suicide attempts
in patients with a primary mood disorder and secondary
panic disorder than in subjects with panic disorder and
secondary mood disorder.
1616
Borderline personality disorder and the traits of aggression and impulsivity have been found to be associated
with suicide. In our study group, we found a significantly
higher rate of borderline personality disorder in attempters than in nonattempters (27.2% versus 6.7%, respectively). Similarly, Friedman et al. (4) reported that the lifetime prevalence of suicide attempts in a group of patients
with borderline personality disorder and panic disorder
was 25%, compared with 2% in patients with panic disorder only. Noyes et al. (21), in a 7-year follow-up study of
patients with panic disorder, found completed suicide
only in panic disorder patients with comorbid severe depression or personality disorder. This suggests that suicide
is not related to panic disorder alone, a possibility that is
consistent with our results.
Levels of aggression and impulsivity correlate with past
suicidal behavior (7), but few studies have examined the
relationship of aggression, impulsivity, and anxiety symptoms. We previously reported (7) that suicide attempters
have more lifetime aggression and impulsivity than nonAm J Psychiatry 157:10, October 2000
History of Suicide
Attempts (%)
254
20
Community subjects
(N=18,000)
Outpatients (N=100)
Inpatients (N=3,302)
Outpatients (N=293)
a
0
Study
Weissman et al., 1989 (1)
Outpatients (N=75)
Inpatients and
outpatients (N=954)
Community subjects
(N=1,002)
Outpatients (N=900)
Outpatients (N=82)
Community subjects
(N=627)
Inpatients and
outpatients (N=47)
Outpatients (N=437)
a Anxiety neurosis.
b Among those who had attempted
c Nonclinical panic disorder.
History of Suicide
Attempts (%)
4,857
42
234
59
25
50
b
71
82
20
Diagnoses
Other psychiatric diagnoses
25
0
29
57
151
0
749
27
19
23
382
28
11
113
12
0
145
0
19
11
324
suicide, 62% had a history of panic attacks. Among the nonattempters, 28% had had panic attacks.
1617
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