The Presentation of Body Dysmorphic Disorder in Medical Settings

Body dysmorphic disorder (BDD) is a relatively common psychiatric illness that often presents to mental health professionals as well as nonpsychiatric physicians. However, BDD usually goes unrecognized and undiagnosed in clinical settings. It is important to recognize and accurately diagnose BDD because this often secret illness may be debilitating. Patients with BDD typically have markedly impaired functioning, notably poor quality of life, and a high rate of suicidal ideation and suicide attempts. Thus, it is important to screen patients for BDD and avoid misdiagnosing it as another illness. Nonpsychiatric treatments (eg, dermatologic, surgical), which most patients seek and receive, appear ineffective for BDD and can be risky for physicians to provide. This article provides a clinically focused overview of BDD, including its symptoms, morbidity, case examples, nonpsychiatric (ie, cosmetic) treatment, diagnostic "do's" and "don'ts," and suggestions for how to persuade patients to accept appropriate psychiatric care.     

Mortality and Suicide Risk in Treatment-Resistant Depression: An Observational Study of the Long-Term Impact of Intervention

Major depressive disorder is a common global disease that causes a significant societal burden. Most interventional studies of depression provide a limited assessment of the interventions on mortality and suicide risks. This study utilizes data from an observational registry of patients with major depressive disorder to determine the impact of intervention (vagus nerve stimulation or standard pharmacological/non-pharmacological therapy) and a latent factor, patient trajectory toward response, on mortality, suicide and suicidal ideation. A total of 636 patients were available for an intent-to-treat analysis of all-cause mortality, suicide and suicidal ideation. Patients treated with vagus nerve stimulation in addition to standard therapies experienced lower, but not statistically significant, all-cause mortality (vagus nerve stimulation 4.93 per 1,000 person-years vs. 10.02 per 1,000 patient years for treatment as usual) and suicide rates (vagus nerve stimulation 0.88 per 1,000 person-years vs. 1.61 per 1,000 patient years for treatment as usual). Treatment with vagus nerve stimulation produced a statistically lower relative risk of suicidal ideation 0.80, 95% confidence interval (0.68,0.95). Further, patients that responded to either treatment saw a 51% reduction in relative risk of suicidal behavior; relative risk and 95% confidence interval of 0.49 (0.41,0.58). In summary, we find that treatment with adjunctive vagus nerve stimulation can potentially lower the risk of all-cause mortality, suicide and suicide attempts.     

ASSOCIATIONS BETWEEN CHRONOTYPE,SLEEP QUALITY,SUICIDALITY, AND DEPRESSIVE SYMPTOMS IN PATIENTS WITH MAJOR DEPRESSION AND HEALTHY CONTROLS

Research interest concerning associations between sleep characteristics and suicidality in psychopathology has been growing. However, possible linkages of suicidality to sleep characteristics in terms of sleep quality and chronotypes among depressive patients have not been well documented. In the current study, the authors investigated the possible effects of sleep quality and chronotype on the severity of depressive symptoms and suicide risk in patients with depressive disorder and healthy controls. The study was conducted on 80 patients clinically diagnosed with major depression and 80 healthy subjects who were demographically matched with the patient group. All participants completed a questionnaire package containing self-report measures, including the Beck Depression Inventory (BDI), Pittsburgh Sleep Quality Index (PSQI), Morningness–Eveningness Questionnaire (MEQ), and Suicide Ideation Scale (SIS), and subjects were interviewed with the suicidality section of the Mini-International Neuropsychiatric Interview (MINI). Results are as follows: (a) logistic regression analyses revealed that poor sleep quality and depression symptom severity significantly predicted onset of major depression; (b) morningness-type circadian rhythm may play as a significant relief factor after onset of major depression; (c) sleep variables of chronotype and sleep quality did not significantly predict suicide ideation after controlling for depressive symptoms in the major depression group; and (d) suicide ideation and poor sleep quality were antecedents of depression symptom severity in patients with major depression, and in healthy controls. Findings are discussed under the theoretical assumptions concerning possible relations between chronotype, sleep quality, depression, and suicidality. (Author correspondence: dryavuzselvi@yahoo.com)     

Borderline personality disorder

BORDERLINE PERSONALITY DISORDER is a chronic psychiatric disorder characterized by marked impulsivity, instability of mood and interpersonal relationships, and suicidal behaviour that can complicate medical care. Identifying this diagnosis is important for treatment planning. Although the cause of borderline personality disorder is uncertain, most patients improve with time. There is an evidence base for treatment using both psychotherapy and psychopharmacology. The clinical challenge centres on managing chronic suicidality.CaseColleen, a 22-year old student, is seen for a psychiatric assessment after presenting to the emergency department because of taking an overdose of acetaminophen pills. Although the immediate precipitant to her suicide attempt was a break-up with her boyfriend, she has a history of multiple suicide attempts since the age of 14. Colleen reports that she has daily mood swings, from depression to intense anger, and that she often cuts herself on the wrists and arms to relieve dysphoria. When stressed, she experiences feelings of unreality, sometimes hearing a voice telling her to kill herself. Colleen has had highly problematic relationships with men, falling quickly in and out of love and feeling that her life depends on them, even when they have behaved abusively toward her. What is the appropriate diagnosis and management of this patient?Personality disorders constitute a major group in the classification of mental disorders. According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR),¹ these conditions are defined by maladaptive personality characteristics beginning early in life that have consistent and serious effects on functioning. Borderline personality disorder (BPD) is frequently seen in clinical practice.² Characterized by emotional turmoil and chronic suicidality (suicide ideation and attempts), this type of personality disorder presents some of the most difficult and troubling problems in all of psychiatry.     

Alcohol-Related Risk of Suicidal Ideation,Suicide Attempt,and Completed Suicide: A Meta-Analysis

BackgroundSeveral original studies have investigated the effect of alcohol use disorder (AUD) on suicidal thought and behavior, but there are serious discrepancies across the studies. Thus, a systematic assessment of the association between AUD and suicide is required.MethodsWe searched PubMed, Web of Science, and Scopus until February 2015. We also searched the Psycinfo web site and journals and contacted authors. We included observational (cohort, case-control, and cross-sectional) studies addressing the association between AUD and suicide. The exposure of interest was AUD. The primary outcomes were suicidal ideation, suicide attempt, and completed suicide. We assessed heterogeneity using Q-test and I² statistic. We explored publication bias using the Egger''s and Begg''s tests and funnel plot. We meta-analyzed the data with the random-effects models. For each outcome we calculated the overall odds ratio (OR) or risk ratio (RR) with 95% confidence intervals (CI).ResultsWe included 31 out of 8548 retrieved studies, with 420,732 participants. There was a significant association between AUD and suicidal ideation (OR=1.86; 95% CI: 1.38, 2.35), suicide attempt (OR=3.13; 95% CI: 2.45, 3.81); and completed suicide (OR=2.59; 95% CI: 1.95, 3.23 and RR=1.74; 95% CI: 1.26, 2.21). There was a significant heterogeneity among the studies, but little concern to the presence of publication bias.ConclusionsThere is sufficient evidence that AUD significantly increases the risk of suicidal ideation, suicide attempt, and completed suicide. Therefore, AUD can be considered an important predictor of suicide and a great source of premature death.     

Suicidal Risk Factors of Recurrent Major Depression in Han Chinese Women

The relationship between suicidality and major depression is complex. Socio- demography, clinical features, comorbidity, clinical symptoms, and stressful life events are important factors influencing suicide in major depression, but these are not well defined. Thus, the aim of the present study was to assess the associations between the above-mentioned factors and suicide ideation, suicide plan, and suicide attempt in 6008 Han Chinese women with recurrent major depression (MD). Patients with any suicidality had significantly more MD symptoms, a significantly greater number of stressful life events, a positive family history of MD, a greater number of episodes, a significant experience of melancholia, and earlier age of onset. Comorbidity with dysthymia, generalized anxiety disorder (GAD), social phobia, and animal phobia was seen in suicidal patients. The present findings indicate that specific factors act to increase the likelihood of suicide in MD. Our results may help improve the clinical assessment of suicide risk in depressed patients, especially for women.     

Associations between Film Preferences and Risk Factors for Suicide: An Online Survey

Several studies indicate that exposure to suicide in movies is linked to subsequent imitative suicidal behavior, so-called copycat suicides, but little is currently known about whether the link between exposure to suicidal movies and suicidality is reflected in individual film preferences. 943 individuals participated in an online survey. We assessed associations between preferred film genres as well as individual exposure to and rating of 50 pre-selected films (including 25 featuring a suicide) with suicidal ideation, hopelessness, depression, life satisfaction, and psychoticism. Multiple regression analyses showed that preferences for film noir movies and milieu dramas were associated with higher scores on suicidal ideation, depression and psychoticism, and low scores on life satisfaction. Furthermore, preferences for thrillers and horror movies as well as preferences for tragicomedies, tragedies and melodramas were associated with higher scores of some of the suicide risk factors. There was also a dose-response relationship between positive rating of suicide films and higher life satisfaction. Due to the cross-sectional design of the study causality cannot be assessed. Individual film genre preferences seem to reflect risk factors of suicide, with film genres focusing on sad contents being preferred by individuals with higher scores on suicide risk factors. However, suicide movies are more enjoyed by viewers with higher life satisfaction, which may reflect a better ability to cope with such content.     

Selective serotonin reuptake inhibitors and risk of suicide: a systematic review of observational studies

Background

It is unclear whether the use of selective serotonin reuptake inhibitors (SSRIs) and other antidepressant drugs reduce the risk of suicide in people with depression. We explored the association between exposure to SSRIs and risk of suicide completion or attempt.

Methods

We conducted a systematic review of observational studies that reported completed or attempted suicide in depressed individuals who were exposed to SSRIs compared with those who were not exposed to antidepressants. We assessed the overall risk of completed or attempted suicide.

Results

Eight studies involving more than 200 000 patients with moderate or severe depression were included in the meta-analysis. Although exposure to SSRIs increased the risk of completed or attempted suicide among adolescents (odds ratio [OR] 1.92, 95% confidence interval [CI] 1.51–2.44), the risk was decreased among adults (OR 0.57, 95% CI 0.47–0.70). Among people aged 65 or more years, exposure to SSRIs had a protective effect (OR 0.46, 95% CI 0.27–0.79). Sensitivity analyses did not change these findings. In particular, for studies that used completed suicide as an outcome, exposure to SSRIs was associated with increased risk among adolescents (OR 5.81, 95% CI 1.57–21.51) and decreased risk among adults (OR 0.66, 95% CI 0.52–0.83) and older people (OR 0.53, 95% CI 0.26–1.06).

Interpretation

Based on data from observational studies, use of SSRIs may be associated with a reduced risk of suicide in adults with depression. Among adolescents, use of SSRIs may increase suicidality.There is uncertainty about the safety of selective serotonin reuptake inhibitors (SSRIs), which may cause worsening of suicidal thoughts in vulnerable people.^1,2 In 2005, a systematic review of published randomized controlled trials comparing SSRIs with another active treatment or placebo found an almost 2-fold increase in the odds of fatal and nonfatal suicide attempts among those exposed to SSRIs.³ No increase in risk was observed, however, when only fatal suicide attempts were included. Another systematic review,⁴ which included both published and unpublished randomized controlled trials submitted by pharmaceutical companies to the safety review of the Medicine and Healthcare products Regulatory Agency compared the use of SSRIs and placebo in adults with depression and other clinical conditions.⁴ This review showed no evidence of increased risk of completed suicide and only weak evidence of increased risk of self-harm.More recently, the US Food and Drug Administration (FDA) performed a meta-analysis of individual patient data from 372 randomized placebo-controlled trials of antidepressants with a total of nearly 100 000 patients.⁵ This study reported that the incidence of reported suicidal behaviour was strongly related to age.⁵ The risk associated with antidepressant use relative to placebo was increased among patients aged 25 or fewer years, and it was reduced among patients aged 65 or more years.⁵ The risk among patients aged 25–64 years was neutral; however, risk was reduced when suicidal behaviour and ideation were considered together.⁵ Based on these findings, in May 2007 the FDA ordered that all antidepressant drugs carry an expanded black-box warning on their label that included information about increased risk of suicidal behaviour in young adults aged 18–24 years.^6,7A controversial point of the FDA analysis is that the included trials were not primarily designed to measure suicidality (a composite outcome that includes suicide ideas, preparatory acts, suicide attempts and deaths by suicide).⁵ Of all suicidality events, less than 30% were serious suicide attempts or deaths. Additionally, considering that suicidality was self-reported rather than observed by others in most clinical trials, it is possible that antidepressant treatment, particularly in younger individuals, enhanced communication about suicidality, which may have allowed them to become more articulate and open about their thoughts and actions. Alternatively, antidepressant treatment might have enhanced communication about suicidality in all age groups, but increased attention to adverse effects might have led to enhanced detection of suicidality in younger individuals.⁵It is unlikely that individual randomized trials will be designed to primarily investigate the effect of antidepressant use on suicidality, and future systematic reviews of clinical trial data will not be able to overcome the limitations of the FDA analysis. Therefore, we sought to further explore the association between SSRI exposure and risk of completed or attempted suicide by conducting a systematic review and meta-analysis of observational studies. By including a large, broad spectrum of individuals followed under naturalistic circumstances, systematic reviews of observational studies may offer an added dimension in the evaluation of drug safety that is complementary to that provided by clinical trials.^8,9 Additionally, observational studies may allow researchers to move from the controversial concept of suicidality to hard outcomes such as suicide attempt and completion. Specifically, we set out to quantify the risk of completed or attempted suicide among people in different age groups with depression after exposure to SSRIs.     

Suicide Ideation of Individuals in Online Social Networks

Suicide explains the largest number of death tolls among Japanese adolescents in their twenties and thirties. Suicide is also a major cause of death for adolescents in many other countries. Although social isolation has been implicated to influence the tendency to suicidal behavior, the impact of social isolation on suicide in the context of explicit social networks of individuals is scarcely explored. To address this question, we examined a large data set obtained from a social networking service dominant in Japan. The social network is composed of a set of friendship ties between pairs of users created by mutual endorsement. We carried out the logistic regression to identify users’ characteristics, both related and unrelated to social networks, which contribute to suicide ideation. We defined suicide ideation of a user as the membership to at least one active user-defined community related to suicide. We found that the number of communities to which a user belongs to, the intransitivity (i.e., paucity of triangles including the user), and the fraction of suicidal neighbors in the social network, contributed the most to suicide ideation in this order. Other characteristics including the age and gender contributed little to suicide ideation. We also found qualitatively the same results for depressive symptoms.     

Single-Item Measurement of Suicidal Behaviors: Validity and Consequences of Misclassification

Suicide is a leading cause of death worldwide. Although research has made strides in better defining suicidal behaviors, there has been less focus on accurate measurement. Currently, the widespread use of self-report, single-item questions to assess suicide ideation, plans and attempts may contribute to measurement problems and misclassification. We examined the validity of single-item measurement and the potential for statistical errors. Over 1,500 participants completed an online survey containing single-item questions regarding a history of suicidal behaviors, followed by questions with more precise language, multiple response options and narrative responses to examine the validity of single-item questions. We also conducted simulations to test whether common statistical tests are robust against the degree of misclassification produced by the use of single-items. We found that 11.3% of participants that endorsed a single-item suicide attempt measure engaged in behavior that would not meet the standard definition of a suicide attempt. Similarly, 8.8% of those who endorsed a single-item measure of suicide ideation endorsed thoughts that would not meet standard definitions of suicide ideation. Statistical simulations revealed that this level of misclassification substantially decreases statistical power and increases the likelihood of false conclusions from statistical tests. Providing a wider range of response options for each item reduced the misclassification rate by approximately half. Overall, the use of single-item, self-report questions to assess the presence of suicidal behaviors leads to misclassification, increasing the likelihood of statistical decision errors. Improving the measurement of suicidal behaviors is critical to increase understanding and prevention of suicide.     

Melasma,a photoaging disorder

Melasma is a common hyperpigmentary disorder. The impact on the quality of life of affected individuals is well demonstrated, demanding new therapeutic strategies. However, the treatment of melasma remains highly challenging. Melasma is often considered as the main consequence of female hormone stimulation on a predisposed genetic background. Although these two factors do contribute to this acquired pigmentary disorder, the last decade has revealed several other key players and brought new pieces to the complex puzzle of the pathophysiology of melasma. Here, we summarize the latest evidence on the pathophysiology of melasma, and we suggest that melasma might be a photoaging skin disorder affecting genetically predisposed individuals. Such data must be taken into consideration by clinicians as they could have a profound impact on the treatment and the prevention of melasma.     

Fluoxetine and suicide: a meta-analysis of controlled trials of treatment for depression.

OBJECTIVE--A comprehensive meta-analysis of clinical trial data was performed to assess the possible association of fluoxetine and suicidality (suicidal acts and ideation). DESIGN--Retrospective analysis of pooled data from 17 double blind clinical trials in patients with major depressive disorder comparing fluoxetine (n = 1765) with a tricyclic antidepressant (n = 731) or placebo (n = 569), or both. MAIN OUTCOME MEASURES--Multiple data sources were searched to identify patients with suicidal acts. Suicidal ideation was assessed with item 3 of the Hamilton depression rating scale, which systematically rates suicidality. Emergence of substantial suicidal ideation was defined as a change in the rating of this item from 0 or 1 at baseline to 3 or 4 during double blind treatment; worsening was defined as any increase from baseline; improvement was defined as a decrease from baseline at the last visit during the treatment. RESULTS--Suicidal acts did not differ significantly in comparisons of fluoxetine with placebo (0.2% v 0.2%, p = 0.494, Mantel-Haenszel adjusted incidence difference) and with tricyclic antidepressants (0.7% v 0.4%, p = 0.419). The pooled incidence of suicidal acts was 0.3% for fluoxetine, 0.2% for placebo, and 0.4% for tricyclic antidepressants, and fluoxetine did not differ significantly from either placebo (p = 0.533, Pearson''s chi 2) or tricyclic antidepressants (p = 0.789). Suicidal ideation emerged marginally significantly less often with fluoxetine than with placebo (0.9% v 2.6%, p = 0.094) and numerically less often than with tricyclic antidepressants (1.7% v 3.6%, p = 0.102). The pooled incidence of emergence of substantial suicidal ideation was 1.2% for fluoxetine, 2.6% for placebo, and 3.6% for tricyclic antidepressants. The incidence was significantly lower with fluoxetine than with placebo (p = 0.042) and tricyclic antidepressants (p = 0.001). Any degree of worsening of suicidal ideation was similar with fluoxetine and placebo (15.4% v 17.9%, p = 0.196) and with fluoxetine and tricyclic antidepressants (15.6% v 16.3%, p = 0.793). The pooled incidence of worsening of suicidal ideation was 15.3% for fluoxetine, 17.9% for placebo, and 16.3% for tricyclic antidepressants. The incidence did not differ significantly with fluoxetine and placebo (p = 0.141) or tricyclic antidepressants (p = 0.542). Suicidal ideation improved significantly more with fluoxetine than with placebo (72.0% v 54.8%, p less than 0.001) and was similar to the improvement with tricyclic antidepressants (72.5% v 69.8%, p = 0.294). The pooled incidence of improvement of suicidal ideation was 72.2% for fluoxetine, 54.8% for placebo, and 69.8% for tricyclic antidepressants. The incidence with fluoxetine was significantly greater than with placebo (p less than 0.001) and did not differ from that with tricyclic antidepressants (p = 0.296). CONCLUSIONS--Data from these trials do not show that fluoxetine is associated with an increased risk of suicidal acts or emergence of substantial suicidal thoughts among depressed patients.     

The suicide assessment scale: Psychometric properties of a Norwegian language version

ABSTRACT: BACKGROUND: Rating scales are valuable tools in suicide research and can also be useful supplements to the clinical interview in suicide risk assessments. This study describes the psychometric properties of a Norwegian language version of the Suicide Assessment Scale Self-report version (SUAS-S). METHODS: Participants were fifty-two patients (mean age = 39.3 years, SD = 10.7) with major depression (53.8%), bipolar disorder (25.0%) and/or a personality disorder (63.5%) referred to a psychiatric outpatient clinic. The SUAS-S, the screening section of the Beck Scale for Suicidal Ideation (BSS-5), the Beck Depression Inventory (BDI), Beck's Hopelessness Scale (BHS), the Symptom Check-List-90 R (SCL-90R) and the Clinical Global Impression for Severity of Suicidality (CGI-SS) were administered. One week later, the patients completed the SUAS-S a second time. RESULTS: Cronbach's alpha for SUAS-S was 0.88 and the test-retest reliability was 0.95 (95% CI: 0.93- 0.97). SUAS-S was positively correlated with the BSS-5 (r = 0.66; 95% CI: 0.47-0.85) for the study sample as a whole and for the suicidal (r = 0.52) and non-suicidal groups (r = 0.50) respectively. There was no difference between the SUAS-S and the BSS-5 in the ability to identify suicidality. This ability was more pronounced when the suicide risk was high. There was a substantial intercorrelation between the score on the SUAS-S and the BDI (0.81) and the BHS (0.76). The sensitivity and specificity of the SUAS-S was explored and an appropriate clinical cut-off value was assessed. CONCLUSIONS: The study revealed good internal consistency, test-retest reliability and concurrent validity for the Suicide Assessment Scale Self-report version. The discriminatory ability for suicidality was comparable to that of the BSS-5.     

Personality disorder: a new global perspective

Personality disorder is now being accepted as an important condition in mainstream psychiatry across the world. Although it often remains unrecognized in ordinary practice, research studies have shown it is common, creates considerable morbidity, is associated with high costs to services and to society, and interferes, usually negatively, with progress in the treatment of other mental disorders. We now have evidence that personality disorder, as currently classified, affects around 6% of the world population, and the differences between countries show no consistent variation. We are also getting increasing evidence that some treatments, mainly psychological, are of value in this group of disorders. What is now needed is a new classification that is of greater value to clinicians, and the WPA Section on Personality Disorders is currently undertaking this task.     

Genomewide association scan of suicidal thoughts and behaviour in major depression

Background

Suicidal behaviour can be conceptualised as a continuum from suicidal ideation, to suicidal attempts to completed suicide. In this study we identify genes contributing to suicidal behaviour in the depression study RADIANT.

Methodology/Principal Findings

A quantitative suicidality score was composed of two items from the SCAN interview. In addition, the 251 depression cases with a history of serious suicide attempts were classified to form a discrete trait. The quantitative trait was correlated with younger onset of depression and number of episodes of depression, but not with gender. A genome-wide association study of 2,023 depression cases was performed to identify genes that may contribute to suicidal behaviour. Two Munich depression studies were used as replication cohorts to test the most strongly associated SNPs. No SNP was associated at genome-wide significance level. For the quantitative trait, evidence of association was detected at GFRA1, a receptor for the neurotrophin GDRA (p = 2e-06). For the discrete trait of suicide attempt, SNPs in KIAA1244 and RGS18 attained p-values of <5e-6. None of these SNPs showed evidence for replication in the additional cohorts tested. Candidate gene analysis provided some support for a polymorphism in NTRK2, which was previously associated with suicidality.

Conclusions/Significance

This study provides a genome-wide assessment of possible genetic contribution to suicidal behaviour in depression but indicates a genetic architecture of multiple genes with small effects. Large cohorts will be required to dissect this further.     

Reproductive status,family interactions,and suicidal ideation: Surveys of the general public and high-risk groups

Evolutionary modeling predicts an erosion of self-preservative genetic expression in the conjunction of low reproductive potential and burdensomeness toward kin. Although culture and pathology clearly bear on human suicide, some of its emotional concomitants could reflect such evolution. A survey probing reproductive behavior, quality of family contacts, and suicidal ideation was administered to samples of the general public of Ontario and high-suicide-risk groups, including elderly, psychiatric, criminal psychiatric, and homosexual individuals. Within each sample, variance in suicidal ideation related to reproductive and family-social variables. Social isolation and perceived burdensomeness toward family were especially correlated with suicidal ideation.     

Brain-Derived Neurotrophic Factor Levels in Women with Postpartum Affective Disorder and Suicidality

Our aim was to investigate serum brain-derived neurotrophic factor (BDNF) levels in postpartum women, according to the presence of postpartum affective disorder (PPAD) and suicidality. A cross-sectional study was carried out with women between 45 and 90?days after delivery. PPAD (depression, manic and mixed episode) and suicide risk were assessed using the Mini International Neuropsychiatric Interview. BDNF was assessed using a commercial ELISA kit. Linear regression was used for multivariate analyses. A hundred ninety women participated in the study, 15.3?% had PPAD, 7.4?% showed PPAD with suicide risk. BDNF levels were lower in subjects with three or more Stressful Life Events (P?=?0.01). The serum BDNF levels of women with PPAD presenting suicide risk were significantly lower than those of women without suicide risk (1.50?±?1.38 and 2.33?±?1.28?ng/ml, P?=?0.02). Clinicians should enquire postpartum women about their history of stressful life events, PPAD, and suicidality. This study shows the potential role of BDNF in the neurobiology of the association of PPAD and suicidality.     

Suicidal ideation and reported suicide attempts in Greece during the economic crisis

The financial crisis in Greece is largely impinging on the health and mental health of the population, raising concerns about a potential rise in suicide rates. The aim of this study was to explore changes in suicidal ideation and reported suicide attempts between 2009 and 2011 in a representative sample of the population and in several population subgroups. The socio‐economic predictors of suicidal ideation and suicide attempts in 2011 were also investigated. Two nationwide cross‐sectional telephone surveys were conducted in 2009 and 2011 using the same methodology. A random and representative sample of 2192 and 2256 people, respectively, took part in the surveys. Between 2009 and 2011, there was a substantial increase in the prevalence of suicidal ideation and reported suicide attempts. People suffering from depression, men, married individuals, people experiencing financial strain, people with low interpersonal trust, and individuals with a history of suicide attempts were particularly vulnerable.     

Prevention of suicide

Suicide is the ninth major cause of death in the nation. California, according to the latest comprehensive figures (1949), ranks about 50 per cent above the national average. Yet the importance of suicide as a cause of death is gravely underestimated. At hospitals and other agencies only emergency treatment is given before discharge of persons who attempt suicide, although it is known that many will repeat the attempt. Rarely is psychiatric evaluation carried out or definitive treatment prescribed. Suicidal symptoms are often ignored in other cases. Physicians have a responsibility, as in any disorder, to recognize signs and symptoms of impending suicide and to use all means of prevention. Prevention could be forwarded by the education of physicians and laymen in detecting early signs of depression, in recognizing accident proneness, and in insisting upon legal control of use of barbiturates, a common means of suicide. Lay associations should encourage individuals with suicidal impulses to go to psychiatric clinics for help. Police should learn how to deal with suicidal attempts, and hospitals should include psychiatric examination and advice as to treatment of all such persons. Suicidal attempts should be registered and reported to public health officers in the same way as are other dangerous diseases. More research should be done on case records of these patients, in order to better understand motivations and means of prevention.     

National intelligence, suicide rate in the elderly, and a threshold intelligence for suicidality: an ecological study of 48 Eurasian countries

Across 85 countries around the world, Voracek (2004) found a significant positive relation between estimated national intelligence (IQ) and national male and female suicide rate. The relation was not attenuated when countries' per capita Gross Domestic Product (GDP) and type of national IQ estimation were statistically controlled. Independently, investigating the total national suicide rate only, Lester (2003) arrived at the same conclusion. These two findings are consistent with a corollary of de Catanzaro's (1981) evolutionary theory of human suicide, namely that a threshold intelligence is necessary for suicidality and that intelligence and suicide mortality should thus be positively related. Here, further evidence for this hypothesis is bolstered by focusing on suicide rates of the elderly. Across 48 Eurasian countries, estimated national IQ was significantly positively related to national suicide rates of people aged 65 years and over. This new ecological-level finding survived statistical controlling for a set of seven variables (type of national IQ estimation, national GDP, stableness and recency measures for suicide rates, and rates of adult literacy, urbanization and Roman Catholics), which thus are not confounding factors for the relation of intelligence and suicide mortality. Based on ecological data, the threshold IQ for suicidality is predicted to be 70 or slightly over, an estimate that is consistent with various suicidological observations.