Depression and suicidal behaviour

Psychopathological differences between suicidal and non-suicidal depressive patients

M. Wolfersdorf.
Department of Psychiatry I, University of Ulm, PLK Weissenau,
Weingartshofer Str. 2, D-88214 Ravensburg-Weissenau, Germany.

Abstract
After an introduction to the fundamental structure of suicidal tendencies, the of suicidal behaviour is discussed in depth, in particular suicide and attempted suicides of patients suffering from depression in both the general population as well as patients undergoing clinical treatment. Particular emphasis is placed upon the question of typical psychopathology as a high risk factor, i.e. those psychopathological phenomena that separate suicidal from non-suicidal depressive patients. It is seen that special importance is attributed to thoughts of worthlessness, guilt, despair, depressive delusional symptoms, inner restlessness and agitation, panic attacks and states of anxiety, sleep disorders and previous suicidal behaviour.

Introduction

People suffering from depression have always been considered as prime examples for those persons most likely to commit suicide (Hole, 1973; Haenel & Pöldinger, 1986; Sainsbury, 1986; Wolfersdorf, 1991).
In 1621, Robert Burton wrote: ``Melancholy seldom has a fatal outcome, except in those cases -- and that is namely the greatest and most painful tragedy, this exterior misfortune, -- in which the affected commit suicide''. Griesinger (1867) discussed the question of suicide in connection with ``melancholia accompanied by manifestations of destructive urges''. In this study he advanced the thesis that suicide was not always a symptom or the result of a psychic illness.

A study of the literature dealing with the connections between mental illness and suicidal behaviour brings to light the fact that most authors are specialised in the fields of depression research and therapy and only few have examined suicidal tendencies in relation to schizophrenia (e.g. Roy, 1986; Schüttler et al., 1976, Wolfersdorf & Felber, 1995). And this in spite of the fact that most people seem able to correlate the suicidal tendencies of depressive patients with their close proximity to disparagement and sadness. Indeed, people find these tendencies comprehensible within the framework of an inner depressive logic governed by loss, hopelessness and feelings of inviability. Suicidal behaviour in schizophrenic patients, on the other hand, is often regarded as incomprehensible, impulsive and having its origins in psychopathologic factors, thus rendering it unpredictable and impossible to prevent. The important role, however, played by depression in the suicidal tendencies of schizophrenic patients was established by, among others, Roy (1986) and our own group (Wolfersdorf, 1995).

Depressive disparagement, cognitive reduction limiting thoughts to those of insufficiency, worthlessness and guilt, attitudes of despair and helplessness in relation to chances for future improvement are the reason that depressive patients develop stronger suicidal tendencies than all other groups. The question is now raised whether these tendencies develop as a phenomenon independent of the depression itself or whether there is a direct causal relationship. If one assumes the position that suicidal tendencies can be regarded as an attitude and behaviour that are primarily non-pathological and common to all human beings, then it must be possible to identify specific pathogenetical appearance and developmental patterns for these suicidal tendencies. In this case, the role attributed to the depression would be one of an additional psychopathological factor acting to considerably increase the probability that ubiquitous wishes for death and peace are responsible for transforming suicidal ideas into suicidal behaviour.

The suicidal tendencies of depressive-melancholic cases are best analysed using a developmental model incorporating psychophysical triggers, both acquired and constitutional aspects of personality including physical illness, as well as factors originating in the socio-cultural environment. This permits the integration of psycho-dynamic, inside-psychological, psychiatric-biological and social points of view. Current psycho-biological models regard a defective central impulse control as the cause for suicidal behaviour, which is accompanied by serotonin metabolism dysfunction in the central nervous system. Psychiatric and psycho-pathological approaches describe the status of despair and cognitive perception disorders in depression or schizophrenia, but also in crisis-related psychic limitations. Sociological approaches refer to the importance of the aspects of anomie in society and the difficulties of social integration of the affected groups (for an overview see Maris, 1986; Blumenthal & Kupfer, 1990; Wedler et al., 1992). In the light of aetiopathogenetic and developmental points of view, the following aspects are of importance in the current discussion concerning suicidal tendencies:

1. Suicidal ideas: May appear just as well in healthy people, however, acquire a pathological status when they occur in the context of illness, e.g., depression or physical illness.
2. Biological readiness to act (impulsivity): This refers to a neurobiochemical and genetic disorder involving impulsiveness and behaviour control, which manifests itself on the neurobiochemical level mainly in a central serotonin disturbance (Praag, van., 1986), peripherally in an electodermal hyporeactivity (Edman et al., 1986; Keller et al., 1991; Wolfersdorf & Straub, 1994). In certain circumstances, this biological readiness to act can also be activated by psycho-social or psycho-dynamical means, however also by biological, i.e., medicamentous means. As an example, see the discussion on ``suicide promotion'' caused by anti-depressants.
3. Current psychoreactive triggering factors: In this point, particular importance is attributed to the psychoanalytic and inside-psychological concept of suicidal tendency as the manifestation of a narcissistic crisis (Henseler, 1976; Reimer, 1986) of a significant role model. Loss, insult, existential inviability all play an important role in this experience.
4. Despair, helplessness, hopelessness: Convictions of lacking prospects for the future and the impossibility of changing this outlook are central psychopathological phenomena that form the threshold between suicidal ideas and suicidal action (Beck et al., 1985, 1990).
5. Loss of or loss of effectiveness of protective factors: ``bonds'', social control of aggression (societal norms on aggression control), religious, spiritual or family bonds, group cohesion, etc.

Frequency of suicidal behaviour in depressive patients
Pokornky (1983) estimated that the risk of primarily depressive patients to commit suicide is 30 times greater than that in the general population. Data on the numbers of the diagnosis group for suicides in the general population indicate percentages mainly between 40 and 60 percent (Table 1). In a study on suicide in the general population in the Ravensburg-Oberschwaben region in southern Germany (Wolfersdorf et al., 1993), results based on medical reports and retrospective diagnosis (``psychological, autopsy'' postmortem'') showed that of 454 suicide deaths (326 male, 128 female), depression was the primary diagnosis in 66% of the cases, followed by alcoholism in 28% and personality disorders in 14% of the cases.

According to the overview work done by Guze & Robins (1970), and the estimates of Miles (1977), suicide can be identified as the cause of death in 12--19% and 15% respectively in the deaths of all severely depressed patients. The suicide rate increases with time as shown in a catamnesis in which N = 186 of depressive patients released after a period of hospitalisation (Steiner et al., 1988; Ruppe et al., 1994): in the first year of hospitalisation, the percent share of suicide deaths was 2.2, with the value rising to 8% in the 6 year catamnesis. In a six to eight year catamnesis, Bronisch (1985) counted 6 suicides (12%) from 50 neurotically depressive patients. Table 3 is based upon related literature (for details see Wolfersdorf & Mäulen, 1992) and illustrates the frequency of suicidal behaviour in the three major groups of psychic illness, namely depression, schizophrenia and alcoholism: in 40 to 60 percent of all suicide deaths in the general population, the deceased was suffering at the time of the suicide from a primary depression. In the case of attempted suicides, the share of those suffering from depression is 10--50%. Suicide mortality during longtime course of depression is 12--18% of the total mortality, 20--40% of depressive patients attempt suicide during their illness, 40--80% harbour suicidal thoughts. In this manner, depression remains the illness that involves the highest risk of suicide. Walter Pöldinger (personal communication, April 15--17, 1991) can be apparently quoted as saying that an improvement in the diagnostic and therapy of depression could reduce the suicide rate in the case of depressive patients by 50%.

Risk groups in depression: ``High risk psychopathology''

Psychological testing and neurobiochemical examination methods are not designed for the diagnosis of acute suicidal risk. The psychiatrist/psycholo- gist/psychotherapist must rely upon information received directly from the depressive patient, on their knowledge of the patient's case history as well as on their expertise in current psychopathology. The diagnosis of suicidal tendencies in depressive patients must be based on:

1. information gleaned from interviews with the patient regarding his suicidal tendencies;
2. the progression of the illness including previous suicidal behaviour and crises and how these were overcome; and
3. the knowledge of specific risk groups (psychopathology, psychodynamics, progression in time, special sub-groups) within the umbrella group of depressive patients.

In an overview about depression, suicide and suicide prevention, Sainsbury (1986) lists all the factors having an influence on the risk of suicide. Among the symptoms, he lists sleep disorders, slow speech, weight loss, loss of interest, social withdrawal, despair and pessimism, ideas of worthlessness, psychomotor agitation and restlessness. Barraclough & Pallis (1975) compared 64 suicide deaths to 128 depressive cases without suicide and discovered that the cases involving suicide death suffered much more frequently from sleep disorders, self-degradation, memory losses and had made previous suicide attempts. Fawcett et al. (1987) compared 25 suicide deaths of depressive patients to 929 depressive patients without suicide and found a significantly higher rate of despair, loss of interests and lack of reaction to social contact in the case of the suicidents. In a comparison of 75 depressive patients who committed suicide and 50 depressive patients who did not, Modestin & Kopp (1988) established a significant higher rate of depression with bipolar illness, schizo-depressive patients and patients who were either hospitalised due to suicidal behaviour or displayed suicidal behaviour during their hospital stay. In a similar study, Wolfersdorf (1989) compared depressive patients having committed suicide during hospitalisation with a control group with a parallel age and sex make-up, and the results showed a significantly higher rate of delusional symptoms and attempted suicides during or previous to hospitalisation in the suicide-death group. In a study comparing 25 depressive patients who committed suicide to control groups of depressive in-patients with no suicide incidents, Metzger & Wolfersdorf (1988) found endogenous depression, delusional depression, sleep disorders as well as previous suicide attempts to be much more common in the suicident group. In a follow-up examination of 32 patients, who committed suicide, from a ten-year catamnesis involving over 950 depressive patients Fawcett and co-workers (Fawcett et al., 1990, 1993) differentiated between first-year suicides after index treatment and later suicides. In the case of first-year suicides, occurrences of panic attacks, elevated states of anxiety, psychomotor restlessness and sleep disorders, alcohol abuse, anhedonie and concentration difficulties were significantly greater. Later suicidents showed a much lower incident of panic attacks. The authors are of the opinion that the occurrence of states of anxiety and panic attacks increases the risk of suicide in depressive patients. That comorbidity of suicidal ideations and suicide attempts with depression, anxiety disorders or substance abuse increases risk for suicidal behaviour was shown by Bronisch & Wittchen (1994) (see also Wolfersdorf & Straub, 1995).

Tables 4, and 5 illustrate the results obtained in our own studies. Table 4 presents an overview of the extent of the risk of suicide in depressive in-patients in the depression ward of the Weissenau clinic. Table 5 shows the results of a comparison between depressive in-patients displaying suicidal tendencies and those where were absent; only the variables that show a significant demarcation are listed here (Wolfersdorf & Niehus, 1993). For the purposes of this study, the word ``suicidal'' was defined as ``acute suicidal crises with well-formed suicidal ideas, tendencies or an attempted suicide.'' ``Non-suicidal'' is defined as displaying no suicidal tendencies at the time of recording of the index as well as according to anamnestic data in the case history to date. This underlines the importance of the existence of depressive thoughts, despair, cognitive thought reduction, the extent of the depression and suicidal behaviour in the family of origin.

Discussion and closing remarks

If one were to attempt to evaluate the clinical and psychopathological data gathered in studies and from the literature on depression and suicidal tendencies, the following psychopathological phenomena (Table 6) can be retained with a certain degree of certainty as signs of an increased suicidal risk (``risk psychopathology''): thoughts of worthlessness, guilt; pronounced despair (in particular in combination with tendencies of self-punishment and pseudo-altruistic motives of freeing the world of their own person because of being a burden to others); depressive delusions, in particular delusions of guilt or culpability with self-punishment tendencies; agonising restlessness and psychomotor agitation; panic attacks and generally acute states of anxiety; and altogether strongly pronounced depression (melancholic, psychotic depression). In addition, the occurrence of suicidal behaviour in the current or past case history is equally a sign of a greater risk of suicide.

Depressive patients form a high-risk group for suicidal behaviour. As a matter of principle, one should always presuppose suicidal tendencies in the case of depressive patients until these have been excluded in a comprehensible and credible manner -- as far as this is possible. In the case of insistent suicidal tendencies, it is necessary to apply the correct therapeutic care measures such as reassuring care (in-patient or out-patient treatment and crisis intervention), increased empathetic contacts (control aspects and communication), psychotherapeutical crisis intervention and psycho-pharmaceutical therapy of the underlying illness and anxiolytic-sedative medication.

It is amazing that in spite of important advances in the psychopharmacological and psychotherapeutical fields that have improved the treatment for people suffering from depression in the last decades that the number of suicide deaths has, on the whole, barely retreated. This is possibly less a therapy-related problem than it is a problem of the timely and correct diagnosis of depressive and suicidal tendencies, and this, more likely than not, at the level of out-patient treatment and general practitioners. Psychologists and psychotherapists, however, cannot be left out here either.

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