Nine out of ten individuals who commit suicide have a mental disorder at the time of act and up to two thirds of them have depression. Only a quarter of those who die by suicide with major depression are in contact with psychiatric services at the time of their death.20% of those who die by suicide have seen their doctor (GP/family doctor ) in the week before death indicating the significant role primary care could play in preventing suicide.Identifying those at risk is an important task both in psychiatric and primary care settings.
Keith Hawton, Carolina Casan ̃as Comabella, Camilla Haw and Kate Saunders from Centre for Suicide Research, University of Oxford, UK reports the results of systematic review of risk factors for suicide in people with depression.
Thirty-two articles fulfilled the eligibility criteria (criteria diagnosed depression ( either cohort or case control studies) reporting an outcome of suicide with risk factors.28 articles were included in this review, from a total of 19 studies. All of the studies except two were conducted among patients under psychiatric care.
Suicide risk was significantly greater in males (OR = 1.76, 95% CI 1.08 to 2.86).It was not associated with marital status, living alone, having children or employment status. Risk was increased where there was a family history of mental disorder (OR =1.41, 95% CI 1.0 to 1.97). A history of suicide attempts or self-harm was strongly associated with increased risk of suicide (OR = 4.84, 95% CI 3.26 to 7.20). More severe depressive psychopathology was associated with suicide risk (OR=2.20, 95% CI 1.05 to 4.60), but not presence of psychotic features.Risk increased where individuals had expressed feelings of hopelessness (OR=2.20. 95% CI 1.49 to 3.23). Suicide was significantly increased in the presence of current substance misuse (i.e. alcohol and/or drug, OR = 2.17, 95% CI 1.77 to 2.66). Risk increased with the presence of an Axis II (i.e. personality) disorder (OR 4.95, 95% CI 1.99 to 12.33).
Most of these factors are generally known as risk factors in suicide in general.
Limitations: Half of studies used case control methodology ( which is not the ideal one). All studies (except one) were among patients under psychiatric care limiting generalisability. Only one study was from a non Western country . Heterogeneity of findings among studies is another factor to consider while making conclusions.
Conclusion: Male gender, family history of psychiatric disorder, previous attempted suicide, more severe depression, hopelessness, and comorbid disorders ( anxiety and misuse of alcohol and drugs) increase the risk of suicide in those with depression.These factors should be considered while assessing people with depression. However , due to the low base rate of suicide and the poor specificity of risk factors, the predictive power of such assessment is bound to be extremely limited.We require more studies in primary care population from more diverse countries.
Summary of the article:
Hawton K, Casañas I Comabella C, Haw C, Saunders K. J Affect Disord. 2013 May;147(1-3):17-28