Mental Illness

							                 Mental Illness
• Understanding Mental Illness

• Mental Illness and Suicidal Acts

• Psychiatric Diagnoses Associated with Suicidal Behavior

• Models Relating Mental Illness & Suicidal Acts




                                                            1
                 Mental Illness
• What % of the general population has a mental illness?

• Lifetime likelihood?

• Mental Illness is associated with suicide

• Treatment of mental illness reduces risk




                                                           2
 Understanding Mental Illness
• What is a mental illness?

• Substantive impairment


• Who determines?




                                3
  Understanding Mental Illness
• What is Mental Health?




                                 4
                Emotional Maturity
             by William C. Menninger, MD
• Deal constructively with reality

• Adapt to change

• Freedom from symptoms produced by tension & anxiety

• Relate to others in a consistent manner with mutual
  satisfaction and helpfulness

• Sublimate instinctive hostile energy into creative and
  constructive outlets

• The capacity to love
                                                           5
               Mental Illness
• Two major classification systems

• ICD-10: International Classification of Disease

• DSM-IV-TR: Diagnostic and Statistical Manual
                  of Mental Disorders




                                                    6
                  Mental Illness
• Underlying Assumption

• Both still evolving

• Good inter-rater reliability

• Very useful for diagnosis and treatment

• Useful for communication w/professionals

• DSM-IV-TR Required
                                             7
              Mental Illness
• DSM allows for multiple classifications (5)
  – Clinical Disorder/Condition focus of treatment
  – Personality Disorder or Mental Retardation
  – General Medical Condition
  – Psychosocial and Environmental Problems
  – Global Assessment of Functioning (0 – 100)




                                                     8
 Mental Illness: DSM Diagnosis
• Axis I: 296.22 Major Depressive Disorder, Single Episode,
                 Moderate, Without Psychotic Features
          305.00 Alcohol Abuse

• Axis II: 301. 6 Dependent Personality Disorder

• Axis III: None

• Axis IV: Threat of Academic Dismissal

• Axis V: GAF = 60 (current)


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      Mental Illness and Suicide
Problems re: Suicide
1. Definition of self-harm?

2.   Differentiation between suicide thoughts, attempts, and
     completed suicides?

3.   Cause of Death: coroner’s knowledge

4.   Categorical vs. Dimensional approach


                                                          10
                 Mental Illness
Problems
• ICD: suicidality as complication of mental illness

• DSM: suicidality as part of 2 diagnoses

• Can a person can be diagnosed with either condition
  without the presence of suicidality?

• What does this suggest?



                                                        11
           Association between
        Mental Illness & Suicidal Acts
•   Prospective Studies
•   Retrospective Studies
•   Concurrent Studies
•   Methodological Issues




                                         12
      Mental Illness & Suicide
Prospective Studies
• Follow individuals in groups over time
• Example: Bipolar vs. Attempters
• Determine overlap
• Need large number of individuals in each group




                                                   13
     Mental Illness & Suicide
Prospective studies
• Deaths by suicide in General Population

• Deaths by suicide among individuals who
  have been diagnosed with Mentally Illness




                                            14
      Mental Illness & Suicide

Retrospective Studies
• Examine history (suicidality or mental illness) of
  specific group
Completed Suicides
• In 19 studies, ~ 29% of completed suicides had at least
  one prior mental health contact

• One study: 12% of suicides had contact with mental
  health within 6 months prior to suicide

• Does this mean they had a mental illness?

                                                       15
       Mental Illness & Suicide
Retrospective Studies
• Problems:
   – Consultation due to Suicidal Ideation not mental
     illness
   – Few countries keep good enough records
   – Most people who present at a clinic will receive
     diagnoses for insurance




                                                        16
                 Mental Illness
Retrospective Studies
  – Attempters more likely to have had diagnosis at some
    point in their lives than general population

  – In clinical population
     • 70 to 90% of attempters had previous diagnoses
     • data may be over inflated if past contact was for SI and
       patient received diagnosis




                                                                  17
             Mental Illness
Retrospective
• Psychological Autopsy
  In ~ 90% of suicides could establish mental
    illness (consistent 4 decades)
  ~ half had personality disorder




                                                18
               Mental Illness
Concurrent Studies:
Methodological Problems
• Sampling bias
• Male : Female Ratio
• Suicides following hospitalization
• Suicide may occur at different stage of illness




                                                    19
                 Mental Illness
Methodological Problems
• Personality Disorders don’t know if suicides increase or
  decrease with age

• Inappropriate to withhold treatment

• Many suicidal patients excluded from treatment protocols




                                                             20
          Mental Illness
What do we know?




                           21
    Specific Psychiatric Diagnoses
       Associated with Suicide
• Mood Disorders and Substance Abuse
   – most commonly associated with completed suicides


• Substance Abuse and Anxiety
   – presenting complaint most commonly associated with attempts
     (mood disorder as predisposing condition or lifetime issue)


• What do we mean by “Mood Disorder”




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 Specific Psychiatric Diagnoses
Mood Disorders Include:
• Major Depressive Disorder (2 types + NOS)
• Dysthymic Disorder
• Bipolar Disorder (7 types + NOS)
• Cyclothymic Disorder

Other conditions with dysphoric or depressed mood:
   – Adjustment Disorder with Depressed Mood
   – Bereavement


                                                     23
        Major Depressive Episode
                         (DSM)
A.   Five (or more) of the following symptoms have been
     present during 2 week period and represent a change
     from previous functioning: at least one of the
     symptoms is either depressed mood or loss of interest
     or pleasure.




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       Major Depressive Episode
1)   Depressed mood
2)   Markedly diminished interest or pleasure
3)   Significant weight loss (not dieting) or gain
4)   Insomnia or hypersomnia
5)   Psychomotor agitation or retardation
6)   Fatigue or loss of energy
7)   Worthlessness or excessive inappropriate guilt
8)   Diminished ability to think or concentrate
9)   Recurrent thought of death, recurrent suicidal ideation
     without plan, or a suicide attempt or a specific plan


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      Major Depressive Episode
B.   The symptoms do not meet criteria for mixed episode

C.   The symptoms cause clinically significant distress or
     impairment in social, occupational, or other important
     areas of functioning




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           Major Depressive Episode
D.   The symptoms are not due to the direct
     physiological effects of a substance (e.g., drug
     abuse, a medication) or a general medical
     condition (hypothyroidism)

E.   The symptoms are not better accounted for by
     Bereavement, i.e., after the loss of a loved one, the
     symptoms persist for longer than 2 months or are
     characterized by marked functional impairment,
     morbid preoccupation with worthlessness, suicidal
     ideation, psychotic symptoms or psychomotor
     retardation.

                                                             27
           Mood Disorders
• Higher risk than other disorders, but
  complicated picture when we examine
  individual mood disorder
• Example
  – More completed suicides among depressed
  – Equal number of attempts between depressed
    and bipolar


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            Mood Disorder
• Example
  – Equally high suicidal ideation between
    adjustment disorder and depression
  – Fewer suicidal behaviors among adjustment
    disorders than depression
  – Dysthymic Disorder: early onset have higher
    risk for suicide but not late onset
  • Gets more complicated …


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            Mood Disorders
NIMH Collaborative Depression Study
• Three symptom clusters appear to be
  more predictive of suicide than actual
  diagnosis of Depression
  – Anhedonia & Helplessness
  – Agitation, Anxiety, & Panic
  – Aggression & Impulsivity


                                           30
              Mood Disorders
• Other studies link: Severity, agitation, insomnia,
  self-neglect, hopelessness

• Beck: Hopelessness major risk factor
   – Treatment Implications?

• Psychotic symptoms: unclear

• Male:Female ratio for individuals with a history of
  hospitalization levels off
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              Psychotic Illnesses
• Mood disorders w/psychotic symptoms: No increase
• Schizophrenia & Paranoia: Increased risk
• Why?
   –   Downward drift- going down in socioeconomic status
   –   Acute illness
   –   Stigma
   –   Intensity of symptoms
   –   Realization that one is “crazy”
• Negative Symptoms may offer some protection (all lower
  risk of suicide)
   – Affective flattening – very “blah” subdued mood (lowers one’s
     risk of suicide
   – Avolition – lack of motivation
   – Alogia – lack of cognitive thoughts                             32
              Psychotic Illness
• Schizophrenia: Paranoid Type

• Delusional Disorder: Paranoid Type

• Brief Psychotic Disorder

• Substance-Induced Psychotic Disorder


• Mood Disorder with Psychotic Features

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             Anxiety Disorders
1.   Panic Disorder
2.   Agoraphobia
3.   Specific Phobia (Simple Phobia)
4.   Social Phobia (Social Anxiety Disorder)
5.   Obsessive Compulsive Disorder
6.   Posttraumatic Stress Disorder
7.   Acute Stress Disorder
8.   Generalized Anxiety Disorder



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                 Panic Attacks
•   Palpitations            • Nausea/Distress
•   Sweating                • Faint/Dizzy
•   Trembling/Shaking       • Derealization or
•   Shortness of Breath       Depersonaliztion
•   Chest Pain/Discomfort   • Fear of going crazy
•   Feeling of Chocking     • Fear of Dying




                                                    35
             Anxiety Disorders
New England Journal of Medicine (1989)

• Panic Attacks: increases risk
  – Most common and untreated anxiety disorder
• Follow-up studies:
  – Minor support, most did not find increased risk
  – Anxiety increase suicide risk when
     • Associated with mood disoder
     • Substance abuse
     • Anxiety secondary to suicidal ideation
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           Personality Disorder
A.   Enduring pattern of inner experience and behavior that
     differs markedly from one’s culture. Manifested in 2 or
     more areas: cognition, affect, interpersonal, impulse
     control

B.   The enduring pattern is pervasive and inflexible in a
     variety of settings




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           Personality Disorder
C.   Leads to distress or impairment in social, occupational,
     or other area

D.   Stable and long duration with onset in adolescence or
     young adulthood

E.   Not due to another mental disorder

F.   Not due to other mental or physical illness


                                                             38
         Personality Disorders
~ 6% of population has one

~31-57% of completed suicides qualify as PD- (obviously,
  science isn’t down well on this…)

~17% of PDs have SI or behaviors vs. ~8% general pop
  (ECA study by Samuels, et al, 1994)


Gets complicated...

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          Personality Disorders
Cluster A            Cluster C
• Schizoid           • Dependent
• Schizotypal        • Obsessive Compulsive
• Paranoid           • Avoidant
Cluster B
• Histrionic         • NOS
• Antisocial
• Borderline
• Narcissistic


                                              40
    Borderline Personality Disorder
            (5 or more of the following)
• Abandonment issues
• Unstable & intense relationship
• Identity disturbance
• Impulsivity
• Recurrent suicidality
• Affective instability- when things are good, they
  are very good, but when they are bad…
• Chronic emptiness
• Inappropriate anger
• Stress related paranoia or severe dissociation

                                                      41
          Personality Disorders
Borderline Personality Disorder
• Suicidality as diagnostic criteria
   – Recurrent suicidal behavior or
   – Gestures or threats or
   – Self-mutilating behavior

• ~3 to 9% of patients with BPD complete suicide

• Substance abuse with completions

• Depression with attempts                         42
          Other Diagnoses
• Mental Retardation: low suicide rate

• Epilepsy: elevated rate




                                         43
                 Comorbidity
• Complex and growing area since 1981

• Possibly up to 95% of patients have more than one
  diagnosis




                                                      44
              Comorbidity
Must reconsider impact of single disorder
Examples
• Edmonton Study:
  – Non-fatal attempts = 2.3 diagnoses/person
• Finish Study
  – Non-fatal attempts = 82% had more than 1
  – Completed suicides = 88% had more than 1


                                                45
                   Comorbidity
Problems

• How to establish independent contribution of each
  diagnoses

• How to establish amount of impact or degree of
  contribution of each (cumulative vs. interactive)




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                    Comorbidity
• Depression with other diagnoses
  – Depression and
     •   Anxiety
     •   Substance abuse
     •   Schizophrenia
     •   Bipolar Disorder
• Personality Disorders
  – Unclear if
     • Substance abuse
     • Depression


                                    47
   Relationship Between Mental
     Diagnoses and Suicide
There is a relationship, but
• Not all suicidal persons are mentally ill

• Not all mentally ill are at risk for suicide

• In other words, do not overestimate the strength of the
  statistical relationship




                                                            48
                   Five Models
1.   Direct impact
        Experience of time- distortion of time= direct impact
        of mental illness

2.   Indirect impact
        Severity of disorder amplifies distress or
        Impairs adaptive coping- like losing friends due to
        mental illness, thus loosing connectedness

3.   Complications of diagnoses
       Suicides result from shame of disorder
       Suicides solve unbearable disorder
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                    Five Models
4. Mental illness and suicides share common
   origin
     1. loneliness > isolation > substances > depression > suicide
     2. sexual abuse > PTSD > low self-esteem > coping deficits >
        suicide
5. Independence between mental illness and
   suicide
     Suicide trait
     Suicide is a separate mental illness
     Freud’s Death Instinct?

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