Archives of Suicide Research, 19:48–59, 2015 Copyright # International Academy for Suicide Research ISSN: 1381-1118 print=1543-6136 online DOI: 10.1080/13811118.2014.915777
Depressed Suicide Attempters with Posttraumatic Stress Disorder Maria Ramberg, Barbara Stanley, Mette Ystgaard, and Lars Mehlum Posttraumatic stress disorder and major depressive disorder are well-established risk factors for suicidal behavior. This study compared depressed suicide attempters with and without comorbid posttraumatic stress disorder with respect to additional diagnoses, global functioning, depressive symptoms, substance abuse, history of traumatic exposure, and suicidal behavior. Adult patients consecutively admitted to a general hospital after a suicide attempt were interviewed and assessed for DSM-IV diagnosis and clinical correlates. Sixty-four patients (71%) were diagnosed with depression; of them, 21 patients (32%) had posttraumatic stress disorder. There were no group differences in social adjustment, depressive symptoms, or suicidal intent. However, the group with comorbid depression and posttraumatic stress disorder had more additional Axis I diagnoses, a higher degree of childhood trauma exposure, and more often reported previous suicide attempts, non-suicidal self-harm, and vengeful suicidal motives. These findings underline the clinical importance of diagnosis and treatment of posttraumatic stress disorder in suicide attempters. Keywords
attempt, comorbidity, depression, hospital admission, PTSD, suicide
INTRODUCTION
associated with suicide attempt (Sareen, Houlahan, Cox et al., 2005; Panagioti, Gooding, & Tarrier, 2012). PTSD is frequently comorbid with Major Depressive Disorder (MDD), co-occurring in 48% to 79% of patients (Brown, Campbell, Lehman et all, 2001; Clover, Carter, & Whyte, 2004; Cougle, Resnick, & Kilpatrick, 2009; Kessler, Sonnega, Bromet et al., 1995). The comorbidity of PTSD and MDD is associated with especially high rates of suicidal behavior (Cougle, Resnick, & Kilpatrick, 2009; Gradus, Qin, Lincoln et al., 2010; Panagioti, Gooding, & Tarrier, 2009; Panagioti, Gooding, & Tarrier, 2012). It is, therefore, important to
The majority of patients admitted to a general hospital for a suicide attempt have a diagnosable mood disorder (Haw, Hawton, Houston et al., 2001), with depression being the most frequent diagnosis (Beautrais, 2000; Kessler, Borges, & Walters, 1999). In population-based studies, comorbid anxiety disorders have been shown to amplify the risk of suicide attempt in individuals with mood disorders (Sareen, Cox, Afifi et al., 2005), but posttraumatic stress disorder (PTSD) is the only anxiety disorder found to be uniquely
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study individuals with comorbid PTSD and MDD in order to determine if they exhibit unique risk factors for suicidal behavior and if their suicidal behavior differs with respect to frequency and motivation. To date, few studies have reported on the presence of PTSD and PTSD-MDD comorbidity in suicide attempters. One study of hospitalized suicide attempters found that 27% had a PTSD diagnosis, and of these, 79% had a comorbid mood disorder (Clover, Carter, & Whyte, 2004). In a sample of psychiatric outpatients with recent suicidal behavior or ideation, 32% had current PTSD, and 97% of these had one or more comorbid diagnoses (mainly affective disorders and other anxiety disorders) (Rudd, Dahm, & Rajab, 1993). The relationship among PTSD, MDD, and suicidal behavior may be influenced by environmental factors, such as childhood maltreatment, a known risk factor for many types of psychopathology (Chen, Murad, Paras et al., 2010; Gilbert, Widom, Browne et al., 2009; Perepletchikova & Kaufman, 2010). Sexual, physical, and emotional abuse and neglect all increase the risk of suicidal behavior, with the most consistent findings related to childhood sexual abuse (Brodsky & Stanley, 2008; Enns, Cox; Afifi et al., 2006; Mandelli, Carli, Roy et al., 2011; Molnar, Berkman, & Buka, 2001; Ystgaard, Hestetun, Loeb et al., 2004). Further, patients with comorbid MDD and PTSD have a history of childhood abuse more often than patients with MDD who do not have PTSD (Oquendo, Brent, Birmaher et al., 2005). Several studies of both epidemiological and clinical samples have described a substantially increased risk of revictimization in adulthood for men and women who were exposed to childhood sexual and physical abuse (Coid, Petruckevitch, Feder et al., 2001; Desai, Arias, Thompson et al., 2002). As for depressed suicide attempters with comorbid PTSD, childhood abuse
and revictimization in adulthood is poorly described. Mental disorders are well-documented risk factors for attempted suicide, but whether motives for suicidal behavior are different in different psychiatric diagnoses is less known. Research on suicidal motives has mainly focused on suicidal intent and psychosocial risk factors (Groholt, Ekeberg, & Haldorsen, 2000; Hjelmeland, Hawton, Nordvik et al., 2002; McAuliffe, Arensman, Keeley et al., 2007). Still, what characterizes suicidal motives in those exposed to trauma or have a diagnosis of PTSD is poorly described in the research literature. Based on what is known about PTSD-MDD comorbidity and suicidal behavior, we hypothesized that depressed suicide attempters with PTSD admitted to a general hospital would differ from those without PTSD beyond the differences in clinical symptoms. We examined whether depressed suicide attempters with PTSD would report a history of more frequent suicidal behavior in the past, have different suicidal motives and precipitating factors for the index suicide attempt, and have more additional comorbidity, depressive symptoms, substance abuse, and lower level of functioning than depressed suicide attempters without PTSD. We also examined exposure to trauma in childhood, the type of trauma reported as precipitating PTSD and when it occurred, and adulthood retraumatization of suicide attempters with comorbid PTSD. METHOD
This study is a secondary analysis of the suicide attempters diagnosed with depression, in a larger follow-up study of suicide attempters consecutively admitted to a general hospital in Oslo, which serves a catchment area of 130,000 inhabitants, over a period of 26 months.
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Participants
were collected after discharge by two specifically trained interviewers.
Patients who had deliberately taken an overdose or had otherwise deliberately injured themselves, reported suicidal intent, and were older than 15 years were included in the study. Patients were excluded if they were cognitively impaired or did not speak Norwegian. Of the 121 eligible patients admitted during the inclusion period, 90 (74%) consented to participate in the study. There were no significant differences between the individuals who participated and those who did not in terms of age, sex, and marital status. The participants were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV, (2011) using the Norwegian version of the Mini International Neuropsychiatric Interview (Sheehan, Lecrubier, Sheehan et al., 1998). Of the 90 participants, 64 (71%) were diagnosed with MDD. This subsample of 64 patients with MDD was the basis for the current study. All participants were interviewed while hospitalized and 52 again after discharge (12 patients declined to participate in the post-discharge interview). Procedure
Informed consent was obtained from all participants. The study was approved by the Regional Committee for Medical research and Ethics. The participants were interviewed within 2 days after their suicide attempt, while hospitalized, and after discharge about childhood trauma. At the hospital, data were collected through semistructured interviews by a psychiatrist or psychiatric nurse, and through questionnaires. The interviews were audiotaped and interrater reliability was checked by re-rating a random sample of 15 interviews. Data on childhood traumatic exposure
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Measures
The European Parasuicide Study Interview Schedule (EPSIS), described in detail elsewhere (Hjelmeland, Hawton, Nordvik et al., 2002; Kerkhof, Bille-Brahe, & Lonnqvist, 1994), was used to collect sociodemographic data. Social adjustment was rated on a 5-point Social Adjustment Scale (SAS) with a score of 5 being the highest and most favorable. This scale is comprised of dichotomous ratings of current living situation, economy, employment, psychiatric treatment, and social activity (Petersen, 1974). BPD was diagnosed using the Structured Clinical Interview for DSM-IV Personality Disorders (SCID II) (First, 1997). The patients’ global functioning was assessed with the Global Assessment of Functioning (GAF) (DSM VI, 2011). Depressive symptoms were measured by the Montgomery–Asberg Depression Rating Scale (MADRS) (Montgomery & Asberg, 1979). Lifetime substance abuse and substance use in the last 3 months was assessed with the Drug Abuse Screening Test (DAST) (Gavin, Ross, & Skinner, 1989) and calculated as a sum score of the 20 items, resulting in a total range from 0 to 20 with a clinical cut-off score of 6 or higher. Alcohol abuse was measured with the 10-item Alcohol Use Disorders Identification Test (AUDIT); a sum score of 11 or above suggests a drinking problem (Fleming, Barry, & MacDonald, 1991). Suicide attempt history was assessed using a question similar to that used for the index suicide attempt: ‘‘Have you at any time earlier in your life, taken an overdose or deliberately injured yourself?’’ with an added question about the patient’s suicidal intent. Events with suicide intent were classified as suicide attempts, while those
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without suicide intent were classified as nonsuicidal self-harm (NSSH), which was defined as: ‘‘any act of intentional self-poisoning or injury without suicide intent’’ (National Institute for Clinical Excellence, 2004). Suicide intent for the index attempt was measured using the Suicide Intent Scale (SIS) (Beck, Morris, & Beck, 1974). The EPSIS interview was used to collect data on precipitating factors and motives for the index suicide attempt, exploring 10 possible precipitating factors and assessing motives using the 14-item Motives for Parasuicide Questionnaire (MPQ) (Kerkhof, Bernasco, Bille-Brahe et al., 1993). The variables from both Precipitating Factors and MPQ were dichotomized into ‘‘no influence’’ and ‘‘influence.’’ The Childhood Experience of Care and Abuse Interview Schedule (CECA) assess adverse experiences before age 18 (Bifulco, Brown, & Harris, 1994). The CECA focuses on collecting factual information that can potentially be validated, and contains four scales measuring neglect, antipathy, and physical and sexual abuse. Previous studies have shown that suicidal behavior is typically related to severe negative experiences, such as sexual abuse with penetration, therefore the CECA scores were dichotomized into ‘‘severe events’’ and ‘‘mild or no such event’’ (Mullen, Martin, Anderson et al., 1993). A thorough description of all the scales and procedures is provided in Ystgaard, Hestetun, Loeb et al. (2004). Data Analysis
Demographic, trauma-related, and clinical variables were compared between MDD patients with and without PTSD. The significance of observed associations and=or differences between variables was tested using Pearson’s chi-squared test and Fisher’s exact test, when appropriate,
for categorical variables, and Student’s t-test for continuous variables. The Mann– Whitney U test was used for variables with a non-normal distribution. All analyses were performed using the IBM SPSS Statistics 17 software (SPSS Inc., 2008). RESULTS
All participants were depressed suicide attempters admitted to a general hospital (n ¼ 64) and 21 of these patients (33%) were diagnosed with current PTSD. Sociodemographic Characteristics
The mean age in the sample, was 36 years (SD ¼ 14.5; range ¼ 16–77 years). Forty-six (72%) of the 64 were women, 19 (30%) were married or living with a partner, 36 (56%) were employed or studying full time, and 37 (58%) had children. There were no significant group differences between patients with PTSD and without PTSD in demographic variables or social adjustment scores (Table 1). Clinical Characteristics
Patients with PTSD had significantly more Axis I diagnoses, with a higher frequency of other anxiety disorders, than the non-PTSD group (75% vs. 47%). Sixteen patients (25%) met criteria for BPD and there were no significant between group differences in the distribution of BPD (Table 2). Patients with PTSD scored significantly higher (p ¼ 0.005) on lifetime substance abuse, but not on current substance abuse or alcohol abuse (Table 2). There were no significant group differences in MADRS or GAF scores (Table 2). Suicidal Behavior
Of the 64 patients, the majority (n ¼ 51) had used self-poisoning (taken an
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TABLE 1. Sociodemographic Characteristics and Childhood Traumatic Exposure Assessed with the Childhood Experience of Care and Abuse Interview (CECA), in Depressed Suicide Attempters With and Without PTSD Patients without PTSD (n ¼ 43)
Patients with PTSD (n ¼ 21)
28 (65) 15 (35) 37.5 (15.8)
18 (86) 3 (14) 32.3 (11.0)
14 (33) 29 (67)
5 (25) 15 (75)
Sex Female n (%) Male n (%) Age mean (SD) Marital Status Married=cohabitating n (%) Single=divorced=widowed n (%) Children Yes n (%) No n (%) Occupation Employed or fulltime student n (%) No occupation (unemployed, living on welfare, retired) n (%) Social Adjustment Scale Mean (SD) Childhood Traumatic Exposure Any childhood traumatic exposure n (%) Severe sexual abuse n (%) Severe physical abuse n (%) Severe neglect n (%) Severe antipathy n (%)
p-value 0.085
0.134 0.543
0.726 25 (66) 13 (34)
12 (71) 5 (29)
25 (61) 16 (39)
11 (58) 8 (42)
3.2 (1.4) n = 35 18 (51) 8 (23) 5 (14) 8 (23) 13 (37)
2.8 (1.4) n = 17 15 (88) 13 (77) 6 (35) 5 (29) 8 (47)
0.821
0.231 0.014 0.001 0.145 0.735 0.556
Note. Categorical variables were tested with Pearson’s v2 and continuous variables with a normal distribution were tested with Student t-test. The categorical trauma-related variables were tested with Fishers Exact test, two sided; p 0.05, p 0.001.
overdose) as their method for the index suicide attempt. The patients with PTSD were more likely to have a history of suicide attempts, previous episodes with NSSH, and to report problems with addiction as a precipitating factor of the suicide attempt (Table 3). Also, the patients with PTSD reported significantly more interpersonal vengeful motives for the index suicide attempt (Table 3). Specifically, they were more likely to endorse motives such as ‘‘I wanted others to pay for how they treated me’’ and ‘‘I wanted someone to feel guilty’’ for their suicide attempt. The mean Suicide Intent Scale (SIS) score for the
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entire sample was high, 15.1 (SD ¼ 6.77) with no significant differences between groups (Table 3). Traumatic Exposure
Thirty-three patients (64%) reported childhood exposure to trauma, and the patients with PTSD reported childhood trauma more often than the non-PTSD group (Table 1). Of the 17 patients with comorbid PTSD, only two reported little or no exposure to childhood trauma. Significantly more of the patients with PTSD
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TABLE 2. Clinical Characteristics of Depressed Suicide Attempters With and Without PTSD Characteristics n ¼ 64 Additional axis I diagnoses mean (SD)1 BPD diagnosis n (%) DAST lifetime mean (SD)1 DAST last 3 months mean (SD)1 AUDIT mean (SD)1 MADRS mean (SD) GAF mean (SD)
Patients without PTSD (n ¼ 43)
Patients with PTSD (n ¼ 21)
p-value
0.6 (0.7)
1.1 (0.9)
0.031
10 (24) 3.4 (4.2) 1.7 (3.1) 8.7 (7.6) 23.(8.6) 53.0 (10.6)
6 7.7 3.5 11.2 25.5 48.6
(29) (5.7) (5.1) (13.3) (5.77) (13.8)
0.682 0.005 0.196 0.906 0.385 0.200
Note. Categorical variables are tested with Pearson’s v2 and continuous variables with a normal distribution are tested with Student t-test. The n varied from 31 till 43 in those without PTSD and from 15 till 21 in those with PTSD; in ‘‘DAST last 3 months’’ data on 18 patients is missing. 1 Mann Whitney U-test were used for variables with a non-normal distribution. p-value < 0.05.
TABLE 3. Characteristics of Suicidal Behavior in Suicide Attempters With and Without PTSD Patients without PTSD (n ¼ 43) SIS index suicide attempt mean (SD) 15.70 (7.37) Previous suicide attempts yes n (%) 21 (50) NSSH lifetime yes n (%) 7 (21) Motives for index suicide attempt 36 (86) ‘‘Unbearable thoughts’’1 n (%) 1 39 (93) ‘‘The situation was intolerable’’ n (%) ‘‘Wanted to get away for a while’’ n (%) 28 (68) ‘‘Wanted help from someone’’ n (%) 23 (55) 35 (83) ‘‘Wanted to die’’1 n (%) ‘‘Wanted others to pay for how they treated 10 (24) me’’ n (%) ‘‘Wanted someone to feel guilty’’ n (%) 10 (24) Major influence of problem precipitating the index suicide attempt Problems with your partner n (%) 21 (53) Feelings of loneliness n (%) 23 (56) Mental illness and psychiatric symptoms n 13 (33) (%) Physical illness or disability n (%) 7 (17) 3 (8) Addiction n (%)1
Patients with PTSD (n ¼ 21)
p-value
13.68 (5.26) 17 (85) 8 (47)
0.276 0.008 0.050
18 19 11 13 17 12
(95) (100) (58) (68) (90) (63)
0.418 0.545 0.432 0.315 0.707 0.003
11 (58)
0.009
6 (30) 11 (58) 6 (32)
0.099 0.896 0.944
5 (25) 7 (35)
0.465 0.023
Note. Categorical variables were tested with Pearson’s v2 or where appropriate. 1 Fisher’s Exact Test and continuous variables with a normal distribution were tested with Student t-test. N varies from 41 till 43 in those without PTSD and from 19 till 21 in those with PTSD. p-value < 0.05.
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were exposed to severe sexual abuse in their childhood, and they were more often exposed to several types of childhood trauma (p ¼ 0.014, Mann-Whitney U test) compared to the non-PTSD group (Table 1). The 5 patients with PTSD who reported only one type of childhood maltreatment were exposed to sexual abuse. Given the high degree of childhood traumatic exposure in the whole sample, we examined whether the depressed suicide attempters with a history of severe childhood trauma would differ on the characteristics of their suicidal behavior compared to those without such history. There were no group differences on SIS scores, Precipitating Factors or MPQ. Forty patients (63%) reported having experienced an unusual traumatic event, which qualifies for the A-criterion of the PTSD-diagnosis according to the DSM IV. The trauma reported by the 21 PTSD patients as their A-criterion were as follows: rape or other sexual abuse (N ¼ 12) (7 reported repetitive sexual abuse); physical abuse (N ¼ 5) (4 reported repetitive physical abuse), traumatic bereavement (N ¼ 7) (3 witnessed the unexpected sudden death or murder of a close relative, 2 were traumatized by the death of their infant and=or child, 2 were traumatized by the unexpected news of the death of their spouse=boyfriend), and 2 patients were threatened at gunpoint during robbery. Of the 21 patients with comorbid PTSD, 5 (24%) patients reported more than one type of traumatic event as qualifying for the A-criterion and only 6 patients (29%) reported the A-criterion trauma had happened in their childhood, before they were 18 years old. DISCUSSION
To the best of our knowledge, this is the first study to describe comorbid current PTSD and current MDD in suicide
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attempters consecutively admitted to a general hospital. In the current study, the comorbidity of PTSD and depression is similar to comorbidity rates reported in an outpatient sample (Rudd, Dahm, & Rajab, 1993) and a sample of patients treated for deliberate self-poisoning (Clover, Carter, & Whyte, 2004). Several of our findings are in accordance with previous research on PTSD samples, in which the PTSD patients also had a high rate of comorbidity with other anxiety disorders (Brady, Killeen, Brewerton et al., 2000; Clover, Carter, & Whyte, 2004; Kessler, Sonnega, Bromet et al., 1995), a high rate of reported lifetime substance abuse (Brady, Killeen, Brewerton et al., 2000; Gielen, Havermans, Tekelenburg et al., 2012), and did not differ in the level of suicide intent compared to the non-PTSD group (Oquendo, Brent, Birmaher et al., 2005; Oquendo, Friend, Halberstam et al., 2003). While previous reports (Alvarez, Roura, Foquet et al., 2012; Cougle, Resnick, & Kilpatrick, 2009; Monnin, Thiermard, Vandel et al., 2012; Oquendo, Brent, Birmaher et al., 2005; Zlotnick, Mattia, & Zimmerman, 1999) have found comorbid PTSD to be associated with a history of suicide attempts, we have replicated this association and additionally found an association between comorbid PTSD and more frequent history of NSSH. The patients with PTSD reported significantly more interpersonal vengeful suicidal motives, more than twice as often as the non- PTSD group. The percentage of patients without PTSD reporting vengeful motives is consistent with results reported from other samples of suicide attempters (Groholt, Ekeberg, & Haldorsen., 2000; Hawton, Houston, Haw et al., 2003; McAuliffe, Aresman, Keeley et al., 2007). Existing literature suggests that anger may be a characteristic of PTSD (Olatunji, Ciesielski, & Tolin, 2010), and one hypothesis is that the vengeful motives reported
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by suicide attempters with comorbid PTSD are related to this anger. The patients with PTSD reported exposure to childhood trauma, in particular sexual abuse, and exposure to multiple types of childhood trauma, significantly more often than the non-PTSD group. These findings are in accordance with previous studies (Zlotnick, Johnson, Kohn et al., 2008; Zlotnick, Johnson, Yen et al., 2003), but now, for the first time, reported in suicide attempters with comorbid PTSD. Childhood abuse has been found to increase the risk of suicide attempts throughout the lifespan (Brodsky & Stanley, 2001; Dube, Anda, Felitti et al., 2001; van der Kolk, Perry, & Herman, 1991). There is also a certain dose–response relationship between the number of traumatic events and the subsequent odds for a suicide attempt (Stein, Chiu, Hwang et al., 2010). In our study, 66% of the patients with comorbid PTSD exposed to trauma in childhood were revictimized later in adulthood. A similar result has been reported from a sample of depressed women, in which those with a history of childhood sexual abuse were more likely to report a recent assault and more likely to have attempted suicide (Gladstone, Parker, Mitchell et al., 2004). Since trauma in both childhood and adulthood is associated with increased suicidal risk, it may be that the combination of a substantial amount of childhood trauma and revictimization in adulthood is part of the explanation for why comorbid MDD and PTSD is found to enhance risk of suicidal behavior. It is well known that BPD is linked to suicidal behavior and that it is frequently comorbid with PTSD and MDD (Pagura, Stein, Bolton et al., 2010; Wedig, Silverman, Frankenburg et al., 2012; Zanarini, Frankenbrug, Dubo et al., 1998). Oquendo, Brent, Birmaher et al (2005), found comorbid cluster B personality disorders to be a risk factor for suicidal acts in patients with a lifetime history of MDD and PTSD,
compared to patients with only MDD. However, we found BPD to be equally distributed between the two groups. This discrepancy could be attributed to the difference between lifetime and current diagnoses, as we have examined current diagnoses and not lifetime. More depressive symptoms have been reported in patients with comorbid MDD and PTSD than those without PTSD (Oquendo, Brent, Birmaher et al., 2005), but we found no such difference. This may be because the samples were different with respect to suicidal behaviors; unlike the sample in the study by Oquendo, Brent, Birmaher et al., all patients in our sample were suicide attempters. This suggests that, for an already suicidal depressed patient, the presence of PTSD does not add much to the depression rating, even though the two disorders share a number of symptoms. Strengths and Limitations
The brief time between the suicide attempt and the assessment is a methodological strength; it should limit the negative influence of recall bias for data concerning clinical correlates and current suicidal behavior. Another methodological strength of the study is the use of the CECA interview schedule to assess childhood traumatic exposure. The CECA has a detailed and contextualizing approach, yields reliable data, and was highly recommended in a recent review of features and limitations of instruments assessing childhood adversities (Thabrew, de Sylva, & Romans, 2012). As for the generalizability of the results, the sample was based on suicide attempters consecutively admitted to one general hospital in Oslo, which serves a catchment area of 130,000 inhabitants. All general hospitals in the city of Oslo serve geographical sectors, and thus all socioeconomic classes are served by the same hospital.
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Study limitations include the relatively small sample size as it might cause type II errors or minimize detection of true associations. Retrospective reporting concerning childhood maltreatment, previous suicide attempts, and lifetime reports on nonsuicidal self-harm may be biased by the respondents’ mental state with a potential risk of both under- and over-reporting the frequency of events and their severity. However, the interview method and the use of trained interviewers are likely to counterbalance the problem. Conclusion
There are important differences in suicide attempters with comorbid depression and PTSD compared to those without PTSD. As previously reported, those with both depression and PTSD are more likely to have a history of suicide attempts. In addition, this study found that they are more likely to have a history of non-suicidal self-harm; and they report vengeful motives for their suicidal behavior more often, suggesting that anger is a strong component of their suicidal actions. The symptom overlap between PTSD and depression may result in the underdiagnosis of PTSD among suicide attempters admitted to the hospital (Mueser, Goodman, Trumbetta et al., 1998). Therefore, clinicians need to be mindful of PTSD symptoms, and inquire about them in depressed suicide attempters, to accurately assess their suicide risk and to customize their treatment. AUTHOR NOTE
Maria Ramberg, National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway. Barbara Stanley, National Centre for Suicide Research and Prevention, Institute
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of Clinical Medicine, University of Oslo, Norway, and Department of Psychiatry, New York State Psychiatric Institute and Columbia University, New York, New York, USA. Mette Ystgaard, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Norway. Lars Mehlum, National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway. Correspondence concerning this article should be addressed to Maria Ramberg, National Centre for Suicide Research and Prevention, Sognsvannsveien 21, Building 12, NO-0372 Oslo, Norway. E-mail: maria. [email protected]
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Depressed Suicide Attempters with Posttraumatic Stress Disorder Maria Ramberg, Barbara Stanley, Mette Ystgaard, and Lars Mehlum Posttraumatic stress disorder and major depressive disorder are well-established risk factors for suicidal behavior. This study compared depressed suicide attempters with and without comorbid posttraumatic stress disorder with respect to additional diagnoses, global functioning, depressive symptoms, substance abuse, history of traumatic exposure, and suicidal behavior. Adult patients consecutively admitted to a general hospital after a suicide attempt were interviewed and assessed for DSM-IV diagnosis and clinical correlates. Sixty-four patients (71%) were diagnosed with depression; of them, 21 patients (32%) had posttraumatic stress disorder. There were no group differences in social adjustment, depressive symptoms, or suicidal intent. However, the group with comorbid depression and posttraumatic stress disorder had more additional Axis I diagnoses, a higher degree of childhood trauma exposure, and more often reported previous suicide attempts, non-suicidal self-harm, and vengeful suicidal motives. These findings underline the clinical importance of diagnosis and treatment of posttraumatic stress disorder in suicide attempters. Keywords
attempt, comorbidity, depression, hospital admission, PTSD, suicide
INTRODUCTION
associated with suicide attempt (Sareen, Houlahan, Cox et al., 2005; Panagioti, Gooding, & Tarrier, 2012). PTSD is frequently comorbid with Major Depressive Disorder (MDD), co-occurring in 48% to 79% of patients (Brown, Campbell, Lehman et all, 2001; Clover, Carter, & Whyte, 2004; Cougle, Resnick, & Kilpatrick, 2009; Kessler, Sonnega, Bromet et al., 1995). The comorbidity of PTSD and MDD is associated with especially high rates of suicidal behavior (Cougle, Resnick, & Kilpatrick, 2009; Gradus, Qin, Lincoln et al., 2010; Panagioti, Gooding, & Tarrier, 2009; Panagioti, Gooding, & Tarrier, 2012). It is, therefore, important to
The majority of patients admitted to a general hospital for a suicide attempt have a diagnosable mood disorder (Haw, Hawton, Houston et al., 2001), with depression being the most frequent diagnosis (Beautrais, 2000; Kessler, Borges, & Walters, 1999). In population-based studies, comorbid anxiety disorders have been shown to amplify the risk of suicide attempt in individuals with mood disorders (Sareen, Cox, Afifi et al., 2005), but posttraumatic stress disorder (PTSD) is the only anxiety disorder found to be uniquely
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study individuals with comorbid PTSD and MDD in order to determine if they exhibit unique risk factors for suicidal behavior and if their suicidal behavior differs with respect to frequency and motivation. To date, few studies have reported on the presence of PTSD and PTSD-MDD comorbidity in suicide attempters. One study of hospitalized suicide attempters found that 27% had a PTSD diagnosis, and of these, 79% had a comorbid mood disorder (Clover, Carter, & Whyte, 2004). In a sample of psychiatric outpatients with recent suicidal behavior or ideation, 32% had current PTSD, and 97% of these had one or more comorbid diagnoses (mainly affective disorders and other anxiety disorders) (Rudd, Dahm, & Rajab, 1993). The relationship among PTSD, MDD, and suicidal behavior may be influenced by environmental factors, such as childhood maltreatment, a known risk factor for many types of psychopathology (Chen, Murad, Paras et al., 2010; Gilbert, Widom, Browne et al., 2009; Perepletchikova & Kaufman, 2010). Sexual, physical, and emotional abuse and neglect all increase the risk of suicidal behavior, with the most consistent findings related to childhood sexual abuse (Brodsky & Stanley, 2008; Enns, Cox; Afifi et al., 2006; Mandelli, Carli, Roy et al., 2011; Molnar, Berkman, & Buka, 2001; Ystgaard, Hestetun, Loeb et al., 2004). Further, patients with comorbid MDD and PTSD have a history of childhood abuse more often than patients with MDD who do not have PTSD (Oquendo, Brent, Birmaher et al., 2005). Several studies of both epidemiological and clinical samples have described a substantially increased risk of revictimization in adulthood for men and women who were exposed to childhood sexual and physical abuse (Coid, Petruckevitch, Feder et al., 2001; Desai, Arias, Thompson et al., 2002). As for depressed suicide attempters with comorbid PTSD, childhood abuse
and revictimization in adulthood is poorly described. Mental disorders are well-documented risk factors for attempted suicide, but whether motives for suicidal behavior are different in different psychiatric diagnoses is less known. Research on suicidal motives has mainly focused on suicidal intent and psychosocial risk factors (Groholt, Ekeberg, & Haldorsen, 2000; Hjelmeland, Hawton, Nordvik et al., 2002; McAuliffe, Arensman, Keeley et al., 2007). Still, what characterizes suicidal motives in those exposed to trauma or have a diagnosis of PTSD is poorly described in the research literature. Based on what is known about PTSD-MDD comorbidity and suicidal behavior, we hypothesized that depressed suicide attempters with PTSD admitted to a general hospital would differ from those without PTSD beyond the differences in clinical symptoms. We examined whether depressed suicide attempters with PTSD would report a history of more frequent suicidal behavior in the past, have different suicidal motives and precipitating factors for the index suicide attempt, and have more additional comorbidity, depressive symptoms, substance abuse, and lower level of functioning than depressed suicide attempters without PTSD. We also examined exposure to trauma in childhood, the type of trauma reported as precipitating PTSD and when it occurred, and adulthood retraumatization of suicide attempters with comorbid PTSD. METHOD
This study is a secondary analysis of the suicide attempters diagnosed with depression, in a larger follow-up study of suicide attempters consecutively admitted to a general hospital in Oslo, which serves a catchment area of 130,000 inhabitants, over a period of 26 months.
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Participants
were collected after discharge by two specifically trained interviewers.
Patients who had deliberately taken an overdose or had otherwise deliberately injured themselves, reported suicidal intent, and were older than 15 years were included in the study. Patients were excluded if they were cognitively impaired or did not speak Norwegian. Of the 121 eligible patients admitted during the inclusion period, 90 (74%) consented to participate in the study. There were no significant differences between the individuals who participated and those who did not in terms of age, sex, and marital status. The participants were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV, (2011) using the Norwegian version of the Mini International Neuropsychiatric Interview (Sheehan, Lecrubier, Sheehan et al., 1998). Of the 90 participants, 64 (71%) were diagnosed with MDD. This subsample of 64 patients with MDD was the basis for the current study. All participants were interviewed while hospitalized and 52 again after discharge (12 patients declined to participate in the post-discharge interview). Procedure
Informed consent was obtained from all participants. The study was approved by the Regional Committee for Medical research and Ethics. The participants were interviewed within 2 days after their suicide attempt, while hospitalized, and after discharge about childhood trauma. At the hospital, data were collected through semistructured interviews by a psychiatrist or psychiatric nurse, and through questionnaires. The interviews were audiotaped and interrater reliability was checked by re-rating a random sample of 15 interviews. Data on childhood traumatic exposure
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Measures
The European Parasuicide Study Interview Schedule (EPSIS), described in detail elsewhere (Hjelmeland, Hawton, Nordvik et al., 2002; Kerkhof, Bille-Brahe, & Lonnqvist, 1994), was used to collect sociodemographic data. Social adjustment was rated on a 5-point Social Adjustment Scale (SAS) with a score of 5 being the highest and most favorable. This scale is comprised of dichotomous ratings of current living situation, economy, employment, psychiatric treatment, and social activity (Petersen, 1974). BPD was diagnosed using the Structured Clinical Interview for DSM-IV Personality Disorders (SCID II) (First, 1997). The patients’ global functioning was assessed with the Global Assessment of Functioning (GAF) (DSM VI, 2011). Depressive symptoms were measured by the Montgomery–Asberg Depression Rating Scale (MADRS) (Montgomery & Asberg, 1979). Lifetime substance abuse and substance use in the last 3 months was assessed with the Drug Abuse Screening Test (DAST) (Gavin, Ross, & Skinner, 1989) and calculated as a sum score of the 20 items, resulting in a total range from 0 to 20 with a clinical cut-off score of 6 or higher. Alcohol abuse was measured with the 10-item Alcohol Use Disorders Identification Test (AUDIT); a sum score of 11 or above suggests a drinking problem (Fleming, Barry, & MacDonald, 1991). Suicide attempt history was assessed using a question similar to that used for the index suicide attempt: ‘‘Have you at any time earlier in your life, taken an overdose or deliberately injured yourself?’’ with an added question about the patient’s suicidal intent. Events with suicide intent were classified as suicide attempts, while those
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without suicide intent were classified as nonsuicidal self-harm (NSSH), which was defined as: ‘‘any act of intentional self-poisoning or injury without suicide intent’’ (National Institute for Clinical Excellence, 2004). Suicide intent for the index attempt was measured using the Suicide Intent Scale (SIS) (Beck, Morris, & Beck, 1974). The EPSIS interview was used to collect data on precipitating factors and motives for the index suicide attempt, exploring 10 possible precipitating factors and assessing motives using the 14-item Motives for Parasuicide Questionnaire (MPQ) (Kerkhof, Bernasco, Bille-Brahe et al., 1993). The variables from both Precipitating Factors and MPQ were dichotomized into ‘‘no influence’’ and ‘‘influence.’’ The Childhood Experience of Care and Abuse Interview Schedule (CECA) assess adverse experiences before age 18 (Bifulco, Brown, & Harris, 1994). The CECA focuses on collecting factual information that can potentially be validated, and contains four scales measuring neglect, antipathy, and physical and sexual abuse. Previous studies have shown that suicidal behavior is typically related to severe negative experiences, such as sexual abuse with penetration, therefore the CECA scores were dichotomized into ‘‘severe events’’ and ‘‘mild or no such event’’ (Mullen, Martin, Anderson et al., 1993). A thorough description of all the scales and procedures is provided in Ystgaard, Hestetun, Loeb et al. (2004). Data Analysis
Demographic, trauma-related, and clinical variables were compared between MDD patients with and without PTSD. The significance of observed associations and=or differences between variables was tested using Pearson’s chi-squared test and Fisher’s exact test, when appropriate,
for categorical variables, and Student’s t-test for continuous variables. The Mann– Whitney U test was used for variables with a non-normal distribution. All analyses were performed using the IBM SPSS Statistics 17 software (SPSS Inc., 2008). RESULTS
All participants were depressed suicide attempters admitted to a general hospital (n ¼ 64) and 21 of these patients (33%) were diagnosed with current PTSD. Sociodemographic Characteristics
The mean age in the sample, was 36 years (SD ¼ 14.5; range ¼ 16–77 years). Forty-six (72%) of the 64 were women, 19 (30%) were married or living with a partner, 36 (56%) were employed or studying full time, and 37 (58%) had children. There were no significant group differences between patients with PTSD and without PTSD in demographic variables or social adjustment scores (Table 1). Clinical Characteristics
Patients with PTSD had significantly more Axis I diagnoses, with a higher frequency of other anxiety disorders, than the non-PTSD group (75% vs. 47%). Sixteen patients (25%) met criteria for BPD and there were no significant between group differences in the distribution of BPD (Table 2). Patients with PTSD scored significantly higher (p ¼ 0.005) on lifetime substance abuse, but not on current substance abuse or alcohol abuse (Table 2). There were no significant group differences in MADRS or GAF scores (Table 2). Suicidal Behavior
Of the 64 patients, the majority (n ¼ 51) had used self-poisoning (taken an
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Comorbid MDD and PTSD in Suicide Attempters
TABLE 1. Sociodemographic Characteristics and Childhood Traumatic Exposure Assessed with the Childhood Experience of Care and Abuse Interview (CECA), in Depressed Suicide Attempters With and Without PTSD Patients without PTSD (n ¼ 43)
Patients with PTSD (n ¼ 21)
28 (65) 15 (35) 37.5 (15.8)
18 (86) 3 (14) 32.3 (11.0)
14 (33) 29 (67)
5 (25) 15 (75)
Sex Female n (%) Male n (%) Age mean (SD) Marital Status Married=cohabitating n (%) Single=divorced=widowed n (%) Children Yes n (%) No n (%) Occupation Employed or fulltime student n (%) No occupation (unemployed, living on welfare, retired) n (%) Social Adjustment Scale Mean (SD) Childhood Traumatic Exposure Any childhood traumatic exposure n (%) Severe sexual abuse n (%) Severe physical abuse n (%) Severe neglect n (%) Severe antipathy n (%)
p-value 0.085
0.134 0.543
0.726 25 (66) 13 (34)
12 (71) 5 (29)
25 (61) 16 (39)
11 (58) 8 (42)
3.2 (1.4) n = 35 18 (51) 8 (23) 5 (14) 8 (23) 13 (37)
2.8 (1.4) n = 17 15 (88) 13 (77) 6 (35) 5 (29) 8 (47)
0.821
0.231 0.014 0.001 0.145 0.735 0.556
Note. Categorical variables were tested with Pearson’s v2 and continuous variables with a normal distribution were tested with Student t-test. The categorical trauma-related variables were tested with Fishers Exact test, two sided; p 0.05, p 0.001.
overdose) as their method for the index suicide attempt. The patients with PTSD were more likely to have a history of suicide attempts, previous episodes with NSSH, and to report problems with addiction as a precipitating factor of the suicide attempt (Table 3). Also, the patients with PTSD reported significantly more interpersonal vengeful motives for the index suicide attempt (Table 3). Specifically, they were more likely to endorse motives such as ‘‘I wanted others to pay for how they treated me’’ and ‘‘I wanted someone to feel guilty’’ for their suicide attempt. The mean Suicide Intent Scale (SIS) score for the
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entire sample was high, 15.1 (SD ¼ 6.77) with no significant differences between groups (Table 3). Traumatic Exposure
Thirty-three patients (64%) reported childhood exposure to trauma, and the patients with PTSD reported childhood trauma more often than the non-PTSD group (Table 1). Of the 17 patients with comorbid PTSD, only two reported little or no exposure to childhood trauma. Significantly more of the patients with PTSD
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TABLE 2. Clinical Characteristics of Depressed Suicide Attempters With and Without PTSD Characteristics n ¼ 64 Additional axis I diagnoses mean (SD)1 BPD diagnosis n (%) DAST lifetime mean (SD)1 DAST last 3 months mean (SD)1 AUDIT mean (SD)1 MADRS mean (SD) GAF mean (SD)
Patients without PTSD (n ¼ 43)
Patients with PTSD (n ¼ 21)
p-value
0.6 (0.7)
1.1 (0.9)
0.031
10 (24) 3.4 (4.2) 1.7 (3.1) 8.7 (7.6) 23.(8.6) 53.0 (10.6)
6 7.7 3.5 11.2 25.5 48.6
(29) (5.7) (5.1) (13.3) (5.77) (13.8)
0.682 0.005 0.196 0.906 0.385 0.200
Note. Categorical variables are tested with Pearson’s v2 and continuous variables with a normal distribution are tested with Student t-test. The n varied from 31 till 43 in those without PTSD and from 15 till 21 in those with PTSD; in ‘‘DAST last 3 months’’ data on 18 patients is missing. 1 Mann Whitney U-test were used for variables with a non-normal distribution. p-value < 0.05.
TABLE 3. Characteristics of Suicidal Behavior in Suicide Attempters With and Without PTSD Patients without PTSD (n ¼ 43) SIS index suicide attempt mean (SD) 15.70 (7.37) Previous suicide attempts yes n (%) 21 (50) NSSH lifetime yes n (%) 7 (21) Motives for index suicide attempt 36 (86) ‘‘Unbearable thoughts’’1 n (%) 1 39 (93) ‘‘The situation was intolerable’’ n (%) ‘‘Wanted to get away for a while’’ n (%) 28 (68) ‘‘Wanted help from someone’’ n (%) 23 (55) 35 (83) ‘‘Wanted to die’’1 n (%) ‘‘Wanted others to pay for how they treated 10 (24) me’’ n (%) ‘‘Wanted someone to feel guilty’’ n (%) 10 (24) Major influence of problem precipitating the index suicide attempt Problems with your partner n (%) 21 (53) Feelings of loneliness n (%) 23 (56) Mental illness and psychiatric symptoms n 13 (33) (%) Physical illness or disability n (%) 7 (17) 3 (8) Addiction n (%)1
Patients with PTSD (n ¼ 21)
p-value
13.68 (5.26) 17 (85) 8 (47)
0.276 0.008 0.050
18 19 11 13 17 12
(95) (100) (58) (68) (90) (63)
0.418 0.545 0.432 0.315 0.707 0.003
11 (58)
0.009
6 (30) 11 (58) 6 (32)
0.099 0.896 0.944
5 (25) 7 (35)
0.465 0.023
Note. Categorical variables were tested with Pearson’s v2 or where appropriate. 1 Fisher’s Exact Test and continuous variables with a normal distribution were tested with Student t-test. N varies from 41 till 43 in those without PTSD and from 19 till 21 in those with PTSD. p-value < 0.05.
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were exposed to severe sexual abuse in their childhood, and they were more often exposed to several types of childhood trauma (p ¼ 0.014, Mann-Whitney U test) compared to the non-PTSD group (Table 1). The 5 patients with PTSD who reported only one type of childhood maltreatment were exposed to sexual abuse. Given the high degree of childhood traumatic exposure in the whole sample, we examined whether the depressed suicide attempters with a history of severe childhood trauma would differ on the characteristics of their suicidal behavior compared to those without such history. There were no group differences on SIS scores, Precipitating Factors or MPQ. Forty patients (63%) reported having experienced an unusual traumatic event, which qualifies for the A-criterion of the PTSD-diagnosis according to the DSM IV. The trauma reported by the 21 PTSD patients as their A-criterion were as follows: rape or other sexual abuse (N ¼ 12) (7 reported repetitive sexual abuse); physical abuse (N ¼ 5) (4 reported repetitive physical abuse), traumatic bereavement (N ¼ 7) (3 witnessed the unexpected sudden death or murder of a close relative, 2 were traumatized by the death of their infant and=or child, 2 were traumatized by the unexpected news of the death of their spouse=boyfriend), and 2 patients were threatened at gunpoint during robbery. Of the 21 patients with comorbid PTSD, 5 (24%) patients reported more than one type of traumatic event as qualifying for the A-criterion and only 6 patients (29%) reported the A-criterion trauma had happened in their childhood, before they were 18 years old. DISCUSSION
To the best of our knowledge, this is the first study to describe comorbid current PTSD and current MDD in suicide
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attempters consecutively admitted to a general hospital. In the current study, the comorbidity of PTSD and depression is similar to comorbidity rates reported in an outpatient sample (Rudd, Dahm, & Rajab, 1993) and a sample of patients treated for deliberate self-poisoning (Clover, Carter, & Whyte, 2004). Several of our findings are in accordance with previous research on PTSD samples, in which the PTSD patients also had a high rate of comorbidity with other anxiety disorders (Brady, Killeen, Brewerton et al., 2000; Clover, Carter, & Whyte, 2004; Kessler, Sonnega, Bromet et al., 1995), a high rate of reported lifetime substance abuse (Brady, Killeen, Brewerton et al., 2000; Gielen, Havermans, Tekelenburg et al., 2012), and did not differ in the level of suicide intent compared to the non-PTSD group (Oquendo, Brent, Birmaher et al., 2005; Oquendo, Friend, Halberstam et al., 2003). While previous reports (Alvarez, Roura, Foquet et al., 2012; Cougle, Resnick, & Kilpatrick, 2009; Monnin, Thiermard, Vandel et al., 2012; Oquendo, Brent, Birmaher et al., 2005; Zlotnick, Mattia, & Zimmerman, 1999) have found comorbid PTSD to be associated with a history of suicide attempts, we have replicated this association and additionally found an association between comorbid PTSD and more frequent history of NSSH. The patients with PTSD reported significantly more interpersonal vengeful suicidal motives, more than twice as often as the non- PTSD group. The percentage of patients without PTSD reporting vengeful motives is consistent with results reported from other samples of suicide attempters (Groholt, Ekeberg, & Haldorsen., 2000; Hawton, Houston, Haw et al., 2003; McAuliffe, Aresman, Keeley et al., 2007). Existing literature suggests that anger may be a characteristic of PTSD (Olatunji, Ciesielski, & Tolin, 2010), and one hypothesis is that the vengeful motives reported
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by suicide attempters with comorbid PTSD are related to this anger. The patients with PTSD reported exposure to childhood trauma, in particular sexual abuse, and exposure to multiple types of childhood trauma, significantly more often than the non-PTSD group. These findings are in accordance with previous studies (Zlotnick, Johnson, Kohn et al., 2008; Zlotnick, Johnson, Yen et al., 2003), but now, for the first time, reported in suicide attempters with comorbid PTSD. Childhood abuse has been found to increase the risk of suicide attempts throughout the lifespan (Brodsky & Stanley, 2001; Dube, Anda, Felitti et al., 2001; van der Kolk, Perry, & Herman, 1991). There is also a certain dose–response relationship between the number of traumatic events and the subsequent odds for a suicide attempt (Stein, Chiu, Hwang et al., 2010). In our study, 66% of the patients with comorbid PTSD exposed to trauma in childhood were revictimized later in adulthood. A similar result has been reported from a sample of depressed women, in which those with a history of childhood sexual abuse were more likely to report a recent assault and more likely to have attempted suicide (Gladstone, Parker, Mitchell et al., 2004). Since trauma in both childhood and adulthood is associated with increased suicidal risk, it may be that the combination of a substantial amount of childhood trauma and revictimization in adulthood is part of the explanation for why comorbid MDD and PTSD is found to enhance risk of suicidal behavior. It is well known that BPD is linked to suicidal behavior and that it is frequently comorbid with PTSD and MDD (Pagura, Stein, Bolton et al., 2010; Wedig, Silverman, Frankenburg et al., 2012; Zanarini, Frankenbrug, Dubo et al., 1998). Oquendo, Brent, Birmaher et al (2005), found comorbid cluster B personality disorders to be a risk factor for suicidal acts in patients with a lifetime history of MDD and PTSD,
compared to patients with only MDD. However, we found BPD to be equally distributed between the two groups. This discrepancy could be attributed to the difference between lifetime and current diagnoses, as we have examined current diagnoses and not lifetime. More depressive symptoms have been reported in patients with comorbid MDD and PTSD than those without PTSD (Oquendo, Brent, Birmaher et al., 2005), but we found no such difference. This may be because the samples were different with respect to suicidal behaviors; unlike the sample in the study by Oquendo, Brent, Birmaher et al., all patients in our sample were suicide attempters. This suggests that, for an already suicidal depressed patient, the presence of PTSD does not add much to the depression rating, even though the two disorders share a number of symptoms. Strengths and Limitations
The brief time between the suicide attempt and the assessment is a methodological strength; it should limit the negative influence of recall bias for data concerning clinical correlates and current suicidal behavior. Another methodological strength of the study is the use of the CECA interview schedule to assess childhood traumatic exposure. The CECA has a detailed and contextualizing approach, yields reliable data, and was highly recommended in a recent review of features and limitations of instruments assessing childhood adversities (Thabrew, de Sylva, & Romans, 2012). As for the generalizability of the results, the sample was based on suicide attempters consecutively admitted to one general hospital in Oslo, which serves a catchment area of 130,000 inhabitants. All general hospitals in the city of Oslo serve geographical sectors, and thus all socioeconomic classes are served by the same hospital.
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Comorbid MDD and PTSD in Suicide Attempters
Study limitations include the relatively small sample size as it might cause type II errors or minimize detection of true associations. Retrospective reporting concerning childhood maltreatment, previous suicide attempts, and lifetime reports on nonsuicidal self-harm may be biased by the respondents’ mental state with a potential risk of both under- and over-reporting the frequency of events and their severity. However, the interview method and the use of trained interviewers are likely to counterbalance the problem. Conclusion
There are important differences in suicide attempters with comorbid depression and PTSD compared to those without PTSD. As previously reported, those with both depression and PTSD are more likely to have a history of suicide attempts. In addition, this study found that they are more likely to have a history of non-suicidal self-harm; and they report vengeful motives for their suicidal behavior more often, suggesting that anger is a strong component of their suicidal actions. The symptom overlap between PTSD and depression may result in the underdiagnosis of PTSD among suicide attempters admitted to the hospital (Mueser, Goodman, Trumbetta et al., 1998). Therefore, clinicians need to be mindful of PTSD symptoms, and inquire about them in depressed suicide attempters, to accurately assess their suicide risk and to customize their treatment. AUTHOR NOTE
Maria Ramberg, National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway. Barbara Stanley, National Centre for Suicide Research and Prevention, Institute
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of Clinical Medicine, University of Oslo, Norway, and Department of Psychiatry, New York State Psychiatric Institute and Columbia University, New York, New York, USA. Mette Ystgaard, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Norway. Lars Mehlum, National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway. Correspondence concerning this article should be addressed to Maria Ramberg, National Centre for Suicide Research and Prevention, Sognsvannsveien 21, Building 12, NO-0372 Oslo, Norway. E-mail: maria. [email protected]
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