From the Editor
Overwhelmed by the divorce, she made a serious attempt on her life, saved from certain death by a police officer who was running late for work and drove through an industrial area of Scarborough. After days of observation, I concluded that she had an unfortunate life circumstance, but not a psychiatric disorder.
How commonly do people without mental disorders attempt suicide? What can be done to help them? Dr. Maria A. Oquendo (of the University of Pennsylvania) and her co-authors try to answer these questions in a new JAMA Psychiatry paper. In their study of healthy individuals and suicide attempts, they drew on a US database involving more than 36 000 people who had attempted suicide. “An estimated 19.6% of individuals who attempted suicide did so despite not meeting criteria for an antecedent psychiatric disorder.” We consider the study and its implications.
In the second selection, Yueh-Yi Chiang (of the University of Maryland) and her co-authors focus on youth and polypharmacy in a new JAMA Network Open research letter. Concerningly, past work has suggested that polypharmacy is growing more common in the young. Chiang et al. tapped Medicaid data from one US state including almost 127 000 youth. “In this cross-sectional study, we observed a 4% increased odds of psychotropic polypharmacy per year from 2015 to 2020, indicating growing concomitant use of multiple psychotropic classes.”
And in the third selection, reporter Jim Coyle writes about former Prime Minister Brian Mulroney in the Toronto Star. The essay is deeply personal – Coyle discusses his own problems with alcohol and his connection with the former prime minister, who had also struggled with it. “Mulroney knew that alcoholism is no respecter of rank or status, that alcoholics understand each other across any divide, and better than anyone else can.”
There will be no Readings for the next two weeks.
DG
Selection 1: “Lifetime Suicide Attempts in Otherwise Psychiatrically Healthy Individuals”
Maria A. Oquendo, Melanie Wall, Shuai Wang, et al.
JAMA Psychiatry, 21 February 2024 Online First
Not all people who die by suicide have a psychiatric disorder. Estimates vary, but in Western high-income countries, the percentage of those who die by suicide with no psychiatric disorder is reported to range between 5% and 40%. Suicide deaths without apparent antecedent psychiatric disorders are observed even when psychological autopsy methods, shown to be robust, are applied and clinical researchers interview next of kin and friends in addition to reviewing medical records to determine whether psychiatric disorders were present. Low- and middle-income countries report higher rates of suicide with no evidence of a psychiatric disorder, with studies estimating that only 58%… of persons who died by suicide had a psychiatric disorder. In China, about 40% of suicide decedents are reported not to have met criteria for a psychiatric disorder…
Yet, little is known about lifetime suicide attempts among ostensibly psychiatrically healthy volunteers… A large study (157 366 participants aged 45-82 years) based on a UK Biobank subsample showed that 88% of those who reported self-harm, which includes both suicide attempts and nonsuicidal self-injury, met criteria for at least 1 psychiatric disorder, suggesting that 12% did not. Another study (N = 9282) found that 20% of those with suicide attempts did not meet criteria for a mental disorder…
To our knowledge, no prior epidemiologic study has focused on the occurrence of lifetime suicide attempts in healthy volunteers without apparent antecedent psychiatric diagnoses.
So begins a paper by Oquendo et al.
Here’s what they did:
- The authors conducted a cross-sectional study to determine what percentage of people who attempt suicide meet criteria for a psychiatric disorder.
- They used data from the NESARC-III, a “face-to-face survey conducted with a nationally representative sample of the US civilian noninstitutionalized population, and included persons with lifetime suicide attempts who were aged 20 to 65 at survey administration (April 2012 to June 2013).” To evaluate suicide attempts, respondents were directly asked: “In your entire life, did you ever attempt suicide?”
- The main outcome: measuring the absence of a psychiatric disorder before the first lifetime suicide attempt.
- Among those with lifetime suicide attempts, analyses were done on those who had a first attempt before the onset of a psychiatric disorder, as well as gender and age.
Here’s what they found:
- The total sample had 36 309 respondents. 1 948 respondents had lifetime suicide attempts.
- Gender and suicide attempts. Females were nearly twice as likely as males to attempt suicide.
- Lifetime suicide attempts without psychiatric diagnosis. 6.2% had no lifetime psychiatric diagnoses; 13.4% made their first suicide attempt prior to psychiatric disorder onset. “Thus, 19.6% of respondents attempted suicide without an antecedent psychiatric disorder.”
- Ethnicity. 70.9% non-Hispanic White; 14%, Hispanic; 9.8%, non-Hispanic Black; 3.5% non-Hispanic American Indian or Alaska Native.
- Age and sex. 66.8% with lifetime suicide attempts were female. “No significant age or sex differences were detected in the frequencies of lifetime suicide attempts in those without psychiatric disorders.” In the disorder group: females were more likely than males to attempt suicide in the year of psychiatric disorder onset (14.9% vs. 8.6%); attempts were less frequent among those older than 50-65 years (3.9% vs. 6.1% for 35-50 years and 6.2% for 20-34 years).
A few thoughts:
1. This is an interesting study, drawing on a robust dataset with clinical and policy implications. It is also published in a major journal.
2. The main finding in a sentence: about 1 in 5 didn’t have a psychiatric disorder who attempted suicide.
3. The clinical implications? “These findings suggest that a history of suicide attempts should be obtained regardless of whether the person has a psychiatric disorder given that suicide attempts are associated with future attempts and future suicide. Although suicidal behavior is often viewed as a condition that improves if an accompanying disorder is controlled, evidence-based treatments that directly target suicidal thoughts and behaviors, such as cognitive therapy for suicidal behavior, dialectical behavioral therapy, Collaborative Assessment and Management of Suicidality, and the Safety Planning Intervention, may be effective.”
They also argue that there are policy implications:
“[S]creening for suicide risk, which in most contexts is focused on those with recognized psychiatric conditions, may miss one-fifth of those at risk. Thus, policy makers, clinicians, and health systems should weigh the costs and benefits of expanding suicide risk screening beyond the current targets and consider universal screening to prevent suicide attempts, which have significant morbidity as well as medical and other costs.” It’s a reasonable point, but would universal screening actually reach people at risk? Would it simply spread resources thin?
4. Of course, we can consider larger questions. Is suicide always pathological? Is there a concept of rational suicide? Those of us in psychiatry tend to find such questions unsettling, but they are very relevant in a time of MAiD, especially as countries like Canada consider expansion to include those who primarily have mental disorders.
5. Like all studies, there are limitations. The authors note several including that common psychiatric diagnoses such as autism spectrum, obsessive-compulsive, and intermittent explosive disorder – all associated with suicide attempts – were not assessed in the survey. Another limitation: the data utilized dates back more than a decade.
The full JAMA Psych paper can be found here:
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2814937
Selection 2: “Psychotropic Polypharmacy Among Youths Enrolled in Medicaid”
Yueh-Yi Chiang, Alejandro Amill-Rosario, Phuong Tran, et al.
JAMA Network Open, 16 February 2024
Concomitant use of medications for attention-deficit/hyperactivity disorder (ADHD), antipsychotics, mood-stabilizing anticonvulsants, and antidepressants is referred to as psychotropic polypharmacy. Over the past 2 decades, psychotropic polypharmacy in youths increased, raising safety concerns. Our goal was to examine trends from 2015 to 2020 in psychotropic polypharmacy among youths aged 17 years or younger who were enrolled in Medicaid to identify temporal changes and characteristics associated with psychotropic polypharmacy.
So begins a research letter by Chiang et al.
Here’s what they did:
- They conducted “a sequential, annual, cross-sectional study using Medicaid eligibility files and fee-for-service and managed care medical encounter claims from 2015 to 2020 from a single US state.”
- “For each annual cohort, we included youths who were 17 years or younger, had received at least 1 pharmacy claim for psychotropic medication, and had 90 days or more of continuous Medicaid enrollment.”
- In terms of the medications: “[W]e classified psychotropic medications into 6 therapeutic classes: antipsychotics, ADHD medications, mood-stabilizing anticonvulsants, antidepressants, anxiolytics, and sedatives. Use of 3 or more different psychotropic classes that overlapped for 90 consecutive days or longer in each study year defined psychotropic polypharmacy.”
- They did a multivariable logistic regression model using independent variables including age, sex, race, and mental disorders.
Here’s what they found:
- 126 972 unique youths met the inclusion criteria.
- Psychotropic polypharmacy prevalence. Among youths who used psychotropics, polypharmacy increased from 4.2% in 2015 to 4.6% in 2020.
- Adjusted odds ratios. “The adjusted odds ratios (AORs) of psychotropic polypharmacy for the year was 1.04… a 4% increase in the odds of psychotropic polypharmacy per year.”
- Special populations. “Psychotropic polypharmacy was significantly more likely among youths who were disabled (AOR, 3.68…) or in foster care (AOR, 3.31…) relative to youths in the low-income group.”
A few thoughts:
1. This research letter offers some data – though there are clear limitations here.
2. To summarize the main finding in a word: up. Prescribing is up and particularly in some specific groups: “Among youths enrolled in Medicaid with any psychotropic use, individuals who were disabled or in foster care were significantly more likely than individuals with low income to receive 3 or more psychotropic classes overlapping for 90 days or more.”
3. That said, the research letter drew on data from just one state. (Interestingly, the researcher withheld the name of that state.) Needless to say, generalizability is problematic.
4. In an earlier study published in Pediatrics, researchers found an increase in polypharmacy from 2006 to 2015. Again, we are limited in our interpretations by the data set, but the research letter suggests that the trend may have continued – particularly among those in vulnerable populations, such as youth in foster care.
The full JAMA Netw Open research letter can be found here:
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2815234
Selection 3: “Brian Mulroney knew the ravages of alcohol and was there for anyone struggling – including me”
Jim Coyle
Toronto Star, 1 March 2024
It was a late morning in June about 10 years ago and I had just turned into the parking lot of a No-Frills supermarket in Toronto when my cellphone rang.
It was the Office of the Prime Minister asking if I would hold for a call.
I was working as a Star reporter at the time. My first thought was, Why would Stephen Harper be calling me? I hadn’t written anything about him lately.
Then the call was patched through the PMO switchboard and I heard that voice.
It was a little raspier, perhaps, than in his prime, but still a resonant baritone.
And how are you, young Mr. Coyle?’ asked former prime minister Brian Mulroney, spoofing a line of his that I had used…”
So begins an essay by Coyle.
The writer describes the conversation. “He had called to congratulate me on sobering up. ‘But most of all I want to congratulate your wife!’ he said, knowing who it is in a family that bears the brunt of alcoholism.” The author adds: “we talked for 15 minutes about how it had been for me, how it had been for him, mutual acquaintances who’d sobered and people we know who’d died from the horrors of addiction.” And he marvels at the moment: “I thought how astonishing it was that I – son of immigrants who never got to high school – should be trading drunk stories with a former prime minister of Canada.”
Coyle quotes the former prime minister’s autobiography. “I realized I would have to come to grips with the fact that I had developed what could only be described as a serious drinking problem.”
He then mentions Mulroney’s willingness to reach out. “The stories were many among the problem drinkers of Ottawa – and Lord knows, there were enough of us in his day – of Mulroney calling people, friend or foe alike, with encouragement if he heard they were in trouble.” He describes a tough moment for a journalist on the campaign plane who needed to talk to someone to help him calm down. He found the right person: “The two slipped into Mulroney’s private section and, until Small settled down, shared drunk stories.”
“It was work Brian Mulroney did frequently and with no thought of publicity or political gain.”
A few thoughts:
1. The essay is personal and well written.
2. This line is worth repeating: “alcoholism is no respecter of rank or status, that alcoholics understand each other across any divide, and better than anyone else can…” That clearly applies to prime ministers, celebrated journalists, and people who have less august careers.
3. With his death last week, many are considering the life and legacy of Brian Mulroney. This essay doesn’t mull political victories and defeats or policy gains and losses, but it does describe a person with a history of alcohol use disorder who was willing to reach out to others, and that’s not a bad legacy in itself.
4. Coyle has written extensively on the subject of alcohol in his e-book, To Hell and Back: Alcoholism, addiction and lessons they taught me. It’s an amazing read, gripping from the first lines:
“This story is dedicated to the men and women who have shared the road, and to those who died terrible and premature deaths; to the families and friends who loved us beyond all reasonable expectation and understanding; to those brave enough to speak difficult truths that we were for too long unable to hear; and especially to those who are yet to learn that there’s a better way to be.”
You can find the e-book here:
The full Toronto Star essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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