Suicide in a clinical and a general population, with focus on comorbidity. Studies from the Lund Suicide Research Center and the Lundby Study.

Objective: To identify possible suicide risk factors in a clinical sample and suicide risk in a general population, with primary focus on mental disorders, signs, symptoms and comorbidity. Methods: In the first two studies, subjects who had been admitted to a specialised psychiatric ward after a suicide attempt were investigated. Fifteen suicide completers were compared to matched survivors in terms of comorbidity and symptom ratings at index, as well as subsequent psychiatric morbidity, psychiatric care and suicide attempts during the time from index until death of the suicide completers. Suicide attempters with dysthymia (N=35) were then compared to persons with major depressive disorder (MDD, N=81) in order to disentangle their symptomatic characteristics. The subsequent three papers were parts of the Lundby Study. A general population of 3563 subjects, who had been followed prospectively during 50 years, was studied with regard to suicide risk in mental disorders and the impact of comorbidity. The temporal sequence of mental disorders over time in the 68 suicide victims was described. The age at onset and the time from onset to suicide were investigated. Results: Suicide completers previously admitted after suicide attempt had more psychiatric hospitalisations and more suicide attempts compared to survivors. They also had higher ratings on the Suicide Assessments Scale (SUAS) at index, especially those who died within the first year. Suicidal patients with dysthymia more often had DSM-III-R personality disorders compared to persons with MDD. They reported more aches and pains, somatic complaints and agitation from the Comprehensive Psychopathological Rating Scale (CPRS). Dysthymia patients who had killed themselves reported more aches and pains than those still alive. In the Lundby population, the proportion of persons who had died from suicide at end of follow-up and with no mental disorder was 0.3%, with one disorder 3.4%, and with two or more diagnoses 6.2%. The highest occurrence was found for depression, psychosis and alcohol use disorder (6-7%). The association with suicide was high for persons with one mental disorder (OR: 11.76), but significantly higher for two or more diagnoses (OR: 21.00, P < 0.0005). In the follow-up, the strongest association with suicide was found in men with both alcohol use disorder and depression (OR: 25). Alcohol use disorder was the most common first diagnosis in suicide victims (38.2%). The difference was found in men but not in women. Persons with depression had a relatively high age at onset (median 48 years), but a short time from onset to suicide (median 2.5 years). In the other diagnostic groups, the timespans were usually longer and the suicide events occurred spread over time. Conclusions: Comorbid conditions are confirmed to be important risk factors for suicide in both the clinical and general populations examined. People with mental disorders, often complicated by personality disorder and a long period with recurrent psychiatric impairment, psychiatric care and suicide attempts, seem to be at a high risk of suicide. For patients with dysthymia, pain appear to be a risk factors for suicide. Results in this thesis also suggest that men with alcohol use disorder should be followed carefully and attention paid to additional mental disorders, especially depression, which seem to elevate the suicide risk significantly for many years ahead. In most disorders, the risk of suicide will persist during lifetime, but in persons suffering from depression, suicide usually occurs early in the course. Intensive interventions are apparently necessary for a long time. (Less)