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Anxiety Disorders

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Research articles:

Alonso, P. P., Segalàs, C. C., Real, E. E., Pertusa, A. A., Labad, J. J., Jiménez-Murcia, S. S., & ... Menchón, J. M. (2010). Suicide in patients treated for obsessive–compulsive disorder: A prospective follow-up study. Journal of Affective Disorders, 124(3), 300-308. doi:10.1016/j.jad.2009.12.001

Abstract: Background: To describe the occurrence of persistent suicidal ideation and suicide attempts in a sample of obsessive–compulsive patients followed-up prospectively during 1 to 6years, and to determine the existence of predictors of suicide behavior. Method: Two hundred and eighteen outpatients with DSM-IV OCD, recruited from a specialized OCD Unit in Barcelona, Spain, between February 1998 and December 2007, were included in the study. Suicide ideation was assessed by item 3 of the Hamilton Depression Rating Scale. Suicide attempts were evaluated by the Beck Suicide Intent Scale. Patients with and without persistent suicidal thoughts and suicide attempters and non-attempters were compared on sociodemographic and clinical variables. A Cox proportional hazards regression analysis was used to estimate potential predictors of suicide. Results: Patients completed a mean follow-up period of treatment of 4.1years (SD: 1.7; range: 1–6years). During this period, eighteen patients (8.2%) reported persistent suicidal ideation, two patients (0.91%) committed suicide and 11 (5.0%) attempted suicide. Being unmarried, presenting higher basal scores in the HDRS, current or previous history of affective disorders and symmetry/ordering obsessions were independently associated with suicidal behaviors. Limitations: Patients were recruited from a specialized OCD clinic and received exhaustive treatment. Influence of variables including social support, life events, hopelessness and substance abuse/dependence was not assessed. Conclusions: Suicide behavior is not a highly common phenomenon in OCD, but it should not be disregarded, especially in unmarried patients, with comorbid depression and symmetry/ordering obsessions and compulsions, who appear to be at a greater risk for suicide acts. [Copyright &y& Elsevier]

Balci, V., & Sevincok, L. (2010). Suicidal ideation in patients with obsessive–compulsive disorder. Psychiatry Research, 175(1/2), 104-108. doi:10.1016/j.psychres.2009.03.012

Abstract: The risk factors for suicidal behaviour in obsessive-compulsive disorder (OCD) have been less studied compared than in other anxiety disorders. In the present study, we examined the demographic and clinical correlates of current suicidal ideation (SI) in patients with OCD. Forty-four patients were grouped into those with (n =23) and without current SI (n =21) as assessed by the Scale for Suicidal Ideation. The Yale-Brown Obsessive–Compulsive Scale (Y-BOCS) was used to assess the obsessive–compulsive (OC) symptomatology. Following Bonferroni correction, only the severity of depression differed significantly between the two groups. The presence of major depression and aggressive obsessions, the level of hopelessness, and the severity of OC symptomatology were significant predictors of current SI in patients with OCD. The relatively low frequency of some comorbid Axis I disorders is based on small sample size and therefore may be vulnerable to type II error. We did not examine the relationship between the recent suicidal attempts and OCD. Also, we did not assess the effect of impulsivity in the occurrence of SI in patients with OCD. Associated depression, hopelessness, and aggressive obsessions might play an important role in the occurrence of SI in patients with OCD. However, future studies with a psychological autopsy design are required to systematically determine the presence for OCD among those who have completed suicide. [Copyright &y& Elsevier]

Cougle, J. R., Keough, M. E., Riccardi, C. J., & Sachs-Ericsson, N. (2009). Anxiety disorders and suicidality in the national comorbidity survey-replication. Journal of Psychiatric Research, 43(9), 825-829. doi:10.1016/j.jpsychires.2008.12.004

Abstract: Objective: The current study sought to examine the unique associations between anxiety disorders and suicidality using a large nationally representative sample and controlling for a number of established risk factors for suicide. Method: Data from the National Comorbidity Survey-Replication were used for analyses. Lifetime diagnostic history and demographics were obtained in this survey through a structured interview. Lifetime suicidal ideation and attempts were also assessed. Results: Multivariate analyses covarying for psychiatric comorbidity and demographic variables found social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and panic disorder (PD) to be unique predictors of suicidal ideation, while only SAD, PTSD, and GAD were predictive of suicide attempts. Analyses by gender indicated that each of these four disorders were predictive of suicidal ideation or suicide attempts among women, while only PTSD and PD acted as risk factors among men. Conclusions: Findings provide further evidence of the negative impact of anxiety disorders, suggest efforts should be made towards their early detection and treatment, and emphasize the importance of suicide risk assessment in treating individuals with anxiety disorders. [Copyright &y& Elsevier]

Gradus, J. L., Ping, Q., Lincoln, A. K., Miller, M., Lawler, E., Sørensen, H., & Lash, T. L. (2010). Posttraumatic stress disorder and completed suicide. American Journal of Epidemiology, 171(6), 721-727. doi:10.1093/aje/kwp456

Most research regarding posttraumatic stress disorder (PTSD) and suicide has focused on suicidal ideation or attempts; no known study of the association between PTSD and completed suicide in a population-based sample has been reported. This study examined the association between PTSD and completed suicide in a population-based sample. Data were obtained from the nationwide Danish health and administrative registries, which include data on all 5.4 million residents of Denmark. All suicides between January 1, 1994, and December 31, 2006, were included, and controls were selected from a sample of all Danish residents. Using this nested case-control design, the authors examined 9,612 suicide cases and 199,306 controls matched to cases on gender, date of birth, and time. Thirty-eight suicide cases (0.40%) and 95 controls (0.05%) were diagnosed with PTSD. The odds ratio associating PTSD with suicide was 9.8 (95% confidence interval: 6.7, 15). The association between PTSD and completed suicide remained after controlling for psychiatric and demographic confounders (odds ratio = 5.3, 95% confidence interval: 3.4, 8.1). Additionally, persons with PTSD and depression had a greater rate of suicide than expected based on their independent effects. In conclusion, a registry-based diagnosis of PTSD based on International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, is a risk factor for completed suicide. [ABSTRACT FROM PUBLISHER]

Guerra, V. S., & Calhoun, P. S. (2011). Examining the relation between posttraumatic stress disorder and suicidal ideation in an OEF/OIF veteran sample. Journal of Anxiety Disorders, 25(1), 12-18. doi:10.1016/j.janxdis.2010.06.025

Abstract: This study examined the relation between posttraumatic stress disorder (PTSD) and suicidal ideation among U.S. military veterans deployed during Operation Enduring Freedom and/or Operation Iraqi Freedom. Specific aims included investigation of (1) whether PTSD was associated with suicidal ideation after controlling for combat exposure and history of suicide attempt(s), (2) whether PTSD was associated with suicidal ideation absent a co-occurring depressive disorder (MDD) or alcohol use disorder (AUD), (3) whether co-occurring MDD or AUD increased risk of suicidal ideation among those with PTSD and (4) whether PTSD/MDD symptom clusters were differentially associated with suicidal ideation. Results pointed to unique effects associated with prior suicide attempt(s), PTSD and MDD. PTSD-diagnosed participants with co-occurring MDD or AUD were not significantly more likely to endorse suicidal ideation than PTSD-diagnosed participants without such comorbidity. The ‘emotional numbing’ cluster of PTSD symptoms and the ‘cognitive-affective’ cluster of MDD symptoms were uniquely associated with suicidal ideation. [ABSTRACT FROM AUTHOR]

Huang, M., Yen, C., & Lung, F. (2010). Moderators and mediators among panic, agoraphobia symptoms, and suicidal ideation in patients with panic disorder. Comprehensive Psychiatry, 51(3), 243-249. doi:10.1016/j.comppsych.2009.07.005

Objectives: The most important change of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) is the use of dimensional approach to assess the severity of symptoms across different diagnosis. There are 2 purposes in this study: the first purpose was to identify the proportion of outpatients with panic disorder who have suicidal ideation. The second aim was to examine the relationships among panic, agoraphobic symptoms, and suicidal ideation in patients with panic disorder, adjusting by age, social support, and alcohol use. Methods: Sixty patients with panic disorder were recruited from outpatient psychiatric clinics in southern Taiwan. Suicidal ideation in the preceding 2 weeks was measured. The Panic and Agoraphobic Symptoms Checklist, Social Support Scale, Questionnaire for Adverse Effects of Medication for Panic Disorder, and Social Status Rating Scale were used to understand the severity of panic and agoraphobia, social support, drug adverse effects, and social status. Significant variables from the univariate analysis were included in a forward regression model. Then, we used structural equation modeling to fit the model. Results: We found that 31.7% of outpatients with panic disorder had had suicidal ideation in the preceding 2 weeks. Multiple regression analysis showed that younger age, current alcohol use, more severe panic symptoms, and less social support were associated with suicidal ideation. In addition, the structural equation model illustrated the recursive model from panic to agoraphobia and suicidal ideation. Agoraphobia had no association with suicidal ideation. Panic symptom was a mediator to suicidal ideation but not agoraphobic symptoms. Conclusions: A high proportion of patients with panic disorder had suicidal ideation. We found that panic symptoms, social support, age, and alcohol use affected suicide and could be identified. The 3-level model from panic to agoraphobia revealed that panic was a predictor of agoraphobia and agoraphobia was not a predictor of panic. This verified the evolution of the diagnostic view of the DSM. Panic symptom was a mediator to suicidal ideation. With the dimensional model in DSM-V, panic symptoms can be used as a marker for greater morbidity and severity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Kamath, P., Reddy, Y., & Kandavel, T. (2007). Suicidal behavior in obsessive-compulsive disorder. Journal of Clinical Psychiatry, 68(11), 1741-1750. doi:10.4088/JCP.v68n1114

Objective: There are limited data on suicidal behavior in obsessive-compulsive disorder (OCD). This study examines suicidal behavior and its clinical correlates in OCD subjects. Method: One hundred consecutive DSM-IV OCD subjects attending the specialty OCD clinic and the inpatient services of a major psychiatric hospital in India from November 1, 2003, to October 31, 2004, formed the sample of this study. Subjects were assessed systematically by using structured interviews and various rating scales. The Scale for Suicide Ideation-worst ever (lifetime) and -current measured suicidal ideation. The 24-item Hamilton Rating Scale for Depression (HAM-D) measured severity of depression, and the Beck Hopelessness Scale (BHS) measured hopelessness. We performed assessments at study entry. We employed binary logistic regression (Wald) forward stepwise analysis for prediction of suicidal ideation and suicide attempt, and we used structural equation modeling for identifying the potential factors contributing to suicidal ideation. Results: The rates of suicidal ideation, worst ever and current, were 59% and 28%, respectively. History of suicide attempt was reported in 27% of the subjects. For past suicide attempt, worst ever suicidal ideation (p < .001) was the only significant predictor, with an overall prediction of 89%, and accounted for 60% of the variance. For worst ever suicidal ideation, major depression (p = .043), HAM-D score (p = .013), BHS score (p = .011), and history of attempt (p = .009) were significant predictors, with an overall prediction of 82% and variance of 56%. Somewhat similar predictors emerged as significant for current suicidal ideators, with an overall prediction of 85% and variance of 50%. In the structural equation model, too, presence of depression and high BHS score contributed to suicidal ideation. Conclusions: OCD is associated with a high risk for suicidal behavior. Depression and hopelessness are the major correlates of suicidal behavior. It is vital that patients with OCD undergo detailed assessment for suicide risk and associated depression. Aggressive treatment of depression may be warranted to modify the risk for suicide. Future studies should examine suicidal behavior in a prospective design in larger samples to examine if severity of OCD and treatment nonresponse contribute to suicide risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Khan, A., Leventhal, R. M., Khan, S., & Brown, W. A. (2002). Suicide risk in patients with anxiety disorders: A meta-analysis of the FDA database. Journal of Affective Disorders, 68(2/3), 183. Retrieved from EBSCOhost.

Background: Previous reports of suicide risk in patients with anxiety disorders have been inconsistent. Methods: Using the FDA database, we assessed suicide and suicide attempt risk among patients, participating in recent clinical trials evaluating new anti-anxiety medications, with diagnosis of panic disorder (PD), social anxiety disorder or social phobia (SP), generalized anxiety disorder (GAD), post traumatic stress disorder (PTSD), and obsessive compulsive disorder (OCD). Results: Overall, among 20076 participating anxious patients, 12 committed suicide and 28 attempted suicide. The annual suicide risk rate was 193/100?000 patients and annual suicide attempt risk was 1350/100?000 patients. Limitations: Clinical trial data have limited applicability to clinical practice. Participants in clinical trials are a highly selected, nonrepresentative sample of the clinical population. A number of patients never complete clinical trials and thus data are based on a limited sub-sample. These trials were not primarily designed to assess suicide risk. Conclusions: Suicide risk in patients with anxiety disorders is higher than previously thought. Patients with anxiety disorders warrant explicit evaluation for suicide risk. [Copyright &y& Elsevier]

Krysinska, K., & Lester, D. (2010). Post-traumatic stress disorder and suicide risk: A systematic review. Archives of Suicide Research, 14(1), 1-23. doi:10.1080/13811110903478997

There is a gap in the literature regarding suicide risk among traumatized individuals with post-traumatic stress disorder (PTSD) and this article aims to systematically review literature on the relationship between PTSD and suicidal behavior and ideation. A meta-analysis of 50 articles that examined the association between PTSD and past and current suicidal ideation and behavior was conducted. There was no evidence for an increased risk of completed suicide in individuals with PTSD. PTSD was associated with an increased incidence of prior attempted suicide and prior and current suicidal ideation. Controlling for other psychiatric disorders (including depression) weakened, but did not eliminate, this association. The evidence indicates that there is an association between PTSD and suicidality with several factors, such as concurrent depression and the pre-trauma psychiatric condition, possibly mediating this relationship. There are significant clinical implications of the reported relationship for suicide risk assessment and therapy, and further studies might help to understand the mediating pathways between PTSD and increased suicide risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Lemaire, C. M., & Graham, D. P. (2011). Factors associated with suicidal ideation in OEF/OIF veterans. Journal of Affective Disorders, 130(1/2), 231-238. doi:10.1016/j.jad.2010.10.021

Abstract: Background: The purpose of this project was to examine factors associated with suicidal ideation in returning Iraq and Afghanistan war veterans. Methods: A cross-sectional review of 1740 veterans'' initial mental health screening evaluations. One-hundred and thirteen (6.5%) OEF/OIF veterans reported active suicidal ideation at the time of the interview. Results: Prior exposures of physical or sexual abuse and having a history of a prior suicide attempt(s) were associated with the presence of current suicidal ideation, as were having a diagnosis of a psychotic disorder, a depressive disorder, or posttraumatic stress disorder (PTSD). Deployment concerns related to training (protective), the deployment environment, family concerns, deployment concerns, post-deployment support (protective), and post-deployment stressors were also associated with current suicidal ideation. Logistic regression analysis revealed the major risk factors were having a prior suicide attempt, female gender, and a depressive disorder diagnosis; while more perceived current social support was a protective factor. Logistic regression analysis also revealed having comorbid PTSD and depression carried a higher odds ratio for risk than did having either PTSD or depression alone; and that the PTSD avoidance symptom-cluster was associated with more risk than either the re-experiencing or hyper-arousal symptom clusters for current suicidal ideation. Limitations: As a cross-sectional retrospective medical chart review, limitations include limited generalizability and causal relationships cannot be evaluated. Conclusions: Further investigation of these risk factors is warranted to aid in suicide risk assessment and in the development of targeted interventions to mitigate the identified risk factors and bolster the identified protective factor. [Copyright &y& Elsevier]

Nepon, J., Belik, S., Bolton, J., & Sareen, J. (2010). The relationship between anxiety disorders and suicide attempts: Findings from the national epidemiologic survey on alcohol and related conditions. Depression & Anxiety, 27(9), 791-798. doi:10.1002/da.20674

Background: Previous work has suggested that anxiety disorders are associated with suicide attempts. However, many studies have been limited by lack of accounting for factors that could influence this relationship, notably personality disorders. This study aims to examine the relationship between anxiety disorders and suicide attempts, accounting for important comorbidities, in a large nationally representative sample. Methods: Data came from the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2. Face-to-face interviews were conducted with 34,653 adults between 2004 and 2005 in the United States. The relationship between suicide attempts and anxiety disorders (panic disorder, agoraphobia, social phobia, specific phobia, generalized anxiety disorder, posttraumatic stress disorder (PTSD)) was explored using multivariate regression models controlling for sociodemographics, Axis I and Axis II disorders. Results: Among individuals reporting a lifetime history of suicide attempt, over 70% had an anxiety disorder. Even after adjusting for sociodemographic factors, Axis I and Axis II disorders, the presence of an anxiety disorder was significantly associated with having made a suicide attempt (AOR=1.70, 95% confidence interval (CI): 1.40–2.08). Panic disorder (AOR=1.31, 95% CI: 1.06–1.61) and PTSD (AOR=1.81, 95% CI: 1.45–2.26) were independently associated with suicide attempts in multivariate models. Comorbidity of personality disorders with panic disorder (AOR=5.76, 95% CI: 4.58–7.25) and with PTSD (AOR=6.90, 95% CI: 5.41–8.79) demonstrated much stronger associations with suicide attempts over either disorder alone. Conclusion: Anxiety disorders, especially panic disorder and PTSD, are independently associated with suicide attempts. Clinicians need to assess suicidal behavior among patients presenting with anxiety problems. Depression and Anxiety, 2010. © 2010 Wiley-Liss, Inc. [ABSTRACT FROM AUTHOR]

Panagioti, M., Gooding, P. A., Dunn, G., & Tarrier, N. (2011). Pathways to suicidal behavior in posttraumatic stress disorder. Journal of Traumatic Stress, 24(2), 137-145. doi:10.1002/jts.20627

This study investigated paths to suicidal behavior in 94 civilian participants with chronic posttraumatic stress disorder (PTSD). Two statistical modeling programs, TETRAD II version 2.1 and Mplus 5.21 were used to construct a working model of suicide in PTSD. Two paths to suicidal behavior were identified. In the first path, suicidal behavior was directly associated with greater life impairment, which in turn was associated with poorer occupational and social functioning. In the second path, suicidal behavior was directly associated with depressive symptoms, which in turn were associated with more severe PTSD symptoms. Psychotropic medication, employment status, and threat to life further contributed to the model. The findings suggest that negative perceptions of functional impairment and depression are strongly associated with suicidal behavior in PTSD. [ABSTRACT FROM AUTHOR]

Torres, A., AT, Torresan, R., M, Hercos, A., & Guimaraes, A. (2007). Prevalence and associated factors for suicidal ideation and behaviors in obsessive-compulsive disorder. The International Journal of Neuropsychiatric Medicine, 12(10), 771-778. Retrieved from EBSCOhost.

INTRODUCTION: Patients with obsessive-compulsive disorder (OCD) have historically been considered at low risk for suicide, but recent studies are controversial. Objective: To study the prevalence of suicidal thoughts and attempts in OCD patients and to compare those with and without suicidality according to demographic and clinical variables. METHODS: Fifty outpatients with primary OCD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) from a Brazilian public university were evaluated. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was used to assess OCD severity, the Beck Depression Inventory to evaluate depressive symptoms and the Alcohol Use Disorders Identification Test to assess alcohol problems. RESULTS: All patients had obsessions and compulsions, 64% a chronic fluctuating course and 62% a minimum Y-BOCS score of 16. Half of the patients presented relevant depressive symptoms, but only three had a history of alcohol problems. Seventy percent reported having already thought that life was not worth living, 56% had wished to be dead, 46% had suicidal ideation, 20% had made suicidal plans, and 10% had already attempted suicide. Current suicidal ideation occurred in 14% of the sample and was significantly associated with a Y-BOCS score >16. Previous suicidal thoughts were associated with a Beck Depression Inventory score >19. CONCLUSION: Suicidality has been underestimated in OCD and should be investigated in every patient, so that appropriate preventive measures can be taken.

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