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Mental disorders, comorbidity and suicidal behavior: Results from the National Comorbidity Survey Replication

Abstract

Mental disorders are among the strongest predictors of suicide attempts. However, little is known regarding which disorders that are uniquely associated with suicidal behavior because of high levels of psychiatric comorbidity. We examined the unique associations between individual disorders and subsequent suicidal behavior (suicide ideation, plans and attempts) using data from the National Comorbidity Survey Replication, a nationally representative household survey of 9282 US adults. Results revealed that approximately 80% of suicide attempters in the United States have a temporally prior mental disorder. Anxiety, mood, impulse-control and substance use disorders all significantly predict subsequent suicide attempts in bivariate analyses (odds ratios (OR)=2.7–6.7); however, these associations decrease substantially in multivariate analyses controlling for comorbidity (OR=1.5–2.3) but remain statistically significant in most cases. Disaggregation of the observed effects reveals that depression predicts suicide ideation, but not suicide plans or attempts among those with ideation. Instead, disorders characterized by severe anxiety/agitation (for example, post-traumatic stress disorder) and poor impulse control (for example, conduct disorder, substance use disorders) predict which suicide ideators who go on to make a plan or attempt. These results advance understanding of the unique associations between mental disorders and different forms of suicidal behavior. Future research must further delineate the mechanisms through which people come to think about suicide and progress from suicidal thoughts to attempts.

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References

  1. Goldsmith SK, Pellmar TC, Kleinman AM, Bunney WE (eds.) Reducing Suicide: A National Imperative. The National Academies Press: Washington, DC, 2002.

    Google Scholar 

  2. Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC, Lee S . Suicide and suicidal behaviors. Epidemiol Rev 2008; 30: 133–154.

    Article  PubMed  Google Scholar 

  3. Harris EC, Barraclough B . Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatry 1997; 170: 205–228.

    Article  CAS  PubMed  Google Scholar 

  4. Pokorny AD . Prediction of suicide in psychiatric patients. Report of a prospective study. Arch Gen Psychiatry 1983; 40: 249–257.

    Article  CAS  PubMed  Google Scholar 

  5. Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM . Psychological autopsy studies of suicide: a systematic review. Psychol Med 2003; 33: 395–405.

    Article  CAS  PubMed  Google Scholar 

  6. Beautrais AL, Joyce PR, Mulder RT, Fergusson DM, Deavoll BJ, Nightengale SK . Prevalence and comorbidity of mental disorders in persons making serious suicide attempts: a case–control study. Am J Psychiatry 1996; 153: 1009–1014.

    Article  CAS  PubMed  Google Scholar 

  7. Wunderlich U, Bronisch T, Wittchen HU . Comorbidity patterns in adolescents and young adults with suicide attempts. Eur Arch Psychiatry Clin Neurosci 1998; 248: 87–95.

    Article  CAS  PubMed  Google Scholar 

  8. Weissman MM, Klerman GL, Markowitz JS, Ouellette R . Suicidal ideation and suicide attempts in panic disorder and attacks. N Engl J Med 1989; 321: 1209–1214.

    Article  CAS  PubMed  Google Scholar 

  9. Bostwick JM, Pankratz VS . Affective disorders and suicide risk: a reexamination. Am J Psychiatry 2000; 157: 1925–1932.

    Article  CAS  PubMed  Google Scholar 

  10. Phillips MR, Yang G, Li S, Li Y . Suicide and the unique prevalence pattern of schizophrenia in mainland China: a retrospective observational study. Lancet 2004; 364: 1062–1068.

    Article  PubMed  Google Scholar 

  11. Kessler RC, Berglund P, Borges G, Nock MK, Wang PS . Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003. JAMA 2005; 293: 2487–2495.

    Article  CAS  PubMed  Google Scholar 

  12. Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A et al. Cross-national prevalence and risk factors for suicidal ideation, plans, and attempts in the WHO World Mental Health Surveys. Br J Psychiatry 2008; 192: 98–105.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Kessler RC, Borges G, Walters EE . Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry 1999; 56: 617–626.

    Article  CAS  PubMed  Google Scholar 

  14. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE . Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62: 617–627.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Pilowsky DJ, Wu LT, Anthony JC . Panic attacks and suicide attempts in mid-adolescence. Am J Psychiatry 1999; 156: 1545–1549.

    Article  CAS  PubMed  Google Scholar 

  16. Anthony JC, Petronis KR . Panic attacks and suicide attempts. Arch Gen Psychiatry 1991; 48: 1114.

    Article  CAS  PubMed  Google Scholar 

  17. Vickers K, McNally RJ . Panic disorder and suicide attempt in the National Comorbidity Survey. J Abnorm Psychol 2004; 113: 582–591.

    Article  PubMed  Google Scholar 

  18. Hornig CD, McNally RJ . Panic disorder and suicide attempt. A reanalysis of data from the Epidemiologic Catchment Area study. Br J Psychiatry 1995; 167: 76–79.

    Article  CAS  PubMed  Google Scholar 

  19. Rudd MD, Dahm PF, Rajab MH . Diagnostic comorbidity in persons with suicidal ideation and behavior. Am J Psychiatry 1993; 150: 928–934.

    Article  CAS  PubMed  Google Scholar 

  20. Borges G, Angst J, Nock MK, Ruscio AM, Kessler RC . Risk factors for the incidence and persistence of suicide-related outcomes: a 10-year follow-up study using the National Comorbidity Surveys. J Affect Disord 2008; 105: 25–33.

    Article  PubMed  Google Scholar 

  21. Brent DA, Mann JJ . Family genetic studies, suicide, and suicidal behavior. Am J Med Genet C Semin Med Genet 2005; 133: 13–24.

    Article  Google Scholar 

  22. Brent DA, Mann JJ . Familial pathways to suicidal behavior—understanding and preventing suicide among adolescents. N Engl J Med 2006; 355: 2719–2721.

    Article  PubMed  Google Scholar 

  23. Bondy B, Buettner A, Zill P . Genetics of suicide. Mol Psychiatry 2006; 11: 336–351.

    Article  CAS  PubMed  Google Scholar 

  24. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, 4th edn. American Psychiatric Association: Washington, DC, 1994.

  25. Kessler RC, Merikangas KR . The National Comorbidity Survey Replication (NCS-R): Background and aims. Int J Methods Psychiatric Res 2004; 13: 60–68.

    Article  Google Scholar 

  26. Rubin DB . Using propensity scores to help design observational studies: Application to the tobacco litigation. Health Serv Outcomes Res Methodol 2001; 2: 169–188.

    Article  Google Scholar 

  27. Kessler RC, Berglund P, Chiu WT, Demler O, Heeringa S, Hiripi E et al. The US National Comorbidity Survey Replication (NCS-R): Design and field procedures. Int J Methods Psychiatric Res 2004; 13: 69–92.

    Article  Google Scholar 

  28. Kessler RC, Ustun TB . The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatric Res 2004; 13: 93–121.

    Article  Google Scholar 

  29. First MB, Spitzer RL, Gibbon M, Williams JBW . Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-Patient Edition (SCID-I/NP). Biometrics Research, New York State Psychiatric Institute: New York, NY, 2002.

    Google Scholar 

  30. Haro JM, Arbabzadeh-Bouchez S, Brugha TS, de Girolamo G, Guyer E, Jin R et al. Concordance of the Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) with standardized clinical assessments in the WHO World Mental Health Surveys. Int J Methods Psychiatric Res 2006; 15: 167–180.

    Article  Google Scholar 

  31. Efron B . Logistic regression, survival analysis, and the Kaplan Meier curve. J Am Sociol Assoc 1988; 83: 414–425.

    Article  Google Scholar 

  32. Wolter KM . Introduction to Variance Estimation. Springer-Verlag: New York, NY, 1985.

    Google Scholar 

  33. SUDAAN. Professional Software for Survey Data Analysis [computer program]. Research Triangle Institute: Research Triangle Park, NC, 2002.

  34. Angold A, Erkanli A, Costello EJ, Rutter M . Precision, reliability and accuracy in the dating of symptom onsets in child and adolescent psychopathology. J Child Psychol Psychiatry 1996; 37: 657–664.

    Article  CAS  PubMed  Google Scholar 

  35. Hardt J, Rutter M . Validity of adult retrospective reports of adverse childhood experiences: review of the evidence. J Child Psychol Psychiatry 2004; 45: 260–273.

    Article  PubMed  Google Scholar 

  36. Schlesselman JJ . Case–Control Studies: Design, Conduct, and Analysis. Oxford University Press: New York, NY, 1982.

    Google Scholar 

  37. Moffitt TE, Harrington H, Caspi A, Kim-Cohen J, Goldberg D, Gregory AM et al. Depression and generalized anxiety disorder: cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. Arch Gen Psychiatry 2007; 64: 651–660.

    Article  PubMed  Google Scholar 

  38. Angst J, Sellaro R, Ries Merikangas K . Multimorbidity of psychiatric disorders as an indicator of clinical severity. Eur Arch Psychiatry Clin Neurosci 2002; 252: 147–154.

    Article  PubMed  Google Scholar 

  39. Shneidman ES . Suicide as psychache. J Nerv Ment Dis 1993; 181: 145–147.

    Article  CAS  PubMed  Google Scholar 

  40. Baumeister RF . Suicide as escape from self. Psychol Rev 1990; 97: 90–113.

    Article  CAS  PubMed  Google Scholar 

  41. Hawton K, Houston K, Haw C, Townsend E, Harriss L . Comorbidity of axis I and axis II disorders in patients who attempted suicide. Am J Psychiatry 2003; 160: 1494–1500.

    Article  PubMed  Google Scholar 

  42. Fawcett J, Busch KA, Jacobs D, Kravitz HM, Fogg L . Suicide: a four-pathway clinical-biochemical model. Ann NY Acad Sci 1997; 836: 288–301.

    Article  CAS  PubMed  Google Scholar 

  43. Mann JJ, Waternaux C, Haas GL, Malone KM . Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 1999; 156: 181–189.

    CAS  PubMed  Google Scholar 

  44. Fawcett J . Treating impulsivity and anxiety in the suicidal patient. Ann NY Acad Sci 2001; 932: 94–102.

    Article  CAS  PubMed  Google Scholar 

  45. Joiner TE . Why People Die by Suicide. Harvard University Press: Cambridge, MA, 2005.

    Google Scholar 

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Acknowledgements

This study was supported by the National Institute of Mental Health (NIMH; MH077883). The National Comorbidity Survey Replication (NCS-R) was supported by NIMH (U01-MH60220), with supplemental support from the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Robert Wood Johnson Foundation (RWJF; Grant 044780) and the John W Alden Trust. NCS-R was carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative. We thank the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork and consultation on data analysis. These activities were supported by the National Institute of Mental Health (R01 MH070884), the John D and Catherine T MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (U13-MH066849, R01-MH069864 and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil Pharmaceutical Inc., GlaxoSmithKline and Bristol-Myers Squibb.

Collaborating NCS-R investigators: Ronald C Kessler (Principal Investigator, Harvard Medical School), Kathleen Merikangas (Co-Principal Investigator, NIMH), James Anthony (Michigan State University), William Eaton (The Johns Hopkins University), Meyer Glantz (NIDA), Doreen Koretz (Harvard University), Jane McLeod (Indiana University), Mark Olfson (New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University), Harold Pincus (University of Pittsburgh), Greg Simon (Group Health Cooperative), Michael Von Korff (Group Health Cooperative), Philip Wang (Harvard Medical School), Kenneth Wells (UCLA), Elaine Wethington (Cornell University) and Hans-Ulrich Wittchen (Max Planck Institute of Psychiatry; Technical University of Dresden).

Additional information: A complete list of NCS publications and the full text of all NCS-R instruments can be found at http://www.hcp.med.harvard.edu/ncs. All correspondence can be sent to ncs@hcp.med.harvard.edu.

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Nock, M., Hwang, I., Sampson, N. et al. Mental disorders, comorbidity and suicidal behavior: Results from the National Comorbidity Survey Replication. Mol Psychiatry 15, 868–876 (2010). https://doi.org/10.1038/mp.2009.29

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