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. 2019 Jun 1;76(6):603-613.
doi: 10.1001/jamapsychiatry.2018.4513.

Severity and Variability of Depression Symptoms Predicting Suicide Attempt in High-Risk Individuals

Nadine M Melhem  1 , Giovanna Porta  2 , Maria A Oquendo  3 , Jamie Zelazny  1 , John G Keilp  4 , Satish Iyengar  5 , Ainsley Burke  4 , Boris Birmaher  1 , Barbara Stanley  4 , J John Mann  4 , David A Brent  1
Affiliations

Severity and Variability of Depression Symptoms Predicting Suicide Attempt in High-Risk Individuals

Nadine M Melhem et al. JAMA Psychiatry. .

Abstract

Importance: Predicting suicidal behavior continues to be among the most challenging tasks in psychiatry.

Objectives: To examine the trajectories of clinical predictors of suicide attempt (specifically, depression symptoms, hopelessness, impulsivity, aggression, impulsive aggression, and irritability) for their ability to predict suicide attempt and to compute a risk score for suicide attempts.

Design, setting, and participants: This is a longitudinal study of the offspring of parents (or probands) with mood disorders who were recruited from inpatient units at Western Psychiatric Institute and Clinic (Pittsburgh) and New York State Psychiatric Institute. Participants were recruited from July 15, 1997, to September 6, 2005, and were followed up through January 21, 2014. Probands and offspring (n = 663) were interviewed at baseline and at yearly follow-ups for 12 years. Lifetime and current psychiatric disorders were assessed, and self-reported questionnaires were administered. Model evaluation used 10-fold cross-validation, which split the entire data set into 10 equal parts, fit the model to 90% of the data (training set), and assessed it on the remaining 10% (test set) and repeated that process 10 times. Preliminary analyses were performed from July 20, 2015, to October 5, 2016. Additional analyses were conducted from July 26, 2017, to July 24, 2018.

Main outcomes and measures: The broad definition of suicide attempt included actual, interrupted, and aborted attempts as well as suicidal ideation that prompted emergency referrals during the study. The narrow definition referred to actual attempt only.

Results: The sample of offspring (n = 663) was almost equally distributed by sex (316 female [47.7%]) and had a mean (SD) age of 23.8 (8.5) years at the time of censored observations. Among the 663 offspring, 71 (10.7%) had suicide attempts over the course of the study. The trajectory of depression symptoms with the highest mean scores and variability over time was the only trajectory to predict suicide attempt (odds ratio [OR], 4.72; 95% CI, 1.47-15.21; P = .01). In addition, we identified the following predictors: younger age (OR, 0.82; 95% CI, 0.74-0.90; P < .001), lifetime history of unipolar disorder (OR, 4.71; 95% CI, 1.63-13.58; P = .004), lifetime history of bipolar disorder (OR, 3.4; 95% CI, 0.96-12.04; P = .06), history of childhood abuse (OR, 2.98; 95% CI, 1.40-6.38; P = .01), and proband actual attempt (OR, 2.24; 95% CI, 1.06-4.75; P = .04). Endorsing a score of 3 or higher on the risk score tool resulted in high sensitivity (87.3%) and moderate specificity (63%; area under the curve = 0.80).

Conclusions and relevance: The specific predictors of suicide attempt identified are those that clinicians already assess during routine psychiatric evaluations; monitoring and treating depression symptoms to reduce their severity and fluctuation may attenuate the risk for suicidal behavior.

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Conflict of interest statement

Conflict of Interest Disclosures: .Dr Melhem reported receiving research support from the National Institute of Mental Health (NIMH), Brain and Behavior Research Foundation, and the American Foundation for Suicide Prevention (AFSP). Dr Oquendo reported receiving royalties from Research Foundation for Mental Hygiene for the commercial use of the Columbia-Suicide Severity Rating Scale, and owning stock in Bristol-Myers Squibb. Drs Burke, Stanley, and Mann reported receiving royalties from Research Foundation for Mental Hygiene for the commercial use of the Columbia-Suicide Severity Rating Scale. Dr Stanley also reported receiving research support from NIMH and AFSP. Dr Keilp reported receiving support from AFSP and owning stocks in Pfizer and Zoetis. Dr Birmaher reported receiving research support from the National Institute of Mental Health (NIMH) and royalties for publications from Random House Inc, Lippincott Williams & Wilkins, and UpToDate. Dr Iyengar reported receiving research support from NIMH. Dr Brent receives research support from NIMH, AFSP, and the Once Upon a Time Foundation, honoraria from the Klingenstein Third Generation Foundation royalties for scientific board membership and grant review, from Guilford Press, royalties from the electronic self-rated version of the C-SSRS from ERT, Inc., royalties from performing duties as an UpToDate Psychiatry Section Editor, payment for serving as an Associate Editor for Psychological Medicine, and consulting fees from Healthwise. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Longitudinal Trajectories for 6 Measures of Suicide Attempt
A, Depression symptoms class 1 (n = 430), class 2 (n = 174), and class 3 (n = 43). B, Hopelessness class 1 (n = 485) and class 2 (n = 165). C, Impulsivity class 1 (n = 492) and class 2 (n = 151). D, Aggression class 1 (n = 547) and class 2 (n = 112). E, Impulsive aggression class 1 (n = 288) and class 2 (n = 349). F, Irritability class 1 (n = 490) and class 2 (n = 159). Only 34 offspring had a follow-up duration beyond 12 years. Data from these follow-ups were truncated and removed from the analyses. During the course of this longitudinal study, the impulsivity and impulsive aggression questionnaires were eliminated at year 8 to reduce the assessment battery.
Figure 2.
Figure 2.. Time to Onset of Suicide Attempt by Trajectories for Depression Symptoms
See this image and copyright information in PMC

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