By Aeron Haworth

Preventing patients from leaving psychiatric wards without staff agreement could avoid up to 50 suicide deaths every year, say University of Manchester researchers.

A new report by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness suggests that the ward environment may play a part in the level of patients leaving the ward, and that attempts should be made to optimize it. It also urges mental health services to improve awareness among staff of the antecedents of suicide among high-risk groups.

The study, published in the journal BMC Psychiatry, collected data on 50,352 people who had died by suicide or unexplained causes in England and Wales between 1997 and 2006.

During this 10-year period there were 13,331 suicide deaths in individuals who had been in contact with mental health services in the year prior to death, of which 1,851, or 14%, were suicides by current psychiatric patients. The report noted that patient deaths had fallen sharply over the course of the study period, from 221 in 1997 to 141 in 2006.

The majority of the 1,851 patient cases – 1,292, or 70% – occurred off the ward: 469 of these suicides were by patients who had absconded from the ward. The remaining 761 had been given permission to leave the ward.

“Our findings have confirmed previous studies that a substantial proportion of in-patient suicide deaths occur after absconding from the ward,” said Dr Isabelle Hunt, who led the research in the University’s Centre for Suicide Prevention.

“Over the 10-year study period, while the number of in-patient suicide deaths declined, the proportion of these deaths which occurred among patients who had absconded remained unchanged at about 40%.”

The team were also able to identify different character traits of vulnerable patients, as well as the most likely method of suicide by different patient groups.

“Compared to individuals who died when they were off the ward with staff agreement, those who absconded were more likely to be young, unemployed and homeless,” said Dr Hunt. “Schizophrenia was the most common diagnosis, and rates of previous violence and substance misuse were high.

“Those who died following absconding were more likely than in-patients on agreed leave to have been formally detained for treatment, be non-compliant with medication, and to have died in the first week of admission. The method of suicide was also more likely to be violent compared to other in-patients, with nearly half of absconders dying by jumping.”

The researchers suggest that improving the ward environment to provide a more supportive and less intimidating experience may contribute to reduced risk. They also state that tighter control of ward exits and more intensive observation of patients, particularly in the early days of admission, might be one way to limit the likelihood of a patient taking their own life.

Dr Hunt added: “It is clearly a challenge to prevent patients leaving a general psychiatry open ward but our findings can inform staff of the clinical characteristics associated with absconding suicides, such as schizophrenia, substance misuse and noncompliance.

“Particular attention could be paid by staff in observing not only the patients themselves but also ward exits, while improved ward security through video monitoring or swipe-card systems to regulate patients’ entry and exit may be effective.

“Other measures to prevent in-patient suicide might include regular risk assessments during recovery and prior to granting leave, staff-training programmes in the management of risk, and improved staff communication.”

By Sherri McGinnis González

Despite government warnings about an increased risk of suicidal thoughts and actions while taking antiepileptic drugs, these medications do not appear to be associated with increased risk of suicide attempts in individuals with bipolar disorder, and may have a possible protective effect, according to a report in the December issue of Archives of General Psychiatry, one of the JAMA/Archives journals.

Antiepileptic drugs are life-saving for those with seizure disorders and are also used to treat many other conditions, including mood disorders and nerve pain, the authors write as background information in the article. The 11 antiepileptic drugs include gabapentin, pregabalin, topiramate and carbamazepine. “On Jan. 31, 2008, the Food and Drug Administration issued an alert regarding increased risk of suicidal thoughts and behavior related to use of antiepileptic drugs,” the authors wrote. “On July 10, 2008, a Food and Drug Administration scientific advisory committee voted that, yes, there was a significant positive association between antiepileptic drugs and suicidality but voted against placing a black box warning on antiepileptic drugs for suicidality.”

Individuals with bipolar disorder—often treated with antiepileptic drugs—have a higher risk of attempted and completed suicide than the general population. “That makes this a population of interest in detecting the effect on suicide risk of antiepileptic drugs compared with a no-treatment control group,” the authors wrote. Robert D. Gibbons, Ph.D., of the University of Illinois at Chicago, and colleagues studied a cohort of 47,918 patients with bipolar disorder who had at least one year of data before and after their diagnosis in a national database of medical claims.

A total of 13,385 patients received one of 11 antiepileptic drugs and 25,432 received neither antiepileptic medications nor lithium. After treatment, those taking antiepileptic medication had similar rates of suicide attempts (13 per 1,000 patients per year) as those taking lithium (18 per 1,000 patients per year) or those who did not receive treatment (13 per 1,000 patients per year).

Among those taking antiepileptic drugs, the rate of suicide attempt was significantly lower after treatment (13 per 1,000 patients per year) than before treatment (72 per 1,000 patients per year). In patients who were not receiving treatment with another antiepileptic, an antidepressant or an antipsychotic medication, taking any antiepileptic mediation appeared protective against suicide attempts relative to no pharmacologic treatment (three per 1,000 suicide attempts per patient per year vs. 15 per 1,000 per patient per year).

“Our analysis also reveals that there is a selection effect, in that the pretreatment suicide attempt rate is five times higher than the rate in untreated patients,” the authors wrote. “If pretreatment suicide attempt rates reflect the severity of illness, it is the more severely impaired patients who receive treatment with an antiepileptic drug or lithium. Nevertheless, the post-treatment suicide attempt rate is significantly reduced relative to their elevated pretreatment levels to the level found at or below patients not receiving treatment. This finding suggests a possible protective effect of antiepileptic drug treatment on suicidality.”

By Todd Datz

Young adults with higher blood lead levels appear more likely to have major depression and panic disorders, even if they have exposure to lead levels generally considered safe, according to a report in the December issue of Archives of General Psychiatry, one of the JAMA/Archives journals.

“Lead is a well-known neurotoxicant that is ubiquitous in the environment, found in air, soil, dust and water,” the authors wrote as background information in the article. Eliminating lead from gasoline has led to a dramatic decline in average blood levels, but remaining sources of exposure include paint, industrial processes, pottery and contaminated water. “Research on the neurotoxic effects of low-level lead exposure has focused on the in utero and early childhood periods. In adult populations, the neurotoxic effects of lead have been studied mainly in the context of occupational exposures, with levels of exposure orders of magnitude greater than that experienced by the general population.”

Maryse F. Bouchard, Ph.D., M.Sc., of the Universite de Montreal, Canada, and Harvard School of Public Health, Boston, and colleagues analyzed data from 1,987 adults age 20 to 39 years who participated in the National Health and Nutrition Examination Survey between 1999 and 2004. Participants underwent medical examinations that included collection of a blood sample, and also completed a diagnostic interview to identify major depressive disorder, panic disorder and generalized anxiety disorder.

The number of young adults who met diagnostic criteria for major depressive disorder was 134 (6.7 percent), 44 (2.2 percent) had panic disorder and 47 (2.4 percent) had generalized anxiety disorder. The average blood lead level was 1.61 micrograms per deciliter. The one-fifth of participants with the highest blood lead levels (2.11 micrograms per deciliter or more) had 2.3 times the odds of having major depressive disorder and nearly five times the odds of panic disorder as the one-fifth with the lowest lead levels (0.7 micrograms per deciliter or less).

Smoking is related to blood lead levels, so the researchers conducted additional analyses excluding the 628 smokers. Among non-smokers, the elevation in risk between the highest and lowest blood lead levels was increased to 2.5-fold for major depressive disorder and 8.2-fold for panic disorder.

Low-level lead exposure may disrupt brain processes, such as those involving the neurotransmitters catecholamine and serotonin, that are associated with depression and panic disorders, the authors note. Exposure to lead in individuals predisposed to these conditions could trigger their development, make them more severe or reduce response to treatment.

“These findings suggest that lead neurotoxicity may contribute to adverse mental health outcomes, even at levels generally considered to pose low or no risk,” they concluded. “These findings, combined with recent reports of adverse behavioral outcomes in children with similarly low blood lead levels, should underscore the need for considering ways to further reduce environmental lead exposures.”