"What mental health practitioners need to hear," Zlatka Russinova, Ph.D., told 

, "is that people with serious mental illness do have the capacity to go back to work." Russinova is senior research associate at Boston University's Center for Psychiatric Rehabilitation and has specialized in researching the connections between mental illness and employment.

 "I'll give you one example. I had a colleague who is a postdoctoral fellow and who has been conducting interviews for our study. She has been so amazed that, as a clinician, she never believed that people with serious mental illness could do this or think clearly about serious economic decision making. She said to me, 'There probably are so many other mental health professionals out there who think the way I thought.'"

Where occupational therapy was once seen as a treatment tool, the ability to work and earn a living is now recognized as a realistic outcome for many patients. In one study of workers with serious mental illness, Russinova and her colleagues found that 74% of the 687 participants had held the same job for 24 months or longer. In that group, 28% suffered from major depression, 17% had schizophrenia or schizoaffective disorder, 42% had been diagnosed with bipolar disorder, and 11% had posttraumatic stress disorder or other dissociative disorder.

Across the country, programs are going beyond just training people with mental illnesses for jobs and helping them find employment opportunities. They are creating businesses in which workers who are mentally ill take an active part in running the enterprise, dealing with customers and sharing in the economic fruits of their labor.

 "We've seen this happening around the country," said Ron Honberg, J.D., national director for policy and legal affairs at the National Alliance for the Mentally Ill. He told 

, "A lot of times they are food establishments. That's a successful model, but it's not widespread. It's a very cool approach, involving people in all aspects of the enterprise, giving them a stake in how it does. It's a progressive approach to addressing a need that is very profound for people with mental illness." Examples can be seen in the Table.

Eloise Newell runs Restoration Project Inc., a vocational rehabilitation program that trains people who are mentally ill in furniture upholstery and refinishing in Acton, Mass. "We do an annual survey of our graduates," she told 

. "Over the 10 years we've been in existence, more than 70% of them remain employed. Their recovery appears to be permanent."

Newell was a university-level physics instructor when her own son was diagnosed with schizophrenia as a college sophomore. "Sixteen years ago, programs weren't geared toward recovery," she said. "He was always ambitious and had a strong work ethic. He said he knew if he could work he would be better."

She founded Restoration Project on the Montessori model. "My mother started the first Montessori school in North Carolina. Our work here is based on Montessori principles and on constructionism. Stations are set up, and people choose where they want to work. We have a facilitator who looks after the different stations."

As part of their training, participants work on jobs brought in by consumers. Other upholstery businesses in the area don't resent the competition, according to Newell.

"The other businesses have reacted very well," she said. "At first they didn't think we were any competition, but now they realize that we are. But we're different: We don't work that fast, our product is our people. 

 "We charge less than the going rate. I think that's required as part of nonprofit status, but we're only about 10% less. But we're not that much competition. The fact that we take longer to do the job makes a difference. Our customers are loyal, and they're also our supporters, the source of much of our funding."

 Participants attend the project two days a week and are supposed to spend some of the time away from the work environment preparing to look for outside work. "A person absorbs what they've learned after they do an exercise, which is why you need three days away after working," Newell explained. "Everything we do here is normal vocational training, skills built on top of skills, problem-solving. It is empowering if you want a person to go forward."

While participants learn a useful trade and are helped to find a real-world job, Newell said that the project's focus includes a broader agenda. "Our participants go through the normal stages of recovery. First they work on acquiring transportation, getting a driver's license, and then a car. Then they work on housing. They learn to advocate for themselves on medications. In about six months, they're usually ready to get a job."

Newell added that a consulting psychiatrist monitors patients' progress, but, "Our program is really based on educational models rather than psychiatric models. We don't treat our participants like 'people with mental illness,' whatever that means. We don't treat them as patients. The first thing I discovered was that they understood my jokes; they're not really much different than my students in my physics classes. 

 "I reject completely the idea that people with mental illness don't excel. Many of them are smart and talented people. If you treat them like great people, pretty soon they start feeling like great people."

Russinova is more emphatic in extolling the abilities of people with mental illness. "One of the old myths was that people with serious mental illness could only do low-level jobs--the so-called F jobs: flowers, filing, food. We have done studies that have documented capacity of the mentally ill to be successful.

"For example, in the late 1990s, I did a study with Marsha Langer Ellison [Ph.D., M.S.W.] looking at professional and managerial careers. We studied 495 participants around the country who were able to maintain a high-level job successfully for at least six months. Many of these were people who held jobs for years and years, despite their mental illnesses.

"Some of them were in technical jobs, some in sales, some in middle or upper management," she added. "These were definitely not in low-level, menial jobs. Forty-eight percent were in professional specialties. Forty-six percent were in executive positions or were program directors. Only 3% were in clerical and sales jobs, and 2% in low-level technical positions."

Russinova said the group "had a very interesting distribution: 75% of the whole sample was employed full time; 62% had held their position for more than two years; 28% had held the same job for more than five years. What was most interesting was that they had the capacity to keep such high-level jobs for a long time. Thirty-three percent of this sample were working in non-helping professions; 16% were working in health and social services other than mental health--we separated the health services. Thirty percent were in mental health; 21% in self-help advocacy jobs. All in all, it was a very surprising, very positive picture."

Many of the study participants were dependent on continuing treatment to maintain their positions, Russinova said. "These people haven't been cured. Eighty-eight percent of the study participants were taking psychotropic medications at the time of study. They had well-maintained, well-managed illness. Seventy-three percent were in some kind of psychotherapy at the time of study. 

"These people made heavy use of the mental health system to maintain their working capacity," she added. "We asked these folks about the things that helped them succeed vocationally. The most important was consistent use of medications. Number two was the support of a spouse or significant other. Third was the support of a therapist. The list varies somewhat per diagnosis. The group with bipolar disorder had a higher percentage of people who were married or in a relationship. In other groups, medications and the support of a therapist were the most important factors contributing to success."

Last May, the Boston University research team presented baseline findings from a five-year study of sustained employment. Of the 696 individuals who met the study criteria of both a serious psychiatric condition and sustained employment in the two years prior to enrolling in the study:

74% were continuously employed for the entire two years; 


17% were employed for 18 of the 24 months;


9% were employed for 12 to 18 of the 24 months;


80% had at least one psychiatric hospitalization in the past;


95% were taking psychotropic medications at the time of the study;


74% were working 35 hours or more a week;


53% had professional or technical jobs and 24% had managerial or administrative jobs;


32% had total annual income of more than $40,000 and 38% had incomes of between $20,000 and $40,000;


42% lived with a spouse or significant other.

The researchers noted, "Psychiatric diagnosis was not associated with participants' ability to sustain employment during the two years prior to entering the study. However, diagnosis was associated with participants' occupational status, the number of hours they worked per week, and the salary they earned per hour. On average, the group of participants who reported a diagnosis of bipolar disorder had a higher occupational status, worked more hours per week, and earned a higher salary per hour than the other diagnostic groups. At the same time, the group of participants who reported a diagnosis of schizophrenia or schizoaffective disorder, on average, had a lower occupational status, worked fewer hours per week, and earned a lower salary per hour than the other diagnostic groups."

 "The bottom line is that people with mental illness are able to sustain employment," Russinova said. "They can succeed both over time and by moving up in higher level positions. The other thing we found was the importance of education. It makes a difference in peoples' capacity to get and to sustain better jobs. People will do better if they acquire a better education prior to getting sick or acquire schooling through vocational rehabilitation programs."  

Articles

It's often believed--even by mental health care professionals--that people with mental illnesses could be employed in low-level jobs. Studies and demonstration projects have shown, however, that these individuals can sustain employment in high-level positions with the proper training and support.

Employment Programs Help Patients With Mental Illnesses Succeed

Advances in understanding the genetic causes underlying psychiatric disorders and ongoing research and development by pharmaceutical companies in search of the next blockbuster promise to introduce exciting, new treatments in the coming years. But realizing gains from current scientific advances may take some time.

These days, drug companies appear to be a bit more risk-aversive and are looking to license drugs from other companies that may already have preliminary data. The increased cost of drug development and the current regulatory climate has had a chilling effect on taking risks and pursuing novel strategies. "It's a huge investment for a company to decide to go off in a truly novel direction," said Jeffrey Lieberman, M.D., in an interview with 

. Lieberman is professor and vice chairperson for research and scientific affairs in the department of psychiatry at the University of North Carolina School of Medicine.

Developing new drugs is an expensive and risky venture. Pharmaceutical companies spend an average of $802 million to get a new drug to market, according to the Tufts Center for the Study of Drug Development. That amount jumps to $897 million when including the cost of post-approval studies required by the U.S. Food and Drug Administration to determine long-term safety and effectiveness in a wider range of patients or in specific patient subgroups.

On average, it takes a compound 10 to 15 years to get from the lab to the pharmacy. Only five compounds out of 5,000 in preclinical tests get as far as human trials. And only one in five drugs that make it to clinical testing gets approved.

According to a report issued last year by the Pharmaceutical Research and Manufacturers of America (PhRMA), the drug industry has 99 medicines in development for treating mental illnesses involving 44 pharmaceutical and biotechnology companies (Figure). 

(Due to copyright concerns, this figure cannot be reproduced online. Please see p10 of the print edition--Ed.

) These potential drugs are either in clinical trials or awaiting approval from the FDA.

"The new medicines in the pipeline offer hope of reducing the human and economic costs of mental illnesses," PhRMA reported. Those costs include $100 billion for directly treating mental illnesses in the United States and an additional $80 million in indirect costs.

The challenge that pharmaceutical companies face, Lieberman explained, is being able to develop new successful products-presumably more effective or safer and thus more desirable to use-while also generating profits. These companies have a range of strategies available for developing treatments from traditional, proven approaches to novel, innovative approaches.

This spectrum of drug development strategies can be viewed in the context of how much financial risk is involved, Lieberman said. Known ways of developing a drug or group of drugs is a low-risk strategy, but it also has lower potential gain. Novel strategies are higher risk but have higher potential gain. Companies have different development programs based on this continuum of risk.

The problem is that it is hard to find a novel strategy or mechanism of action that is going to be effective in treating an illness, according to Lieberman. For example, antipsychotic drugs have historically targeted the dopamine-2 receptor. Each new drug over the years has been a variation of that, first with the introduction of atypical antipsychotics and now with the introduction of aripiprazole (Abilify), which he said could possibly represent a new generation of antipsychotic drug.

Referred to by some researchers as a dopamine-serotonin system stabilizer, aripiprazole works on the dopamine-2 receptor. But while other atypicals act as a full antagonist, aripiprazole acts as a partial agonist-partially inhibiting the receptor at the same time that it partially stimulates it. Still, it is an iteration of an older mechanism, Lieberman said. A truly novel antipsychotic would have no dopamine-2 receptor activity. And while there have been some efforts to develop such a drug, none have been successful so far.

Currently, several companies are working to develop non-dopamine-based therapies, such as looking at serotonin-2A receptor antagonists, neurokinin-3 receptor antagonists and cannabinoid receptor antagonists.

"They're much more novel strategies but they're higher risk," Lieberman explained.

There's a similar phenomenon in the development of drugs for depression. Traditionally, these drugs have inhibited reuptake transporters, specifically serotonin or norepinephrine. "Now we're seeing the introduction of dual reuptake inhibitors and triple reuptake inhibitors," he said. For example, the newly approved duloxetine (Cymbalta) targets dopamine, norepinephrine and serotonin.

However, these innovations are not entirely novel. Rather than producing new paradigms for drug mechanisms of action, these drugs are iterations of a traditional approach, namely to develop molecules that work as catecholamine or indolamine uptake inhibitors, Lieberman said. 

However, there are some novel strategies being pursued. A number of pharmaceutical companies are pursuing a neurokinin-1 receptor antagonist and corticotropin-releasing factor antagonists, among other novel molecules.

Beyond this, an ongoing approach is recognizing that any one treatment may not be able to alleviate all the dimensions of an illness, and combined treatments may be necessary, Lieberman said. For instance, antipsychotic drugs are the mainstay of treatment for schizophrenia, but existing antipsychotic drugs don't always work well on negative symptoms, cognitive deficits and prevention of mood-associated symptoms. "This may be because certain dimensions of the illness are related to other pathophysiological processes other than just dopamine hyperactivity," Lieberman said.

Consequently, there has been an effort to develop drugs that target systems believed to underlie these other symptom dimensions, he said. A prime example has been glutamate's role in cognition. There has been a tremendous effort to develop compounds that act on the glutamate system for treatments that might help against cognitive impairment, negative symptoms and behavioral deficits. "However, these treatments can't be used alone," Lieberman said. "These treatments in all likelihood would need to be used with an antipsychotic drug."

As researchers continue to unlock the secrets of the human genome, more advanced medicines that target specific genes can be expected. But it could take years for these kinds of advances to translate into pharmaceutical products.

The cancer treatment imatinib (Gleevec) was the first to emerge as a molecular designer drug. It selectively blocks cellular proliferation by inhibiting tyrosine kinase. Blocking the enzyme prevents the rapid growth of white blood cells that occurs in patients with chronic myeloid leukemia.

Similar successes are likely to be seen in treatments for Alzheimer's disease because the illness has a well-characterized neurobiology, Lieberman said.

It is hard to predict how long it will take for genetic breakthroughs to result in the development of successful therapeutic agents, he said. The gene for Huntington's disease, for example, was discovered in 1993 but has yet to result in a treatment.

The same holds true for disorders such as cystic fibrosis and Rett syndrome. While the genes behind these disorders have been discovered, effective treatments based on that genetic information have not.

The idea of applying genomics to identifying genes that can point to targets for drug development is a very powerful one, and ultimately will revolutionize the way that treatments are developed, Lieberman said. However, "it's not necessarily an easy process."

The pace of research is accelerating as different types of genetic-based technologies are developed.

Linkage and association studies, in which researchers painstakingly examine possible genetic origins for disorders within families or isolated populations, are giving way to powerful technologies such as gene multi-array chips, which can hold the code for thousands of genes. These microchips are hybridized with a patient's tissue--whether it's postmortem brain tissue, spinal fluid or blood--in order to examine gene expression and look for differences associated with a particular disorder.

Proteomics, another emerging technology, searches for gene products, usually proteins, in biologic fluids or specimens.

"These are powerful ways that can help to ultimately identify targets for drug development and ultimately may lead to individualization and selection of treatments for specific patients," Lieberman said.

Most research begins in government-funded studies; the findings of which become public domain.

In September, the National Institute of Mental Health announced a new program that would expand its in-house research into the genetics of schizophrenia. "For the first time, we have half a dozen vulnerability genes to explore," NIMH Director Thomas Insel, M.D., announced in a press release.

Multidisciplinary research teams will examine how these genes work at molecular, cellular and systems levels to determine the "risk architecture" of schizophrenia and to examine changes in the brain that alter thinking and emotions in ways that are associated with the disorder. The work will involve everything from cell-culture models to brain imaging.

"Genes don't directly encode for the hallucinations, delusions and blunted affect of schizophrenia," said Daniel Weinberger, M.D., chief of the NIMH Clinical Brain Disorders Branch (CBDB). "Rather, there is a very complicated path between a gene's influence on the regulation and function of a protein and such psychiatric phenomena."

The studies--which will examine two versions of the COMT gene, as well as GRM3, DISC1, dysbindin and neuregulin--will attempt to identify biological tests for the disorder and ways to switch genes "on" and "off" in order to develop prevention and treatment strategies. "Such findings emerging from the fast-track intramural effort will serve to stimulate spin-off studies by extramural, or grant-supported, researchers," Insel added.

One gene identified by CBDB that looks like a risk factor for schizophrenia is COMT. The enzyme produced by COMT is one that already has a drug that can act on it, Lieberman said. This points to justification for developing drugs that act as COMT inhibitors.

In July, NIMH announced funding for the Center for Collaborative Genetic Studies on Mental Disorders at Rutgers University. The university's previous research center, also funded by NIMH, established more than 17,000 cell lines from blood samples and distributed more than 25,000 DNA samples to more than 100 investigators worldwide.

The new center will continue that work by enhancing research collaborations and developing novel methods for data analysis that will help in the replication of genetic discoveries, according to Steven Moldin, Ph.D., NIMH project director for the Center. "The Center's activities are expected to greatly accelerate gene discovery in mental disorders such as autism, mood disorders and schizophrenia, and lead to the identification of novel targets for new therapies," Molding stated in a press release. "Ultimately, we expect these results to revolutionize the diagnosis, treatment and prevention of these disorders."  

There may be exciting new treatments for psychiatric disorders in the coming years due to advances in genetic testing. However, the increased cost of drug development and the current regulatory climate has had a chilling effect on taking risks and pursuing novel strategies.

On the Hunt for Breakthrough Therapies

The managed care revolution of the past two decades has largely transformed health care delivery by shifting the majority of U.S. workers from a fee-for-service system to HMOs and preferred provider organizations (PPOs). In fact, the percentage of health plan participants covered by managed care in HMOs or PPOs increased from 48% in 1992 to the current level of 87% (Employee Benefit Research Institute, 1999). 

While many clinicians and patients recognize the potential social value that could be associated with a thoughtful allocation of limited health care resources, they also experience frustration and anger as a result of managed care's effects on service availability and the relationship between clinicians and patients. Through various forms of pressure and incentives, managed care organizations or their representatives (e.g., carveouts) have reduced payments to providers and institutions, influenced length of hospital stays, limited patients' choices of physicians, and restricted patients' access to specialists. They have also imposed limitations on the availability of outpatient treatment sessions, decreased autonomy in treatment planning and perpetuated distinctions between coverage limits for mental disorders versus other medical illnesses. While the backlash to these changes has been intense (i.e., resulting in many states legislating patient bills of rights), the relationships between providers, patients and managed care companies continue to evolve. 

In the midst of these ongoing changes in health care coverage and service delivery, suicidal patients continue to seek evaluation and treatment. In many cases, much can be done to help. Acute interventions with pharmacotherapy and psychotherapy can often reduce immediate pain and avert a tragic clinical outcome. Over the long term, we have medications such as lithium (Eskalith, Lithobid) and clozapine (Clozaril) and psychotherapies such as dialectical behavior therapy that can reduce suicide risk when used appropriately. Unfortunately, suicide continues to be a leading cause of death in the United States. According to the latest report from the National Center of Health Statistics, the 2000 suicide rate for the general population was 10.7 per 100,000, a slight decrease from a rate of 11.3 in 1998 (Centers for Disease Control and Prevention [CDC], 2002).

Suicide remains all too common among adolescents and ranks third among causes of death for individuals ages 10 to 24. The elderly, particularly white males, also account for many suicide deaths. Among adults ages 74 to 85, there are now 17.7 suicide deaths per 100,000 and, among adults 85 and over, the rate is 19.4 deaths per 100,000, well above the national average. This means that adults over 64 account for 12.4% of the population, but a full 18% of suicide deaths (CDC, 2002). These figures become especially salient when considering the aging U.S. population, the possibility for a greater overall incidence of suicide if elderly suicide rates continue at their relatively high level and the ongoing pressures on older adults to join managed care insurance plans.

While many critics of managed care express concern that an undue focus on cost savings must undermine the quality of clinical care, HMOs and PPOs possess certain features that conceivably could reduce their members' suicide rates. Health maintenance organizations increase the availability of health care by keeping insurance costs lower than they would otherwise be, enabling more employers to offer health care benefits to their employees. The more individuals who have access to health care services, the more likely mental illness will be diagnosed and treated. The risks of suicide are potentially mitigated by many HMOs' and PPOs' emphasis on preventive care, including coverage of routine physical exams and encouragement of mental health screenings that can identify individuals at risk for the mental illnesses that often precede suicide attempts.

Other HMO benefits that may help reduce the risk of suicide among members include prescription coverage, which significantly reduces the potentially prohibitive costs of medications that can treat psychiatric disorders and, in some cases, reduce suicide risk; provision of, or a requirement for, emergency coverage; a system for referral to specialists (although access may be limited); and systematic educational initiatives offered to providers. Some HMOs and PPOs have specifically offered training for their providers in the recognition of suicidal patients and the treatment of depression. One quality improvement intervention at a managed behavioral health care company led to an improvement in suicide risk assessment (Brown et al., 2003).

What is the actual outcome of this interplay of benefits and restrictions that may affect patients' vulnerability to suicide? Few studies have attempted to approach this difficult question. Related research, however, has examined the quality with which managed care organizations assess and treat patients with depression, a group particularly vulnerable to suicide (Halpern-Felsher et al., 2000). Wells and colleagues (1999) suggested that the rate and quality of care for depression were merely low to moderate in observed managed care primary practices, particularly for patients with severe but silent symptoms like suicidal ideation. These findings become all the more significant in light of the observation that half of adults who committed suicide saw their primary care physicians shortly before the act (Andersen et al., 2000; Diekstra and van Egmond, 1989). 

The practices of managed care systems, however, must be compared with those of unmanaged care settings, where there is much variability of quality. A survey of pediatricians in a single HMO by Halpern-Felsher and colleagues (2000), for example, found that preventive services were provided to adolescent patients at rates below the HMO's recommendations, yet above the rates measured in other practice settings. The authors found that improvement was needed in the areas of preventive care that contribute most to adolescent mortality, including depression and suicide assessment, for which, respectively, only 46% and 35% of practitioners screened.

Provider education offered by HMOs and PPOs aims to reduce treatment variations, cut costs and standardize quality. Materials sponsored by managed care companies, however, are not uniformly welcomed by providers. Educational lessons, packaged as practice enhancements and/or evidence-based practice guidelines, are seen by some clinicians as tools that attempt to restrict practice options and discourage independence and creativity. 

In a randomized trial of the effects of guideline dissemination, Azocar et al. (2003) found that the dissemination efforts of a managed behavioral health care organization failed to improve the adherence of mental health care clinicians to practice guidelines. Sharar and colleagues (in press), furthermore, surveyed executives and managers at managed behavioral health care organizations and concluded that the guidelines they prepare may lack objectivity and be subject to political pressures that affect their development.

Limitations on specialty referrals, sessions and medications all threaten to curtail the ability of the psychiatrist to care for the suicidal patient. Indeed, many clinicians who treat adolescents and who participated in a service provider survey perceived that not all of their desired psychiatric services were offered within the network (Yanos et al., 2003). Van Voorhees et al. (2003), in a questionnaire sent to primary care physicians, reported that a higher level of managed care market penetration was associated with lower perceived access to mental health services. In a review of the Massachusetts Behavioral Health program, then in its seventh year, the program was deemed an overall success, but not without its shortcomings (Beinecke and Vore, 2002). Providers complained of limited access, especially to inpatient and community residential programs, and were also worried about alarmingly short hospital and residential stays. Furthermore, the report cited a lack of coordination among state agencies, as well as lower than expected levels of integrated care. The latter was seen as a result of low or no reimbursement for collateral contacts (Beinecke and Vore, 2002). Sadly, all three reports suggest that managed care influences providers' perceived access to mental health care specialty providers--clinicians who should be made especially accessible in addressing a suicidal patient's crisis.

Patients with especially acute and intense risk for suicidal behavior are sometimes most safely and effectively cared for in inpatient settings, so managed care restrictions on access to inpatient care is perceived by clinicians as a particular concern. Some treatment systems that treat large numbers of patients insured by managed care systems have developed alternative outpatient programs to meet the needs of suicidal patients. Harney (2001) provided guidelines for clinicians trying to provide such alternatives to hospitalization and reported that one of the benefits of the managed care revolution has been the development and expansion of good outpatient services for suicidal patients. The benefit of such programs may provide some explanation for the observation that a 56% reduction in mandated state transfers to a psychiatric hospital in Fulton County, Ga., was not accompanied by any increase in the suicide rate (Garlow et al., 2002).

Administrative paperwork, used to justify payments and continued treatment, is an important aspect of managed care systems that impacts clinicians' treatment of suicidal patients. The added workload allows less time to spend with patients and strains the clinicians' ability to care for high-need patients, especially those who are suicidal (Beinecke and Vore, 2002; Yanos et al., 2003). The additional time-consuming task of bargaining with utilization managers for resources and treatment authorization adds significant time to the providers' job, often requiring unreimbursed additional hours of work.

In light of the ubiquitous presence of managed care in our current health care environment, some recommendations can be made for clinicians treating suicidal patients.

First, clinicians assessing new patients must not curtail the suicide evaluation process, including history of present illness, examination of mental state, and pertinent past and family history (Maltsberger, 1988). While time pressures imposed by managed care may tempt the practitioners to hurry the evaluation process and cut corners, the compressed treatment periods imposed by HMOs make accurate diagnosis--especially of suicide risk, substance abuse or psychosis--even more critical. At follow-up visits, clinicians must remain ready to explore changes in safety or suicide risk if warranted by any changes in a patient's circumstances, behavior or mental status.

Second, clinicians must make use of specialty services when necessary, including hospitals, partial hospitals and respite alternatives. While the least restrictive environment for effective care is preferred, there are times when a secure environment such as an inpatient unit remains necessary for ensuring a patient's safety.

Third, clinicians must know and remember that it is their responsibility to appeal the HMO's restrictions on treatment when these intolerably threaten a patient's safety. The legal onus for accurately assessing safety, suicide risk and the likelihood of other untoward outcomes, and planning appropriate care, lies squarely on the physician and not on the managed care company (Hall et al., 1999; Keyes, 2001).When there is a dispute between clinician and insurer, the clinician should not submit to a treatment plan that is unsafe. 

In managed care systems that restrict psychiatrist visits to brief pharmacotherapy sessions or cut pharmacy costs by reducing the access barriers to large quantities of potentially toxic pharmaceuticals, clinicians should consider the suggestions listed in the Table. 

Fourth, it is important to maintain patient safety and avoid overdosing by prescribing only the amount of medication appropriate. The cost-savings offered by 90-day mail-in prescriptions may be tempting to the patient and their managed care company, but are dangerous when careful monitoring of adherence is necessary. Likewise, changes in medical health and changes in the use of concurrent drugs or prescribed medications may alter the effects or safety of the psychopharmacology, making shorter-term prescriptions a better choice.

Fifth, in larger psychiatric settings, where mental health care is provided by a team, communication and documentation are paramount. Both from a legal and patient health perspective, it is required that team members make contemporaneous notes and also read the notes made by others. Similarly, recording the suicide risk assessment, documentation of family members' concerns and rationale for significant clinical decisions are all advisable. Keyes (2001) reminded clinicians that documentation does not remove the need for oral communication. Caregivers should speak to appropriate team members about serious concerns and document themappropriately.

Managed care has penetrated deeply into our health care system and is likely to remain with us for the foreseeable future. Therefore, we recommend that clinicians remain alert to the risks inherent in managed care while learning to make use of its potential resources. Further studies are needed to truly assess managed care's impact on suicide, and such studies must address the relative advantages and disadvantages presented by managed care in comparison to other health care payment systems.

 Andersen UA, Andersen M, Rosholm JU, Gram LF (2000), Contacts to the health care system prior to suicide: a comprehensive analysis using registers for general and psychiatric hospital admissions, contacts to general practitioners and practicing specialists and drug prescriptions. Acta Psychiatr Scand 102(2):126-134.
 

 Azocar F, Cuffel B, Goldman W, McCarter L (2003), The impact of evidence-based guideline dissemination for the assessment and treatment of major depression in a managed behavioral health care organization. J Behav Health Serv Res 30(1):109-118.
 

 Beinecke RH, Vore N (2002), Provider assessments of the Massachusetts Behavioral Health Program: year 7. Adm Policy Ment Health 29(6):519-524.
 

 Brown GS, Jones ER, Betts E, Wu J (2003), Improving suicide risk assessment in a managed-care environment. Crisis 24(2):49-55.
 

 CDC (2002), National Center for Health Statistics: Fast Stats: Suicide. Available at: www.cdc.gov/nchs/fastats/suicide.htm. Accessed Sept. 10, 2003. 
 

 Diekstra RF, van Egmond M (1989), Suicide and attempted suicide in general practice, 1979-1986. Acta Psychiatr Scand 79(3):268-275.
 

 Employee Benefit Research Institute (1999), Health Confidence Survey: Managed Care Confusion. Available at: www.ebri.org/hcs/1999/fact8-mancareconfus.pdf. Accessed Sept. 10, 2003.
 

 Garlow SJ, D'Orio B, Purselle DC (2002), The relationship of restrictions on state hospitalization and suicides among emergency psychiatric patients. Psychiatr Serv 53(10):1297-1300.
 

 Hall RC, Platt DE, Hall RC (1999), Suicide risk assessment: a review of risk factors for suicide in 100 patients who made severe suicide attempts. Evaluation of suicide risk in a time of managed care. Psychosomatics 40(1):18-27.
 

 Halpern-Felsher BL, Ozer EM, Millstein SG et al. (2000), Preventive services in a health maintenance organization: how well do pediatricians screen and educate adolescent patients? Arch Pediatr Adolesc Med 154(2):173-179.
 

 Harney PA (2001), Managed care, brief hospitalization, and alternatives to hospitalization in the care of suicidal patients. In: Treatment of Suicidal Patients in Managed Care, Ellison JM, ed. Washington, D.C.: American Psychiatric Press Inc., pp39-58.
 

 Keyes C (2001), Risk management issues for clinicians who treat suicidal patients in managed systems. In: Treatment of Suicidal Patients in Managed Care, Ellison JM, ed. Washington, D.C.: American Psychiatric Press Inc., pp153-172.
 

 Maltsberger JT (1988), Suicide danger: clinical estimation and decision. Suicide Life Threat Behav 18(1):47-54.
 

 Sharar D, Huff S et al. (in press), Organizational Ethics in Managed Behavioral Health care: Perspectives from Executives and Managers. Critical Issues in Human Sciences and Services.
 

 Van Voorhees BW, Wang NY, Ford DE (2003), Managed care organizational complexity and access to high-quality mental health services: perspective of U.S. primary care physicians. Gen Hosp Psychiatry 25(3):149-157.
 

 Wells KB, Schoenbaum M, Unutzer J et al. (1999), Quality of care for primary care patients with depression in managed care. Arch Fam Med 8(6):529-536.
 

 Yanos PT, Garcia CI, Hansell S et al. (2003), Managed care and clinical decision-making in child and adolescent behavioral health: provider perceptions. Adm Policy Ment Health 30(4):307-321.

The current climate of managed care has dramatically changed how psychiatrists deal with the issue of suicide. What should clinicians know, both about the safety and welfare of their patients and to protect themselves legally, when dealing with managed care companies in cases of potential suicidality?

Managed Care's Role in Caring for Suicidal Patients

Patients suffering from depressive disorders, particularly those with a history of suicide attempt, are at increased risk for future suicidal acts. Neurobiological studies of suicidal behavior have investigated anomalies that distinguish suicide attempters and completers from individuals who are depressed but do not engage in any suicidal behavior. To aid in the development of a predictive model in which both biological measures and clinical instruments are used to identify those at risk for future suicidal acts, studies have focused on biological correlates of behavioral and other factors identified by clinical studies as indicative of higher risk for suicidal behavior, such as aggression/impulsivity.

Neuroendocrine challenge and cerebrospinal fluid (CSF) studies suggest that suicide attempters have decreased function in the serotonin system (Malone et al., 1996; Siever et al., 1984; Virkkunen et al., 1989). Among individuals with depression, high-lethality suicide attempts are associated with even lower serotonergic function (Malone et al., 1996; Mann and Malone, 1997). Neuroendocrine challenges and CSF measures are, however, unable to provide specific information about the anatomical location of abnormality. So far, it is known from studies mapping postmortem serotonin receptor binding that cortical serotonergic abnormalities associated with suicide are localized to the ventral prefrontal cortex (PFC) region of the brain (Arango et al., 1997). Positron emission tomography (PET) studies offer a distinct advantage over previous methodologies, allowing for more precise in vivo identification and study of the activity of brain regions that differ in those who have survived a suicide attempt of high lethality, compared to those surviving a low-lethality attempt. Given the findings of CSF and neuroendocrine studies with respect to differences in serotonin levels between high- and low-lethality attempters, PET studies of high-lethality attempters would be expected to reveal pronounced differences.

In a recent study, my colleagues and I examined regional brain glucose metabolism with placebo and after administration of fenfluramine (Pondimin), a serotonin-releasing drug, in order to discern regional differences in glucose metabolism associated with serotonergic activity between high- and low-lethality depressed suicide attempters (Oquendo et al., 2003). Changes in metabolism, which include both increases and decreases, reflect changes in neuronal activity, owing to the surge of serotonergic activity caused by fenfluramine. The changes can occur in both directions because serotonin has both inhibitory and indirect excitatory effects in different brain regions. These differences in response by different brain regions due to serotonergic activity can be visualized with PET.

Our PET study of the regional serotonergic function in patients who are depressed and have a history of high-lethality suicide attempts compared to patients who are depressed and have a history of low-lethality suicide attempts revealed differences in brain activity between the two groups (Oquendo et al., 2003). High-lethality suicide attempters showed less activity in the ventral, medial and lateral PFC, compared to low-lethality suicide attempters, indicating a relative hypofunction in the PFC in high-lethality attempters. There were two specific regions of interest (ROIs) where differences were identified between low- and high-lethality attempters. One was in the anterior cingulate and the medial frontal gyri (ROI #1) and the second in the anterior cingulate and right superior frontal gyri (ROI #2). The first ROI was located bilaterally in the anterior cingulate and medial frontal gyrus (BA 32 and 8). The second ROI was located in the right midcingulate and superior frontal gyri (BA 24 and 6).

One way to further understand the meaning of these neurobiological differences between the two groups is to assess the relationship between the regions showing differences in glucose metabolism and clinical measures. In our study, more impulsive depressed patients who made low-lethality attempts showed higher activity in the two ROIs of the PFC compared to the less impulsive high-lethality attempters (Figure 1 and Figure 2) (Oquendo et al., 2003). (

Due to copyright concerns, these figures cannot be reproduced online. Please see p50 of the print edition--Ed.

) This higher activity was also associated with greater impulsivity and lower age. Age and impulsivity were negatively correlated, suggesting possibly that age influences suicide lethality via an age-related decrease in PFC activity that reduced impulsivity. In contrast, suicide intent correlated inversely with ROI #1, but not ROI #2 or age, suggesting that the effect of suicidal intent on lethality may be mediated by a more restricted area of the PFC and be independent of age and impulsivity.

Lower activity in the PFC was associated with lower lifetime impulsivity, higher suicidal intent (planning) and high-lethality attempts. Further, we found that high-lethality attempters had later onset of depression and suicidal behavior but not a different number of episodes. This suggests that these people may have different biological and clinical characteristics (such as less impulsivity and more intent) and, consequently, a higher risk for high-lethality suicide behavior than patients with an earlier onset. In our study, suicide intent and impulsivity correlated independently with suicide-attempt lethality (Oquendo et al., 2003). It has been reported that low-lethality attempters are more impulsive than high-lethality attempters (Baca-Garcia et al., 2001; Mann and Malone, 1997). In addition, impulsivity declines with age and more planful suicidal acts occur with increasing age (Conwell et al., 1998).

A negative correlation between lethality and serotonin receptor activity PFC is consistent with our hypothesis that PFC function has a role in suicidal behavior (Mann et al., 1999). Postmortem studies have shown that alterations in serotonin transporter (SERT) binding and 5-HT1A binding in suicide victims compared with psychiatric controls are localized to Brodmann areas 11, 12, 45, 46 for SERT and more ventrolateral PFC areas for 5-HT1A, respectively, in the ventral PFC (Arango et al., 2002, 1997). Lesion studies have linked the ventral and medial PFC to behavioral inhibition, which may be partly mediated by serotonin input into these brain regions (Godefroy et al., 1999).

Our in vivo PET study found abnormalities in PFC (Brodmann areas 6, 8, 9, 24, 32) that are close, but not identical, to the regions with reported postmortem receptor changes. Further in vivo studies measuring specific serotonin receptor binding in PFC are needed to determine whether the serotonergic hypofunction we have described in high-lethality attempters is associated with the same receptor changes as those found in suicide victims.

Positron emission tomography studies may eventually offer a means to measure neurobiological correlates of different types of suicidal behavior, thereby allowing the identification of individuals at more acute risk of suicide completion. The differences we found in the PFC of high- and low-lethality attempters were associated with differences in impulsivity. It may be that the presence of impulsivity and/or decision-making difficulties, well-documented functions of the PFC, affect planning of suicidal behavior and explain the tendency toward high- or low-lethality attempts. Positron emission tomography studies, undertaken in conjunction with clinical studies, can thus offer a more comprehensive picture of the traits and states that precipitate suicidal activity of differing levels of lethality and can help scientists elaborate the meaning of neurobiological findings.

 Arango V, Underwood MD, Mann JJ (1997), Postmortem findings in suicide victims. Implications for in vivo imaging studies. Ann N Y Acad Sci 836:269-287.
 

 Arango V, Underwood MD, Mann JJ (2002), Serotonin brain circuits involved in major depression and suicide. Prog Brain Res 136:443-453.
 

 Baca-Garcia E, Diaz-Sastre C, Basurte E et al. (2001), A prospective study of the paradoxical relationship between impulsivity and lethality of suicide attempts. J Clin Psychiatry 62(7):560-564.
 

 Conwell Y, Duberstein PR, Cox C et al. (1998), Age differences in behaviors leading to completed suicide. Am J Geriatr Psychiatry 6(2):122-126.
 

 Godefroy O, Cabaret M, Petit-Chenal V et al. (1999), Control functions of the frontal lobes. Modularity of the central-supervisory system? Cortex 35(1):1-20.
 

 Malone KM, Corbitt EM, Li S, Mann JJ (1996), Prolactin response to fenfluramine and suicide attempt lethality in major depression. Br J Psychiatry 168(3):324-329.
 

 Mann JJ, Malone KM (1997), Cerebrospinal fluid amines and higher-lethality suicide attempts in depressed inpatients. Biol Psychiatry 41(2):162-171.
 

 Mann JJ, Oquendo MA, Underwood MD, Arango V (1999), The neurobiology of suicide risk: a review for the clinician. J Clin Psychiatry 60(suppl 2):7-11 [discussions, pp18-20, 113-116].
 

 Oquendo MA, Placidi GP, Malone KM et al. (2003), Positron emission tomography of regional brain metabolic responses to a serotonergic challenge and lethality of suicide attempts in major depression. Arch Gen Psychiatry 60(1):14-22.
 

 Siever LJ, Murphy DL, Slater S et al. (1984), Plasma prolactin changes following fenfluramine in depressed patients compared to controls: an evaluation of central serotonergic responsivity in depression. Life Sci 34(11):1029-1039.
 

 Virkkunen M, De Jong J, Bartko J, Linnoila M (1989), Psychobiological concomitants of history of suicide attempts among violent offenders and impulsive fire setters. [Published erratum: Arch Gen Psychiatry 46(10):913.] Arch Gen Psychiatry 46(7):604-606.

Can PET scans show differences in suicide risk among depressed patients? What are the risk factors for high-lethality suicide attempts versus low-lethality attempts?

Identifying Neurobiological Correlates of Suicide Risk in Depression

Borderline personality disorder (BPD) is characterized by unstable relationships, self-image and affect, as well as impulsivity, that begin by early adulthood. Patients with BPD make efforts to avoid abandonment. They often exhibit recurrent suicidal and/or self-injuring behavior, feelings of emptiness, intense anger, and/or disassociation or paranoia. Suicidal and non-suicidal self-injury are extremely common in BPD. Zanarini et al. (1990) found that over 70% of patients with BPD had self-injured or made suicide attempts, as compared to only 17.5% of patients with other personality disorders. Nevertheless, clinicians consistently misunderstand and mistreat this aspect of BPD. 

There has been considerable controversy surrounding the diagnosis of BPD, ranging from a sense that the term itself is misleading and frightening, to the fact that the diagnosis is often made in an inconsistent manner (Davis et al., 1993), to a lack of clarity about whether the diagnosis should be Axis I or Axis II (Coid, 1993; Kjellander et al., 1998). Furthermore, these patients are often excluded from clinical trials due to perceived risk. 

More important, however, is the fact that suicidal self-injurious behavior is usually understood within the context of major depressive disorder, while the phenomenology of this behavior within BPD is quite different. In addition, self-injurious non-suicidal behavior is often understood by clinicians to be synonymous with suicidal behavior, but again, it may be distinguished separately, particularly within the context of BPD. It is possible that, although self-injury and suicidal behavior are distinct, they may serve similar functions. This phenomenon has important implications for treatment recommendations. 

Suicidality in BPD Versus Major Depression 

In traditional conceptualizations developed from suicidality seen as an aspect of major depression, suicidal behavior is usually understood to be a response to a deep sense of despair and desire for death, which, if unsuccessful, typically results in a persistence of depression. Vegetative signs are prominent, and the suicidal feelings subside when the major depression is successfully treated with antidepressants, psychotherapy or their combination. In contrast, suicidality in the context of BPD seems to be more episodic and transient in nature, and patients often report feeling better afterward. 

Risk factors for suicidal behavior in BPD show some differences, as well as similarities, with individuals who are suicidal in the context of major depression. Brodsky et al. (1995) noted that dissociation, particularly in patients with BPD, is correlated with self-mutilation. Studies of comorbidity have produced unclear results. Pope et al. (1983) found that a large number of patients with BPD also display a major affective disorder, and Kelly et al. (2000) found that patients with BPD alone and/or patients with BPD plus major depression are more likely to have attempted suicide than patients with major depression alone. In contrast, Hampton (1997) stated that the completion of suicide in patients with BPD is often unrelated to a comorbid mood disorder (Mehlum et al., 1994) and to degree of suicidal ideation (Sabo et al., 1995).

Suicidal behavior is usually defined as a self-destructive behavior with the intent to die. Thus, there must be both an act and intent to die for a behavior to be considered suicidal. Non-suicidal self-harm generally implies self-destructive behavior with no intent to die and is often seen as being precipitated by distress, often interpersonal in nature, or as an expression of frustration and anger with oneself. It usually involves feelings of distraction and absorption in the act, anger, numbing, tension reduction, and relief, followed by both a sense of affect regulation and self-deprecation. Confusion in the field regarding the definition of the term parasuicide can lead to a misunderstanding of the differences in function and danger of suicidal and non-suicidal self-injury. Parasuicide, or false suicide, groups together all forms of self-harm that do not result in death--both suicide attempts and non-suicidal self-injury. Many people who engage in non-suicidal self-harm are at risk for suicidal behavior. 

We propose that non-suicidal self-injury in BPD uniquely resides on a spectrum phenomenologically with suicidality. Perhaps the most distinguishing factor, as pointed out by Linehan (1993), is that self-injury may help patients to regulate their emotions--an area with which they have tremendous difficulty. The act itself tends to restore a sense of emotional equilibrium and reduces an internal state of turmoil and tension. One striking aspect is the fact that physical pain is sometimes absent or, conversely, may be experienced and welcomed, as validation of psychological pain and/or a means to reverse a sense of deadness. Patients often report feeling less upset following an episode. In other words, while the self-injury is borne out of a sense of distress, it has served its function and the patient's emotional state is improved. Biological findings pointing to relationships among impulsivity and suicidality support the notion that suicidality and self-mutilation, particularly within the context of BPD, may occur on a continuum (Oquendo and Mann, 2000; Stanley and Brodsky, in press).

It is crucial to recognize, however, that even if patients with BPD self-mutilate and attempt suicide for similar reasons, death may be the accidental and unfortunate result. Because patients with BPD try to kill themselves so often, clinicians often underestimate their intent to die. In fact, individuals with BPD who self-injure are twice as likely to commit suicide than others (Cowdry et al., 1985), and 9% of the 10% of outpatients who are diagnosed with BPD eventually commit suicide (Paris et al., 1987). Stanley et al. (2001) found that suicide attempters with cluster B personality disorders who self-mutilate die just as frequently but are often unaware of the lethality of their attempts, compared to patients with cluster B personality disorders who do not self-mutilate.

Treatment of Suicidal Behavior and Self-Injury 

While non-suicidal self-harm can result in death, it is more likely not to and, in fact, only occasionally leads to serious injury such as nerve damage. Yet, patients are often hospitalized on a psychiatric unit in the same way that they would be for a frank suicide attempt. In addition, while the intent is most often to alter the internal condition, as opposed to an external condition, clinicians and those in relationships with self-injurers experience this behavior as manipulative and controlling. It has been noted that self-injury can elicit quite strong countertransference reactions from therapists. 

Although there is clearly a biological component to this disorder, the results of pharmacologic interventions have been inconclusive. Different classes and types of medications are often used for different aspects of the behavior (e.g., sadness and affective instability, psychosis and impulsivity) (Hollander et al., 2001). 

One class of psychological intervention has been cognitive-behavioral therapy (CBT), of which there are a few models, e.g., Beck and Freeman (1990), cognitive-analytic therapy (CAT) developed by Wildgoose et al. (2001), and an increasingly well-known form of CBT called dialectical behavior therapy (DBT), developed by Linehan (1993) specifically for BPD. Dialectical behavior therapy is characterized by a dialectic between acceptance and change, a focus on skill acquisition and skill generalization, and a consultation-team meeting. In the psychoanalytic arena, there is controversy as to whether a confrontative, interpretative approach (e.g., Kernberg, 1975) or a supportive, empathic approach (e.g., Adler, 1985) is more effective. 

This paper addresses contemporary conceptual and treatment issues that come into play in understanding suicidal and self-injuring behavior in the context of BPD. Diagnostic issues and the phenomenology of self-injurious behavior are important to consider. Treatment approaches include pharmacologic interventions, psychotherapy and their combination. 

 Adler G (1985), Borderline Psychopathology and Its Treatment. New York: Aronson.
 

 Beck AT, Freeman A (1990), Cognitive Therapy of Personality Disorders. New York: The Guilford Press.
 

 Brodsky BS, Cloitre M, Dulit RA (1995), Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder. Am J Psychiatry 152(12):1788-1792 [see comment].
 

 Coid JW (1993), An affective syndrome in psychopaths with borderline personality disorder? Br J Psychiatry 162:641-650.
 

 Cowdry RW, Pickar D, Davies R (1985), Symptoms and EEG findings in the borderline syndrome. Int J Psychiatry Med 15(3):201-211.
 

 Davis RT, Blashfield RK, McElroy RA Jr (1993), Weighting criteria in the diagnosis of a personality disorder: a demonstration. J Abnorm Psychol 102(2):319-322.
 

 Hampton MC (1997), Dialectical behavior therapy in the treatment of persons with borderline personality disorder. Arch Psychiatr Nurs 11(2):96-101.
 

 Hollander E, Allen A, Lopez RP et al. (2001), A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 62(3):199-203.
 

 Kelly TM, Soloff PH, Lynch KG et al. (2000), Recent life events, social adjustment, and suicide attempts in patients with major depression and borderline personality disorder. J Personal Disord 14(4):316-326.
 

 Kernberg OF (1975), Borderline Conditions and Pathological Narcissism. New York: Aronson.
 

 Kjellander C, Bongar B, King A (1998), Suicidality in borderline personality disorder. Crisis 19(3):125-135.
 

 Linehan MM (1993), Cognitive-Behavioral Treatment for Borderline Personality Disorder: The Dialectics of Effective Treatment. New York: The Guilford Press.
 

 Mehlum L, Friis S, Vaglum P, Karterud S (1994), A longitudinal pattern of suicidal behavior in borderline disorder: a prospective follow-up study. Acta Psychiatr Scand 90(2):124-130.
 

 Oquendo MA, Mann JJ (2000), The biology of impulsivity and suicidality. Psychiatr Clin North Am 23(1):11-25.
 

 Paris J, Brown R, Nowlis D (1987), Long-term follow-up of borderline patients in a general hospital. Compr Psychiatry 28(6):530-535.
 

 Pope HG Jr, Jonas JM, Hudson JI et al. (1983), The validity of DSM-III borderline personality disorder. A phenomologic, family history, treatment response, and long-term follow-up study. Arch Gen Psychiatry 40(1):23-30.
 

 Sabo AN, Gunderson JG, Najavits LM et al. (1995), Changes in self-destructiveness of borderline patients in psychotherapy. A prospective follow-up. J Nerv Ment Dis 183(6):370-376.
 

 Stanley B, Brodsky B (in press), Suicidal and self-injurious behavior in borderline personality disorder: the self-regulation model. In: Borderline Personality Disorder Perspectives: From Professional to Family Member, Hoffman P, ed. Washington, D.C.: American Psychiatric Press Inc.
 

 Stanley B, Gameroff MJ, Michalsen V, Mann JJ (2001), Are suicide attempters who self-mutilate a unique population? Am J Psychiatry 158(3):427-432.
 

 Wildgoose A, Clarke S, Waller G (2001), Treating personality fragmentation and dissociation in borderline personality disorder: a pilot study of the impact of cognitive analytic therapy. Br J Med Psychol 74(pt 1):47-55.
 

 Zanarini MC, Gunderson JG, Frankenburg FR, Chauncey DL (1990), Discriminating borderline personality from other axis II disorders. Am J Psychiatry 147(2):161-167.

Unlike other forms of self-injury, suicidal self-injury has special meaning, particularly in the context of borderline personality disorder. How is suicidal self-injury differentiated from non-suicidal self-injury in these patients, and how can their behavior be properly assessed and treated?

Suicidal Self-Injurious Behavior in People With BPD

Assessment and treatment of suicidal patients is one of the most difficult and anxiety-provoking tasks for mental health care professionals. In the case of elderly patients who may often talk about death and dying, assessing suicide risk is even more challenging.

Epidemiological data may help to understand risk and protective factors but they cannot guide the evaluation of individual patients. Suicide rates vary greatly with age, gender and ethnicity. The elderly population has the highest suicide rates in almost all countries in the world where data are available. Some countries follow the Hungarian pattern (i.e., suicide rate increases with age in both genders), while others show the U.S. pattern (i.e., suicide rate increases with age only in men). The elderly (65 and over) made up 12.4% of the U.S. population in 2001 while they represented 17.6% of suicides (McIntosh, 2003). Men accounted for about four out of five completed suicides in the 65 and older age group over the past two decades. This is partly explained by the fact that men are more likely to use more lethal methods of suicide. Seventy-six percent of men and 33% of women who completed suicide used firearms, while 3% of men and 33% of women who completed suicide overdosed on medications (McIntosh, 2003).

The suicide rate of white, Chinese-American, Japanese-American and Filipino-American men increases with age. In comparison, the middle-aged group of African-American, Hispanic, Native American and Alaskan Native men have the highest suicide rate. As a consequence of the gender and ethnic differences in the United States, the suicide rate by age 80 ranges from 3/100,000 among African-American women to 60/100,000 among white men (McIntosh, 2003). 

Investigating risk factors and protective factors across ethnic groups may help to understand the unexplained striking differences in suicide rates.

So far, identified risk factors for suicide attempts and completed suicides in late-life include past history of suicidal behavior, depression, substance abuse, hopelessness and certain personality characteristics (e.g., rigidity and lack of openness to new experience) (Duberstein et al., 1994). 

The role of medical comorbidity is controversial, as medical illness in general is frequent among the elderly; previous non-controlled studies may have overestimated its role. One case-controlled study from New Zealand failed to find differences in physical illness (Beautrais, 2002), while a Swedish study found that visual impairment and neurological and malignant disease were associated with suicide risk (Waern et al., 2002a). Interestingly, this association was only true for men. This finding needs to be replicated prior to further interpretation due to the small sample size of women. 

A preliminary unpublished data from a Hungarian psychological autopsy study conducted by my colleagues and me indicated that fear of serious physical illness plays an important role in late-life suicide. In addition to anticipatory anxiety, change in functional status and pain may be better correlates of suicidality than physical illness itself. 

Physical illness may contribute to suicidality in another way. Waern and colleagues (1999) found that physicians were less likely to discuss suicidal feelings with patients in poor physical health. If depression is detected in an elderly patient, suicidal feelings should also be evaluated.

The most robust predictor of completed suicide is a past history of suicide attempt. According to data from middle-aged groups, up to 40% of individuals who eventually committed suicide made a prior suicide attempt (Rubenowitz et al., 2001). In addition, lethality and suicide intent increased in those who repeatedly attempted suicide. Although the attempt to completion ratio is much smaller in the elderly than in younger age groups (4:1 versus 10:1 in the general population), 56% of elderly women and 30% of elderly men who committed suicide had a prior suicide attempt. During their final year of life, suicide attempts were made by 20% of the elderly who died by suicide (15% males, 28% females). Suicide attempts by the elderly considered to be "failed suicides"--as these attempts are often long-planned--involve highly lethal methods that, in addition to the fact that older patients are medically frail and frequently live alone, increase the probability of a fatal outcome. The rare but highly lethal attempts and the fact that 70% of elderly men who die by suicide did not have a prior suicide attempt have two implications for clinical practice: 1) elderly patients who attempt suicide in late-life are at a very high risk for completed suicide, 2) the suicide risk of older men may be more difficult to detect than the risk of older women as they are less likely to have had a history of previous attempts. 

Depression is the most common diagnosis in elderly suicide attempters and suicide completers. The association of mental disorders with risk for completed suicide in the elderly is shown in the Table (Waern et al., 2002b). (

Due to copyright concerns, this table cannot be reprinted online. Please see p52 of the print edition--Ed.

) In the only U.S. case-controlled psychological autopsy study, 71.4% of the elderly who died by suicide suffered from mood disorders and 35.7% had a substance use disorder (Conwell et al., 1996). 

When patients report sad mood or loss of interest in previously pleasurable activities, appear to be depressed, or have an increase in substance abuse, questioning patients if they have been feeling sad to the point that they were thinking about death or dying is helpful for evaluation. Direct questions about suicidal ideation should also follow. Patients should also be questioned if family members report changes in mood.

High symptomatic levels of depression, hopelessness, complicated grief and anxiety, and lower levels of perceived support are associated with suicidal ideation (Szanto et al., 1998, 1997). A secondary analysis of 395 elderly subjects treated for a current major depressive episode found that, at the beginning of treatment, 77.5% of patients reported suicidal ideation, thoughts of death or feelings that life is empty (Szanto et al., 2003). By week 12, suicidal ideation had resolved in all treated patients although 4.6% still reported thoughts of death. While suicidal ideation resolved early in treatment, many of the patients who reported suicidal ideation at the beginning of treatment had recurrent thoughts of death that lasted for weeks. Thoughts of death persisted in 8% of the participants up to 12 weeks. 

Patients who had suicidal ideation or had recurrent thoughts of death had poorer treatment response than non-suicidal patients. These moderate- to high-risk patients had a median time to response of six and five weeks, respectively, compared to low-risk patients with a median time to response of three weeks. Patients received antidepressant treatment with a tricyclic antidepressant (nortriptyline [Aventyl, Pamelor]) or a selective serotonin reuptake inhibitor (paroxetine [Paxil]) in combination with weekly interpersonal psychotherapy. Rates of remission were significantly lower in the moderate- to high-risk patients than the low-risk patients. These findings show that it is crucial to develop a more focused suicide intervention that will target clinical characteristics that are associated with suicidality. 

It is striking that another study at the other end of the life span found similar results. In a clinical trial, the impact of suicidality on treatment course and outcome of adolescents with depression was studied (Barbe et al., in press). The results showed that adolescents who are suicidal and depressed had a higher dropout rate and were more likely to be depressed at the end of treatment. The relationship between suicidality and treatment response was mediated by severity of depression and hopelessness at intake. 

Suicide-specific treatments that target not only depression, but also hopelessness, anxiety and substance use are needed. Treatment should involve a significant other whenever possible to help motivate the patient to remain in treatment, comply with pharmacotherapy and psychotherapy, and abstain from alcohol. When working with suicide attempters, clinicians should inquire whether there was suicidal communication before the suicide attempt. In a non-blaming manner, clinicians should explore how the significant other felt about this and how they reacted to this communication. It is frequent for significant others to deliberately ignore suicidal communication and this may be a significant factor that further increases a sense of isolation and despair in a suicidal elderly person. 

Barbe RP, Bridge J, Birmaher B et al. (in press), Suicidiality and its relationship to treatment outcome in depressed adolescents. Suicide Life Threat Behav. 
 

Beautrais AL (2002), A case control study of suicide and attempted suicide in older adults. Suicide Life Threat Behav 32(1):1-9. 
 

Conwell Y, Duberstein PR, Cox C et al. (1996), Relationships of age and axis I diagnoses in victims of completed suicide: a psychological autopsy study. Am J Psychiatry 153(8):1001-1008.
 

Duberstein PR, Conwell Y, Caine ED (1994), Age differences in the personality characteristics of suicide completers: preliminary findings from a psychological autopsy study. Psychiatry 57(3):213-224.
 

Assessing and treating suicidal behavior in the elderly can be difficult. What are the risk factors and how can this population best be treated?

Psychiatric Times Vol 20 No 13

Employment Programs Help Patients With Mental Illnesses Succeed

On the Hunt for Breakthrough Therapies

Managed Care's Role in Caring for Suicidal Patients

Identifying Neurobiological Correlates of Suicide Risk in Depression

Suicidal Self-Injurious Behavior in People With BPD

Suicidal Behavior in the Elderly

Suicide Risk: Assessing the Unpredictable

The Relationship of Suicide Risk to Family History of Suicide and Psychiatric Disorders