The prevention of recurrent suicidal acts.

Abstract

1 There have been few controlled prospective investigations into the prevention of suicidal behaviour and by and large they have failed to demonstrate the efficacy of social work, psychotherapy or psychiatric treatment. 2 A group of 58 high‐risk patients with multiple episodes of suicidal behaviour was treated with mianserin 30 mg at night or placebo in a six month double‐blind trial of the efficacy of an antidepressant in reducing suicidal behaviour. 3 Patients were screened for depression, schizophrenia and organic disease. Patients were diagnosed as suffering from personality disorders according to DSM‐III criteria mainly borderline or histrionic. 4 There was no significant difference in outcome between the mianserin and placebo treated group at any point in the six month study. 5 An item analysis of the MADRS showed that at entry the item ‘reduced appetite’ predicted subsequent suicidal attempt. The total MADRS score did not predict further suicidal acts at entry but was highly significant at four weeks. At four weeks the items ‘reduced sleep’ and ‘reduced appetite’ were highly significant predictors of further suicidal acts and the items ‘lassitude’, ‘suicidal thoughts’, ‘inability to feel’ and ‘pessimistic thoughts' were significant predictors.

Evidence-based pharmacotherapy for personality disorders

“…In addition, small sample sizes predominated, and most studies lasted f3 months. The few trials lasting o6 months suffered from high drop-out rates (Frankenburg & Zanarini, 2002 ;Zanarini & Frankenburg, 2001) or concomitant recruitment of subjects without BPD (Battaglia et al 1999 ;Montgomery et al 1983 ;Verkes et al 1998). Moreover, RCTs with BPD subjects appear to be prone to high placebo response rates (Lieb et al 2004 ;Salzman et al 1995), meaning that open-label trial data should be interpreted with caution.…”

“…Early studies employed a distinct nosology in characterizing subjects, some of whom actually had what might be called BPD today (Rifkin et al 1972). In studies on suicidal or parasuicidal subjects, the majority often have BPD (Battaglia et al 1999 ;Montgomery & Montgomery, 1982 ;Montgomery et al 1983 ;Verkes et al 1998). Early studies often included combinations of BPD and SPD subjects (Goldberg et al 1986 ;Serban & Siegel, 1984 ;Soloff et al 1986 c), and studies recruiting a range of all personality disorders ultimately include BPD as the most frequent diagnosis (Coccaro & Kavoussi, 1997 ;Hollander et al 2003).…”

“…Nevertheless, early research on TCAs for BPD proved disappointing (Montgomery et al 1983 ;Soloff et al 1989). Amitryptiline has been associated with paradoxical increases in suicidality, paranoia, and behavioural dysregulation, attributed to 'generalized disinhibition of cognitive and affective controls ' (Soloff et al 1986a(Soloff et al , 1987.…”

Interventions to reduce repetition of deliberate self-harm

“…One such intervention is the provision of an emergency card with information on how to make privileged contact with psychiatric services as an alternative to DSH (Cotgrove et al, 1995;Evans et al, 1999Morgan et al, 1993. D isturbance of mood and poor impulse control are common amongst those who present following DSH and these observations have led to the evaluation of antidepressants and neuroleptics in preventing repetition of D SH (Hirsch et al, 1982;Montgomery et al, 1983). There is evidence to suggest that the serotonin system may play an important role in both suicide and DSH (A Ê sberg et al, 1976;Lester, 1995) and there has been a trial of paroxetine, a selective serotonin re-uptake inhibitor, in non-depressed individuals with a previous history of DSH (Verkes et al, 1998).…”

The concept and efficacy of the treatment of parasuicide.

“…This must be because of the potential lethality of the older generation antidepressants. However, Montgomery et al, 1983, this issue) have recently reported a comparison of nomifensine and placebo in 38 highrisk patients who had had three or more parasuicides, but their study excluded patients with depression (see Table 1). They found that 47% of significant difference between treatments which certainly bears further investigation as it is the only study to The mean GHQ and Hamilton Depression Scores for this group of 114 patients were 41 and 18, respectively (see Table 2) at the onset of the trial and 20 and seven respectively, at both six and 12 would not be considered a psychiatric case at six weeks, using the criterion of a score below 11 on the GHQ as established by Goldberg & Hillier (1972).…”