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Clinical and Research News
Comorbid Axis I–Axis II Disorders Increase Suicide Risk
Psychiatric News
Volume 38 Number 16 page 31-31

Suicide attempters who have comorbid psychiatric and personality disorders show marked differences from those who do not. And comorbidity of Axis I and Axis II disorders may contribute to significantly greater suicide risk, according to a study published in the August American Journal of Psychiatry.

Author Keith Hawton, D.Sc., and colleagues say poor problem-solving skills and low self-esteem are major characteristics that distinguish suicidal patients with comorbid disorders from those without them. These patients also show greater impulsivity and aggression—also known to be factors in suicide—but Hawton and colleagues say these may be secondary to the poor problem-solving skills and low self-esteem.

Hawton is in the department of psychiatry at the Centre for Suicide Research, University of Oxford, Warneford Hospital in England.

A representative sample of 111 patients who had attempted suicide was assessed for personality and other psychiatric disorders. The characteristics of patients with both types of disorder were compared with those of patients without comorbid disorders. A semistructured interview and standardized questionnaires were used to investigate patients’ background characteristics, circumstance of suicide attempts, and outcome after 12 to 20 months.

At intake 44 patients (49 percent) had comorbid personality and other psychiatric disorders. Compared with patients without comorbid disorders, more patients with comorbid disorders had made previous suicide attempts (84 percent versus 45 percent) and made repeated attempts during the follow-up period (51 percent versus 15 percent).

Patients with comorbid disorders were also more depressed and hopeless, reported more episodes of aggression, were more impulsive, and had lower self-esteem and problem-solving skills.

Hawton and colleagues reported that statistical analysis of the data indicates that the key factors distinguishing patients with and without comorbid disorders were lower self-esteem and poorer self-rated problem-solving skills.

"Such traits may be exacerbated by psychiatric disorders and increase the likelihood of a suicidal act when an individual is feeling hopeless because of depression or other disorders and is facing seemingly insurmountable problems," the authors stated.

"Other important factors, such as aggression, a factor known to be important in suicidal behavior, might be secondary to low self-esteem and frustration over difficulties in problem solving."

Treatment of comorbid patients at risk for suicide is a major clinical challenge. "It remains uncertain how best to influence the longer-term psychological characteristics of these individuals, which appear from the present study to include poor problem-solving skills and low self-esteem," the authors stated. "Psychological treatments include dialectical behavior therapy, which has promising results for female patients with borderline personality disorders. Mood stabilizers, selective serotonin reuptake inhibitor antidepressants, or low-dose neuroleptics may ameliorate some of the characteristics that contribute to risk."

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