Proceedings of the International Meeting “Suicide: Interplay of Genes and Environment”
2000; Hogrefe Verlag; Volume: 21; Issue: 4 Linguagem: Inglês
10.1027//0227-5910.21.4.189
ISSN2151-2396
Autores Tópico(s)Child Welfare and Adoption
ResumoHorizonsProceedings of the International Meeting “Suicide: Interplay of Genes and Environment”Anne Farmer and Andrej MarusicAnne FarmerSearch for more papers by this author and Andrej MarusicSearch for more papers by this authorPublished Online:September 01, 2006https://doi.org/10.1027//0227-5910.21.4.189PDFView Full Text ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMorecriCrisisThe Journal of Crisis Intervention and Suicide Prevention 0227-5910Hogrefe & Huber PublisherscriCrisisThe Journal of Crisis Intervention and Suicide Prevention 0227-5910Hogrefe & Huber PublisherscriCrisisThe Journal of Crisis Intervention and Suicide Prevention 0227-5910Hogrefe & Huber PublisherscriCrisisThe Journal of Crisis Intervention and Suicide Prevention 0227-5910Hogrefe & Huber PublisherscriCrisisThe Journal of Crisis Intervention and Suicide Prevention 0227-5910Hogrefe & Huber PublisherscriCrisisThe Journal of Crisis Intervention and Suicide Prevention 0227-5910Hogrefe & Huber PublisherscriCrisisThe Journal of Crisis Intervention and Suicide Prevention 0227-5910Hogrefe & Huber PublisherscriCrisisThe Journal of Crisis Intervention and Suicide Prevention 0227-5910Hogrefe & Huber PublisherscriCrisisThe Journal of Crisis Intervention and Suicide Prevention 0227-5910Hogrefe & Huber PublisherscriCrisisThe Journal of Crisis Intervention and Suicide Prevention 0227-5910Hogrefe & Huber Publisherscri_21_4_189_b2007-17316-001Horizons History and Regionality of Suicide Behavior in SloveniaAndrej Marusic12 1 SGDP Research Center, Institute of Psychiatry, London, UK 2 Institute of Public Health of Republic of Slovenia, Ljubljana, Slovenia 92000October 20002141891902000Hogrefe & Huber Publisherscri_21_4_190_a2007-17320-001Horizons Depression and Parasuicide in Refugee and Slovene AdolescentsVera Slodnjak3, Anica Kos3, William Yule4 3 Center for Psychosocial Help to Refugees, Ljubljana, Slovenia 4 Department of Psychology, Institute of Psychiatry, London, UK 92000October 20002141901902000Hogrefe & Huber Publisherscri_21_4_190_b2007-17319-001Horizons What Can Psychiatric Genetics Offer Suicidology?Peter McGuffin5 5 SGDP Research Center, Institute of Psychiatry, London, UK 92000October 20002141901912000Hogrefe & Huber Publisherscri_21_4_191_a2007-17321-001Horizons Serotonergic Genes and SuicidalityLisheng Du67, David Bakish67, Pavel D Hrdina67 6 Institute of Mental Health Research at Royal Ottawa Hospital, Ontario, Canada 7 University of Ottawa, Ontario, Canada 92000October 20002141911912000Hogrefe & Huber Publisherscri_21_4_191_b2007-17322-001Horizons A Sib-Pair Study of Suicide IdeationAnne Farmer8 8 SGDP Research Center, Institute of Psychiatry, London, UK 92000October 20002141911912000Hogrefe & Huber Publisherscri_21_4_192_a2007-17326-001Horizons A Stress-Diathesis Model of Suicidal BehaviorKees van Heeringen9 9 Unit for Suicide Research, Department of Psychiatry, University Hospital Gent, Belgium 92000October 20002141921922000Hogrefe & Huber Publisherscri_21_4_192_b2007-17325-001Horizons After DurkheimSimon Wessely10 10 Institute of Psychiatry, London, UK 92000October 20002141921932000Hogrefe & Huber Publisherscri_21_4_193_a2007-17324-001Horizons Attempted Suicide among Asians in the United KingdomDinesh Bhugra11 11 Institute of Psychiatry, London, UK 92000October 20002141931932000Hogrefe & Huber Publisherscri_21_4_193_b2007-17323-001Horizons Suicide in the Indian SubcontinentMurad M Khan12 12 Institute of Psychiatry, London, UK 92000October 20002141931932000Hogrefe & Huber Publisherscri_21_4_193_c2007-17327-001Horizons Evidence-Based Prevention Strategies of Suicide Behavior in the World and Possibilities of their Implementation in SloveniaClaire Henderson13, Marija Brecelj14, Paola Dazzan13, Mojca Dernovsek14, Oscar Meehan15, Rok Tavcar14 13 Institute of Psychiatry, London, UK 14 University Psychiatric Hospital Ljubljana, Slovenia 15 Hospital E. Mira y López — MEELAR SRL — Medicina Psicológica, Cordoba, Argentina 92000October 20002141931942000Hogrefe & Huber PublishersSlovenia is a small but geographically diverse European state having the Adriatic Sea, the Alps, and the Panonian Plain as its main features. Until 1918 Slovenia was a part of the Austrian-Hungarian Empire. In the years between the two World Wars, Slovenia was separated into a Western part, which was under Italian control, and an Eastern part, which together with the other South Slavic countries came to constitute Yugoslavia. Unfortunately, there exist data on suicide only for the Eastern part, where the suicide rate was 19.4/100,000 persons/year [Pirc & Pirc, 1937]. Since 1943 and for the next almost 50 years the two parts of Slovenia formed the North-Western Republic of the Yugoslav Federation. The severity of the Slovenian suicide problem escaped international attention, because overall Yugoslavia had a much lower suicide rate of approximately 16/100,000 persons/year. This was described as the “Yugoslav suicide paradox” [Milcinski & Mrevlje, 1990] because the Northern areas showed suicide rates ten times higher than the areas in the South. Most recently, the Slovenes won their independence after the short war and occupation by the Yugoslav army in 1991.The average suicide rate between 1985 and 1999 has been around 30/100,000 persons/year; the trend is stable with insignificant fluctuations despite significant political and socio-economical changes in these years. In addition, Slovene suicidal behavior differs from that found elsewhere in three ways. First, the most common method of suicide in Slovenia is hanging (about two-thirds of all suicide victims). Second, the Slovenes are at a higher risk of committing suicide than any other nationality group in Slovenia, including the Hungarian minority. This might come as a surprise since Hungary overall has a higher suicide rate than Slovenia. Finally and very important for further research, the range between the highest and the lowest regional suicide rate in Slovenia is almost as high (around 40) as the one between the highest and lowest rate countries (Lithuania and Albania) in Europe.The association between depression and traumatic experiences, stress, loss, and bereavement is well known from the literature. It was expected that Bosnian refugee adolescents who fled from war zones to Slovenia would develop a higher level of depression than their Slovene peers without war traumatic experiences.Two years after the beginning of the war in Bosnia 256 refugee students from the 8th grade of primary schools aged 14 to 15 years were assessed with CDI Children's Depression Inventory and compared with the sample of 195 Slovene students of the same age.Compared to their Slovene peers, the Bosnian refugees show significantly lower rates of depressive symptomotology despite very high rates of posttraumatic stress symptoms (as much as 70% have on the Impact of Event Scale score 30 and more). CDI scores of ≥18 indicating “possible” depressive disorder were found in 12% of refugees and 22% of Slovene adolescents. Slovene adolescents also showed significantly lower self-esteem and greater feelings of inadequacy in the academic field. In addition, they were more likely to have feelings of not being loved, and they more often expressed the wish to kill themselves. Refugees described more sadness, worry about the future, and about physical pains, but they do not show disturbances in psychosocial functioning—unlike their Slovene counterparts. Reassessment of the refugee sample 3 years later showed significant reduction in posttraumatic stress reactions without any increase in their rates of depressive symptoms.The results indicate that the association between traumatic experiences and depressive symptoms are not inevitable, and that other factors including culture influences should be taken into account.There is good evidence from recent studies that depression is familial, and that a substantial proportion of the variation in liability is explained by genes. Suicidal behavior, including completed suicide, also seems to cluster in families. First degree relatives of individuals who have committed suicide (included dizygotic twins) have a more than doubling of their risk, compared with the general population. For identical co-twins of suicides, the relative risk increases to about 11. Applying a simple structural equation model to the published data suggests a heritability for completed suicide of about 43% (95% confidence intervals 25–60). It is not known at present whether the genes predisposing to suicide are identical with those predisposing to affective disorder, but since only about half of those committing suicide have a diagnosis of depression, it seems unlikely that the overlap is incomplete. The mode of inheritance of suicidal behavior is likely to be complex, involving many genes, and there have already been some initial studies of allelic association with polymorphisms in candidate genes such as those involved in serotonergic transmission. Further progress is likely to come from candidate gene and linkage disequilibrium studies that are capable of detecting multiple genes of small effect.Several lines of evidence indicate that abnormalities in functioning of the central serotonergic system are involved in the pathogenesis of depressive illness and suicidal behavior. Studies have shown that the number of brain and platelet serotonin transporter binding sites are reduced in patients with depression and suicide victims, and that the density of 5–HT2A receptors is increased in brain regions of depressed suicide victims and in platelets of depressed suicidal patients. Since abnormalities in functioning of the central serotonergic system have been implicated in pathogenesis of suicidal behavior, several genes, such as tryptophan hydroxylase, 5-HT transporter, and 5-HT2A receptor, which code for proteins involved in regulating serotonergic neurotransmission, are major candidate genes for association studies in suicidal behavior. Recent studies by our group and by others have shown that genetic variations in the serotonin system related genes might be associated with suicidal ideation and completed suicide. We have shown that the 102 C allele in 5-HT2A receptor gene was significantly associated with suicidal ideation (χ2= 8.5, p< .005) in depressed patients. Patients with a 102 C/C genotype had a significantly higher mean HAMD item #3 score (indication of suicidal ideation) than T/C or T/T genotype patients. Our results suggest that the 102T/C polymorphism in 5-HT2A receptor gene is primarily associated with suicidal ideation in patients with major depression and not with depression itself. We also found that the 5-HT transporter gene S/L polymorphism was significantly associated with completed suicide. The frequency of the L/L genotype in depressed suicide victims was almost double of that found in control group (48.6% vs. 26.2%). The odds ratio for the L allele was 2.1 (95% CI 1.2–3.7). The association between polymorphism in serotonergic genes and suicidality supports the hypothesis that genetic factors can modulate suicide risk by influencing serotonergic activity.Depression is associated with high rates of suicidal ideation, which varies in intensity from transient thoughts of wishing to be dead to the making of plans and then attempts to kill oneself. There is limited evidence from family, twin, and adoption studies [Roy 1993] that completed suicide is familial and has a genetic etiological component. However, it is unclear whether suicidal ideation is also familial. The familiarity of suicidal ideation has been examined in the subjects who participated in the Cardiff Depression Study, namely, 108 depressed probands, their nearest aged siblings, and 105 healthy control subjects and their siblings. The study showed that 66% of depressed subjects had experienced suicidal ideation in the week prior to interview, and that this was significantly associated with recurrent illness. Suicidal ideation was not shown to be familial. However, somewhat surprisingly, 6% of the healthy, never depressed subjects admitted to having had transient suicidal thoughts. Suicidal ideation was significantly associated with high neuroticism and psychoticism scores and severe threatening life events.Evidence is accumulating that the occurrence of suicidal behavior is determined by the interaction between stress and a diathesis. The term stress refers to psychiatric, psychological, or biological phenomena following the exposure to adverse events. Such events may activate the stress system, as can be demonstrated by means of, among others, an increased activity of the hypothalamic-pituitary-adrenal axis in association with state-dependent psychiatric problems. The diathesis concept refers to a predisposition or persistent vulnerability, which can be described in psychological or biological terms. Research in the psychological domain has demonstrated that suicidal persons share trait-dependent perceptual characteristics, i. e., attentional biases toward being a loser, and the sense of being entrapped when confronted with particular stressful events, leading to feelings of hopelessness due to a deficiency in generating positive future events. From a biological point of view the involvement of the serotonergic system in the development of suicidal behavior has been one of the most replicated findings in biological psychiatry, showing that this deficiency indeed has trait-dependent characteristics. More recently, functional neuroimaging studies have confirmed postmortem findings of changes in the serotonergic system in association with suicidal behavior. Interestingly, the binding potential of prefrontal cortex 5-HT2a receptors thereby showed a significant negative correlation with levels of hopelessness. In addition to early life experiences, genetic factors are thought to play a crucial role in the development of the diathesis.Finally, the term interaction in the stress-diathesis model refers, first, to the possibility that the diathesis may predispose individuals to the occurrence of stressful life events, and, second, to the possibility that the occurrence of such events and the subsequent activation of the stress system may have a detrimental effect on the diathesis by affecting the serotonergic system through a reduction of the metabolism of serotonin and/or cytotoxic effects. Further study of the psychobiology of suicidal behavior is needed to provide additional evidence for this interactive model, which can explain the progression of suicidality under the form of the suicidal process, as it has been demonstrated in epidemiological research.There is a difference between individual risk factors and risk factors in populations. We rarely assume that the two do interact—for example, if you smoke, you are 12 times more likely to develop lung cancer than if you don't. This figure is the same in a country with high smoking rates or low smoking rates. A smoker is at the same risk in London as in Ljubljana. But there are instances in psychiatry where this is not true. For example, the effect of unemployment may depend on the local level of unemployment. In times of full employment those who are still unemployed may feel more marginalized than during times of high unemployment. This observation can be traced back to the classic work of Faris and Dunham in Chicago. The same can be applied to the effect of ethnicity—at its crudest being a black person in a white area brings status conflict, but in a black area status conformity. This effect has been given many different labels—risk concentration/dilution, ecological effect modification, status integration, or buffering.The work of Jan Neeleman has provided empirical evidence to support these theoretical constructs in the area of suicide and deliberate self-harm. Looking at suicide within the 103 electoral wards that make up South London, he showed that the suicide rate for a member of an ethnic minority varied accordingly to the density of that minority. For example, if the proportion of black people living in the ward changes, the suicide rate for black people goes down, and that for white people goes up, even after the appropriate adjustments for deprivation. Indeed, adjustment for social deprivation actually increases this effect, since areas with high ethnic densities are more deprived, thus hiding the dilution effect of high ethnic density protecting against suicide—an example of negative ecological confounding. Neeleman continued the same theme looking at rates of deliberate self harm, and again showed a strong ethnic density effect.The conclusion is that the strength of the effect of ethnicity on suicide rates depends on the its own prevalence in the unit of assessment, and this is not accounted for by residual effects of socio-economic deprivation. In other words, social factors operate according to the prevalence of that factor—and what is a risk factor in one area can be protective in another.The rates of attempted suicide among Asian females aged 18—30 are more than twice compared with their white, age-matched counterparts. The rates among Asian and white adolescents up to the age of 16 are similar, thereby suggesting that some individuation and cultural factors may well be at play. Previous studies have highlighted cultural conflict as a key factor in explaining the high rates. However, in one study nearly a quarter reported a racial life event. Domestic violence and alcohol are other factors. Asian women are also more likely to repeat their attempts. The Asian community acknowledges that the reasons for attempted suicide are many, and that community and society need to change its attitudes. In this paper some of these findings are presented. The educational leaflets were found to be acceptable and culturally sensitive.The countries of the Indian subcontinent (India, Pakistan, Bangladesh, Sri Lanka, Afghanistan, Nepal, Bhutan, and Maldives) represents a major part of the world's population with a combined population of approximately 1.3 billion. Although these countries share many common cultural, traditional, and family values, there are important variations of religions, ethnicity, socioeconomic conditions, and health care systems. Generally, suicidal behavior is not well studied and researched in the subcontinent. Most of the available data is from India and Sri Lanka with a few studies from Pakistan, but virtually nothing is known about suicidal behavior in the remaining countries. Only Sri Lanka, with one of the highest suicide rates (47/100,000 persons) reports its suicide mortality statistics to the WHO. Data collection poses formidable challenge with underreporting, misdiagnosis, stigma, and legal issues being important factors. The available data suggests more than 100,000 suicides occurring in the subcontinent annually. The ratio of men to women appears to be much narrower, and in some cases female rates are higher than male rates, married as opposed to single women being at higher risk, high use of organophosphate insecticides and interpersonal relationship problems rather than psychiatric illness as the cause. However, psychiatric illness may be grossly underrecognized and diagnosed as shown by recent studies. The most important aspect of prevention in the countries of the subcontinent is recognizing suicide as a social problem. Interventions should be aimed at the legal status of suicide and attempted suicide, recognizing the family as an important social unit and addressing the wider social problems. Increasing rates of suicide highlight the need for more and better information on suicidal behavior as well as urgency for preventive action in several countries of the subcontinent.Suicide prevention strategies currently operate at several levels. They take either a population-based approach through public policy, a high-risk target-group approach through mental health and prison service development, or an intermediate approach, for example, school-based programs and primary health-care services, which reach greater numbers than those targeting high-risk groups but do not operate at a population level. Much of what is done or could be proposed at all three levels is based on evidence on risk factors for suicide from epidemiological studies and routine inquiries into suicide. Very little evidence is available from intervention studies on whether either policy changes or service developments can reduce rates of suicide. At the population level, the impact of policy changes may be hard to disentangle from other societal changes influencing population rates. Service developments, whether targeting large numbers at lower risk (e.g., general practice, schools) or smaller numbers at high risk (prisons and mental health services) are difficult to evaluate because of the small numbers of events. However, a systematic review of randomized controlled trials of community mental health teams (CMHTs) versus hospital-based care (provided by professionals not working in teams) suggests that CMHTs may reduce suicide by people with severe mental illnesses and disordered personality. The risk factors for suicide in such groups indicate ways in which CMHTs may be able to achieve this reduction. Evidence for possibilities for further reduction and the impact that this could have on overall rates in countries such as the UK are considered. Suggestions are made as to the types of information to be used in order to better gauge the implications of such work for countries such as Slovenia, where suicide rates are high and community mental health team services are little developed.References Pirc, B. , Pirc, I. Zdravje v Sloveniji. I. knjiga [Health in Slovenia. I. Book]. Ljubljana: Higijenski Zavod v Ljubljani, 1937. Google Scholar Milcinski, L , Mrevlje, G. Epidemiology of suicide in Yugoslavia—methodological questions.. Med Pregl 1990; 43: 453–456. Medline, Google ScholarReference American Academy of Child and Adolescent Psychiatry. AACAP official action: Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry 1998; 37: 4S–26S. Google ScholarReferences Neeleman, J , Wessely, S. Ethnic minority suicide: A small area geographical study in South London. Psychol. Med 1999; 29: 429–436. Crossref Medline, Google Scholar Neeleman, J , Wilson, Jones C , Wessely, S. Ethnic density and deliberate self harm: A small area study in South East London. J. Epi. Comm. Health (in press). Google ScholarReference Tyrer, P , Coid, J , Simmonds, S , et al. Community mental health teams for people with severe mental illnesses and disordered personality. The Cochrane Library, Issue 3. Google ScholarFiguresReferencesRelatedDetailsCited byMurder Followed by Suicide: Filicide-Suicide Mothers in Italy from 1992 to 201014 January 2013 | Journal of Forensic Sciences, Vol. 58, No. 2Commentary: suicide prevention and the right to die2 January 2018 | Psychiatric Bulletin, Vol. 25, No. 11 Volume 21Issue 4July 2000ISSN: 0227-5910eISSN: 2151-2396 InformationCrisis (2000), 21, pp. 189-194 https://doi.org/10.1027//0227-5910.21.4.189.© 2000Hogrefe & Huber PublishersPDF download
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