Suicide in Primary Affective Disorders Revisited: A Systematic Review by Treatment Era
J Clin Psychiatry 2001;62(10):804-811
© Copyright 2014 Physicians Postgraduate Press, Inc.
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Background: We reviewed suicide rates in
affective disorder and their variation with electroconvulsive
therapy (ECT) and antidepressant availability.
Method: Suicide rates were calculated from 75
follow-up studies, identified by systematic literature searches
and analyzed for differences over time eras characterized by the
availability of specific treatments.
Data Sources and Study Selection: MEDLINE,
EMBASE, BIOSIS Previews, and Psychological Abstracts literature
searches were conducted for the years 1966 to 1995. References
from review articles identified from these sources from 1985
onward and textbook references were also included. Publications
prior to 1966 were obtained from article references identified
for the period 1966 to 1976 and reviews. Inclusion criteria were
(1) articles written in English, French, or German; (2) sample
size > 30; (3) age at recruitment between 18 and 64 years for
each subject; (4) sample had to contain subjects hospitalized at
time of recruitment; and (5) naturalistic follow-up of at least 6
Results: Suicide rates decreased with longer
follow-up periods. For follow-up periods over 20 years, the mean
rate was 3.76/1000 person-years (95% confidence interval [CI] =
2.35 to 5.17). Suicides accounted for 12.3% (95% CI = 8.52 to
16.04) of all deaths in samples in which 40% or more of patients
had died. For studies with minimal overlap between eras, the mean
suicide rate differed significantly between eras (pretreatment,
before 1940: 6.3/1000; ECT treatment, 1940 to 1959: 5.7/1000;
antidepressant treatment, 1960 onward: 3.3/1000; F = 31.4, df =
2,42; p < .001).
Conclusion: The risk of suicide in follow-up
studies of affective disorder has decreased compared to that
reported in previous reviews. The availability of ECT and
antidepressants may have contributed to this decrease, but
prescription of these treatments cannot be assumed for all