suicide in non-major depressions

.IOURNAL OF

ELSEVIER Journal of Affective Disorders 36 (1996) 117- 127

AFFECTIVE DISORDERS

Erkki

Research report

Suicide in non-major depressions

IsometsB a, * , Martti Heikkinen a, Markus Henriksson a,b, Hillevi Aro a,c, Mauri Marttunen ayb, Kimmo Kuoppasalmi a3b, Jouko Lannqvist a

a National Public Health Institute, Department of Mental Health, Helsinki, Finland b Department of Psychiatry, Helsinki University, Helsinki, Finland

’ School of Public Health, University of Tampere, Tampere. Finland

Received 12 May 1995; revised 7 August 1995; accepted 7 August 1995

Abstract

We compared depressive suicides who had unipolar depression not fulfilling the diagnostic criteria of major depression (non-major depressions) with suicides who had major depression. A random sample of 229 suicides representing all suicides in Finland within a 12-month period were comprehensively examined using the psychological autopsy method and diagnosed according to DSM-III-R criteria. We included in this study all cases of current depressive disorder not otherwise

specified (n = 48), adjustment disorder with depressed mood (n = 6) and dysthymia (n = 4). These 58 cases of suicide in non-major depressions were compared with the suicides with unipolar major depression (n = 71) in the same random

sample. The non-major depressive victims were younger, and comprised more males, more cases with psychoactive substance use disorders, more secondary depressives, and more cases not having contact with health care, or cases not having communicated suicidal intent despite such contact. Recent life events were also reported more common among those with non-major depressions, particularly during the final week. The findings suggest that suicides in major depression and in unipolar depressions not fulfilling the criteria for major depression are likely to differ in several clinically relevant characteristics besides depressive symptomatology.

Keywords: Depression; Suicide; Comorbidity; Life event

1. Introduction

Mild depressive disorders not reaching the diagnostic threshold of major depression are likely to be among the most common mental disorders (Weiss-

man et al., 1981; Roberts and Vernon, 1982; Blazer

’ Corresponding author. Address: Department of Mental Health, Mannerheimintie 166, SF-00300 Helsinki, Finland. Fax: (358) (0)

et al., 1988; Lehtinen et al., 1990; Angst, 1992; Johnsson et al., 1992; Maier et al., 1992). Depressive

symptoms have been shown to have major implica- tions for psychosocial and medical outcome (Murphy

et al., 1987; Wells et al., 1989; Broadhead et al.,

1990; Wells et al., 1993) and, due to their great prevalence, mildly depressed patients seem to burden health care comparably with major depressives (Johnsson et al., 1992).

4744478. While there is no doubt

016%0327/96/$15.00 0 1996 Elsevier Science B.V. All rights reserved SSDI 0165-0327(95)00067-4

over the strong causal

118 E. Isometsti et nL/Journal ofAffective Disorders 36 (1996) 117-127

link between depression and suicide, the issue of suicide in milder depressions is controversial. Miles

(1977) in an extensive review of suicide studies

concluded that suicide risk in neurotic depression does not differ from that in major affective disorders.

On the other hand, follow-up data from the Swedish Lundby study revealed higher suicide risk among the

severely depressed (Hagnell et al., 1981), and com-

parisons of suicide victims with clinical cases have

found the former to be more severely depressed

(Barraclough et al., 1974; Modestin and Kopp, 1988).

Early psychological autopsy studies did not use any of the current diagnostic classifications (Robins et

al., 1959; Dot-pat and Ripley, 1960; Barraclough et

al., 1974; ‘Beskow, 1979; Chynoweth et al., 1980; Mitterauer, 1981) but the more recent ones that have

used DSM-III (APA, 1980), DSM-III-R (APA, 1987),

or RDC (Spitzer et al., 1978) criteria have reported

4-42% cases of depression milder than major depression among suicides (Rich et al., 1986; Shafii et

al., 1988; Runeson, 1989; Arato et al., 1988; Wsg&d,

1990; Marttunen et al., 1991; Henriksson et al., 1993; Apter et al., 1993; Brent et al., 1993; Lesage et

al., 1994). Mild depression appears to be particularly prevalent among adolescent and young adult suicides (Shafii et al., 1988; Brent, 1989; Runeson, 1989; Marttunen et al., 1991; Brent et al., 1993; Lesage et

al., 1994) and comorbidity with other psychiatric disorders and physical illness has been common

among these cases. In our study describing the diagnostic breakdown

of a random sample of Finnish suicides comprehen-

sively examined using the psychological autopsy

method (Henriksson et al., 1993) a significant number of cases (27%) received a diagnosis of unipolar

depression not fulfilling the criteria of major depression. The present study examines these cases further, and compares them with suicides with major depres-

sion.

2. Methods

2.1. National suicide prevention project in Finland

This study is part of the National Suicide Preven- tion Project in Finland (Marttunen et al., 1991; Hen- riksson et al., 1993; IsometsH et al., 1994a). Finland

has an ethnically homogeneous population of five million. During the research phase of the project, all

suicides committed in Finland between 1 April 1987

and 3 1 March 1988 (n = 1397) were comprehensively recorded and analyzed using the psychological

autopsy method (Litman et al., 1963; Shneidman, 1981). The definition of suicide was based on Finnish

law for determining causes of death - in every case

of violent, sudden or unexpected death the possibility

of suicide is assessed by police and medicolegal

investigations involving autopsy and forensic exami-

nations. For the 12-month duration of the research

phase of the project this gathering of data was more

detailed than usual. Data concerning victims classified as suicides in forensic examination were col-

lected via comprehensive interviews of the relatives

and attending health care personnel; from psychi-

atric, medical and social agency records and suicide

notes (Marttunen et al., 1991; Henriksson et al., 1993; Isometsa et al., 1994a, b, c).

The mental disorders of suicide victims in Finland

have been examined in the diagnostic study of a

random sample of 229 (16.4%) of the total 1397

suicides in this period (Henriksson et al., 1993). Altogether, 66% of the victims had suffered from a

mood syndrome (Table 1) and 43% alcohol dependence or abuse; only 12% of the victims had one axis I diagnosis with no comorbidity. Of the 229 victims, 7 1 (3 1%) received a DSM-III-R diagnosis of

current unipolar major depression, 52 (23%) depressive disorder not otherwise specified (NOS) (includ-

ing four cases with schizophrenia), 6 (3%) adjustment disorder with depressed mood, and 4 (2%) dysthymia without current major depression. Exclud-

ing the four persons with both schizophrenia and depressive disorder nos, the 58 victims with either depressive disorder NOS, dysthymia or adjustment

disorder with depressed mood were included into this study as a population of non-major depressives,

and the 71 victims with major depression became the comparison group. The depressive victims with bipolar disorder, schizoaffective disorder or organic mood disorder were excluded from the present study.

2.2. Data collection

The interview forms used were planned for the project, and the interviewers were mental health

E. Isometsii et al./ Journal of Affective Disorders 36 (1996) I 17-127 119

professionals trained in their use. Four types of

interview were made: (1) Face-to-face interviews of

family members were usually conducted in their

homes, with informed consent obtained beforehand. The structured interview forms contained 234 items

concerning the victim’s everyday life and behavior,

family factors, use of alcohol and other drugs, previ-

ous suicidality, help seeking and recent life events.

Interviews of family members of the non-major de-

pressives were made in 50 (86%) of the cases, on

average 4 months after suicide (mean interval 134

days, SD 83 days, range 25-430 days). The inter-

view lasted about 3 h (mean 175 min, SD 55 min,

range 90-330 mini. In eight cases no next of kin

was found, or they refused to participate in the study.

(2) Health care professionals who had attended the victim during the previous 12 months were inter-

viewed face-to-face with a structured form containing 113 items about the victim’s state of health,

treatment in the health care system, psychosocial

stressors and level of functioning. The interview,

including a cross-sectional symptom questionnaire

and items about longitudinal aspects of mood disor-

ders and substance abuse, was accomplished in 19 (33%) of the cases. In the remaining cases no attending personnel could be interviewed due to lack of

recent, more than random contacts with health care

by the victim. (3) The last contact with health or social agency professionals was separately evaluated

by interviewing the attending person either face-to- face or by telephone with a semi-structured interview containing eight items. This interview was made in

30 (52%) of cases, the remainder usually having had no contact with health care or a social agency during

the last year. (4) Additional unstructured interviews

were made by telephone if needed. The total number of interviewed persons per vic-

tim was 2.3 (median 2.1, SD 1.4, range O-7). In

addition, information was included from psychiatric

(33%), medical (78%), social agency, police, foren-

sic examination and other available records, as well

as suicide notes. A multidisciplinary team discussed

all the cases and a comprehensive case report was

written on the basis of all information available. In

the comparison group of major depressive suicides

the number of interviewed persons per victim was a

little higher (mean 2.9, SD 1.4, range O-81, and due

to more contact with health care, more structured interviews were made (next of kin 87%, attending

personnel 69%, last contact 83%).

2.3. Diagnostic evaluation

The retrospective diagnostic evaluation of the cases according to DSM-III-R criteria (APA, 1987)

weighing and integrating all the evidence, took place

as part of the diagnostic study (Henriksson et al., 1993). First, two pairs of psychiatrists independently made provisional diagnoses the reliability of which

was tested using the Kappa statistics (Fleiss, 1975). Second, all cases of diagnostic disagreement were reanalyzed by a third psychiatrist to achieve consensus for the final best estimate diagnoses. The reliability achieved was good or at least moderate in all

Table 1

Retrospective best estimate DSM-III-R diagnoses of depressive suicides within a random sample of 229 suicide cases representing all

suicides in Finland in 12.month period (from Hemiksson et al., 1993)

Diagnosis Males Females Total

No.(%) ( n = 172) No.(%) (n = 57) No.(%) (n = 229)

Major depression

Nonmajor depressions

Depressive disorder not otherwise specified a

Adjustment disorder with depressed mood

Dysthymia

Bipolar disorder

Schizoaffective disorder

Organic mood disorder

Total

45 (26)

43 (25)

4 (2)

4 (2)

5 (3)

5 (3)

3 (2)

109 (63)

26 (46)

9 (16)

2 (4)

0 (0)

3 (5)

3 (5)

0 (0) 43 (75)

71 (31)

52 (23)

6 (3)

4 (2)

8 (3)

8 (3)

3 (1) 152 (66)

’ Includes four male cases with schizophrenia which were excluded from this study

120 E. Isometsii et al. /Journal of Affective Disorders 36 (I 996) I 17-127

categories included here: Kappa 0.74 for major de-

pression (95% confidence limits 0.64-0.841, 0.56

(c.1. 0.42-0.71) for depressive disorder not otherwise

specified, 0.92 (c.1. 0.87-0.97) for alcohol depen-

dence, 0.65 (c.1. 0.47-0.84) for alcohol abuse, 0.52

(c.1. 0.17-0.87) for adjustment disorder, and 0.78

(c.1. 0.69-0.87) for the presence of an axis II disor-

der. Diagnoses of physical illness on axis III were

based on evaluation of medical records, autopsy and

forensic examination findings, reported symptoms

and information gathered from interviews; the diag-

noses were made in consensus meetings (Henriksson

et al., 1993).

The classification of cases into primary and sec-

ondary depressives was based on all available infor-

mation concerning the temporal sequence of onsets

of different mental and physical disorders. The cases

were classified as probably primary, probably sec-

ondary, or undetermined cases. Depression was clas-

sified as probably secondary if the reported first

episode of depression was preceded by alcohol dependence or abuse, personality disorder, an anxiety

disorder, or by an incapacitating, potentially life- threatening or chronically painful physical illness.

Depression was classified as probably primary if the first episode of depression was not preceded by any of the above-mentioned disorders. Thus, the criteria were more similar to the Feighner (Feighner et al.,

1972) than the RDC (Spitzer et al., 1978) criteria for primary-secondary distinction, but included more

both psychiatric disorders and physical diseases to

which the depression could be classified as secondary than either of these classifications.

2.4. Suicidal behavior

The details of clinical history, treatment contacts and previous suicidal behavior are reported on the basis of all available information. The communication of suicidal intent during the last 3 months was rated present if the verbal communication of intent to kill oneself was explicit. Ambiguous suggestions, communicated wishes for death and suicidal gestures or attempts were not rated as suicide intent commu- nications. Suicide methods are reported according to the classified immediate causes of death in forensic examination, including toxicological analysis. Sui- cide methods classified as violent included hanging,

shooting, cutting, use of explosives, jumping from

high places or in front of trains, but they did not

include drowning, use of gases or any intoxicants,

drugs or poisons.

2.5. Treatment variables

The treatment setting of the depression at the time

of death of the victim was defined according to the

contacts the victim had had with different treatment

organizations before death. The victims were classi-

fied into five subgroups: (A) Psychiatric care, includ-

ing mental health centers and outpatient departments,

mental hospitals, psychiatric consultants of general

hospitals, and private psychiatrists and psychothera-

pists. (B) Primary care, comprising all kinds of

general practice. (C) Other medical and surgical

specialties, comprising both in- and outpatients. (D)

No contact, including both cases in which there was

no contact with health care during the final 3 months,

and cases in which the examinations and treatment had been explicitly terminated either by the profes-

sional or the patient. (E) Undetermined treatment setting, if it was impossible to determine which was

the principal one responsible. Information concerning prescribed drug treatment

immediately before death and electroconvulsive therapy during the 3 final months was obtained from

medical and psychiatric records. Only drugs used regularly were included. Antidepressant treatment

was classified as in a study by Modestin (Modestin, 1985) and our previous studies of major depressive

suicides (Isometsa et al., 1994a, b, c> in four categories: (1) None. (2) Probably ineffective; doses of tricyclic antidepressants or maprotiline between 1

and 74 mg/day or mianserin l-29 mg/day. (3) Possibly effective; doses of tricyclic antidepressants or maprotiline 75-149 mg/day or mianserin 30-59 mg/day. (4) Probably effective; doses of tricyclic

antidepressants or maprotiline 150 to 300 mg/day or mianserin 60- 120 mg/day.

Psychotherapeutic contact was defined as a treatment contract with a mental health professional irre- spective of profession (psychiatrist, resident, psy- chologist, nurse etc.) involving regular meetings with the patient at least once a week for at least three visits with the explicit aim of helping the patient by discussing his or her problems. Psychotherapy proper

E. Isometsii et al./Journal of Affective Disorders 36 (1996) I1 7-127 121

was recorded if the uninterrupted duration of the into either (a) events independent of victim’s own treatment was at least 1 month, the therapist had behavior or(b) events possibly dependent on victim’s relevant training in individual psychotherapy and own behavior. The independent events included, e.g., visits occurred at least once a week. Psychotherapies death or severe illness of spouse or close relative, and psychotherapeutic contacts were included only if while the possibly dependent events included, e.g., at least one of the visits had occurred during the last separation, substantial financial deterioration or job 3 months (Isometsi et al., 1994a). problems (IsometsZ et al., 1995).

2.6. Examination of life euents 2.7. Statistical methods

Recent life events preceding suicide were exam-

ined via a list of 33 structured questions on different

aspects of adult life (Heikkinen et al., 1994; Isometsl

et al., 1995). The questionnaire was included in the

interview of the next of kin, and was performed in

50 (86%) cases of the non-major depressive study group and in 62 (87%) of the comparison group of

major depressives. Life event data on four subjects

of the non-major depressive group and six major

depressive victims were excluded because the inter-

viewer did not consider the informants’ reports on

life events sufficiently reliable. One questionnaire item (‘change in get-togethers with friends’) was

excluded from the analysis because of the ambiguity of the question and its symptom-like implication (Lehman, 1978). The life event questionnaire had

been developed for an epidemiological survey in Finland (Lehtinen et al., 1985). It was based on the Recent Life Change Questionnaire insmment by

Rahe (1977) with some modifications from the list by Paykel and associates (Paykel et al., 1969). The 32 life events included were combined into 13 larger

categories according to area of life. Subjects with

more than one event in any category were counted only once for that category. Under category separa-

tion we included divorce, separation due to argu- ments, and breakup of steady dating. Under category death we included death of spouse, death of another family member, and death of a close friend. Further-

more, we combined the categories death and separation into a metacategory of interpersonal loss; this metacategory was further combined with family dis-

cord into a metacategory of interpersonal loss/conflict. Two time periods, the last 3 months and the final week, were evaluated. The events that occurred during the final week were also included in the events of the 3-month period. In addition, all 32 items included were classified on logical grounds

In statistical analysis N X 2 chi-square tables, the

chi-square test with Yates’ correction for continuity,

Fisher’s exact test and the two-sample I-test were

used when appropriate. The Mantel-Haenszel test

was used when controlling for a possible confound-

ing factor was necessary. Due to missing data in

some cases, the number of cases included in analysis

is indicated in square brackets.

3. Results

The suicide victims in the non-major depressive

subgroup were significantly younger than the major

depressives (mean age non-major 41.O[SD 16.21 vs. major 50.0[16.6.], t= 3.08, df = 127, P = 0.003),

and comprised more males (non-major 47/58[81%] vs. major 45/71[63%], x2 = 4.04, df = 1, P = 0.044). They also clearly had more comorbid psy-

choactive substance use disorders (non-major 34/58[59%] vs. major 22/71[31%], x2 = 8.83, df = 1, P = 0.003), and somewhat more cases with

personality disorder (non-major 25/47[53%] vs. ma-

jor 22/65[34%], x2 = 3.44, P = 0.06). While the tendency for less cases with no comorbidity among them did not reach statistical significance (non-major

3/58[5%] vs. 11/71[15%], x2 = 2.53, NS), they did include markedly more probably secondary cases than those with major depression (non-major 45/50[90%] vs. major 30/6447%], x2 = 21,32, df

= 1, P < 0.001) (Table 2). The groups also differed clearly in treatment set-

tings and treatment received (Table 2). The non-major

suicides were less likely to have been treated in psychiatric care (9% vs. 45%, x2 = 18.99, df = 1, P < O.OOl>, and more commonly had had no contact with health care (40% vs. 17%, x2 = 7.25, df = 1, P = 0.007). Fewer of them had a previous history of

122 E. Isomeki et aL/Journal ofAffectioe Disorders 36 (1996) 117-127

psychiatric treatment (non-major 38% vs. major 75%, x2 = 16.21, df = 1, P < 0.001) or psychiatric hospi-

tal treatment (non-major 19% vs. major 59%, x2 =

19.67, df = 1, P < 0.001). However, the number of

cases with previous suicide attempts reported was

not significantly different between the groups (non-

major 20 [34%] vs. major 34 [48%], x2 = 1.84,

df = 1, NS).

Before suicide, the major depressives had signifi-

cantly more often received psychopharmacological

treatment (major 58%[35/60] vs. non-major

17%[9/54], x2 = 19.10, df = 1, P < O.OOl), and

specifically, antidepressant treatment (major

22/66[33%] vs. non-major 4%[2/56], x2 = 15.15,

df = I, P < 0.001). However, the antidepressant

treatment received before death was considered

probably effective in only two cases (3%) of the

major depressive group, and in none of the non-major depressive group. Psychotherapeutic contacts (major

25% vs. non-major 2%, x2 = 12.37, df = 1, P < 0.001) as well as psychotherapy proper (major 7%

vs. non-major O%, Fisher’s exact test, P = 0.09)

were more common among the major depressives.

Of those having contact with health care, the non-

major depressives had communicated the suicidal

intent to personnel significantly less often (non-major

2/35[6%] vs. major 24/59[41%], x2 = 11.73, P < 0.00 1).

Recent life events were reported more common

among the non-major depressive suicides both dur-

ing the last 3 months (non-major 89% [40/45] vs.

major 66% [37/56], x2 = 5.97, df = 1, P = 0.0151,

and during the final week (non-major 70% [31/44]

vs. major 42% [23/55], x2 = 6.97, df = 1, P =

Table 2

Comparison of characteristics and treatment histories of suicides in nonmajor depressions (non-MD) and major depressions (MD)

Variable Non-MD suicides

No.(%) (n = 58)

MD suicides

No.(%) (n = 71)

Sex

Male

Female

Comorbidity

Psychoactive substance use disorders a

Anxiety disorder

Personality disorder b

Physical illness

Type of depression ’

Primary

Secondary

History of suicidality

Previous suicide attempt(s)

Lifetime history

Psychiatric treatment

Psychiatric hospitalization

Current treatment setting

Psychiatric care

Primary care

Other medical and surgical specialties

No contact

Undetermined

47 (81)

11 (19)

34 (59)

9 (16) 2.5 (53)

27 (47)

5 (10) 45 (90)

20 (34)

22 (38)

11 (19)

5 (9)

22 (38)

5 (9)

23 (40)

3 (5)

45 (63) *

26 (37)

22 (31) **

12 (17)

22 (34)

37 (52)

34 (53) ’ * * 30 (47)

34 (48)

53 (75) * l *

42 (59) l * *

32 (45) +++

20 (28)

7 (10) 12 (17)

0 (0)

a Includes alcohol dependence or abuse in 34 of non-MD and 20 of MD cases. h n = 47 for non-MD and n = 65 for MD suicides.

’ See Methods for definitions.

+++ ,$,df=4, P <O.OOl.

’ X’.df= 1, P <0.05.

* * x2, df = 1, I’< 0.01.

*I* ,y*.df=l, P<O.OOl.

E. Isomersii et al./Journal of Affectiue Disorders 36 (1996) 117-127 123

Table 3

Recent life events during last 3 months and final week as reported

by next of kin among suicides in nonmajor (non-MD) and major

depression (MD)

Life event Non-MD MD

No.(%ioXn = 46) No.(%Xn = 56)

Last 3 months a

Categories

Somatic illness

Illness in family

Death

Separation

Family discord

Residence change

Financial trouble

Job problems

Unemployment

Retirement

Imprisonment

Other events

Metacategories

Interpersonal loss h

Interpersonal loss/conflict

Dependent events

Independent events

Any life event

Final week

Categories

Somatic illness

Illness in family

Death

Separation

Family discord

Residence change

Financial trouble

Job problems

Unemployment

Retirement

Imprisonment

Other events

Metacategories

Interpersonal loss ’

Interpersonal loss/conflict ’

Dependent events

Independent events

Any life event

8/44 (18) 15/56 (27)

5/46 (11) 9/56 (16)

7/46 (14) 3/56 (5)

13/46 (28) 9/56 (16)

14/42 (33) 11 /s4 (20)

6/46 (13) 3/56 (5)

13/45 (29) 4/55 (7) ++

12/43 (28) 8/56 (14)

8/46 (16) 2/56 (4) +

2/46 (4) 2/56 (4)

l/46 (2) O/56 (0)

4/46 (9) 2/56 (4)

19/46 (41)

25/44 (52)

34/45 (76)

21/44 (48)

40/45 (89)

12/56 (21)

16/56 (29) * *

22/56 (39) * l * 23/55 (42)

37/56 (66) *

5/44 (11)

3/46 (6)

l/46 (2)

7/46 (15) 13/42 (31)

o/46 (0) 8/45 (18)

5/41 (12)

7/46 (15)

o/46 (0)

o/46 (0)

2/46 (4)

8/46 (16) 16/43 (37)

27/44 (61)

13/44 (30)

31/44 (67)

lo/56 (18)

3/56 (5)

2/56 (4)

5/56 (9)

9/54 (17)

O/56 (0) l/55 (2) +

4/56 (7) l/56 (2) +

2/56 (4)

O/56 (0)

O/56 (0)

7/56 (13)

12/54 (22)

13/55 (24) * * * 14/55 (25)

23/55 (42) * *

*x2,df=1, P<O.O5.

’ * x2, df = 1, P < 0.01.

“*x2,df=1, P <O.OOl.

++ Fisher’s exact test, two-tailed, P < 0.01.

+ Fisher’s exact test, two-tailed, P < 0.05.

a Includes final week.

h Includes categories death and separation.

’ Includes metacategory interpersonal loss ch) and category family

discord.

0.008) (Table 3). However, this difference was

mainly due to the higher prevalence of possibly dependent events during both the 3-month (non-major

76%[34/45] vs. major 39%[22/56], x2 = 11.86, P < 0.001) and the final week (non-major 61%[27/44]

vs. major 24%[ 13/55], x2 = 12.93, P < 0.001) peri-

ods. There were no significant differences in the

prevalences of independent events during either the

3-month (non-major 48%[21/44] vs. major

42%[23/55], x2 = 0.15, NS) or final week (non-

major 30%[ 13/44] vs. major 25%[14/55], x2 = 0.05, NS) period.

The statistically significant differences between

the victims with major or non-major depressions

remained significant, when sex, age (dichotomized,

cut-off median), or treatment setting (psychiatric care

vs. other settings) were controlled for.

4. Discussion

Suicides with unipolar depression not fulfilling the criteria for major depression seem to differ from

those with major depression in several respects, besides the difference in depressive symptomatology. The findings suggest, that the suicides with less

severe depression may more commonly have other important characteristics, which include risk factors

for suicide, or lack of possible protective factors. Although the major strength of the study is that the

study population and the comparison group represent all suicides in Finland in non-major and major depressions, some methodological limitations of the

study should be considered. First, the study shares problems common to retrospective studies in general, and to the psychological autopsy method specifi-

cally. To some extent the problems related to psychological autopsy can be overcome by using several informants per case and including record data when available, thereby weighing and integrating all infor-

mation (Brent, 1989; Beskow et al., 1990). Second, the DSM-III-R diagnosis of depressive disorder not

otherwise specified is used in cases of clinically significant unipolar, non-organic depressive syn- dromes not fulfilling the criteria of specific mood

disorders (APA, 1987). Due to the stringent docu- mentation required, some cases received this diagno-

124 E. lsometsii et al./ Journal of Affective Disorders 36 (1996) I I7-127

sis if information concerning diagnostic criteria was contradictory or insufficient for a more specific diag-

nosis. The heterogeneous population of non-major

depressives may therefore include cases of true ma-

jor depression, as well as more cases of adjustment disorder with depressed mood or dysthymia than

now reported. Consequently, the true differences be-

tween the subgroups may either be somewhat di-

luted, or skewed, due to the fact that some degree of

information bias is present. Although the differences

between non-major and major depressives remain

significant even if psychiatric treatment setting (i.e.,

more diagnostic information) is controlled for, the

findings have to be interpreted with some caution. Third, the methods used in differentiating primary

from secondary depressives were not very sophisti-

cated, and the possibility cannot be excluded that in some cases an initial primary depressive episode

early in the life history of the victim remained

unnoticed. Thus the number of secondary depressives found might be inflated. Furthermore, we in-

cluded more physical diseases and more categories of psychiatric disorders as possible primary disorders than in the Feighner (Feighner et al., 1972) or RDC

(Spitzer et al., 1978) criteria, both inclusions increas-

ing the probability of a secondary depression. On the other hand, focusing on the initial episode (as in

Feighner criteria) rather than the current one (as in RDC) is likely to give considerably smaller proportions of secondary cases (Giles et al., 1987). In any

case, the methodological differences are unlikely to

explain the strong differences found between the groups. The criteria for distinguishing primary and

secondary cases were chosen because they were considered most reliable given our data set.

Fourth, the possibility exists that some victims who had suffered from mild depression had not

communicated the symptoms to anyone, and thus become a false-negative in our study. However, since

the random sample from which the data were derived represents all suicides in Finland, and since the remainder mostly suffered from other mental and physical disorders, any false-negative cases are likely to have been comorbid, and therefore little different from the cases included. The presence of false-nega- tives would thus be unlikely to bias the results. Fifth, the time frame for the life event questionnaire was the last 3 months, shorter than in several other

suicide studies (Paykel and Dowlatshahi, 1988; Heikkinen et al,, 1993) and therefore likely to gener-

ate under-rather than overestimates.

While the majority of mildly depressed patients in

the community and in clinical populations are fe-

males (Weissman et al., 1976; Roberts and Vernon,

1982; Blazer et al., 1988; Lehtinen et al., 1990;

Angst, 1992; Johnsson et al., 1992; Maier et al.,

1992), the vast majority (8 1%) of non-major depres-

sive suicide victims in the present study were males.

This preponderance of males was even greater than

among the major depressive (63%) suicide victims,

but not much different from the sex distribution of

all suicides in the random sample (75%). In contrast

to the marked differences in characteristics between

sexes we found in major depressives suicides (Iso-

metsa et al., 1994a, c) among these non-major depressive suicides the sexes were strikingly similar,

and the differences between non-major and major depressives remained significant even when sex (or

age) was controlled for.

Almost all (95%) of the suicide victims in the non-major depression subgroup were comorbid cases.

Most commonly the victims had suffered from alcoholism (59%), personality disorder (53%) or physical

illness (47%), and having three or more diagnoses was common. In comparison with the suicides in

major depression, particularly alcoholism, but also personality disorders were more common among the

non-major depressives. Comorbidity among depressive suicides has been reported in several psychological autopsy studies (Rich et al., 1986; Shafii et al.,

1988; Brent, 1989; Runeson, 1989; Arato et al., 1988; Asg&rd, 1990; Marttunen et al., 1991; Henriks- son et al., 1993) and Carlson et al. (1991) have

suggested that one of the secular trends among suicide populations is the rising proportion of comorbid

depression. In the present study, the proportion of secondary cases was very significantly higher among

the milder depressives (90% vs. 47%, P < 0.001). Some cohort studies with small numbers of suicides (Martin et al., 1985; Akiskal et al., 1978) have suggested higher suicide risk among secondary depressives, although this was not confirmed in a large cohort study (Black et al., 1987). However, none of these studies compared mild with major depressives in this respect. As alcoholism (Roy and Linnoila, 1986; Murphy and Wetzel, 1990), personality disor-

E. Isometsii et al. / Journal of Affective Disorders 36 (19961 I 17-127 125

ders (Stone, 1993; Paris, 1993) and presumably some physical diseases (Whitlock, 1986) all predispose to

suicide, it would not be surprising if the threshold of

suicide were more frequently reached with low addi-

tional depressive burdens among these secondary

cases than uncomplicated primary ones.

Given the representativeness of our suicide popu-

lation, and the fact that most studies have found

primary depression to be two to three-fold more

common than secondary in both the both the general

and clinical populations (Costello and Scott, 1991), it

could be suggested that suicide risk may be signifi-

cantly higher among secondary than primary non-

major depressives. Conversely, given the rarity of

primary non-major depressives among suicides, sui-

cide risk in primary non-major depression might be

relatively low. Considering also the higher prevalence of mild depression among females in the gen-

eral population, and the scarcity of females (19%) in

this population, it could be suggested that the risk of suicide in non-major depressions among females

compared with males may be lower. However, these

tentative epidemiological hypotheses need to be tested in studies designed to estimate suicide risk in

various types of depression among males and females.

Despite accumulating evidence for benefits of

both psychotherapy and pharmacotherapy in treatment of dysthymia and other milder depressions

(Paykel, 1994; L apierre, 1994), there is no general consensus regarding the issue of adequate treatment in depressions which do not meet the criteria of major depression. However, it is obvious from our findings that even the half of victims having had

contact with health care before death were almost

completely untreated as regards their current depression. Even undertreatment, relatively common among major depressive suicide victims both in Finland

(Isometsa et al., 1994a, c) and elsewhere (Bar- raclough et al., 1974; Chynoweth et al., 1980; Mod-

estin, 198.5; Rihmer et al., 1990) was uncommon. If

judged by the dose criteria used in major depression, none of these victims had received adequate antide-

pressant treatment. Neither had anyone received weekly psychotherapy from a properly trained therapist. The lack of treatment for depression could be partly a consequence of the secondary nature of the

depression in most cases. For suicide prevention it

would seem important to evaluate the applicability of the current treatments for depression in milder secondary depressions, besides improving recognition

and access to treatment.

Recent stressful life events have been shown to be

associated with the onset of depression (Paykel and

Cooper, 1992) as well as suicide (Paykel and

Dowlatshahi, 1988; Heikkinen et al., 1993). In our

study, suicides in non-major depressions seemed to

be more often be related to life events than suicides

in major depression. In particular, there seemed to be

a difference concerning the very recent stressors

occurring during the final week before suicide. In

two thirds (70%) of the non-major depressives (in

42% of the major depressives) at least one adverse

life event during the final week was reported. How-

ever, the differences between these two groups were mainly due to a significantly higher proportion of

cases with possibly dependent events among the

victims with non-major depressions, and no differences were found if only independent events were

included. Thus, many of the recent life events expe-

rienced by particularly the non-major victims before suicide were likely to be consequences of the victim’s

own behavior, although probably rarely intentionally

inflicted. As discussed by Miller et al. (19861, such adverse events may nonetheless have a major impact

on the individuals life. As both the small number of adjustment disorder diagnoses and the high propor-

tion of victims with events in the final week impli- cate, the depression was usually already present when the adverse events occurred. If the adverse life events had a role in the suicide, they seemed to thus usually

trigger suicidal behavior in already depressed persons rather than to initiate the final episode.

5. Conclusions

Suicides in non-major depressions seemed to oc-

cur mainly among males suffering from comorbid,

secondary depressions. Most cases had primary alcohol dependence or abuse, personality disorder, or

severe physical illness preceding the final episode of depression, and were associated with recent adverse life events. Suicide victims with non-major depressions are likely to differ from those with major depression in terms of age, sex, comorbidity, pri-

126 E. Isometsii et al. /Journal of Affectiue Disorders 36 (I 996) 117-127

mary-secondary distinction, treatment history and

communication of suicide intent to health care as well as recent life events. The findings suggest, that

suicides with less severe depression may more com-

monly have other clinically relevant characteristics,

which include risk factors for suicide, or lack of

possible protective factors.

Acknowledgements

This study has been supported by grants from the

Academy of Finland and the Finnish Medical Soci-

ety Duodecim.

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