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. 2000 Nov 18;321(7271):1290.
Suicidal ideation in patients with rheumatoid arthritis
Editor—The finding of Carson et al — that depression associated with progressive physical (neurological) illness may lead to suicidal ideation — has important clinical implications and may be generalisable.1 Rheumatoid arthritis, the most prevalent chronic inflammatory musculoskeletal disease,2 has been associated with several negative psychological outcomes, including depression.3
Our ongoing studies indicate that almost 11% of hospital outpatients with rheumatoid arthritis (13 out of 123; 95% confidence interval 5% to 16%) experience suicidal ideation, as detected by the Nottingham health profile.4
At first glance, patients with longstanding disease (of more than four years' duration) seem more likely to report suicidal ideation (12%) than those with early rheumatoid arthritis (of less than two years' duration) (7%). Sex may also play a part, with 14% of female patients reporting suicidal ideation compared with only 3% of male patients. However, clinical depression detected by the hospital anxiety and depression scale,5 is the most important factor; 30% of those reporting depression also experience suicidal ideation, a significantly higher proportion than the 7% seen in those who are not depressed (χ2=9.54, P<0.01).
This is confirmed by binary logistic regression of suicidal ideation, used to examine simultaneously the predictive value of age, sex, duration of rheumatoid arthritis, clinical anxiety, and depression. In this analysis only the presence of clinical depression was predictive of suicidal ideation (odds ratio 4.47, P<0.05).
These findings support the suggestion by Carson et al that mental health assessment of physically ill patients should form part of routine clinical evaluation, particularly in chronic illness. Further research may help identify a demographic, physical and psychosocial profile that could predict patients at high risk of developing suicidal ideation.
References
1.Carson AJ, Best S, Warlow C, Sharpe M. Suicidal ideation among outpatients at general neurology clinics: prospective study. BMJ. 2000;320:1311–1312. doi: 10.1136/bmj.320.7245.1311. . (13 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Newman SP, Fitzpatrick R, Revenson TA, Skevington S, Williams G. Understanding rheumatoid arthritis. London: Routledge; 1996. [Google Scholar]
3.Pincus T, Griffith J, Pearce S, Isenberg D. Prevalence of self-reported depression in patients with rheumatoid arthritis. Br J Rheumatology. 1996;35:879–883. doi: 10.1093/rheumatology/35.9.879. [DOI] [PubMed] [Google Scholar]
4.Hunt SM, McEwan J, McKenna S. Measuring health status. New Hampshire: Croom Helm; 1986. [Google Scholar]
5.Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67:361–370. doi: 10.1111/j.1600-0447.1983.tb09716.x. [DOI] [PubMed] [Google Scholar]
BMJ. 2000 Nov 18;321(7271):1290.
Natural course of suicidal ideation and treatment efficacy need to be known
Editor—Government white papers (Health of the Nation and Our Healthier Nation) and the national service framework for mental health have set targets for reducing suicide rates. The paper of Carson et al reporting a 9% prevalence of suicidal ideation in outpatients attending neurology clinics was timely.1-1 The authors used a tight definition of suicidal ideation—patients had to have thought about active plans for committing suicide which is much closer to suicidal intention than ideation and thus their findings are important. We reported a prevalence of up to 36% in elderly inpatients who were acutely medically ill.1-2,1-3 Furthermore, physical illness is a well recognised risk factor for suicide.
Carson et al advocate screening for suicidal ideation by general practitioners and other specialists and referral to psychiatrists for treatment.1-1 Before recommending such a course of action, using an ideal evidence based approach, two important pieces of evidence are necessary.
Firstly, information on the natural course of suicidal ideation through longitudinal follow up studies is needed. If the suicidal ideation (and associated depression) improves with treating the physical illness then the role of psychiatric services may be less important.
Secondly, information on the efficacy of intervention from psychiatric services in reducing suicidal ideation and associated mental illness is unestablished.
We retrospectively reanalysed data from our single blind, randomised and controlled study of early identification of depression and pragmatic intervention by psychogeriatric consultation.1-4 The original one year study with 47 subjects showed that the intervention was not effective in improving the depression. There were many potential explanations (including methodological) for this negative finding. Retrospective analysis on the efficacy of this intervention on suicidal ideation showed that the suicidal ideation measured on the Montgomery-Asberg depression rating scale1-5 improved at 10 weeks' follow up. Suicidal ideation measured on other scales did not improve.
Pragmatically, patients who are medically ill and have suicidal ideation could be considered to need treatment both by medical specialists and psychiatrists. However, there are clear implications for distribution and concentration of resources. Should more resources be targeted for the medical specialties (to concentrate efforts on the treatment of medical illness, which may also improve suicidal ideation) or for psychiatry (to develop liaison psychiatric services, for example)? This question can be answered only if more detailed data on the natural course of suicidal ideation in these patients and the efficacy of intervention by psychiatric services are available; there is an unequivocal need for such studies.
References
1-1.Carson AJ, Best S, Warlow C, Sharpe M. Suicidal ideation among outpatients at a general neurology clinic: prospective study. BMJ. 2000;320:1311–1312. doi: 10.1136/bmj.320.7245.1311. [DOI] [PMC free article] [PubMed] [Google Scholar]
1-2.Shah A, Dighe-Deo D, Chapman C, Phongsathorn V, George C, Bielawski C, et al. Suicidal ideation amongst acutely medically ill and continuing care geriatric inpatients. Ageing and Mental Health. 1998;2:3005. [Google Scholar]
1-3.Shah A, Hoxey K, Mayadunne V. Suicidal ideation in acutely medically ill elderly inpatients: prevalence, correlates and longitudinal stability. International Journal of Geriatric Psychiatry. 2000;15:162–169. doi: 10.1002/(sici)1099-1166(200002)15:2<162::aid-gps94>3.0.co;2-t. [DOI] [PubMed] [Google Scholar]
1-4.Shah A, Odutoye K, De T. Depression in acutely medically ill elderly inpatients: a pilot study of early identification and intervention by formal psychogeriatric consultation. J Affect Disord (in press). [DOI] [PubMed]
1-5.Montgomery S, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134:382–389. doi: 10.1192/bjp.134.4.382. [DOI] [PubMed] [Google Scholar]
