Suicidal ideation in patients with rheumatoid arthritis

British Medical Journal, Nov 18, 2000 by Gareth J Treharne, Antonia C Lyons, George D Kitas, Tara Collinge, Ajit Shah

Research may help identify patients at high risk

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 ([chi square] = 9.54, P [is less than] 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 [is less than] 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.

Gareth J Treharne health psychology postgraduate research student

gjt884@bham.ac.uk

Antonia C Lyons lecturer in health psychology a.c.lyons@bham.ac.uk

George D Kitas consultant rheumatologist g.d.kitas@bham.ac.uk

University of Birmingham, Birmingham B15 2TT

[1] Carson Al, Best S, Warlow C, Sharpe M. Suicidal ideation among outpatients at general neurology clinics: prospective study. BMJ 2000;320:1311-2. (13 May.)

[2] Newman SP, Fitzpatrick R, Revenson TA, Skevington S, Williams G. Understanding rheumatoid arthritis. London: Routledge, 1996.

[3] Pincus T Grittith J, Pearce S, Isenberg D. Prevalence of self-reported depression in patients with rheumatoid arthritis. Br J Rheumatology 1996;35:879-83.

[4] Hunt SM, McEwan J, McKenna S. Measuring health status. New Hampshire: Croom Helm, 1986.

[5] Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70.

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] 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.[2 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] 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.[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 scale[5] improved at 10 weeks' follow up. Suicidal ideation measured on other scales did not improve.