Pathways to Late-Life Suicidal Behavior: Cluster Analysis and Predictive Validation of Suicidal Behavior in a Sample of Older Adults With Major Depression
Pathways to Late-Life Suicidal Behavior: Cluster Analysis and Predictive Validation of Suicidal Behavior in a Sample of Older Adults With Major Depression
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DOI：
10.4088/jcp.17m11611
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发表时间：
2018-03-01
影响因子：
5.3
通讯作者：
Dombrovski, Alexandre Y.
中科院分区：
文献类型：
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作者：
Szanto, Katalin;Galfalvy, Hanga;Dombrovski, Alexandre Y.
目的：临床异质性是理解自杀风险的一个关键挑战，因为可能存在不同的自杀行为途径。我们的目的是通过揭示晚年抑郁症病例的潜在类别，并将其与先前和未来的自杀行为联系起来，以确定这些途径。在这项纵向研究中，我们在194名老年（50岁以上）非痴呆抑郁症患者中研究了临床和认知/决策因素与自杀行为的明显相关性; 57名非精神病健康对照提供了基准数据。采用DSM-IV建立诊断标准。我们确定了风险因素的多变量模式，根据人格特征、感知的社会支持、认知表现和决策来定义聚类，并对参与者的自杀行为史进行了盲分析。结果：在5个自杀行为高危因素中，有3个与自杀行为高危因素相关：（1）认知缺陷、人格障碍、低社会支持、高延迟回报意愿和高致死性自杀者比例过高;（2）高人格病理（即，低自尊），最小或没有认知缺陷，以及低致命性攻击者和构想者的比例过高;（3）认知缺陷，不能延迟未来的奖励，以及高和低致命性奖励的相似分布。有显着的集群间差异的数量（P < .001）和致死率（P = 0.002）过去自杀企图和未来自杀企图的可能性（P = 0.010，22例患者30次尝试，2例死亡）和紧急精神病住院治疗，以防止自杀（P = 0.005，31名参与者）。发现老年患者自杀行为的三种途径，其特征是（1）非常高水平的认知和倾向性风险因素，表明痴呆前驱症状，（2）功能障碍的人格特征，（3）冲动决策和认知缺陷。
Objective: Clinical heterogeneity is a key challenge to understanding suicidal risk, as different pathways to suicidal behavior are likely to exist. We aimed to identify such pathways by uncovering latent classes of late-life depression cases and relating them to prior and future suicidal behavior.Methods: Data were collected from June 2010 to September 2015. In this longitudinal study we examined distinct associations of clinical and cognitive/decision-making factors with suicidal behavior in 194 older (50+ years) nondemented, depressed patients; 57 nonpsychiatric healthy controls provided benchmark data. The DSM-IV was used to establish diagnostic criteria. We identified multivariate patterns of risk factors, defining clusters based on personality traits, perceived social support, cognitive performance, and decision-making in an analysis blinded to participants' history of suicidal behavior. We validated these clusters using past and prospective suicidal ideation and behavior.Results: Of 5 clusters identified, 3 were associated with high risk for suicidal behavior: (1) cognitive deficits, dysfunctional personality, low social support, high willingness to delay future rewards, and overrepresentation of highlethality attempters; (2) high-personality pathology (ie, low self-esteem), minimal or no cognitive deficits, and overrepresentation of low-lethality attempters and ideators; (3) cognitive deficits, inability to delay future rewards, and similar distribution of high-and low-lethality attempters. There were significant between-cluster differences in number (P < .001) and lethality (P = .002) of past suicide attempts and in the likelihood of future suicide attempts (P = .010, 30 attempts by 22 patients, 2 fatal) and emergency psychiatric hospitalizations to prevent suicide (P = .005, 31 participants).Conclusions: Three pathways to suicidal behavior in older patients were found, marked by (1) very high levels of cognitive and dispositional risk factors suggesting a dementia prodrome, (2) dysfunctional personality traits, and (3) impulsive decision-making and cognitive deficits.