der, not otherwise specified, dysthymia and adjustment disorder with depressed mood gave a total of 64% depressive syndromes. Schizophrenia (14%) and bor-.
Acta Psychiatr Scand 1989:79:490-497 Key words: suicide; adolescence; psychological autopsy; mental disorder; major depression.
Mental disorder in youth suicide DSM-111-R Axes I and I1 B. Runeson
Department of Psychiatry, University of Gothenburg, Sahlgren’s Hospital, Gothenburg, Sweden
ABSTRACT - A 3-year urban material of suicides in adolescents and young adults (age 15-29 years) was studied retrospectively by means of interviews with survivors (n = 5 8 ) . Classification of mental disorders according to DSM-111-R showed that major depression was important as background to suicides in 41 %, primary (22%) or secondary (19%) to other disorders. Adding major depression, depressive disorder, not otherwise specified, dysthymia and adjustment disorder with depressed mood gave a total of 64% depressive syndromes. Schizophrenia (14%) and borderline personality disorder (28%) constituted other relevant groups. Coexisting substance use disorder occurred in 47%. A majority of the subjects (72%) were known by psychiatric caregivers and 16% committed suicide during inpatient care. Received December 4, 1988; accepted for publication January 27, 1989
Suicide among young people has become a major health problem throughout the western world. Statistics show an increase during the 1970s, followed by somewhat declining figures. Nevertheless, the rate is stiIl increasing in many countries (1). In Sweden, the rate of suicide among adolescents (15-19 years) and young adults (20-29 years) doubled from the 1950s to the 1970s among both males and females. An accentuated increase appeared in males 20-24 years old, for whom the statistical suicide risk increased 3.6 times from 1952 to 1981 (2). Retrospective studies based on interviews with survivors have supplied important knowledge on the psychiatric diagnostic spectrum (3-8). The rise in youth suicides has called for similar studies on young populations, and a few projects from the United States have recently been presented (9-11). In Europe there has been one study of youth suicide so far, but it provides no
information on the prevalence of mental disorders (12). The aim of this study was to investigate the prevalence of different mental disorders as background to youth suicide.
Material and methods The material used was for July 1984 to June 1987 from the city of Gothenburg, the second largest in Sweden. All suicides (ICD E950-959) (13) and undetermined cases (ICD E980-989) in the ages 15-29 years were included, irrespective of where death took place. To increase homogeneity, those born outside Scandinavia were excluded. Data for identification were collected at the Department of Forensic Medicine and checked at the Public Health Committee, where all suicides in Gothenburg are registered.
MENTAL DISORDER IN YOUTH SUICIDE
The material consisted of 64 cases. In all cases but one, face-to-face interviews with one or more informants were performed, using a modification of psychological autopsy. Data from the anatomical investigation and toxicologic analysis and records from hospitals and social care were sought. The theory and technique are extensively described elsewhere (14). Suicidal intention was classified on the basis of 8 items of objective circumstances of the Suicidal Intent Scale (SIS) (15, 16). Considering suicidal method and suicidal intention, an estimate was made according to the Rating Scale for Determining the Degree of Certainty of Suicide (17). By including the categories certain suicide and almost certain suicide, 58 of the 64 deaths were classified as suicide and were further analyzed. According to the original verdict from the medical examiner, 48 of these were suicides and 10 were undetermined.
491
Table 1 Sources of information
Main interview parent/parents sibling partner other Supplementary interview relative, friend, employer health care professional: social care Medical records psychiatric general Forensic reports autopsy toxicologic analysis
n
%
58
100 11
41
7 5
18 13 13
12 9 9 69 31 22 22
42
12
5
9
56 51
91 88
5
40
Records from psychiatric care were available in 40 cases (69%). In 23 cases (40%) the subjects were known to the social authorities.
Interviews Information was gathered (Table 1) through faceto-face interviews with close relatives, preferably parents, siblings or partners, in that order. In 91 % of cases the first approached interviewee agreed to participate. In the remaining cases alternative informants were found: foster parents, landlady or close friends. In some cases supplementary interviews were conducted, face-to-face whenever possible, with other relatives, friends or employers and such professionals as psychiatrists, psychotherapists, ward personnel or social workers. Altogether 87 face-to-face interviews were performed; including telephone interviews, there were 2.2 interviews per subject (range 1-5). All interviews were performed by the author. Interviews were semistructured and lasted 2-6 h with breaks. They were performed in the home of the survivor (75 070) or, at the request of the interviewee, at the hospital. Median time interval from death was 9 weeks (range in most cases 5-20 weeks, occasionally longer). Primary contact had been taken on the phone and a letter of information, which emphasized that participation was voluntary, was sent before the interview. All interviews in which consent was obtained were taperecorded.
Diagnostic evaluation Diagnoses according to DSM-111-R (18) were made by consensus with the supervisor of the study. Diagnoses had the character of best estimate, including and weighting all collected data. DSM-111-R allows multiple diagnoses. The concept of primary and secondary disorders was applied, based on presence or absence of a pre-existing mental disorder (19). Principal diagnosis refers to the mental disorder most relevant to the suicidal process and the suicide. Diagnoses on Axis I indicated point prevalence, referring to condition at the time of suicide. On Axis I1 a hierarchy was applied. When criteria for both borderline and antisocial personality disorder were fulfilled, the first was given priority, because of the larger load of psychological criteria (20).
Results The male/female ratio was 2.6, compared with 2.7 for suicides in all of Sweden. Sex and age distribution was similar to the national statistics (Table 2).
492
B. RUNESON
Table 2 Age and sex distribution of sample and of general population in Sweden Investigated suicides July 1984 - June 1987
Suicides in Sweden
1984 - 1986
Age (years)
Males
Females
Total
VQ
Males
Females
Total
To
15-19 20-24 25-29
6 15 21 42
3 8 5 16
9 23 26 58
16 40 45 101
71 222 300 599
33 90 99 222
110 312 399 821
13 38 49
Total
100
Table 3 Relation between primary DSM-Ill-R Axis 1 disorders and Axis I1 personality disorders Axis I1 Axis I
Borderline personality disorder
Eating disorder Alcohol dependence Other substance use disorder Schizophrenia Schizoaffective disorder Psychotic disorder not otherwise specified Major depression Depressive disorder not otherwise specified Obsessive-compulsive disorder Somatization disorder Adjustment disorder N o Axis I disorder Total
Concurrent classification according to Axis I and Axis I1 is presented in Table 3. Only one diagnosis was marked for each axis. On Axis I the primary diagnosis was noted, and on Axis 11, the personality disorder according to the defined hierarchy. Large groups were major depression, schizophrenia and adjustment disorder on Axis I and borderline personality disorder on Axis 11. Substance use disorder was often combined with borderline personality disorder, whereas most other Axis I diagnoses had no Axis I1 diagnosis. Principal diagnoses are presented in Table 4. Percentages of major disorders were: major depression 22070, schizophrenia 14V0, adjustment disorder 14 Vo and borderline personality disorder 28 VO. Psychiatric morbidity was thus evident in nearly all subjects, even if some diagnoses contain elements of uncertainity. Two cases where information was too scanty for a definite diag-
Antisocial personality disorder
No personality disorder
Total
2 2
3 12 4 8 1 1 14 2 1
8 1
13
I 1 1
8 1
38
1 8 3 58
nosis were classified as psychotic disorder and depressive disorder not otherwise specified. One female who was given no diagnosis was apparently healthy 2 days before a chaotic suicide. So-called neurotic disorders were rare, but there were 2 males with somatization disorder and obsessive-compulsive disorder respectively, both displaying states of depression the final weeks. All but one of the adjustment disorders featured depressive symptoms; the remaining case had mixed emotional features. All schizophrenics were male and over 20 years of age and all people with eating disorders were female. Otherwise there were no statistically significant differences in the spectrum of mental disorders between the age groups 1519, 20-24 and 25-29 years, or for sex. Mood disorders are specified as primary and secondary disorders in Table 5. Primary major depression (n = 13) was recurrent in 7 cases
493
MENTAL DISORDER IN YOUTH SUICIDE
Table 4 Principal diagnosis according to DSM-111-R n = 58
Axis I Eating disorder Dementia Alcohol dependence Schizophrenia paranoid residual undifferentiated Schizoaffective disorder Psychotic disorder not otherwise specified Major depression Depressive disorder not otherwise specified Obsessive-compulsive disorder Somatization disorder Adjustment disorder with depressed mood with mixed emotional features Axis I1 Antisocial personality disorder Borderline personality disorder No diagnosis
%
n 3 1 2 8 4 3 1 1
14
1 13
22
1 1 1 8 7 1 1 16 1
28
n = 58
To 22
11
Primary Alcohol dependence Secondary Alcohol dependence Alcohol abuse Cannabis dependence Cannabis abuse Sedative dependence Polysubstance abuse
19
4
=
58
21 2
VO 47
Table 7 Psychiatric in- and outpatient care, proximity in time (cumulated figures) Inpatient care
14
Table 5 Mood disorder according to DSM-111-R
Primary Major depression bipolar unipolar, single episode unipolar, recurrent (melancholic subtype Depressive disorder not otherwise specified Secondary Major depression Depressive disorder not otherwise specified Dysthymic disorder
Table 6 Substance use disorder according to DSM-111-R, dominant abuse
Last 2 days Last week Last month Last 6 months Last 2 years Ever
In- and outpatient care
n
To
n
9 11 14 19 28 30
16 19 24 33 48 52
13 17 28 31 37 42
TQ 22 29 48 53 64 72
DSM-111-R, was regarded as secondary major depression. Substance abuse or dependence was found in 27 subjects (47%) (Table 6 ) . In all cases but 2, substance abuse or dependence was secondary to other disorders. Alcohol dependence was found in 13 cases (22%) and dependence on other substances in another 6 cases (10%). Combinations of 2 substances were common, especially alcohol and cannabis. Central stimulants were temporarily apparent in some of the cases.
1
(12%). Three of them showed evidence of bipolar disorder. Four of the major depressions were of melancholic subtype. Those with secondary major depression (19 070) had an underlying disturbance of borderline personality disorder (n = 4), schizophrenia (n = 3), anorexia nervosa (n = 1) or other Axis I diagnosis (n = 3). Major depression superimposed on schizophrenia, which is called depressive disorder not otherwise specified in
Treatment Seventy-two percent were known to psychiatric caregivers and many had a recent contact (Table 7). Nine subjects (16%) committed suicide during inpatient care. The 4 major principal diagnoses differed in terms of care supplied (Table 8). All 8 schizophrenics had been admitted for inpatient care and 4 were inpatients at the time of the suicide. Six of the 8 subjects with adjustment disorder had no previous psychiatric care.
494
B. RUNESON
Table 8 Hospital care, means (ranges) Principal diagnosis
Psychiatric inpatients
Number of admissions per patient
Weeks of stay per patient
8
7 (2-18) 3 (1-5) 1 6 (1-29)
73 (4-135)
Schizophrenia (n = 8) Major depression (n = 13) Adjustment disorder (n = 8) Borderline personality disorder (n = 16)
Of 13 with primary major depression, 5 were treated with antidepressant drugs at the time of suicide; only two, however, reached a therapeutic dose, defined as amitriptylin 150 mg/day or equivalent. Of the 11 with secondary major depression, only 2 were treated with antidepressant drugs.
Family history Although a systematic genetic study was not attempted, it was noted that nonpsychotic disorders, predominantly depressive and anxiety disorders, were common among parents. In 71 '70 of the families, a member had consulted a physician or therapist for a mental disorder other than substance abuse, and in 52% of the families at least one member had some form of substance abuse.
Discussion The investigation comprised a total material for a 3-year period and was carried out with minimum dropout. Age and sex distribution and sex ratio are comparable to Sweden as a whole (Table 2). Nevertheless, the urban character of the area and the low number of cases do not permit a generalization of the findings to the whole of Sweden.
Method The method applied has both advantages and disadvantages, which are inherent in retrospective studies on suicide (14). Although there was at least one interview per subject, in a few cases
6
2 10
16 (2-26) 1 21 (0-113)
some data were lacking. Problems of importance are bias of the survivor in describing a deceased child or partner and of a single examiner in assessing the diagnosis. Classification with diagnostic criteria, as in DSM-I11 (21) and subsequent editions, has advantages compared with other classification systems, such as ICD (13). A fairly uniform procedure was ensured since the entire procedure of interviewing, from the first approach to the survivors to the finished interview, was performed by one person, a trained psychiatrist. Review of the cases was made by the supervisor in order to reach consensus in diagnosis.
Diagnosis Schizophrenia is a disorder of high suicide risk, though figures span from 0% to 12% in retrospective investigations (3-8, 10, 11). Young age implies a high risk of suicide (22-25). In addition to the 14% fulfilling the criteria of schizophrenia, one female had a schizoaffective disorder and one man had psychotic disorder of schizophreniform nature, giving a total of 17%. This proportion is larger than in the only other comparable study (lo), where schizophrenia and schizoaffective disorders comprised 8 % . In that study psychoses coexisting with substance abuse were classified as atypical psychoses, since the distinction from other psychotic disorders could not be made. Including these atypical psychoses, the proportion of psychotics is identical with ours (17%). The schizophrenics in the present study were well known to psychiatric caregivers (Table 8). Only few of them had a fully developed second-
MENTAL DISORDER IN YOUTH SUICIDE
ary depressive syndrome (3/8). Most had passed rehabilitation attempts, where they had reported fears of relapse and poor prognosis. The findings agree with other studies, where multiple hospitalizations (22, 25, 26), unability to accept the limitation of a chronic mental illness (27) and low social competence (28) implied high risk of suicide. Adjustment disorders constitute another group with identified stressors and short suicidal process. Practically all had depressed mood. Persons with short recurrent depressive episodes who do not contact psychiatric care may present symptoms of the same severity as persons with longer lasting episodes treated for major depression in psychiatric care (29). The DSM111-R criterion that duration be at least 2 weeks for the diagnosis of major depression may consequently lead to underestimation. On the other hand, DSM-111-R diagnoses are more inclusive than the more stringent Feighner criteria (30, 31). Depressive disorders in youth have become a topic of growing interest and have been studied from a nosologic perspective (32-35). Clinical studies show that affective syndromes often have an early onset (36-38). Population surveys give evidence of increasing depression among young adults. In the Swedish Lundby study, the cumulative probability for mild or moderate depression increased for all ages between 1947 and 1972 (39). For males in their twenties there was a tenfold increase during the period, also involving severe depressions. Studies in the United States indicate that baby-boomers born in the late 1940s have increased rates of depression and related disorders (40). In our study the proportion of major depression, primary and secondary added, was 41070, which is similar to another study of adolescents (1 1) and only slightly lower than in studies of all ages (3-6). The extensive San Diego suicide study (10, 41) showed significantly more major depressions above than below the age of 30 years (19% vs. 7%). In that study a frequent DSM-111 diagnosis for both younger and older people was atypical depression, i.e. a depressive syndrome occurring after the onset of drug or alcohol abuse. Including atypical depression gives a total figure of major depression of 3 1 % in youth
495
compared with our figure of 41%. Depressive symptoms help to provoke most suicides (3, 5, 6, 8). In the present material the proportion of depression, including major depression, depressive disorder not otherwise specified, dysthymia and adjustment disorder with depressed mood, was 64%. Moreover, other individuals presented one or few separate symptoms of depressive character. The presence of depression in youth may be related to the high rates of suicide in these ages. Substance abuse is also a common disorder in retrospective investigations of suicide, especially in youth. In an study of adolescents in the United States, 70% of the suicide victims featured a frequent use of unprescribed drugs or alcohol (9). In the San Diego suicide study, 66% of the people below 30 years of age abused drugs (41). Substance use disorder in our study was less frequent (47%), but still indicated the great importance of a more active approach in care and treatment of substance abuse in youth. The proportion of personality disorders in retrospective studies of suicide has shown great variation, up to a maximum of 44% (42). During the last decade the relation of borderline personality disorder to suicide (43, 44) and to parasuicide (45-48) has been in focus. The large proportion of borderline personality disorder in our study (28%) indicates an increased risk of suicide. The role of personality disorders in youth suicide is elaborated in another report (49).
Implications Too few patients with major depression get adequate pharmacologic treatment (6, 50). It ought to be more widely recognized that major depression is as common in youth as in total series. In the present study many of the young people could probably have been successfully treated, provided that they had consulted a psychiatric clinic. Guidelines directed to the public and to teachers and other professionals in close contact with youth may be one way to find preventive measures. Major depression secondary to schizophreniform disorder, substance use disorder or borderline personality disorder is not as easily recog-
496
B. RUNESON
nized and treated as primary depression. The depressive episodes may be longer, relapses more frequent (11) and the outcome of treatment less consistent (51). This implies a need for intervention from different therapeutic perspectives.
Conclusions Psychiatric morbidity was evident in nearly all suicides in adolescents and young adults. Major depression, primary or secondary to other disorders, was almost as common as in suicide of all ages. Schizophrenia in phases after rehabilitation and borderline personality disorder with secondary substance abuse constitute other important subgroups.
Acknowledgements This work was supported by a grant from The Swedish Ministry of Health and Social Affairs, Commission for Social Research (project no F 87/46:1). My supervisor, Jan Beskow, MD, has been of utmost importance for realization of the study.
References 1. Barraclough B. International variation in the suicide rate of 15-24 year olds. SOCPsychiatry Psychiatr Epidemiol 1988:23:75-84. 2. Asgird U, Nordstrom P, Riback G. Birth cohort analysis of changing suicide risk by sex and age in Sweden 1952 to 1981. Acta Psychiatr Scand 1987:76:456-463. 3. Robins E , Murphy GE, Wilkinson RH, Gassner S , Kayes J. Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides. Am J Public Health 1959:49:888-,899. 4. Dorpat TL, Ripley HS. A study of suicide in the Seattle area. Compr Psychiatry 1960:1:349-359. 5 . Barraclough B, Bunch J, Nelson B, Sainsbury P. A hundred cases of suicide. Br J Psychiatry 1974:125:355-373. 6 . Beskow J. Suicide and mental disorder in Swedish men. Acta Psychiatr Scand 1979:Suppl 277:l-138. 7. Mitterauer B. Mehrdimensionale Diagnostik von 121 Suiziden im Bundesland Salzburg im Jahre 1978. Wien Med Wochenschr 1981:131:229-234. 8. Chynoweth R, Tonge JI, Armstrong J. Suicide in Brisbane. A retrospective psychosocial study. Aust NZ J Psychiatry 1980:14:37-45. 9. Shafii M, Carrigan S, Whittinghill JR, Derrick A. Psychological autopsy of completed suicide in children and adolescents. Am J Psychiatry 1985:142:1061-1064. 10. Rich CL, Young D. Fowler RC. San Diego Suicide Study. I. Young vs old subjects. Arch Gen Psychiatry 1986: 43:577-582. 1 1 . Brent DA, Perper JA, Goldstein CE et al. Risk factors for
adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry 1988:45:581-588. 12 Leblhuber F, Schany W, Fischer F, Sommereder M, Kienbacber G . Study on suicides committed by adolescents in Upper Austria covering a period of three years. In: Soubrier JP, Vedrinne J, eds. Depression et suicide. Paris: Pergamon Press, 1981:652-655. 13 World Health Organization. Manual of the international statistical classification of diseases, injuries and causes of death. 8th revision. Geneva: WHO, 1967. 14. Beskow J, Runeson B, Asgird U. Retrospective investigations of suicide through interviews with survivors. Submitted. 15. Beck AT, Scbuyler D, Herman J. Development of suicidal intent scales. In: Beck AT, Resnick HLP, Lettieri DJ, eds. The prediction of suicide. Bowie, MD: Charles Press, 1974:45-56. 16. Beck AT, Lester D. Components of suicidal intent in completed and attempted suicides. J Psychology 1976: 92:35-38. 17. Lonnqvist J. Suicide in Helsinki. An epidemiological and social psychiatric study of suicides in Helsinki 1960-61 and 1970-71. Monogr Psychiatr Fenn 1977:8:30-33. 18. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed., revised. Washington, DC: American Psychiatric Association, 1987. 19. Robins E, Guze SB. Classification of affective disorders the primary-secondary, the endogenous-reactive, and the neurotic-psychotic concepts. In: Williams TA, Katz MM, Shield J A Jr, eds. Recent advances in the psychobiology of the depressive illnesses. Washington, DC: Government Printing Office, 1972. 20. Widiger TA, Frances A, Spitzer RL, Williams JBW. The DSM-111-R personality disorders: an overview. Am J Psychiatry 1988:145:786-795. 21. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Washington, DC: American Psychiatric Association, 1980. 22. Waltzer H . Suicide risk in young schizophrenics. Gen Hosp Psychiatry 1984:6219-225. 23. Allebeck P , Varla A, Wistedt B. Suicide and violent death among patients with schizophrenia. Acta Psychiatr Scand 1986:74:43-49. 24. Prasad AJ, Kellner P. Suicidal behaviour in schizophrenic day patients. Acta Psychiatr Scand 1988:77:488-490, 25. Modestin J. Three different types of clinical suicide. Eur Arch Psychiatry Neurol Sci 1986:236:148-153. 26. Roy A. Suicide in chronic schizophrenia. Br J Psychiatry 1982:141:171-177. 27. Drake RE, Gates C, Cotton PG, Whitaker A. Suicide among schizophrenics. Who is at risk? J Nerv Ment Dis 1984:172:613-617. 28. Nyman AK, Jonsson H. Patterns of self-destructive bebaviour in schizophrenia. Acta Psychiatr Scand 1986: 73:252-262. 29. Angst I, Dobler-Mikola A. The Zurich Study. 11. The continuum from normal to pathological depressive mood swings. Eur Arch Psychiatry Neurol Sci 1984:234:21-29. 30. Feighner JP, Robins E, Guze SB, Woodruff RA, Winokur
MENTAL DISORDER IN YOUTH SUICIDE
G, Manoz R. Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 1972:26:57-63. 31. Angst J , Dobler-Mikola A. The Zurich Study. 111. Diagnosis of depression. Eur Arch Psychiatry Neurol Sci 1984:234:30-37. 32. Cutryn L, McKnew DH, Bunney WE. Diagnosis of depression in children: a reassessment. Am J Psychiatry 1980:137:22-25. 33. Strober M, Green J, Carlsson G. Phenomenology and subtypes of major depressive disorder in adolescence. J Affective Disord 1981:3:281-290. 34. Kovacs M, Feinberg TL, Crouse-Novak MA, Paulauskas SL, Finkelstein R. Depressive disorders in childhood. I. A longitudinal prospective study of characteristics and recovery. Arch Gen Psychiatry 1984:41:229-237. 35. Kovacs M, Feinberg TL, Crouse-Novak MA, Paulauskas SL, Finkelstein R. Depressive disorders in childhood. 11. A longitudinal study of the risk for a subsequent major depression. Arch Gen Psychiatry 1984:41:643-649. 36. Loranger AW, Levine PM. Age at onset of bipolar affective illness. Arch Gen Psychiatry 1978:35:1345-1348. 37. Joyce PR. Age of onset in bipolar affective disorder and misdiagnoses as schizophrenia. Psychol Med 1984:14:145149. 38. Baron M, Risch N, Medlewics J. Age at onset in bipolarrelated affective illness: clinical and genetic implications. J Psychiatr Res 1983:17:5-18. 39. Hagnell 0, Lanke J , Rorsman B, Ojesjo L. Are we entering an age of melancholy? Depressive illnesses in a prospective epidemiological study over 25 years: the Lundby Study, Sweden. Psychol Med 1982:12:279-289. 40. Klerman GL. The current age of youthful melancholia. Evidence for increase in depression among adolescents and young adults. Br J Psychiatry 1988:152:4-14. 41. Fowler RC, Rich CL, Young D. San Diego Suicide Study. 11. Substance abuse in young cases. Arch Gen Psychiatry 1986:434:962-965.
497
42. Paerregaard G. Attempted suicide and suicide in Copenhagen (dissertation). Copenhagen, 1983:201-211. 43. Kullgren G, Renberg E, Jacobson L. An empirical study of borderline personality disorder and psychiatric suicides. J Nerv Ment Dis 1986:174:328-331. 44. Stone MH, Stone DK, Hurt SW. Natural history of borderline patients treated by intensive hospitalization. Psychiatr Clin North Am 1987:10:185-206, 45. Crumley FE. Adolescent suicide attempts. JAMA 1979: 241:2404-2407. 46. Alessi NE, McManus M, Brickman A, Grapentine L. Suicidal behavior among serious juvenile offenders. Am J Psychiatry 1984:141:286-287. 47. Friedman RC, Aronoff MS, Clarkin JF, Corn R, Hurt SW. History of suicidal behavior in depressed borderline inpatients. Am J Psychiatry 1983:140:1023-1026. 48. Fyer MR, Frances AJ, Sullivan T, Hurt SW, Clarkin J . Suicide attempts in patients with borderline personality disorder. Am J Psychiatry 1988:145:737-739. 49. Runeson B, Beskow J. Borderline personality disorder in youth suicide. Submitted. 50. Modestin J. Antidepressive therapy in depressed clinical suicides. Acta Psychiatr Scand 1985:71:111-116. 51. Reveley AM,Reveley M A . The distinction of primary and secondary affective disorders. Clinical implications. J Affective Disord 1981:3:273-279. Address
Bo Runeson, M.D. Department of Psychiatry University of Gothenburg Sahlgren’s Hospital S-413 45 Gothenburg Sweden
