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How Can Research Prevent Suicide? Stephen H Cambridge University Press 978-1-107-03323-8 - A Concise Guide to Understanding Suicide: Epidemiology, Pathophysiology, and Prevention Edited by Stephen H. Koslow, Pedro Ruiz and Charles B. Nemeroff Excerpt More information Introduction Looking to the future: how can research prevent suicide? Stephen H. Koslow, Pedro Ruiz, and Charles B. Nemeroff Suicide is a leading cause of mortality and morbidity. making subject availability low; (b) there is no accurate Suicide represents a major public health problem method to determine if any individual is going to take based on the fact that there are more than 1 000 000 their own life in the next day(s) or year(s); and suicides worldwide and approximately 40 000 in the (c) potential suicide is based on a variety of factors United States per year. Many people throughout the which includes signs and symptoms and assessment of world have therefore had direct experience with a high-risk cognitive states or high-risk behavior, but suicide by having a relative, friend, or acquaintance there are obvious differences between suicide attempts solve their problems by taking their own life. This is a and completed suicides. Studying the brains of sub- devastating experience, which on the surface is hard to jects who have taken their life ensures that your sample understand and hard to recover from. Reducing the is from a suicide; however whether the biology under- suicide rate and ultimately preventing suicide is a lying suicide is transient or lasting and the debate as to challenging task. The chapters in this Guide were whether there is a unique biology of suicide that cuts developed to provide state of the art information on across diagnostic categories versus suicide as a symp- what is known about suicide, how we currently study tom of various disorders with their own unique biol- it, and how we can reduce its frequency. The latter is ogy remain unresolved. One of the most important the most important goal. Currently most preventive areas for research is obviously the development of an efforts are aimed at erecting physical barriers to sui- accurate, sensitive, and specific method to detect sui- cide and/or hospitalization. None of these efforts are cide potential. This can be a behavioral measure, clin- totally effective. ical signs or symptoms, or a biological marker. All of We designed this Guide for several audiences includ- these are active areas of research. ing clinicians and researchers but also others interested Promising data is offered from genetics research. in this topic. The chapters that comprise this monograph Current major approaches, all with advantages and are purposefully concise but are sufficiently comprehen- disadvantages, include Genome-Wide Association sive. It has been organized into sections on a common Studies (GWAS), candidate gene studies, and epige- theme starting with a series of reports on understanding netics. GWAS is an examination of many common suicide that provide a context for the remainder of the genetic variants in large populations to determine if book. This Guide goes on to provide information any variant is associated with a trait. GWAS typically ranging from specific psychiatric disorders of unique focus on associations between single nucleotide poly- “special” at risk populations highlighting the context morphisms (SNPs) and disease traits. Candidate gene of suicide and treatment within these illnesses and studies focus on SNPs in systems previously implicated populations, through mediators and moderators of sui- to be involved in the pathogenesis of suicide, such as cide from societal to biological mechanisms, including serotonin. Epigenetics focuses on genes that are genomics, and ending with suicide prevention. impacted and changed due to the environment. Both What makes suicide prevention and research so GWAS and epigenetics studies can be conducted from difficult? This theme is focused on throughout this completed suicides. Here the biggest challenge again is volume. The answer is manifold and includes: (a) the the relative low incidence of suicide in the general incidence of suicide is low compared to other illnesses population compared to, for example, diabetes or A Concise Guide to Understanding Suicide, ed. Stephen H. Koslow, Pedro Ruiz, and Charles B. Nemeroff. Published by Cambridge University Press. © Cambridge University Press 2014. 1 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-03323-8 - A Concise Guide to Understanding Suicide: Epidemiology, Pathophysiology, and Prevention Edited by Stephen H. Koslow, Pedro Ruiz and Charles B. Nemeroff Excerpt More information Introduction: looking to the future hypertension, rendering it difficult to get the large sam- currently used to assess suicidality in subjects who ples needed for GWAS. Similarly epigenetics reports are are deemed at risk. These include hopelessness, help- more often based on small numbers of subjects and use lessness, described suicidal behaviors or intention to postmortem brain tissue. Additional research in this carry out suicide, comorbid substance abuse, and/or area is warranted given the paramount importance of alcohol abuse as well as specific alterations in cognitive identifying a biological marker for suicide. Clearly large functions including decision-making. Understanding sample GWAS studies, candidate gene studies, and the neural network and processes involved in decision- more epigenetics studies on well-defined patient popu- making may start to provide insights into the altered lations and controls are warranted. thinking and decision-making that often occur in Another major research goal is to integrate find- suicidal individuals. Other important risk factors ings across high-risk populations including patients discussed in this volume include age, trauma history, with mood and anxiety disorders, schizophrenia, per- family history, past personal history of suicidality, and sonality disorders, substance abuse, eating disorders, of most promise biological markers including genet- epilepsy, and child and adolescent disorders as well as ics. It is paramount to develop a standardized objective specific high-risk populations such as the armed assessment to be used in all studies. If this is accom- forces, emergency room, bereavement and grief, col- plished we can begin to create databases to achieve lege students, other medical illnesses, pregnancy, post- adequate analytical statistical power. partum depression, LGBT, and older adults in order to Currently two drugs which appear efficacious in distill core mediators and moderators leading to sui- preventing suicide in specific populations are lithium cide and understand the biology underpinning these and clozapine. Whether these drugs have specific anti- changes. To do this effectively and efficiently we need suicidal properties or reduce suicide because of their to develop and agree upon developed standard instru- superior efficacy remains unresolved. Should these ments to use in common in all these studies which are drugs be used in other populations specifically for quantitative and objective. Subjective assessments are suicide prevention? To address this question requires often biased and affected by the rater’s experience and a large-scale clinical trial of both drugs. The question do not provide acceptable inter-rater reliability of the dose required to produce an antisuicidal effect is between individual raters. An excellent example of important because at the doses they are currently the ability to integrate among and between studies clinically used they are often poorly tolerated and are the emerging imaging studies. These studies have have unacceptable side effects. Low doses of either of different diagnostic groups; the selection of suicidal these drugs may be effective in suicide prevention. subject is based on various criteria including suicidal Equally important is determining which psychothera- behavior, previous attempters, suicidal ideation, and pies are most likely to reduce suicide. seriousness of the attempt. Different imaging modal- In summary and conclusion the research on sui- ities have been employed including structural MRI, cide should focus on: fMRI, DTI, SPECT, and PET. All of these are a rich 1. Development of a valid, easily usable algorithm source of direct brain data and we need to integrate predicting suicide risk with high sensitivity and these data across population and structure, function, specificity neural circuitry and receptor/transporter binding 2. Definition of biological markers that correlate with which have yielded and will continue to yield new the predictor algorithm (1) above insights into the underlying neural suicide circuit. These could then be the groups studied for neuro- 3. Mapping the neural circuitry and the biological regulatory systems and genomic expressions yielding mechanisms involved in suicide fi both new information for understanding the processes 4. Development of effective and speci c antisuicide involved in suicide, as well as new targets for pharma- treatments including pharmacological and/or cological, genetic, or other interventions. psychotherapeutic In this Guide specific sections focus on the behav- 5. Establishment of an objective standardized ioral assessments and clinical signs and symptoms assessment to be used in all studies on suicide. 2 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-03323-8 - A Concise Guide to Understanding Suicide: Epidemiology,
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