LETTERS

ters

TO THE

as part

biology

EDITOR

of the

NIMH

Collaborative

of Depression

Discrepancies

have more ing and

gave

in rates

to say about

local

referral

treatments

than

in persons

with

practices

of the

of suicide

of attempts

differences

across

clinical

in clinical

or panic

disorders

intensity of thanatophobia, ing associated with fear death (4). Thanatophobia,

samples

protocol

screen-

into

the true rate ofsuicide

that the findings further exploration

Psycho-

attempts.

or “self-selection”

they do about mood

We conclude tainby warrant

Study

a history

specific

attempts

in the community.

are not anomalous on their nature

and cerand cause.

REFERENCES I . Beck AT, Steer RA, Sanderson WC, Skeie TM: Panic disorder and suicidal ideation and behavior: discrepant findings in psychiatric outpatients. Am J Psychiatry 1991; 148:1195-1199 2.

Weissman

MM,

Kierman

GL,

Markowitz

JS,

Ouellette

R: Suici-

dal ideation and suicide attempts in panic disorder and attacks. N EnglJ Med 1989; 321:1209-1214 3. Noyes R: Suicide and panic disorder: a review. J Affective Disord 1991; 22:1-11 4. LepineJP, ChignonJM, Teherani M: Suicidal behavior and onset of panic disorder. Arch Gen Psychiatry 1991; 48:668-669 S. Petronis KR, Samuels JF, Moscicki EK, Anthony JC: An epide-

miologic

investigation

of potential

risk factors

for suicide

tempts. Soc Psychiatry Psychiatr Epidemiol 1990; 25:193-1 6. AnthonyJC, Petronis KR: Panic attacks and suicide attempts ter). Arch Gen Psychiatry 1991; 48:1114 7.

FawcertJ,

Schefrner

W, Clark

W: Clinical predictors disorders: a controlled 144:35-40

D, Hedeker

of suicide prospective

D, Gibbons

at99 (let-

R, Coryell

in patients with major affective study. Am J Psychiatry 1987;

MYRNA M. WEISSMAN, PH.D. GERALD L. KLERMAN, M.D. JIM JOHNSON, PH.D. New York, N.Y.

the unfounded conviction of dyof news that provokes thoughts of

as measured by Kellner’s Illness Attitude Scales, was found to be significantly higher in patients with agoraphobia associated with panic attacks, compared to healthy control subjects, and to wane when agoraphobia was treated by behavioral methods (5). Thirty-eight patients (54.3%) of the 70 here reported scored 4 or above for thanatophobia on the phobia item of the Clinical Interview for Depression. It is rather common in various research interviews to start exploring suicidal ideations by asking whether there has been a period when the patient thought a lot about death. The majority of patients with panic disorder and agoraphobia were found to be obsessed by the idea of death, and yet these thoughts are part of hypochondriacal concerns (4). Unlike experienced clinicians, lay interviewers in epidemiobogical studies may be misled by these thoughts and interpret them as part of suicidal tendencies.

REFERENCES I . Noyes R: Suicide and panic disorder: a review. J Affective Disord 1991; 22:1-11 2. Paykel ES: The Clinical Interview for Depression. J Affective Disord 1985; 9:85-96 3. Fava GA, Keliner R, Lisansky J, Park 5, Perini GI, Zielezny M: Rating depression in normals and depressives. J Affective Disord 1986; 11:29-33 4. Fava GA, Grandi 5: Differential diagnosis of hypochondriacal fears and beliefs. Psychother Psychosom 1991; 55:114-119 S. Fava GA, Kellner R, Zielezny M, Grandi 5: Hypochondriacal fears and beliefs in agoraphobia. J Affective Disord 1988; 14: 239-244 GIOVANNI

SILVANA GIANNI

SIR: Dr. Beck and associates reported on the lack of association between panic disorder and suicidal ideation and behavion in clinical populations, in contrast with previous research evidence mainly based on epidemiologicab studies (1). We investigated the occurrence of suicidal ideations and attempts in a consecutive series of 70 outpatients referred to our Affec-

Dr.

tive Disorders Program (48 women and 22 men; mean age=34.2 years, SD=9.S years), five of whom satisfied the DSM-III-R criteria for panic disorder with agoraphobia. Pa-

we

tients

with

concurrent

major

depressive

disorder

were

cx-

eluded. Suicidal tendencies were evaluated by the 7-point scale of Paykel’s Clinical Interview for Depression, a semistructured research interview (2). This scale consists of specific anchor points, from “no suicidal ideations” (score 1 ) through “patient

has

thoughts

of taking

no plans”

(score

4) to “suicidal

kind” 75%

life,

control disorder

subjects and

but

attempt

(score 7). The cut-off point of patients with DSM-III

healthy panic

his

would

not,

of 4 was

found

tant regarding suggest another ing

some

1412

is a rather

cases,

has

minor

to apply

to

melancholia and to 5% of (3). Only one of the 70 patients with

agoraphobia

(1 .4%)

reported

suicidal

dencies, as identified, in the previous month. These thus support those by Dr. Beck and colleagues. Dr. Beck and colleagues discuss several potential tions for the epidemiobogical vious history

and

of any but most

ten-

findings explana-

discrepancies between their clinical study and findings ( 1 ). We agree that undetected or preof mood disorders may be particularly impor-

suicidal behavior. We have data, explanation of suicidal ideations. common it may occur

however, to Fear of dy-

symptom during panic attacks. also at other times and reach

In the

A. FAVA,

M.D.

GRANDI,

M.D.

SAVRON,

M.D.

SANDRA CONTI, CHIARA RAFANELLI, Bologna,

Beck

and Colleagues

M.D. M.D. Italy

Reply

SIR: Although our article was published in September 1991, wrote it shortly after reading Dr. Weissman and associates’ I 989 article ( I ). Therefore, we are indebted to them for describing more recent reviews and studies. We concur that the original

findings

We address

can

no

longer

be

considered

“anomalous.”

their

points below. 1 . Replication. A critical review of the literature is beyond the scope of this better. However, many of the studies cited by Dr. Weissman and colleagues are not so supportive as suggested. For example, the 1 6 studies reviewed in the article by Noyes consist of eight retrospective studies of the relation of neuroses (not panic disorder) to suicide attempts and eight retrospective studies ofthe relation of anxiety states or anxiety neuroses to suicide attempts. Several of these samples included patients whose diagnoses antedated by several decades the inelusion of panic disorder as a separate entity in DSM-III. Also included in this review were six studies of completed suicides, none of which showed a relationship between panic disorder and suicide. 2. Comorbidity and Multiple Diagnoses. To test the issues about comorbidity raised by Dr. Weissman and associates, we identified a sample of 559 (31.2%) of 1,794 outpatients consecutively evaluated according to DSM-III-R criteria at the Cen-

Am

]

Psychiatry

149:1

0, October

1992

LETTERS

ter for Cognitive Therapy between 1986 and August 1991 who represented the types ofdiagnostic combinations that Dr. Weissman and colleagues suggested might be evaluated with respect to past suicide attempts. We excluded patients from 1985 because some of them were diagnosed according to DSM-III entenia. All of the current patients were diagnosed with the SCID, and the information about a past suicide attempt was gathered with the Scale for Suicide Ideation as in our previous study. Instead of focusing on just secondary comorbid diagnoses, we

extended

our scope

None

of the

disorder

for

to tertiary

53

patients

whom

diagnoses. diagnosed

there

was

no

suicide attempt. Five (3.6%) with a primary panic disorder tiary mood disorder described

(6.4%)

of the 310

patients

with

a primary

panic

described

a past

comorbidity

question

EDITOR

of recent suicide attempters, c) examination of individuals currently diagnosed as having panic disorder, d) “psy-

chobogical gitudinal affective

autopsies”

of completed

prospective studies disorder patients.

suicides, of

We appreciate seeing the letter from who point out several possible sources

panic

and

e) Ion-

disorder

and

Dr. Fava and associates of error (fear of death,

hypochondriacal fixations, etc.) in categorizing death-related thoughts as suicidal ideation. Their overall finding that suicidal ideation is not specifically associated with panic disorder raises further questions regarding the issue of panic disorder as a risk factor in suicidal behavior.

of the

140 patients diagnosed either a secondary or tera past suicide attempt. Twenty

and

diagnosed

with

a primary

mood

disorder for whom there was no comorbidity described having made a past suicide attempt, while four (7A%) of the 56 patients diagnosed with a primary mood disorder and either a secondary or tertiary panic disorder described having made a past suicide attempt. In summary, the presence of a mood disorder, whether primary, secondary, or tertiary, was the consistent correlate of previous suicide attempts. 3. Referrals to the Centerfor Cognitive Therapy. Our finding of 7% for lifetime suicide attempts may not be low for an outpatient sample. In the study by Fawcett (cited by Dr. Weissman and colleagues), 80% of the sample consisted of inpatients, many of whom presumably had been hospitalized because of recent suicide attempts.

A major

TO THE

is the ascertainment

of suicide

REFERENCE 1 . Weissman MM, Klerman GL, Markowitz JS, Ouellette R: Suicidal ideation and suicide attempts in panic disorder and attacks. NEnglJMed 1989; 321:1209-1214 AARON T. BECK, M.D. ROBERT A. STEER, ED.D. WILLIAM C. SANDERSON, PH.D. Philadelphia, Pa.

With

Seizure

and that

Low

Clozapine

of

SIR: I refer to a letter to the Editor by Pierre Thomas, M.D., Michel Goudemand, M.D. ( 1 ). From the letter it appears the patient in reference was prescribed clozapine after he

did not respond

attempts.

Doses

to treatment

have determined stantial degree patients cidal

“filtering

hypothesis,”

that our entire sample of patients of suicidality. In fact, 587 (32.7%)

in all diagnostic

categories

presented

with

we

has a subof 1,794 current

sui-

United

States,

the use of cbozapine would have been premature. Use of a medication with the potential for complications that is carried by clozapine should be reserved for cases where alternative

most

treatments

patients

would

have

been

respond

reasonably

exhausted.

to habopenidob,

While

20 mg/day,

some

ideation.

We recommend

that

further

research,

particularly

prospec-

tive studies, should address a number ofmethodological, clinical, and conceptual issues before we can arrive at any definitive conclusions. Our recommendations include the following: 1 . Ascertainment ofsuicide attempts. A more refined definition that restricts “suicide attempts” to instances in which

there

“deliberate

is an

intent

to

self-harm”

or

die

and

classifies

“parasuicide”

other

acts

ditions

that

fective

disorders,

combination,

can

be

associated

multiple personality

with

suicide

attempts:

af-

depression-anxiety (especially

borderline

personality disorder), and substance use disorders. 5. Comprehensive study ofhypotheses. Convergent validity of the hypothesized association between panic and suicide should be established on the basis of a variety of related studies: a) community surveys (as in the studies by Dr. Weissman and colleagues), b) clinical examination

]

Psychiatry

149;1

0, October

I . Thomas (letter).

P, Goudemand AmJ Psychiatry

M: Seizure with low dose 1992; 149:138-139

of clozapine

JOSEPH MORE, Middletown,

M.D. Conn.

is suggested.

diagnoses, disorders

REFERENCE

as

2. Definition ofpanic disorder. The policy of equating diagnoses of “anxiety states” with the diagnosis of “panic disorder” appears to be unjustified. 3. Sequence. Some kind of program needs to be laid out to address the questions of sequence and of proximal versus distal relationships of clinical diagnoses and suicidal attempt. 4. Comorbidity. Data should include all of the clinical con-

Am

in the

If

patients may require higher doses, and if that failed, a trial with another “conventional” neurobeptic would have been in order. I hope that the letter of Drs. Thomas and Goudemand will serve to encourage us to maintain these standards.

the

prevalent

20 mg/day.

suicide

Regarding

standards

habopenidol,

this

attempts.

is so, by current

with

Many individuals report having made “suicide attempts” but acknowledge not having had any wish to die. It is possible that our stringent criteria for ascertainment of lifetime suicidal attempts may account for what appears to be a low rate. In any event, there is no discernible basis for the suggestion that patients referred to our clinic were screened out for previous

1992

Dr. Goudemand

and Dr. Thomas

SIR: We agree with Dr. precautions to be taken treatment.

More’s before

Reply advice about implementation

However, our purpose was to mention effect (seizure with low doses of clozapine) ticular precautions ing dosage. Thus,

our patient idol

changed,

an unusual adverse and consequent par-

(i.e., during EEG) to be taken while increaswe did not go deeper into the reasons why

was prescribed

treatment,

the reserves and of clozapine

psychotic

moreover,

clozapine features

our patient

treatment. and

delusions

experienced

With

haloper-

persisted

incapacitating

un-

and

incorrigible extrapyramidal symptoms. In our clinical expenience such a combination required an increase in dosage, as webb as the use of another “conventional” neuroleptic. In our ward, since 1989 only 10 patients have been pre-

1413