Drug Use In Assisted Suicide And Euthanasia

Editors: Margaret P. Battin, Arthur G. Lipman
Pharmaceutical Products Press, 10 Alice St, Binghamton, NY 13904-1580 USA
1996/360 pp

Balanced discussion of a controversial topic

Overall Rating

Very good

Strengths

Balanced discussion of ethical, personal, legal, and pharmaceutical aspects of assisted suicide and euthanasia

Audience

All those (potentially) involved in decision making regarding assisted suicide and euthanasia

It is generally assumed that death by assisted suicide or euthanasia is to be caused by lethal doses of drugs, not guns or other violent means. This book addresses issues about the use of drugs in actively bringing about death. However, it offers much more than the title and the purpose suggest.

Many chapters, some written by opponents of assisted suicide and euthanasia and others by advocates of these practices, offer excellent discussions of multiple aspects of assisted suicide and euthanasia, creating deep awareness of the complex issues involved. The perspective of pharmacists, which has often been overlooked, provides insightful information about pharmacists’ attitudes about the use of drugs intended to end the lives of terminally ill patients. Concrete and specific information about the actual practice of drug use in assisted suicide and euthanasia is included.

An important message that is conveyed throughout the book is that, whether we favour or oppose these practices, we cannot deny that they happen. One of the papers demonstrates that self-enacted and assisted death is more common than previously suspected and provides a moving account of what happens when drugs fail.

Palliative care and pain control, which are often suggested as alternatives to assisted suicide and euthanasia, receive ample attention. However, as some papers suggest, it is not always the experience of pain but unbearable suffering that leads terminally ill patients to ask for termination of their lives.

A particularly important issue for physicians is the attention paid to patient-physician communication and the need for long-range planning with patients and families regarding pain control and symptom management.

The final section of the book contains many position statements of various organizations in the United States, followed by a series of brief clinical vignettes and commentaries. These provide a basis for readers to analyze their personal positions on active life-ending acts.

Everyone interested in end-of-life decision making is likely to find something valuable in this book.

There has been continuing speculation about a relationship between fluoxetine (Prozac) use and increased suicidal behavior since six cases were reported in 1990, which were followed by several other similar case reports. However, subsequent retrospective analyses of large patient samples, surveys of psychiatrists, and re-analysis of many clinical studies of fluoxetine and other newer antidepressant drugs failed to find such a relationship.

In 1999, Leon et al. reported a prospective, naturalistic 15-year follow-up study from the National Institute of Mental Health Collaborative Depression Study. Analyses of this study focused on data from the time fluoxetine was available in the United States. Since case reports, retrospective studies, randomized clinical trials and surveys of prescribers all have limitations as to applicability to the general population of patients taking fluoxetine (Prozac), this NIMH study, with its close and frequent clinical assessments, offered the unique opportunity to evaluate this issue in a naturalistic treatment setting.

Method

The study focused on 643 subjects who were followed after approval of fluoxetine (Prozac) by the U.S. Food and Drug Administration at the end of 1987. Women comprised 64% of the sample, and 77% of subjects were inpatients at intake. Diagnosis at intake was major depressive disorder only (72%), mania or hypomania (21%), and schizoaffective disorder (7%).

A total of 185 subjects received fluoxetine (Prozac), 226 subjects received antidepressants other than fluoxetine (with imipramine [Tofranil] equivalence of at least 100 mg daily) and 232 subjects received no treatment. Over 89% of fluoxetine subjects also received at least one other antidepressant at some point during the follow-up period.

Suicidal risk for other selective serotonin reuptake inhibitors could not be assessed since they were not commonly prescribed or available during the study period. Therefore, the majority of subjects taking other antidepressants were using tricyclic antidepressants (TCAs).

Severity of affective psychopathology was rated on a weekly basis, and information on circumstances of suicide attempts and deaths was recorded. Each suicidal act was rated with regard to intent and lethality. Each of the three treatment groups had similar proportions of suicide attempts in the year prior to entry into the study.

Results

In the 185 subjects who received fluoxetine (Prozac), one suicide occurred and six other subjects had 11 suicide attempts. Of the six subjects with a suicide attempt, two patients each were taking 20 mg, 40 mg and 60 mg daily. Five of the six were taking at least one other psychotropic medication at the time of the suicide attempt-three were taking an additional antidepressant, and four an antipsychotic drug. The proportion who exhibited suicidal behavior was significantly reduced from 38.9% during the study follow-up prior to treatment with fluoxetine to just 3.8% during fluoxetine treatment.

There was one suicide and 42 suicide attempts by 23 subjects among the 226 subjects treated with antidepressants other than fluoxetine (Prozac). In the group of 232 subjects not treated with antidepressants, there were three suicides and 66 suicide attempts by 39 subjects.

Comparison of suicide intent and lethality found the highest ratings among those subjects not taking an antidepressant and the lowest ratings for those subjects taking fluoxetine (Prozac), but these differences did not reach statistical significance. In all subjects, the severity of psychopathology was strongly associated with an elevated risk of suicidal behavior.

Relative to no antidepressant treatment, there were nonsignificant reductions in the risk of suicide attempts associated with the use of fluoxetine and with the use of other antidepressant drugs. When factors of gender, age, diagnosis at intake, psychopathology and number of prior suicide attempts were controlled, fluoxetine was associated with a 56% decrease in risk of suicidal behavior. Antidepressants other than fluoxetine were associated with a 40% decrease in risk of suicidal behavior.

Study Conclusions

Study limitations were those inherent in a naturalistic study. Treatment was not randomly assigned, and antidepressant drugs other than fluoxetine (Prozac) were classified in aggregate for the analyses. In addition, long-term follow-up studies typically have high dropout rates, although two-thirds of fluoxetine (Prozac) patients in this study were followed for at least four years. Finally, even though the study numbers were large, it may have been inadequate for the study of an uncommon event such as suicide, and less serious suicide attempts might have been missed.

The results indicate that although fluoxetine (Prozac) was prescribed to more severely ill subjects, their risk of suicidal behavior was not elevated. Only seven of 185 (3.8%) subjects taking fluoxetine had suicidal attempts, compared to 23 of 226 (10.2%) subjects taking other antidepressants and 39 of 232 (16.8%) subjects receiving no antidepressant drug therapy.

The speculation that fluoxetine may increase the risk of suicide was not supported in this naturalistic study. Rather, a nonsignificant reduction in risk of suicidal behavior among patients treated with fluoxetine (Prozac) was found.

Case Reports

In 1990, Teicher et al. reported six cases of emergence, re-emergence or intensification of suicidal ideation in patients with major depression after two to seven weeks of treatment with fluoxetine (Prozac). While all patients were begun on 20 mg daily, four received doses greater than 40 mg per day, one stayed at 20 mg and another was titrated up to 40 mg then lowered back to 20 mg due to adverse effects.

The increased suicidal ideation persisted from three days to three months after fluoxetine was discontinued. Four of the six patients had comorbid psychiatric diagnoses, three were taking other psychotropic medication and four had histories of suicidal ideation or gestures. Four of the patients complained of inner restlessness.

In 1990, additional cases of fluoxetine-associated suicidal ideation were reported by Dasgupta and Hoover, although in one case, similar symptoms developed during subsequent treatment with imipramine, making specific association with fluoxetine (Prozac) unlikely.

Masand et al. in 1991 reported emergence of suicidal ideation in two cases-one was related to nonresponse to fluoxetine (Prozac), the other had both major depression and bulimia nervosa. In all case reports, no clear relationship was demonstrated between the emergence of suicidal thoughts or behavior and fluoxetine (Prozac) doses.

Fluoxetine is not unique in being the only antidepressant with case reports of paradoxical worsening of depressive symptoms, including suicidal ideation. Prior to the report by Teicher and his colleagues, four cases of worsened depressive symptoms and emergence of suicidal ideation after treatment with desipramine (Norpramin) 75 mg to 100 mg were reported (Damluji and Ferguson, 1988).

Within the first two weeks of treatment, all four patients had a noticeable worsening of depressive symptoms, particularly dysphoria, development of suicidal ideation not present prior to treatment and a worsening of neurovegetative symptoms. These symptoms were unrelated to any adverse effects.

In three patients, discontinuation of desipramine resulted in prompt relief of the worsened symptoms, but switching to either nortriptyline (Pamelor, Aventyl), amoxapine (Asendin) and trazodone (Desyrel) resulted in return of suicidal ideation. Interestingly, in one case, trials of both desipramine and amoxapine resulted in emergence of suicidal ideation, but a third trial of fluoxetine led to complete remission of the patient’s symptoms.

Other Studies

While case reports suggest an association between fluoxetine (Prozac) and emergence of suicidal ideation, surveys of prescribers, retrospective postmarketing studies and evaluation of premarketing clinical study data in thousands of fluoxetine patients failed to demonstrate a relationship between fluoxetine (Prozac) and suicide.

In 1991, Fava and Rosenbaum surveyed 27 psychiatrists who treated 1,017 depressed outpatients with an antidepressant drug. Of the 231 patients treated with fluoxetine alone, eight patients (3.5%) became suicidal after treatment was initiated. This compares to 6.5% of patients treated with both a TCA and fluoxetine (Prozac), 1.3% of patients treated with a TCA or lithium alone, and 3% of patients given other antidepressant drugs. No patients reported intense suicidal ideation of the degree described in Teicher et al.

At Eli Lilly and Co., a meta-analysis of clinical trial data by Beasley et al. in 1991 found that 1.2% of fluoxetine-treated patients experienced emergence of suicidal ideation during treatment, as compared to 2.6% on placebo and 3.6% on TCAs. Suicidal ideation improved in 72% of fluoxetine-treated patients compared to 55% of placebo patients.

Some of these case reports speculated that the association of fluoxetine (Prozac) and suicidality may be related to a drug-induced akathisia or restlessness, since four of Teicher’s six cases reported inner restlessness. All serotonin reuptake inhibitor drugs, including fluoxetine, have been reported to cause akathisia.

An analysis of 17 controlled clinical trials was conducted at Lilly Research Laboratories by Tollefson et al. in 1994 to test the hypothesis that patients who develop activation or akathisia from antidepressants might experience an associated emergent suicidal ideation. In the more than 3,000 patients analyzed, no temporal association was found between emergent suicidal ideation and any adverse effect cluster. Suicidality was associated infrequently with treatment-emergent activation, and at comparable rates, among fluoxetine (Prozac), TCAs and placebo-treated patients.

Discussion

While there are case reports of a temporal relationship between fluoxetine (Prozac) treatment and emergent suicidal ideation, this large naturalistic study adds to the substantial literature of meta-analyses of clinical trials with thousands of patients and retrospective reviews that fail to demonstrate such a relationship. The emergence or intensification of suicidal ideation is possible with any antidepressant drug.

One possible explanation of this observation is the lack of clinical response to the antidepressant and continued worsening of the depressive symptoms. Another explanation is that sleep disturbance and lack of energy are usually the first symptoms responsive to antidepressant drug therapy, occurring prior to the improvement of anhedonia and dysphoric mood. The suicidal depressed patient may thus have improved energy yet continued dysphoria and suicidal ideation. This may lead to an attempt at suicide after drug therapy begins.

All of these possible explanations of emergent or intensified suicidal ideation suggest the need for all depressed patients to be carefully monitored and evaluated in the first month or two of treatment.

Risk Management with Suicidal Patients

Bongar B, Berman AL, Mavis RW, Silverman MM, Harris EA, Pakman WL, editors

New York: The Guilford Press; 1998.197 pp with index

ISBN 1-57230-302-6 (cloth)

This book was written in response to the fact that most psychiatrists lose a patient to suicide sometime during their professional life. Suicide cases are a leading reason for malpractice action against mental health professionals. Dr. Bongar begins by suggesting that this book is “a forum for the exploration of avoiding liability in working with the suicidal patient.” In his introduction, Bongar stresses that the book is not intended as a standard of care, but rather “a rich and wide-ranging set of opinions and guidelines.” However, the book is quite contradictory on this point — Chapters 1, 3 and 4 are dedicated to discussing standards of care and the suicidal patient. Since this book, authored by experts in suicidology, and based on work published in the American Association for Suicidology’s official journal, will have an important impact on the care of suicidal patients, its deficiencies must be addressed.

This book includes 3 chapters based on articles previously published in Suicide and Life-threatening Behavior, and 4 new chapters. The contributors include many of the most prominent American suicidologists, including Drs. Alan Berman, Bruce Bongar, Robert Litman, Ronald Maris, Morton Silverman and Andrew Slaby. Chapter 1 is dedicated to the outpatient management of suicidal patients. It discusses common failure scenarios from malpractice proceedings and goes on to outline an outpatient standard of care. Bongar and coauthors originally published this paper in Suicide and Life-threatening Behavior in 1992. In Chapter 2, Dr. Slaby presents the essential elements of outpatient care of the suicidal patient. However, given its all-encompassing goal, the chapter ends up being a cursory discussion of many important issues. For example, when discussing the management of patients with borderline personality disorder, Dr. Slaby simply concludes, “Clinicians are not gods and are not able to predict or prevent all deaths by suicide. This is most true when they are dealing with Axis II personality disorders.” (page 35). Fortunately, the American Psychiatric Association is developing practice guidelines for the care of patients with borderline personality disorder. This will provide a more comprehensive statement about what is known and not known about the care of these patients. Chapters 3 and 4 are based on articles that were published in 1993 and 1994, respectively, in Suicide and Life-Threatening Behavior. The editors have included a commentary of Chapters 3 and 4 from Dr. Robert Litman, who criticizes Dr. Silverman’s Chapter 4 for providing good clinical practice standards, but not the minimal standards that are often the reference point for court proceedings. Chapter 5 is a new contribution by Drs. Goldblatt, Silverman and Schatz-berg, dealing with the psychopharmacological treatment of suicidal inpatients. However, the chapter is disturbingly incomplete. For example, the value of lithium maintenance treatment in reducing the risk of suicide for bipolar disorder and clozapine treatment in reducing the risk of suicide in schizophrenia are inadequately addressed. These treatments may have important indications in the suicidal behaviour of individuals with these specific diagnoses. Also, the discussion of borderline personality disorder is badly outdated; for instance, their most recent reference is from 1986 and recent evidence for using selective serotonin reuptake inhibitors for individuals with impulsive aggressiveness is ignored. Chapter 6, a new contribution by Dr. Silverman, purports to be a model for psychopharmacological interventions for hospitalized patients. A psychiatrist will find this discussion broad and uninformative. I suspect that the target audience for this chapter is the psychologist, who may find discussion of the steps that are needed to determine appropriate psychopharmacotherapy informative. The last chapter on the risk management of suicidal patients, by Drs. Packman and Harris, contains very practical suggestions for minimizing liability. For example, the authors provide an approach for discussing, at the outset of therapy, breach of confidentiality when a highly suicidal patient is in crisis and there is a need to inform the patient’s family. This chapter is more current, as it discusses the issues of liability in the managed care environment. A document that includes in its title “standard of care” for suicidal patients has the potential to do more harm than good. This book is primarily based on data from malpractice claims to develop “standards of care” for suicidal inpatients and outpatients. As a result, most of the chapters are outdated with regard to recent scientific evidence. The 3 reprinted chapters appear to have been published without any attempt to update the references. The new contributions do not provide a clear statement of the nature of the supporting evidence used to develop their approach, and do not appear to include the evidence based on empirical research. Therefore, this book eschews the scientific evidence that has accumulated to guide clinical practice. Drs. Rudd and Joiner have recently published a paper on the assessment, management and treatment of suicidality based on existing literature, and provide an important alternative to the approach by Bongar and colleagues.

The book is under 200 pages, well produced and contains no production errors. Although this book will attain prominence in the fields of psychiatry and psychology, the reviewer cautions that it has employed a very limited methodology to determine standards of care for suicidal patients. This contribution must be seen as only one facet in the development of the appropriate care for suicidal patients.

Edited by John Donnelly
Contemporary Issues in Philosophy; series editors, Robert M. Baird and Stuart E. Rosenbaum. 212 pp
Prometheus Books, Buffalo, NY. 1990
ISBN 0-87975-595-4

This book is a collection of essays on suicide. There are three sections, dealing with background history, definitions, and the rationality and morality of suicide. John Donnelly, the editor, has written a 16-page introduction. It is very short and can act only as a guide toward what to expect from each author. Readers may find the introduction more useful as a revision after reading the essays. There are brief notes and references at the end of each contribution.

In a book of carefully reasoned arguments it is somewhat surprising to see the editor state: “Of course millions of people unsuccessfully attempt suicide every year.” Certainly millions of people in North America may swallow large quantities of pills or cut themselves with razors, but it is likely that only a minority are trying to kill themselves. The term “attempted suicide” has been useful, but in the interests of accuracy “deliberate self-harm”, “self-injury” or even “parasuicide” is preferable.

The historical background section includes essays by Seneca, Immanuel Kant, David Hume and St. Thomas Aquinas. There are five chapters in the section on definitions, and the rather mixed collection in the third part includes works by Edwin S. Schneidman, Thomas S. Szasz and Joyce Carol Oates. The pieces by Shneidman (reprinted from a 1965 article) and Szasz (1971) seem, curiously, more out of date than those of Seneca and Hume, which were published 2000 and 200 years ago respectively. Seneca’s arguments in particular have a present-day feel about them.

Shneidman is evangelical and enthusiastic about prevention. We are now coming to a much more modest view than his. It has to be acknowledged that attempts to change the frequency of suicide in society have been quite without success, and even in individual cases we can legitimately boast only of postponing suicide, not of preventing it.

Szasz destroys his case by overstating it. He adopts the extreme libertarian point of view and, to support his case, denies that suicide can be the product of disorders. He has elsewhere1 argued convincingly that mental illness is a logical absurdity, but here he seems to deny that illnesses or disorders can result in suicide. In the light of what was known even in 1971 about major depression, substance abuse, schizophrenia and organic brain disorders, this position seems disingenuous. Szasz would not expend any effort to prevent people from killing themselves — even, presumably, a woman in a post-partum confusional state or a previously healthy elderly person suffering from an acute major depression. In spite of this, one of his assertions needs to be addressed very seriously. He states that “coerced psychiatric interventions may increase rather than diminish the suicidal person’s desire for self-destruction”. There seems to be no more evidence to refute this argument now than there was in 1971.

There are well-argued discussions on intention as an important criterion in the definition of suicide (by Glenn C. Graber and William E. Tolhurst), and the reader will certainly be interested in the distinction between weak and strong intentions.

Suicide: Right or Wrong? does not pretend to be a practical guide, but I shall certainly reread many of these essays. Clinicians can so easily become narrowly focused in dealing with the everyday reality of suicide risk; it is refreshing to be able to step outside the confines of medical and legal constraints. Reading this book may not make much difference to our clinical decisions, but it serves as a reminder of what complicated attitudes society has toward suicide. As doctors, particularly psychiatrists, we sometimes feel that society requires us to do mutually exclusive things: to allow people the freedom and dignity to manage their own lives (and deaths?) and both to predict suicide accurately (impossible) and to prevent it (impractical).

In summary, I recommend this book most highly. It could serve as a handy and comforting companion to anyone who deals even remotely with the vexed questions raised by self-injurious behaviour and self-inflicted death.

General Principles of Pharmacologic Intervention

A thorough history, physical examination, and basic laboratory studies are important to fully evaluate the patient and rule out medical and medication-related causes of insomnia and depression. Additionally, the selection of the appropriate antidepressant medication (selective serotonin reuptake inhibitors, tricyclic antidepressants [TCAs], monoamine oxidase inhibitors, or atypical antidepressants), adequate dosages, and a sufficient trial period are imperative in the treatment of depression in the elderly. In seniors, an adequate antidepressant trial is longer than that for younger adults, with a complete response often seen after six to 12 weeks. Nuances related to medication therapy in the geriatric population should be clearly expressed by pharmacists in recommendations and educational communications. The impact of aging and medical conditions associated with aging on the pharmacokinetic profile of a medication and the increased risk of associated side effects must be understood with regard to geriatric dosage guidelines, disease-drug contraindications (eg, TCAs and cardiac conduction defects), and drug interactions (eg, CYP450 inhibition and possible toxicities).

When sleep medication is deemed the best course of treatment after careful consideration of nonpharmacologic interventions (eg, sleep hygiene, stimulus-control therapy, and sleep-restriction therapy) in the elderly, short-acting nonbenzodiazepine hypnotics (zolpidem or zaleplon) are recommended. These medications reduce both sleep latency, due to their quick absorption and onset, and the risk of daytime sleepiness the following day, due to their short half-life. Caution should be exercised when a longer-acting hypnotic is prescribed in a geriatric patient since associated side effects may be particularly pronounced in seniors. Longer-acting hypnotic agents may be associated with changes in sleep architecture such as a reduction in delta or deep sleep, morning hangover with excessive daytime sleepiness, impaired motor coordination, and visuospatial problems that may contribute to an increased risk of injury. In an attempt to prevent rebound insomnia, a very gradual taper is recommended when termination of treatment is warranted.

Conclusion

When caring for older patients, it is important to make the distinction between pathological changes and normal aging. Remaining cognizant of this helps to avoid not only dismissing a treatable pathology as merely an accompaniment to old age but also treating a natural aging process as a disease while overlooking the possibility of iatrogenic effects.

Insomnia may be a symptom of medical and psychiatric conditions, changes in lifestyle, or medications, among other precipitating factors. When an elderly patient presents with complaints of insomnia, the clinician should assess for possible depression since many seniors do not seek help for or verbally express symptoms of this condition, which is common among them and is associated with morbidity and mortality. By raising awareness that insomnia, a symptom of depression for many people, may be reported more readily than depressive symptoms, pharmacists may become involved in identifying those at risk for depression and in facilitating the appropriate evaluation, intervention, and education of patients and their families and caregivers.

Depression, Morbidity, and Suicide Risk

Why is it so important to assess the risk for depression in a senior with insomnia who may not feel comfortable with the subject or who feels stigmatized by self-reporting a depressed mood? As mentioned earlier, a depressive disorder is among the most common causes for sleep disturbances in the elderly. Furthermore, depression is one of the most common psychiatric disorders among the elderly, with clinically significant depressive symptoms appearing in 30% of institutionalized seniors and in 8% to 15% of community-dwelling elderly. It has been shown that patients with any medical diagnosis were twice as likely to develop depression than were patients without a medical diagnosis. Depression increases mortality in hospitalized patients, increases medical morbidity, worsens the outcomes of medical disorders, increases the perception of poor health and the use of medical services, and increases the economic burden on the health care system.

It must not be overlooked that depression is the psychiatric disorder most likely to raise the risk of successful suicide in the elderly (TABLE 3). Statistics reveal that suicide rates in the United States are highest in people 70 and older. Suicide in white men is 45% more common in those ages 65 to 69 than in those ages 15 to 19. It is about 85% more common in those ages 70 to 74 and greater than three and one half times more common in men older than 85 than in men in the 15-to-19 age group. While suicide attempts are rarer in older people than in younger people, they are more lethal as a result of more careful planning, more lethal self-destructive acts, and fewer indications of the intent. Younger patients are more likely to seek or respond to suicide interventions than are the elderly. Although mood disorders are more prevalent in women than men across the spectrum of age, successful suicide is disproportionately higher in males, especially in elderly men.

Diagnostic Questioning and the Geriatric Depression Scale (GDS)

Unless specific questions are asked, depression may go unrecognized, as it is well known that as many as 70% of seniors who commit suicide were seen by their primary care physicians within the last few weeks of their lives. Presentation of depression in the elderly varies as compared with that in the younger population. Rather than psychological complaints, somatic complaints often predominate in the clinical scenario. Although older patients often do not report a dysphoric mood, apathy and withdrawal are common. Loss of self-esteem is prominent, and guilt is less common. The inability to concentrate, with a resultant impairment of memory and other cognitive functions, is commonly seen. In addition to a review of systems, health care practitioners can question elderly patients regarding: sleep disturbance, appetite changes, trouble concentrating, lack of energy, and loss of interest. Whenever possible, in addition to ongoing primary care, referral for consultation with an experienced geriatric psychiatrist and/or psychologist is helpful in diagnosing and managing depressive disorders.

Senior care pharmacists may find the Geriatric Depression Scale (GDS) helpful in identifying depressed geriatric patients for referral for a full evaluation. The GDS may also be used subsequently by the pharmacist as an outcomes measure of antidepressant therapy in the management of depression.

The notion that aging is a multifactorial process is commonly accepted. Many of the age-related changes that occur in a senior’s nervous system have an impact on the function of sleep. In the elderly, sleeping difficulties often occur in conjunction with depression. Because depression raises the risk of suicide in this population, it is important for pharmacists to question their elderly patients about sleeping difficulties.

Sleep Difficulties Increase With Aging

Complaints of sleep difficulty increase with age, tend to be more common in women than in men, and occur in about 50% of community-dwelling elderly people. The loss of sleep associated with sleep disturbances directly affects quality of life and often contributes to increased risk of chronic fatigue, falls, and accidents. Insomnia, a complaint of poor quality of sleep, results in a sense of nonrestorative sleep. Through both objective and subjective reporting, it has been shown that elderly adults, as compared to younger adults, have longer sleep latency (time to fall asleep), lower sleep efficiency (amount of sleep given the length of time in bed), a higher number of nighttime awakenings, awaken earlier in the morning than they would like, and need more daytime naps. In fact, the sleep pattern is altered in elderly individuals, with a significant decrease in delta sleep, REM sleep, and total sleep time.

Because of frequent nocturnal awakenings involving wandering and confusion, sleep in institutionalized elderly people living in nursing homes is extremely disturbed. The fragmented sleep seen in these elderly people may be such that in a 24-hour period, not a single hour may be spent fully awake or fully asleep.

Providing both emotional and physical restoration, sleep is essential to life. There is a wide interindividual variability in the amount of sleep required per night, ranging from three to 10 hours.

Insomnia and Depression

It is well documented that insomnia is frequently comorbid with various psychiatric disorders, and researchers have indicated that sleep disturbances may be an early sign or the cause of some psychiatric disorders. While chronic insomnia may trigger depression, the converse has also been shown; that is, depression is a common, prominent cause of insomnia. Depressive and anxiety disorders are among some of the most common causes for sleep disturbances in an elderly individual. The actual relationship between insomnia and depression has been studied in older adults. One British study looked at whether sleep disturbances predict depression in seniors 65 and older. Livingston et al reported that a current sleep disturbance was the strongest predictor of future depression in nondepressed older adults. In another study, Roberts and colleagues looked prospectively at Californians 50 and older and found a variety of factors associated with developing depression one year later: sleep problems, psychomotor agitation, mood disturbance, low self-esteem, and loss of feeling and pleasure. Even though the etiology of sleep disturbances in the development of depression is unclear and sleep problems in older adults may not always be related to depression or result in a future depressive episode, it is important to emphasize that further assessment should be done to rule out all medical, psychiatric, or iatrogenic causes of insomnia. Health care professions should suspect that insomnia lasting more than three weeks may be a symptom of a medical or psychiatric disorder.

While reviewing epidemiologic studies, Ford and Cooper-Patrick found that people in the general population may find it easier and less stigmatizing to report symptoms of insomnia more accurately than symptoms of depression such as poor concentration, fatigue, and depressed mood. Additionally, Ohayon and colleagues reported that a large proportion of individuals with concomitant insomnia and depressive symptoms may seek treatment only for insomnia.

Handbook of Depression. Second Edition

EE Beckham, WR Leber, editors

New York: Guilford Press; 1995. 628 p

This multiauthor book is edited by E Edward Beckham, PhD, and William R Leber, PhD, both associate professors in the Department of Psychiatry and Behavioral Sciences at Oklahoma University. Its 628 pages contain 5 sections and 2 appendices: 1) Defining the Boundaries of Depression (epidemiology, diagnostic classification, assessment of severity and symptom patterns, and relations to other Axis I, Axis II, and Axis III disorders); 2) Biological Processes and Treatments (genetics, biological processes, somatic therapies including drugs, and medical diagnostic procedures); 3) Psychological Therapies (cognitive, behavior, interpersonal, analytic, couple and family, integration, and comparing and combining psychotherapy with pharmacotherapy); 4) Special Populations (children and adolescents, geriatrics, people at risk for suicide, women); and 5) Psychological and Social Contexts (life context and coping processes). The appendices provide information on rating scales available for assessment of depression in children and adults, the adult section including the full Hamilton and Zung rating scales.

This book largely succeeds in its goal of offering a comprehensive and up-to-date review of the field. As a 2nd edition, a number of chapters are polished updates of the 1st edition, and the approach is a scholarly one with plentiful references.

The 1st section on epidemiology, diagnosis, and comorbidity deals successfully with difficult conceptual issues. It also provides useful sections on depression and cancer and other important cardiovascular, neurological, endocrinological, and immunological diseases, including treatments.

The chapter on genetics is restricted, surprisingly, to bipolar illness, in a book otherwise devoted to depression. The chapter on biological processes in depression is substantial (at 66 pages with references) and excellent. The identification of melancholia as a black mood rather than black bile in discussing the views of Hippocrates suggests that the editors need a brushup in the classics!

Treatment for depression is overly weighted toward the psychological therapies, with 6 chapters on psychotherapies, 1 on somatic therapy, and 1 on the combination. The chapter on somatic treatments, brief at 22 pages, succeeds best in its description of the pharmacology of antidepressant drugs. For the psychiatrist reader, the book would have benefitted from separate chapters on electroconvulsive therapy and treatment-resistant depression. Electroconvulsive therapy receives only one-half page, with no reference more recent than 1989 and no reference to the important work of Harold Sackeim and his coworkers at Columbia University. Only a page and a half are given to the treatment of resistant depression; no mention is made of leucotomy, and the references for thyroid hormone augmentation of antidepressant medication are no more recent than 1984, ignoring, for example, recent contributions by Russell Joffe and colleagues. Regarding some statements and recommendations in this chapter, some changes would be advisable: 1st, it takes several weeks (rather than days) to recover normal function of monoamine oxidase after discontinuation of irreversible monoamine oxidase inhibitors; 2nd, 3 to 4 weeks (rather than 2) should elapse after discontinuing an irreversible monoamine oxidase inhibitor before starting serotonin reuptake inhibitors, particularly clomipramine and venlafaxine; and 3rd, it can take considerably longer than 5 weeks for adequate washout of fluoxetine in some patients, and fluoxetine plasma levels can assist in determining when it is safe to commence an irreversible monoamine oxidase inhibitor.

While based on a level of scientific rigor no more advanced than a review of cases treated, the chapter on long-term analytic treatment contains a review of the developments in the psychoanalytic theory of depression and some case descriptions that would be of value to students. The authors assert that “medication ameliorates the more biologically based symptoms (e.g., early morning insomnia, anorexia, or anergia), whereas psychotherapy exerts an effect on the individual’s more psychological functions (e.g., social withdrawal, suicidality, or low self-esteem)” and advocate medication in appropriate cases to permit successful psychotherapy. While it is clear that many patients with depression require psychotherapy in conjunction with medication and that successful pharmacotherapy often creates ideal conditions for successful psychotherapy, it is also clear that medication alone can completely resolve severe “psychological” symptoms of depression, and recent research shows that fluoxetine can even lift mood in normal subjects.

The chapters on special populations are generally balanced and comprehensive. The chapter on women and depression concludes that the female:male ratio for depression of 2:1 is accounted for by social and psychosocial factors rather than biological ones and ends with the warning that DSM nosology may be “a means of perpetuating a white male Eurocentric understanding of what constitutes mental health for this world’s population.” This chapter seemed somewhat 1-sided, but perhaps that is because this reviewer is a biologically oriented white male psychiatrist of European descent!

While the book does appear to have been carefully reviewed and proofed, small errors are inevitably present in a book of this size and scope. For example “ondanserton [sic]” is identified as a 5-HT3 agonist rather than an antagonist at this receptor, and tertiary and secondary amine tricyclics are said to have 3 and 2 methyl groups respectively, rather than 2 and 1.

On balance, the strong points of this book outweigh its weaknesses. It would be a valuable addition to libraries (health sciences, psychology) and would be useful to students in the clinical psychological sciences (psychiatry, clinical psychology) and clinicians and researchers with an interest in depression.