BACKGROUND Mental disorders have a strong association with suicide. This meta-analysis, or statistical overview, of the literature gives an estimate of the suicide risk of the common mental disorders.

METHOD We searched the medical literature to find reports on the mortality of mental disorders. English language reports were located on MEDLINE (1966-1993) with the search terms mental disorders', 'brain injury', 'eating disorders', 'epilepsy', 'suicide attempt', 'psychosurgery', with 'mortality' and 'follow-up studies', and from the reference lists of these reports. We abstracted 249 reports with two years or more follow-up and less than 10% loss of subjects, and compared observed numbers of suicides with those expected. A standardised mortality ratio (SMR) was calculated for each disorder.

RESULTS Of 44 disorders considered, 36 have a significantly raised SMR for suicide, five have a raised SMR which fails to reach significance, one SMR is not raised and for two entries the SMR could not be calculated.

CONCLUSIONS If these results can be generalised then virtually all mental disorders have an increased risk of suicide excepting mental retardation and dementia. The suicide risk is highest for functional and lowest for organic disorders with substance misuse disorders lying between. However, within these broad groupings the suicide risk varies widely.

Suicide as an outcome for mental disorders. A meta-analysis.

This paper is a rough precis of a recent book (GRAY, 1982). It is concerned with the question: what are the brain structures which mediate the psychology as well as the neurology of anxiety? It is clear that, once you start asking questions about the brain, you have to work with animals for reasons that are familiar to everybody. But it is very difficult to start studying emotions in animals, because it is difficult to know what emotions animals experience and whether these are the same as the human emotions. So the first thing one has to look for is a kind of crutch or bridge to get you across from the human domain on one side to the animal domain on the other. Now in the case of anxiety we are quite fortunate in that there are certain drugs which are clinically very effective in controlling anxiety in human subjects. So one can take those drugs and apply them to animals to study their behavioral effects.

The neuropsychology of anxiety

https://link.springer.com/content/pdf/10.1007%2F978-3-642-69631-2_5.pdf

Deep Brain Stimulation of the Ventral Capsule/Ventral Striatum for Treatment-Resistant Depression

Pathophysiology of obsessive-compulsive disorder: a necessary link between phenomenology, neuropsychology, imagery and physiology.

1. 210 patients with long-standing apparently intractable psychiatric illnesses who had undergone the operation of bi-frontal stereotactic tractotomy of the orbital cortex by the use of radioactive yttrium 90 seeds were studied. 150 patients (Group A) together with their relatives and friends were interviewed personally by the psychiatrist and social worker. Information about a further 29 was obtained from other psychiatrists, general practitioners, relatives and a perusal of the relevant clinical records.

2. Of the 150 A cases 49 (33 per cent) recovered completely from their illness and a further 24 (16 per cent) only had minor residual symptoms and required no further treatment. making a total of 49 per cent. A further 35 (23 per cent) improved but still needed treatment, with persistent symptoms. 41 (27 per cent) were unchanged, and one patient was worse.

3. The best results were obtained in the depressions, both recurrent and other forms (56 per cent recovered and much improved). Good results were also obtained in obsessional neurosis (50 per cent recovered and improved). In anxiety states the corresponding figure was 41 per cent. None of the schizophrenic patients did well.

4. No patient showed a gross frontal lobe syndrome post-operatively. In 4 out of the 150 (2.6 per cent) there were some moderate and lasting sequelae. 17 (11.4 per cent) displayed minor and trivial symptoms which were of no practical importance, whereas in 129 (86 per cent) there were no demonstrable personality changes whatsoever. Working capacity and normal enjoyment of pleasure were not affected in any patient.

5. Mortality due to operation was nil.

6. The incidence of permanent epilepsy due to the operation was less than 1 per cent.

7. Of all forms of leucotomy operation stereotactic tractotomy is the one which avoids unnecessary destruction of brain tissue between the cortex and the target area, and it is suggested that further research in this field, with the substantia innominata as a target area, is well worthwhile.

Bi-frontal stereotactic tractotomy. A follow-up study of its effects on 210 patients.

1. Hitherto somnifaine treatment has been regarded as an imperfect form of therapy in mental disorder owing to the toxic risks, which frequently required the treatment to be stopped before any alleviation of the mental illness could take place. The mortality in a large series of cases collected by Muller was 5%. These serious drawbacks have tended to bring the narcotic treatment into disrepute. The fact, however, that by. prolonged narcosis we are able to allay psychotic symptoms not only temporarily, but often permanently, is in itself such an advance that it warranted a search for modified methods of narcosis, which would diminish or abolish toxicity. In this paper a modification of technique has been described, by which it is possible to eliminate dangerous toxic manifestations of somnifaine narcosis.

2. Toxic symptoms which frequently accompany the narcosis have been fully discussed and their significance pointed out. Of these the most important are ketosis, with diminished glucose tolerance, fall of blood-pressure, tachycardia, circulatory collapse, oliguria, albuminuria, disturbances of co-ordination, including difficulty in swallowing, pyrexia and skin-eruptions of an erythematous type. Other changes to be noted are leucocytosis, fall in blood-calcium and slight rise in the blood-urea. Epileptiform convulsions did not occur in the present series.

3. A disturbance of the carbohydrate metabolism of vital organs occurs during prolonged narcosis with somnifaine—a fact which has not previously been recorded in the literature. Clinical evidence of this is seen in the frequent development of ketonuria, which at this hospital has always been regarded as a contra-indication for further treatment. In vitro experiments by other workers in the hospital have shown that narcotics inhibit the oxidation by the brain, liver and heart of substances such as glucose and lactic acid, which are important in carbohydrate metabolism, the inhibitions being much greater with the brain than with other organs. Ketonuria is the outward manifestation of this disturbance, but it is claimed that other symptoms, such as circulatory collapse, can be ascribed to the same fundamental cause.

4. The knowledge that carbohydrate metabolism was affected by narcotics led to the adoption of the administration of insulin and glucose during narcosis with a view to eliminating dangerous symptoms. Of 46 treatments on 40 patients, 14 were carried out without this additional measure, and narcosis had to be prematurely stopped in 5, 4 others being continued with smaller doses. In 15 treatments, insulin and glucose were given on the appearance of ketonuria and major toxic symptoms, with the result that these manifestations entirely disappeared within forty-eight hours. In 17 instances where insulin and glucose were administered from the very beginning no ketosis or other serious complications arose. These results demonstrate that the narcotic treatment has been rendered perfectly safe by means of the modification described.

5. Myocardial degeneration, arteriosclerosis, marasmus and respiratory disorders constitute the chief physical contra-indications for somnifaine treatment.

Somnifaine Narcosis: Toxic Symptoms and their Treatment by Insulin

The value of prolonged narcosis as a form of treatment in mental disorder has been well recognized in Switzerland, Germany, Holland and the U.S.A., but, so far, there has been little tendency to adopt the method in this country. It is true that there has been considerable diversity of opinion about its efficacy, but it must be remembered that much of the literature published reveals that there has been a general lack of uniformity as to technique, duration and drug used, apart from discrepancies in the interpretation of results. Furthermore, one of the most potent arguments against the treatment has been its dangers— a fact which has deterred many psychiatrists from giving it a trial. These dangers, however, instead of stimulating research into possible methods which might eliminate toxicity of narcosis, gave rise to a search for a Utopian narcotic, which would serve therapeutically whilst being free from toxic effects. No less than forty substances (according to Palmer and Paine (1)) have been tried, with but little result except to increase the confusion. In a previous communication by one of us (2) toxic symptoms of narcosis were discussed, and a method was described whereby these could largely be eliminated with doses of narcotic sufficient to produce prolonged, continuous sleep. In the present paper it is proposed to summarize and comment on therapeutic results in 107 mixed cases of mental disorder, in which a total number of 128 treatments were carried out. In 117 of these treatments somnifaine was used, in 9 veronal, and in 2 dial.

Prolonged Narcosis in Mental Disorder: Results of Treatment in 197 Cases

http://bjp.rcpsych.org/content/bjprcpsych/106/444/803.full.pdf

Rolf Ström-Olsen

Papers

Bi-frontal stereotactic tractotomy. A follow-up study of its effects on 210 patients.

Somnifaine Narcosis: Toxic Symptoms and their Treatment by Insulin

Prolonged Narcosis in Mental Disorder: Results of Treatment in 197 Cases

Some Problems in the Study of Psychotic Illness