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Suicide risk in skin disorders

      Abstract

      Suicide accounts for about 1,000,000 deaths worldwide every year and is among the leading causes of death in young adults. Reports of high prevalence of suicidal ideation and increased suicide risk in several skin diseases raised concerns about deliberate self-harm in dermatological patients. The literature consistently points to an increased suicide risk in patients with psoriasis, atopic dermatitis, and acne, with higher risk in patients in whom the skin condition is associated with clinically significant emotional distress, changes in body image, difficulties in close relationships, and impaired daily activities. Other risk factors for suicide include a history of suicide attempts, severe mental or physical disorders, alcoholism, unemployment, bereavement or divorce, and access to firearms or other lethal means. Dermatologists may play an important role in recognizing suicidal ideation and preventing fatal self-harm in their patients. Increasing dermatologists' awareness of the issue of suicide and developing mental health consultation-liaison services within dermatology settings would be instrumental in contributing to suicide prevention in this population.

      Introduction

      At the end of the last century, the report of 16 cases of completed suicide among dermatology patients raised concerns about the potential of deliberate self-harm among patients with skin diseases.
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      • Cunliffe W.J.
      Suicide in dermatological patients.
      Since then, the prevalence of suicidal ideation and attempted suicide in dermatology has begun to be specifically investigated in a growing number of studies, many of which found a high prevalence of suicidal ideation
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      • Gupta A.K.
      Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis.
      • Picardi A.
      • Mazzotti E.
      • Pasquini P.
      Prevalence and correlates of suicidal ideation among patients with skin disease.
      and an increased risk of attempted suicide
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      • Alfredsson L.
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      Association of suicide attempts with acne and treatment with isotretinoin: retrospective Swedish cohort study.
      in several skin diseases.
      Given that only a minority of suicidal individuals seek help for mental health reasons, the dermatological consultation might be a precious opportunity to recognize suicidal ideation and to implement strategies to prevent suicidal behaviors in a population that seems to be at higher risk.
      • Picardi A.
      • Mazzotti E.
      • Pasquini P.
      Prevalence and correlates of suicidal ideation among patients with skin disease.
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      Prevalence of and risk factors for lifetime suicide attempts in the national comorbidity survey.
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      Suicidal behaviors among adolescents in northern Nova Scotia.
      This paper aims to provide clinical dermatologists with basic knowledge on suicide and risk factors for suicide, to present an updated review of the main findings on this issue in specific dermatological disorders, to outline an assessment for suicidal ideation and suicide risk in dermatology patients, and to describe appropriate intervention for suicide prevention.

      Suicide and suicide attempt: definition and epidemiology

      Suicide can be regarded as a process extending over time. Different types of suicidal expression, such as life weariness, death wishes, suicidal ideation, suicidal plans, and suicidal attempts, constitute a possible continuous sequence of phenomena, although there may be exceptions to this pattern.
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      Following Durkheim's classical definition,
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      the term suicide defines the death resulting directly or indirectly from a positive or negative act of the victim himself, who knows that this act will produce this result. A suicide attempt defines any act, including medication overdose, with nonfatal outcome that attempts to cause or actually causes self-harm or would have done so without intervention from others.
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      The epidemiology of suicidal behaviour: a review of three continents.
      In 2000, approximately 1 million people died by suicide, and it is now estimated that by 2020 suicide will become the tenth most common cause of death in the world.
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      Suicide is the third leading cause of death in young people in the United States and the leading cause of death in young adults in China, Sweden, Australia, and New Zealand, among other countries. Suicide attempts are even more common than suicide
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      Suicidal ideation and suicide attempts in panic disorder and attacks.
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      ; for every suicide, there are at least 10 suicide attempts.
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      Suicide attempts increase morbidity and health care costs
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      and are associated with higher risk of subsequent completed suicide.
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      Statistical issues in the identification of risk factors for suicidal behavior: the application of survival analysis.
      Rates of suicide vary substantially among regions and countries. Suicide is responsible for more than 30,000 deaths each year in the United States, representing about 11 suicides per 100,000 people. It has long been known that young adults and elderly people are at greater risk of dying by suicide, with death rates of 12.5 and 15.8 per 100,000, respectively.
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      Within Europe, rates are generally higher in northern than in southern countries.
      Ethnic differences in suicide rates are suggested by the findings of lower suicide rates in Hispanic and African Americans than in European Americans,
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      and of higher suicide rates in indigenous populations as compared with the rest of the population in several countries (ie, Native American people in the United States, Métis and Inuit in Canada, Aborigines in Australia, and Maori in New Zealand).
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      Risk factors

      Most suicidal behaviors occur on a continuum of severity that proceeds from less serious and more frequent behaviors through increasingly severe and less frequent behaviors.
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      At the milder end are behaviors such as casual ideation without specific plans. These behaviors may progress in some individuals through persistent, intense ideation that includes a plan and, for a very small proportion of persons at the other end of the continuum, to failed suicide attempt and suicide completion.
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      Epidemiology of completed and attempted suicide: toward a framework for prevention.
      Many factors contribute to suicide, which is rarely the consequence of one single cause or stressor. Suicidal behavior has multiple causes that are broadly divided into proximal and distal risk factors.
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      Distal risk factors represent the underlying vulnerability for suicidal behavior and can occur at both the individual and environmental levels. On the other hand, proximal risk factors are nearer in time to the suicidal event itself, and can act as precipitants.
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      Epidemiology of completed and attempted suicide: toward a framework for prevention.

      Sociodemographic factors

      Suicide rates differ by age, gender, race, socioeconomic status, and marital status.
      About 80% of suicide completers are men.
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      Gender differences in completed and attempted suicides.
      In developed countries, the male-to-female ratio for suicide is between 2:1 and 4:1, and seems to be increasing.
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      World report on violence and health.
      On the other hand, lifetime prevalence of attempted suicide is significantly more frequent among women.
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      Prevalence and comorbidity of mental disorders in persons making serious suicide attempts: a case-control study.
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      Suicidal attempts among older adolescents: prevalence and co-occurrence with psychiatric disorders.
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      An epidemiologic investigation of potential risk factors for suicide attempts.
      Suicide rates in most industrialized nations increase with age, with the highest suicide rates among persons older than 65 years.
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      Identification of suicide risk factors using epidemiologic studies.
      Marital status is also associated with suicide risk. Many studies have documented a relationship between health status and marital status,
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      Excess mortality among the unmarried: a case study of Japan.
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      The association between gender, family status and mortality.
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      even after controlling for other possible factors, such as socioeconomic status.
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      Marital status and mortality: the national longitudinal mortality study.
      Married individuals are known to have lower suicide rates as compared with nonmarried individuals.
      • Gove W.R.
      Sex, marital status and suicide.
      • Kposowa A.J.
      Divorce and suicide.
      • Kreitman N.
      Suicide, age and marital status.
      It has been pointed out recently that the effect of marital status may differ by gender, with the highest suicide rates found in men among young widowers
      • Smith J.C.
      • Mercy J.A.
      • Conn J.M.
      Marital status and the risk of suicide.
      • Yip P.S.
      • Thorburn J.
      Marital status and the risk of suicide: experience from England and Wales, 1982-1996.
      and divorced/separated people.
      • Kposowa A.J.
      Marital status and suicide in the National Longitudinal Mortality Study.
      Unemployment is also considered a key factor influencing suicidal behavior,
      • Jin R.L.
      • Shah C.P.
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      The impact of unemployment on health: a review of the evidence.
      • Platt S.
      Unemployment and suicidal behaviour: a review of the literature.
      • Platt S.
      • Hawton K.
      Suicidal behaviour and the labour market.
      with a two- to threefold increase in the relative risk of death by suicide.
      • Agerbo E.
      Unemployment and suicide.
      Although there has been debate about the association between suicide and unemployment,
      • Agerbo E.
      Unemployment and suicide.
      • Blakely T.A.
      • Collings S.C.
      • Atkinson J.
      Unemployment and suicide. Evidence for a causal association?.
      a recent study comparing suicide trends and employment rates in 26 European countries did suggest an association between suicide mortality and both unemployment risk and the expectation of inadequate financial resources during unemployment.
      • Yur'yev A
      • Värnik A
      • Värnik P
      • et al.
      Employment status influences suicide mortality in Europe.
      On the other hand, the presence of a social support system may reduce suicide risk.
      • Miller M.
      Geriatric suicide: the Arizona study.
      • Turvey C.L.
      • Conwell Y.
      • Jones M.P.
      • et al.
      Risk factors for late-life suicide: a prospective, community-based study.

      Personal and family history

      A history of self-harm or suicide attempts is a strong risk factor, present in at least 40% of cases.
      • Hawton K.
      • van Heeringen K.
      Among the persons who attempt suicide, up to 2% eventually die from suicide within the following year,
      • Beautrais A.L.
      Subsequent mortality in medically serious suicide attempts: a 5 year follow-up.
      • Hawton K.
      • Fagg J.
      Suicide, and other causes of death, following attempted suicide.
      • Owens D.
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      • House A.
      Fatal and non-fatal repetition of self-harm. Systematic review.
      and up to 7% within 10 years.
      • Owens D.
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      • House A.
      Fatal and non-fatal repetition of self-harm. Systematic review.
      • Ekeberg O.
      • Ellingsen O.
      • Jacobsen D.
      Suicide and other causes of death in a five-year follow-up of patients treated for self-poisoning in Oslo.
      • Holley H.L.
      • Fick G.
      • Love E.J.
      Suicide following an inpatient hospitalization for a suicide attempt: a Canadian follow-up study.
      In individuals with a history of suicide among relatives, the risk of suicidal behaviors is increased.
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      Toward a clinical model of suicidal behavior in psychiatric patients.
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      • et al.
      Risk factors for completed suicide in bipolar disorder.
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      • Carrigan S.
      • Whittinghill J.R.
      • et al.
      Psychological autopsy of completed suicide in children and adolescents.
      • Potash J.B.
      • Kane H.S.
      • Chiu Y.F.
      • et al.
      Attempted suicide and alcoholism in bipolar disorder: clinical and familial relationships.
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      • Haas G.L.
      • Sweeney J.A.
      • et al.
      Major depression and the risk of attempted suicide.
      This increase in the risk of suicidal behaviors among family members seems, at least in part, to be independent of genetic contribution from comorbid psychiatric diagnoses.
      • Vijayakumar L.
      • Rajkumar S.
      Are risk factors for suicide universal? A case-control study in India.
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      • Heath A.C.
      • Bucholz K.K.
      • et al.
      A twin study of genetic and environmental influences on suicidality in men.
      • McGuffin P.
      • Marusic A.
      • Farmer A.
      What can psychiatric genetics offer suicidology?.
      • Turecki G.
      Suicidal behavior: is there a genetic predisposition?.
      A history of childhood abuse has also been suggested to be associated with increased rates of suicidal behaviors, including both completed suicide
      • Plunkett A.
      • O'Toole B.
      • Swanston H.
      • et al.
      Suicide risk following child sexual abuse.
      and suicide attempts.
      • Kaslow N.
      • Thompson M.
      • Meadows L.
      • et al.
      Risk factors for suicide attempts among African American women.
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      Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study.
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      • Lynskey M.T.
      Physical punishment/maltreatment during childhood and adjustment in young adulthood.
      • Felitti V.J.
      • Anda R.F.
      • Nordenberg D.
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study.

      Mental health–related factors

      Psychiatric illness is a major contributing factor, and more than 90% of individuals who take their lives suffer from such an illness.
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      • et al.
      A hundred cases of suicide: clinical aspects.
      • Dorpat T.L.
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      A study of suicide in the Seattle area.
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      • Fogarty L.A.
      • et al.
      San Diego suicide study, III: relationships between diagnoses and stressors.
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      • Murphy G.E.
      • Wilkinson Jr, R.H.
      • et al.
      Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides.
      • Shaffer D.
      • Gould M.S.
      • Fisher P.
      • et al.
      Psychiatric diagnosis in child and adolescent suicide.
      • Drake R.E.
      • Bartels S.J.
      • Torrey W.C.
      Suicide in schizophrenia: clinical approaches.
      • Brent D.A.
      • Johnson B.A.
      • Perper J.
      • et al.
      Personality disorder, personality traits, impulsive violence, and completed suicide in adolescents.
      Indeed, mental disorders, alcohol and drug abuse are the strongest observed risk factors for attempted suicide in all age groups.
      • Mościcki E.K.
      • O'Carroll P.
      • Rae D.S.
      • et al.
      Suicide attempts in the Epidemiologic Catchment Area Study.
      • Lewinsohn P.M.
      • Rohde P.
      • Seeley J.R.
      Adolescent suicidal ideation and attempts: prevalence, risk factors, and clinical implications.
      • Beautrais A.L.
      • Joyce P.R.
      • Mulder R.T.
      • et al.
      Prevalence and comorbidity of mental disorders in persons making serious suicide attempts: a case-control study.
      • Andrews J.A.
      • Lewinsohn P.M.
      Suicidal attempts among older adolescents: prevalence and co-occurrence with psychiatric disorders.
      • Brent D.A.
      • Perper J.A.
      • Goldstein C.E.
      • et al.
      Risk factors for adolescent suicide.
      • Merrill J.
      • Owens J.
      Age and attempted suicide.
      Mood disorders, mainly major depressive disorder and bipolar disorder, are the most common diagnoses in studies of completed suicides for both men and women, across all age groups, and are associated with about 60% of suicides.
      • Barraclough B.
      • Bunch J.
      • Nelson B.
      • et al.
      A hundred cases of suicide: clinical aspects.
      • Dorpat T.L.
      • Ripley H.S.
      A study of suicide in the Seattle area.
      • Robins E.
      • Murphy G.E.
      • Wilkinson Jr, R.H.
      • et al.
      Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides.
      • Isometsä E.
      • Henriksson M.
      • Marttunen M.
      • et al.
      Mental disorders in young and middle aged men who commit suicide.
      • Bertolote J.M.
      • Fleischmann A.
      • De Leo D.
      • et al.
      Suicide and mental disorders: do we know enough?.
      Major depression has even greater importance in suicides among elderly adults.
      • Conwell Y.
      • Brent D.
      Suicide and aging I: patterns of psychiatric diagnosis.
      • Henriksson M.M.
      • Marttunen M.J.
      • Isometsä E.T.
      • et al.
      Mental disorders in elderly suicide.
      Substance (especially alcohol) misuse and schizophrenia are also associated with an increased risk of suicide.
      • Mościcki E.K.
      Epidemiology of completed and attempted suicide: toward a framework for prevention.
      • Hawton K.
      • van Heeringen K.
      Although panic disorder was also found to be associated with an increased risk for attempted suicide,
      • Weissman M.M.
      • Klerman G.L.
      • Markowitz J.S.
      • et al.
      Suicidal ideation and suicide attempts in panic disorder and attacks.
      it has been suggested that it is not an independent risk factor,
      • Beck A.T.
      • Steer R.A.
      • Sanderson W.C.
      • et al.
      Panic disorder and suicidal ideation and behavior: discrepant findings in psychiatric outpatients.
      • Henriksson M.M.
      • Isometsä E.T.
      • Kuoppasalmi K.I.
      • et al.
      Panic disorder in completed suicide.
      • Johnson J.
      • Weissman M.M.
      • Klerman G.L.
      Panic disorder, comorbidity, and suicide attempts.
      as it often co-occurs with other disorders such as mood or substance use disorders that would actually account for the increase in risk.
      Hopelessness, defined as generalized negative expectations of the future,
      • Beck A.T.
      • Weissman A.
      • Lester D.
      • et al.
      The measurement of pessimism: The Hopelessness Scale.
      is considered one of the most important risk factors for suicide in clinical populations.
      • Joiner Jr, T.E.
      • Brown J.S.
      • Wingate L.R.
      The psychology and neurobiology of suicidal behavior.
      The literature has consistently pointed out an association between hopelessness and suicidal thoughts and behaviors.
      • Hawton K.
      • van Heeringen K.
      • Conner K.R.
      • Duberstein P.R.
      • Conwell Y.
      • et al.
      Psychological vulnerability to completed suicide: a review of empirical studies.
      • McMillan D.
      • Gilbody S.
      • Beresford E.
      • et al.
      Can we predict suicide and non-fatal self-harm with the Beck Hopelessness Scale? A meta-analysis.
      Impulsivity, together with high levels of lifetime aggression, also seems to play a role in suicide risk. The role of impulsive-aggressive traits seems to be greater among younger individuals, whereas it has decreasing importance in middle and old age.
      • Ernst C.
      • Lalovic A.
      • Lesage A.
      • et al.
      Suicide and no axis I psychopathology.
      • Maser J.D.
      • Akiskal H.S.
      • Schettler P.
      • et al.
      Can temperament identify affectively ill patients who engage in lethal or near-lethal suicidal behavior? A 14-year prospective study.
      • McGirr A.
      • Renaud J.
      • Bureau A.
      • et al.
      Impulsive-aggressive behaviours and completed suicide across the life cycle: a predisposition for younger age of suicide.

      Physical health–related factors

      Having a general medical condition is associated with an increased risk of completed suicide,
      • Harris E.C.
      • Barraclough B.M.
      Suicide as an outcome for medical disorders.
      suicide attempts,
      • Goodwin R.D.
      • Marusic A.
      • Hoven C.W.
      Suicide attempts in the United States: the role of physical illness.
      and broadly defined suicidal behavior (which encompasses suicidal ideation, suicidal plan, and attempted suicide).
      • Maclean J
      • Kinley DJ
      • Jacobi F
      • et al.
      The relationship between physical conditions and suicidal behavior among those with mood disorders.
      In some cases, such as HIV/AIDS, lung disease,
      • Goodwin R.D.
      • Marusic A.
      • Hoven C.W.
      Suicide attempts in the United States: the role of physical illness.
      cancer,
      • Druss B.
      • Pincus H.
      Suicidal ideation and suicide attempts in general medical illnesses.
      and dermatologic diseases,
      • Gupta M.A.
      • Gupta A.K.
      Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis.
      • Picardi A.
      • Mazzotti E.
      • Pasquini P.
      Prevalence and correlates of suicidal ideation among patients with skin disease.
      this association seems to play an independent role with respect to a comorbid mental illness.
      • Goodwin R.D.
      • Marusic A.
      • Hoven C.W.
      Suicide attempts in the United States: the role of physical illness.
      ,
      • Druss B.
      • Pincus H.
      Suicidal ideation and suicide attempts in general medical illnesses.
      • Taylor A.
      • Dal Grande E.
      • Gill T.
      • et al.
      Detecting determinants of suicidal ideation: South Australian surveillance system results.
      • Scott K.M.
      • Hwang I.
      • Chiu W.T.
      • et al.
      Chronic physical conditions and their association with first onset of suicidal behavior in the world mental health surveys.
      Studies on the risk of suicidal behavior in other physical conditions, such as diabetes, hypertension, and arthritis, gave inconsistent findings.
      • Goodwin R.D.
      • Marusic A.
      • Hoven C.W.
      Suicide attempts in the United States: the role of physical illness.
      • Druss B.
      • Pincus H.
      Suicidal ideation and suicide attempts in general medical illnesses.
      • Taylor A.
      • Dal Grande E.
      • Gill T.
      • et al.
      Detecting determinants of suicidal ideation: South Australian surveillance system results.

      Access to lethal means

      The availability of lethal means, such as firearms, pesticides, and domestic gas, is also associated with increased suicide risk. For instance, many case-control studies found that a gun in the home is independently associated with a large increase in suicide risk, which is entirely because of a large increase in the risk of suicide by firearm.
      • Brent D.A.
      • Bridge J.
      Firearms availability and suicide: evidence, interventions, and future directions.
      • Miller M.
      • Lippmann S.J.
      • Azrael D.
      • et al.
      Household firearm ownership and rates of suicide across the 50 United States.
      Indeed, restricting access to lethal means with initiatives, such as the passage of firearm control laws, detoxification of domestic gas, modification of drug packaging and toxicity, and installation of barriers at jump sites, was found to be effective in preventing suicide.
      • Mann J.J.
      • Apter A.
      • Bertolote J.
      • et al.
      Suicide prevention strategies: a systematic review.
      • Johnson R.M.
      • Coyne-Beasley T.
      Lethal means reduction: what have we learned?.

      Skin diseases and suicide risk

      In a seminal paper on the topic of suicide in skin diseases, 2 dermatologists reported a retrospective study of all their patients presenting with a dermatological problem during the preceding 20 years, who were subsequently known to have committed suicide.
      • Cotterill J.A.
      • Cunliffe W.J.
      Suicide in dermatological patients.
      In contrast to the popular view of dermatologists as “physicians treating patients who never die,” the authors reported 16 cases of patients with dermatologic conditions who completed suicide. Seven of them had acne. In a survey of 341 consultant dermatologists in the United Kingdom published 1 year later, participants reported that they knew of 178 and 28 patients who had either attempted or completed suicide, respectively.
      • Humphreys F.
      • Humphreys M.S.
      Psychiatric morbidity and skin disease: what dermatologists think they see.
      Subsequent studies began to address this topic more specifically. Psoriasis, acne, and atopic dermatitis are the dermatological conditions that have been most studied.

      Psoriasis

      Depressive symptoms and suicidal ideation were assessed with the Carroll Rating Scale for Depression (CRSD) in a large sample of 480 patients with noncystic facial acne (n = 72), alopecia areata (n = 45), atopic dermatitis (n = 146), and psoriasis (n = 79 outpatients and n = 138 inpatients).
      • Gupta M.A.
      • Gupta A.K.
      Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis.
      Inpatients with severe psoriasis (mean percentage of total body surface area affected = 52%) were found to have significantly higher CRSD score and higher prevalence of suicidal ideation as compared with the other patient groups. The prevalence of suicidal ideation as measured by the CRSD item “I have been thinking about trying to kill myself” was 7.2% in psoriasis inpatients, whereas no patient with alopecia areata and only some outpatients with psoriasis (2.5%) and atopic dermatitis (2.1%) reported suicidal thoughts.
      In another study, 333 consecutively recruited dermatological outpatients, 172 hospitalized dermatological patients, and 293 matched healthy controls were administered measures of depressive symptoms and suicidal thoughts, skin-specific health-related quality of life (QOL), and psychological symptoms.
      • Zachariae R.
      • Zachariae C.
      • Ibsen H.H.
      • et al.
      Psychological symptoms and quality of life of dermatology outpatients and hospitalized dermatology patients.
      The study instruments included the Beck's Depression Inventory, the Dermatology Life Quality Index, and the Brief Symptom Inventory. Skin disease severity was rated by a trained dermatologist on a 5-point scale ranging from 1 (“very slight”) to 5 (”very severe”). Consistent with the aforementioned study,
      • Gupta M.A.
      • Gupta A.K.
      Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis.
      a significantly greater percentage of patients with psoriasis (21.2% of 113) had thoughts about suicide as compared with healthy controls (6.8%). A higher prevalence of suicidal ideation was also found among patients with atopic dermatitis (18.9% of 95), whereas patients with eczema (5.8% of 120) and urticaria (6.3% of 32) did not differ from healthy controls. Inpatient status was associated with suicidal ideation. Women reported lower QOL and more severe psychological symptoms than men. This result was mainly because of differences in scores on items related to appearance and embarrassment. The psychosocial impact of psoriasis, atopic dermatitis, eczema, and urticaria seemed to be primarily mediated by the impairment in QOL. Dermatologist-rated disease severity was only weakly associated with psychosocial disability. Consistent with other studies,
      • Picardi A.
      • Abeni D.
      • Melchi C.F.
      • et al.
      Psychiatric morbidity in dermatological outpatients: an issue to be recognized.
      these findings suggest that psychological distress is more strongly associated with the impact of skin disease on daily activities and social relationships than with its clinical severity.
      In another study, 294 dermatological outpatients and 172 inpatients were administered the Patient Health Questionnaire (PHQ) to assess mental health, the 12-item General Health Questionnaire (GHQ-12) to measure psychological distress, and the Skindex-29 to assess the effects of skin disease on QOL.
      • Picardi A.
      • Mazzotti E.
      • Pasquini P.
      Prevalence and correlates of suicidal ideation among patients with skin disease.
      The overall prevalence of suicidal ideation as measured by the relevant PHQ item in this large, heterogeneous sample of patients with dermatologic conditions was as high as 8.6%. Even in outpatients only, the prevalence was still about 5%. Suicidal ideation was present in 10% of the 80 patients with psoriasis. In univariate analysis, the presence of suicidal ideation was associated with female sex, inpatient status, presence of a depressive or anxiety disorder, and higher GHQ-12 and Skindex-29 scores. As easily expected, the presence of depression was by far the stronger predictor of suicidal ideation. In multivariate analysis, only emotional distress and impaired QOL in the social functioning domain were independently associated with suicidal ideation. Among the Skindex-29 items, those covering difficulties in close relationships were the most strongly associated with suicidal ideation, whereas no item of the skin symptoms subscale showed a strong association with suicidal ideation. The consistent finding of a high prevalence of suicidal ideation
      • Gupta M.A.
      • Gupta A.K.
      Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis.
      • Picardi A.
      • Mazzotti E.
      • Pasquini P.
      Prevalence and correlates of suicidal ideation among patients with skin disease.
      • Zachariae R.
      • Zachariae C.
      • Ibsen H.H.
      • et al.
      Psychological symptoms and quality of life of dermatology outpatients and hospitalized dermatology patients.
      in psoriasis and the severe impact of this skin disease on close interpersonal relationships
      • Hong J.
      • Koo B.
      • Koo J.
      The psychosocial and occupational impact of chronic skin disease.
      • Eghlileb A.M.
      • Davies E.E.
      • Finlay A.Y.
      Psoriasis has a major secondary impact on the lives of family members and partners.
      underscores the need to address psychosocial issues in the clinical evaluation of psoriatic patients.

      Acne

      Several studies reported a high prevalence of suicidal ideation in patients with acne. In a large sample of patients suffering from skin diseases,
      • Gupta M.A.
      • Gupta A.K.
      Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis.
      patients with mild-to-moderate facial acne were found to have a high prevalence of suicidal ideation (5.6%) and death wishes (8.3%). Consistent with this finding, a later Pakistani study found a prevalence of suicidal ideation of 8% among patients with acne,
      • Khan M.Z.
      • Naeem A.
      • Mufti K.A.
      Prevalence of mental health problems in acne patients.
      whereas in an Italian study the observed prevalence of suicidal ideation in patients with acne was 7.1%.
      • Picardi A.
      • Mazzotti E.
      • Pasquini P.
      Prevalence and correlates of suicidal ideation among patients with skin disease.
      As expected, suicidal ideation was found to be associated with a diagnosis of depression
      • Picardi A.
      • Mazzotti E.
      • Pasquini P.
      Prevalence and correlates of suicidal ideation among patients with skin disease.
      • Khan M.Z.
      • Naeem A.
      • Mufti K.A.
      Prevalence of mental health problems in acne patients.
      and with greater severity of depressive symptoms.
      • Gupta M.A.
      • Gupta A.K.
      Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis.
      Only one study, carried out on 165 male patients with acne and 150 comparison patients, did not detect any relationship between acne and self-reported depressive symptoms.
      • Rehn L.M.
      • Meririnne E.
      • Höök-Nikanne J.
      • et al.
      Depressive symptoms, suicidal ideation and acne: a study of male Finnish conscripts.
      In this study, about two-thirds of patients with acne had mild facial acne, which may account for the negative result.
      As acne vulgaris is a distressing condition that affects most adolescents, some recent studies, building on these preliminary findings, further investigated psychological distress and risk of suicide in community-based rather than clinical samples of young people with acne. In these studies, the association between acne and psychiatric morbidity, as measured by established assessment instruments, seemed to be less clear at first, with some studies reporting higher psychological distress in adolescents with acne than in those not suffering from the disease,
      • Kilkenny M.
      • Stathakis V.
      • Hibbert M.E.
      • et al.
      Acne in Victorian adolescents: associations with age, gender, puberty and psychiatric symptoms.
      • Smithard A.
      • Glazebrook C.
      • Williams H.C.
      Acne prevalence, knowledge about acne and psychological morbidity in mid-adolescence: a community based study.
      • Uslu G.
      • Sendur N.
      • Uslu M.
      • et al.
      Acne: prevalence, perceptions and effects on psychological health among adolescents in Aydin, Turkey.
      and another study yielding a negative result.
      • Aktan S.
      • Ozmen E.
      • Sanli B.
      Anxiety, depression and nature of acne vulgaris in adolescents.
      A secondary analysis using data from a large randomly selected group of adolescents surveyed in New Zealand, consisting of 9567 secondary school students ages 12 to 18 years, was performed to examine the relationship between acne and depressive symptoms, anxiety, and suicidal behaviors. The main outcome measures were self-reported acne, depressive symptoms as measured by the Reynolds Adolescent Depression Scale, anxiety as measured by the Anxiety Disorder Index from the Multidimensional Anxiety Scale for Children, and self-reported suicide attempts.
      • Purvis D.
      • Robinson E.
      • Merry S.
      • et al.
      Acne, anxiety, depression and suicide in teenagers: a cross-sectional survey of New Zealand secondary school students.
      The statement “having really bad or terrible problem with acne” was found to be independently associated with severity of depressive and anxiety symptoms, and with an increased risk of suicide attempts. The association between acne and suicide attempts remained after controlling for depressive symptoms and anxiety (odds ratio = 1.50; 95% confidence interval [CI] 1.21-1.86).
      These findings were corroborated by a very recent Norwegian study conducted in a large representative community sample of 3775 adolescents ages 18 to 19 years that aimed to examine the relationship between acne and suicidal ideation, mental health problems, and social functioning.
      • Halvorsen JA
      • Stern RS
      • Dalgard F
      • et al.
      Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: a population-based study.
      In this study, nearly 1 in 4 adolescents with severe acne reported suicidal ideation. In girls with severe acne, the prevalence of suicidal ideation was more than twice that of those with no or a little acne, whereas in boys it was 3 times higher. A significant association between substantial acne and suicidal ideation in both genders was still found in a multivariate model that controlled for symptoms of depression, family income, and ethnicity.
      Although an association between isotretinoin treatment and increased risk of depression, suicidal ideation, and suicide in patients with acne has been claimed,
      • Jick S.S.
      • Kremers H.M.
      • Vasilakis-Scaramozza C.
      Isotretinoin use and risk of depression, psychotic symptoms, suicide, and attempted suicide.
      • Wysowski D.K.
      • Pitts M.
      • Beitz J.
      Depression and suicide in patients treated with isotretinoin.
      • Hersom K.M.
      • Neary M.P.P.
      • Levaux H.P.
      • et al.
      Isotretinoin and antidepressant pharmacotherapy: a prescription sequence symmetry analysis.
      • Marqueling A.L.
      • Zane L.T.
      Depression and suicidal behavior in acne patients treated with isotretinoin: a systematic review.
      • Strahan J.E.
      • Raimer S.
      Isotretinoin and the controversy of psychiatric adverse effects.
      • Azoulay L.
      • Blais L.
      • Koren G.
      • et al.
      Isotretinoin and the risk of depression in patients with acne vulgaris: a case-crossover study.
      the available data are conflicting.
      A recent Swedish study examining the risk of attempted suicide before, during, and after treatment with isotretinoin for severe acne failed to establish if isotretinoin treatment was related to additional risk of suicide
      • Sundström A.
      • Alfredsson L.
      • Sjölin-Forsberg G.
      • et al.
      Association of suicide attempts with acne and treatment with isotretinoin: retrospective Swedish cohort study.
      ; however, it succeeded in documenting for the first time that severe acne in the absence of treatment with isotretinoin is associated with an increased risk of attempted suicide.
      The study
      • Sundström A.
      • Alfredsson L.
      • Sjölin-Forsberg G.
      • et al.
      Association of suicide attempts with acne and treatment with isotretinoin: retrospective Swedish cohort study.
      population consisted of 5756 patients who had been prescribed isotretinoin for severe acne between 1980 and 1990, aged 15 to 49 years at the first prescription. The study population was linked to the national patient register of in-hospital care and to a cause-of-death register. Hospital admissions for suicide attempts as well as all deaths, with underlying causes, occurring between 1980 and 2001, were extracted from the registries. Suicide attempts were classified as occurring before, during, or after treatment. Events that occurred before and after treatment were cumulatively counted for up to 3 years before and up to 15 years after treatment. The total time of observation encompassed 17,197 person years for up to 3 years before treatment, 2905 person years during treatment, and 87,120 person years thereafter. The rates of attempted suicide in the different time windows before, during, and after treatment were compared with those of the general population, by using the national patient register of in-hospital care. During the year before treatment, the standardized incidence ratio for attempted suicide was 1.57 (95% CI: 0.86-2.63) for all suicide attempts and 1.36 (95% CI: 0.65-2.50) for first attempts. The standardized incidence ratio during and up to 6 months after treatment was 1.78 (95% CI: 1.04-2.85) for all attempts and 1.93 (95% CI: 1.08-3.18) for first attempts. Three years after the end of treatment, the observed number of attempts was close to the expected number and remained the same during the 15 years of follow-up. The standardized incidence ratios and rates of attempted suicide were higher in female than in male patients. Seventeen male patients and 7 female patients committed suicide by the end of 2001. Although the suicide risk estimates were higher for patients with acne as compared with the general population, the findings were nonsignificant.
      Overall, the literature suggests that patients with moderate to severe acne might be at increased risk of suicide attempts and completed suicide, and underscores the danger inherent in neglecting psychosocial aspects in patients with acne, especially those suffering from the disease after adolescence.

      Atopic dermatitis

      Atopic dermatitis (AD) may have a profound impact on patients' lives. Patients with AD were found to score significantly higher than healthy controls on measures of depressive and anxiety symptoms.
      • Arima M.
      • Shimizu Y.
      • Sowa J.
      • et al.
      Psychosomatic analysis of atopic dermatitis using a psychological test.
      Severe AD was also reported to have a greater impact than severe psoriasis on subjective health status, as well as physical, psychological, and social functioning and well-being.
      • Kurwa H.A.
      • Finlay A.Y.
      Dermatology in-patient management greatly improves life quality.
      Impaired health-related QOL in the mental health domain as measured by the Medical Outcomes Study Short Form-36 Health Survey (SF-36) was found in adults with atopic dermatitis compared with patients with type 2 diabetes.
      • Kiebert G.
      • Sorensen S.V.
      • Revicki D.
      • et al.
      Atopic dermatitis is associated with a decrement in health-related quality of life.
      A pioneer study found a relatively low (2.1%) prevalence of suicidal ideation in patients with AD as compared with a prevalence of 4% in dermatology patients as a group
      • Gupta M.A.
      • Gupta A.K.
      Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis.
      ; however, subsequent studies consistently reported a high prevalence of suicidal ideation in AD. A Danish study reported a prevalence of suicidal thoughts of 18.9% among patients with AD, compared with 5.8%, 6.3%, and 6.8% in patients with dermatitis, patients with urticaria, and healthy controls, respectively.
      • Zachariae R.
      • Zachariae C.
      • Ibsen H.H.
      • et al.
      Psychological symptoms and quality of life of dermatology outpatients and hospitalized dermatology patients.
      In a Japanese study performed on a large sample of 6748 patients with AD, lifetime prevalence of suicidal ideation was 19.6% among the most severely affected patients, 6.0% among moderately affected patients, and 8.1% among 3575 healthy controls.
      • Kimata H.
      Prevalence of suicidal ideation in patients with atopic dermatitis.
      In another study recently performed in Germany, 62 adults aged 21 to 59 years with AD were compared with a matched group of 62 healthy controls with respect to depressive and anxiety symptoms and suicidal ideation. The study measures included the Hospital Anxiety and Depression Scale (HADS) and the Pöldinger's scale to measure suicide risk.
      • Dieris-Hirche J.
      • Gieler U.
      • Kupfer J.P.
      • et al.
      Suizidgedanken, Angst und Depression bei erwachsenen Neurodermitikern.
      A significantly higher prevalence of suicidal ideation as well as higher HADS scores were found among patients with AD. Also, the study revealed a strong correlation between patient-rated severity of dermatological disease, psychological burden, and suicidal ideation.
      Although not all studies of suicidal ideation in AD have yielded consistent results, it is noteworthy that a similar prevalence of suicidal thoughts was found in Danish,
      • Zachariae R.
      • Zachariae C.
      • Ibsen H.H.
      • et al.
      Psychological symptoms and quality of life of dermatology outpatients and hospitalized dermatology patients.
      Japanese,
      • Kimata H.
      Prevalence of suicidal ideation in patients with atopic dermatitis.
      and German
      • Dieris-Hirche J.
      • Gieler U.
      • Kupfer J.P.
      • et al.
      Suizidgedanken, Angst und Depression bei erwachsenen Neurodermitikern.
      patients with severe AD. Also, in the only study evaluating suicidal ideation through a specific questionnaire, the presence of symptoms of depression and anxiety and the self-rated severity of AD were strongly related to suicidal ideation.
      • Dieris-Hirche J.
      • Gieler U.
      • Kupfer J.P.
      • et al.
      Suizidgedanken, Angst und Depression bei erwachsenen Neurodermitikern.
      The available data suggest that suicidal ideation is frequent in AD, at least in patients with severe forms of the disease.

      Assessment and management of suicide risk in clinical practice

      The reviewed literature suggests that some patients coming to the attention of dermatologists are at increased risk for suicide. These patients include those with other known risk factors for suicidal behavior (eg, history of suicide attempts, severe mental or physical disorders, alcoholism, unemployment, bereavement or divorce, and access to firearms or other lethal means), those with skin diseases that were found to be associated with increased risk of suicidal ideation and behavior (severe psoriasis, acne, atopic dermatitis), and those in whom the skin condition is associated with clinically significant emotional distress, changes in body image (eg, skin lesions on exposed body parts), difficulties in close relationships, and impaired daily activities.
      Even in psychiatric practice, the management of people at risk of suicide is often challenging owing to the many causes and the poor evidence base.
      • Hawton K.
      • van Heeringen K.
      Although unplanned suicide attempts are seldom preventable, planned attempts might be. Given that suicidal ideation is associated with a markedly increased probability of planned suicidal behavior, which in turn may result in a suicidal attempt leading to death,
      • Paykel E.S.
      • Myers J.K.
      • Lindenthal J.J.
      • et al.
      Suicidal feelings in the general population: a prevalence study.
      any intervention aimed at early detection and treatment of patients at risk might carry considerable benefit.
      • Picardi A.
      • Mazzotti E.
      • Pasquini P.
      Prevalence and correlates of suicidal ideation among patients with skin disease.
      • Kessler R.C.
      • Borges G.
      • Walters E.E.
      Prevalence of and risk factors for lifetime suicide attempts in the national comorbidity survey.
      • Wang J.
      • Hughes J.
      • Murphy G.T.
      • et al.
      Suicidal behaviors among adolescents in northern Nova Scotia.
      In this paper, we propose some recommendations for the evaluation and management of suicide risk in clinical practice.
      Given the strong association between depression and suicidal ideation, brief depression screening questionnaires that have been validated in dermatological settings,
      • Picardi A.
      • Adler D.A.
      • Abeni D.
      • et al.
      Screening for depressive disorders in patients with skin diseases: a comparison of three screeners.
      such as the PHQ
      • Kroenke K.
      • Spitzer R.L.
      • Williams J.B.
      The PHQ-9: validity of a brief depression severity measure.
      or the Primary Care Screener for Affective Disorders,
      • Rogers W.H.
      • Wilson I.B.
      • Bungay K.M.
      • et al.
      Assessing the performance of a new depression screener for primary care (PC-SAD).
      might be useful to identify patients at increased risk. Also, the dermatologist can assess suicidal ideation by directly inquiring about it. Talking about suicide with the patient does not put the idea in his or her mind. Rather, the assessment of suicidal ideation may provide relief to the suicidal patient by opening an avenue for discussion and giving him or her an opportunity to feel understood.
      American Psychiatric Association
      Practice guideline for the assessment and treatment of patients with suicidal behaviors.
      In asking about suicidal ideas, it is often helpful to begin with milder questions addressing the patient's feelings about living, such as “How do you feel emotionally?” and “How does life seem to you at this point?” If the patient expresses feelings of sadness, hopelessness, or loss of interests and pleasure, the dermatologist may further inquire with some general questions about life weariness and death wishes, such as “Have you ever felt that life was not worth living?” or “Did you ever wish you could go to sleep and just not wake up?” If the patient's response reflects dissatisfaction with life or a desire to escape it, the dermatologist should ask further questions about suicidal thoughts and plans so as to elicit detailed information about specific plans for suicide and any steps that have been taken toward enacting those plans.
      American Psychiatric Association
      Practice guideline for the assessment and treatment of patients with suicidal behaviors.
      In doing so, the clinician should maintain an empathic and nonjudgmental attitude so as to strengthen the therapeutic relationship and minimize the feelings of shame, guilt, and stigma that may be associated with suicidality.
      If suicide risk is present, further assessment should address the imminence of suicidal behavior. Imminent risk is suggested by the presence of intention to die (explicitly expressed or inferred from behavior), suicidal plans, and high levels of hopelessness.
      • Hawton K.
      • Fagg J.
      Suicide, and other causes of death, following attempted suicide.
      Detailed and lethal suicide plans, violent and irreversible methods (such as use of firearms, jumping from height, and motor vehicle accidents) are generally associated with a greater risk of completed suicide. It should also be evaluated whether the patient has access to firearms or other weapons. In the assessment of suicidal intent, the patient's belief about the lethality of the method may be as important as the actual lethality of the method itself.
      American Psychiatric Association
      Practice guideline for the assessment and treatment of patients with suicidal behaviors.
      Attention should also be paid to the presence of established risk factors for suicide, summarized in Table 1.
      Table 1Risk factors for suicide
      • Male gender
      • Widowed, divorced, or unmarried marital status
      • Elderly age
      • Adolescent and young adult age
      • Mood disorders and other severe psychiatric illness
      • Alcohol abuse
      • History of childhood abuse
      • Family history of suicide
      • Family history of mood disorders or other severe mental illness
      • Suicidal thoughts
      • Suicidal plans
      • History of suicide attempts
      • Feelings of hopelessness
      • Impulsivity
      • Aggression
      • Severe or chronic physical illness
      • Recent bereavement or other severely stressful life event
      • Lack of social support
      • Unemployment
      • Access to firearms and other lethal means
      In cases of high or imminent suicide risk, immediate action is needed. The dermatologist should refer the patient to a mental health professional and possibly alert patient's close relatives to the danger and the need of treatment; however, if the patient is unsure of being able to resist suicidal urges, or if the dermatologist fears that the patient may not seek help before committing self-harm, emergency psychiatric evaluation is imperative.
      • Gupta M.A.
      • Gupta A.K.
      Psychiatric and psychological co-morbidity in patients with dermatologic disorders: epidemiology and management.
      • Detmar S.B.
      • Muller M.J.
      • Wever L.D.
      • et al.
      The patient-physician relationship. Patient-physician communication during outpatient palliative treatment visits: an observational study.
      Strategies for the management of acute suicide risk include vigilance and supervision of patients, perhaps through hospitalization, removal of potential methods of suicide, and initiation of vigorous treatment of associated psychiatric disorder.
      • Hawton K.
      • Fagg J.
      Suicide, and other causes of death, following attempted suicide.

      Suicide risk and psychotropic medications

      Psychotropic medications, such as antidepressants, antipsychotics, or mood stabilizing agents, are commonly used by psychiatrists to treat the severe mental disorders associated with suicidal thoughts, plans, or behaviors.
      Antidepressant treatment for major depressive disorder was found to be associated with a decrease in suicide risk;
      • Ernst C.L.
      • Goldberg J.F.
      Antisuicide properties of psychotropic drugs: a critical review.
      however, physicians prescribing these drugs should be aware of an increased suicidal risk that may be observed in the first days of treatment.
      • Jick H.
      • Kaye J.A.
      • Jick S.S.
      Antidepressants and the risk of suicidal behaviors.
      This increase in risk is supposed to be explained by an early nonspecific activating effect of medication during the first days of treatment, when the antidepressant effect has still not taken place.
      • Cohen D.
      Should the use of selective serotonin reuptake inhibitors in child and adolescent depression be banned?.
      Close observation of the patient and careful evaluation and monitoring of suicide risk are mandatory in the early phase of antidepressant treatment.
      Concerns related to the safety of a specific class of antidepressants, the selective serotonin reuptake inhibitors (SSRIs), were raised in the previous decade by warnings from US and European regulatory authorities about the induction of suicidality as a serious side effect of the SSRIs in children and adolescents. A comprehensive review of this issue concluded that antidepressants, including SSRIs, carry a small risk of inducing suicidal thoughts and suicide attempts in people younger than 25 years.
      • Möller H.J.
      • Baldwin D.S.
      • Goodwin G.
      • et al.
      Do SSRIs or antidepressants in general increase suicidality? WPA Section on Pharmacopsychiatry: consensus statement.
      In the treatment of adults with major depressive disorder, the risk was judged as acceptable when balanced against the positive effects on depressive symptoms and when the beneficial as well as potentially harmful effects of treatment are carefully considered by the clinician.
      • Möller H.J.
      • Baldwin D.S.
      • Goodwin G.
      • et al.
      Do SSRIs or antidepressants in general increase suicidality? WPA Section on Pharmacopsychiatry: consensus statement.
      The long-term effectiveness of lithium in reducing the risk of completed and attempted suicide among patients with bipolar disorder is well established.
      • Baldessarini R.J.
      • Tondo L.
      • Davis P.
      • et al.
      Decreased risk of suicides and attempts during long-term lithium treatment: a meta-analytic review.
      The use of alternative drugs, such as anticonvulsants or antipsychotics is usually a second-choice option, although it could become a forced choice in patients with bipolar disorder at risk for suicide with a previous history of psoriasis exacerbated by lithium.
      • Basavaraj K.H.
      • Ashok N.M.
      • Rashmi R.
      • et al.
      The role of drugs in the induction and/or exacerbation of psoriasis.
      As anxiety and agitation are additional risk factors for suicide, it has been suggested that early treatment of anxiety symptoms in depression with sedative/hypnotic agents, especially benzodiazepines, may decrease suicide risk.
      American Psychiatric Association
      Practice guideline for the assessment and treatment of patients with suicidal behaviors.
      To date, the available evidence does not support the effectiveness of sedative/hypnotic treatment as an early adjunct to antidepressants in decreasing suicide risk.
      • Youssef N.A.
      • Rich C.L.
      Does acute treatment with sedatives/hypnotics for anxiety in depressed patients affect suicide risk? A literature review.
      Conversely, other data suggest that sedative/hypnotics can induce depressant or disinhibitory effects in a small proportion of patients.
      • Gardner D.L.
      • Cowdry R.W.
      Alprazolam-induced dyscontrol in borderline personality disorder.
      • Carlsten A.
      • Waern M.
      Are sedatives and hypnotics associated with increased suicide risk of suicide in the elderly?.

      Conclusions

      Although dermatologists may play an important role in recognizing suicidal ideation and preventing fatal self-harm in some of their patients, they also need support from mental health professionals to manage these patients most effectively; however, several dermatologists complain about the scarcity of local clinical psychology or psychiatric liaison services.
      • Humphreys F.
      • Humphreys M.S.
      Psychiatric morbidity and skin disease: what dermatologists think they see.
      Effective assessment and treatment of suicidality in patients with skin diseases depends on the development of consultation-liaison services
      • Gould W.M.
      • Gragg T.M.
      A dermatology-psychiatry liaison clinic.
      • Woodruff P.W.
      • Higgins E.M.
      • du Vivier A.W.
      • et al.
      Psychiatric illness in patients referred to a dermatology-psychiatry clinic.
      within dermatology settings and the implementation of quality improvement programs.
      • de Korte J.
      • Van Onselen J.
      • Kownacki S.
      • et al.
      Quality of care in patients with psoriasis: an initial clinical study of an international disease management programme.
      Such system-level changes, together with increasing dermatologists' awareness of the issue of suicide, would be instrumental in addressing the needs of patients with skin disease who have suicidal ideation and ultimately in contributing to suicide prevention in this population.

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