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Prevalence of suicide attempts and correlates among first-episode and untreated major depressive disorder patients with comorbid dyslipidemia of different ages of onset in a Chinese Han population: a large cross-sectional study

BMC Psychiatry volume 23, Article number: 10 (2023) Cite this article

Abstract

Background

Patients with dyslipidemia are at increased risk for suicide, especially those with major depressive disorder (MDD). Few studies have investigated the independent effects of suicide attempts on comorbid dyslipidemia in patients with MDD. Moreover, there are no comparisons of differences in factors associated with suicide attempts among patients with MDD with dyslipidemia at different ages of onset. The aim of this study was to investigate the prevalence of suicide attempts and associated variables in first episode and untreated patients with MDD with comorbid dyslipidemia at different ages of onset.

Methods

We recruited 1718 patients with first-episode untreated MDD in this study. Demographical and clinical data were collected, and lipid profiles, thyroid function, and blood glucose levels were measured. The Hamilton Depression Scale 17 (HAMD-17), Hamilton Anxiety Scale (HAMA), Clinical Global Impression Severity Scale (CGI), and Positive and Negative Syndrome Scale (PANSS) positive subscale were assessed for depression, anxiety and illness severity, as well as psychotic symptoms, respectively.

Results

The percentage of patients with MDD with comorbid dyslipidemia was 61% (1048/1718). Among patients with MDD with comorbid dyslipidemia, the incidence of suicide attempts was 22.2% (170/765) for early adulthood onset and 26.5% (75/283) for mid-adulthood onset. Independent factors associated with suicide attempts in early adulthood onset patients with MDD with dyslipidemia were as follows: HAMA score (B = 0.328, P < 0.0001, OR = 1.388), Suspicion /persecution (B = -0.554, P = 0.006, OR = 0.575), CGI (B = 0.878, P < 0.0001, OR = 2.406), systolic blood pressure (B = 0.048, P = 0.004, OR = 1.049), hallucinatory behavior (B = 0.334, P = 0.025, OR = 1.397), and TPOAb (B = 0.003, p < 0.0001, OR = 1.003). Independent factors associated with suicide attempts in mid-adulthood onset patients with MDD with comorbid dyslipidemia were as follows: HAMA score (B = 0.182, P < 0.0001, OR = 1.200), CGI (B = 1.022, P < 0.0001, OR = 2.778), and TPOAb (B = 0.002, P = 0.009, OR = 1.002).

Conclusion

Our findings suggest an elevated risk of suicide attempts in patients with MDD with comorbid dyslipidemia. The incidence of suicide attempts was similar in the early- and mid-adulthood onset subgroups among patients with MDD with dyslipidemia, but the factors associated with suicide attempts were different in these two subgroups.

Peer Review reports

Background

The relationship between blood lipids and major depressive disorder（MDD） has attracted widespread attention. Several surveys have found that 52.3% of patients with MDD have hypertriglyceridemia and 44.7% have hypercholesterolemia [1]. Previous studies have indicated that individuals with MDD have lower levels of serum high-density lipoprotein cholesterol (HDL) than healthy controls [2]. One study found has found higher low-density lipoprotein (LDL) cholesterol and a higher LDL/HDL ratio, but lower HDL, in depressed patients than in healthy controls [3].Several studies have shown that metabolic disturbances (low HDL, hypertriglyceridemia, and hyperglycemia) in people with chronic depression who were taking antidepressants [4]. In another study, walking or bicycling excursions lowered LDL cholesterol, serum triglyceride, and total cholesterol, raised HDL levels, and alleviated depressive symptoms in patients with MDD, suggesting that lipid levels are linked to the severity of depression [5].

MDD is the psychiatric disorder most closely associated with suicide. A meta-analysis has reported that 11.1% of depressed patients commit suicide in their lifetime [6]. Approximately one million individuals worldwide choose to die by suicide each year, and roughly half of those who die by suicide can be diagnosed as MDD [7]. According to reports, the suicide rate in the United States is about 85.3 per 100,000 people with depression [8]. Some reports indicate that the annual suicide rate for patients with MDD in the Chinese population is 100 per 100,000 people [9]. Patients with undiagnosed and untreated depression have a very high risk of suicide, especially those with comorbidities (e.g., anxiety and dyslipidemia) and adverse life events [10].

There is growing evidence that blood lipids are associated not only with depression but also with suicide attempts [11, 12]. Several studies have shown that low levels of Total cholesterol (TC) and LDL could predict suicidal behavior in individuals with MDD [13]. A previous study noted that suicide attempters who experienced MDD had lower serum triglycerides [14]. Other studies have suggested that low lipid metabolism may be a biological marker for assessing suicide risk [15]. Other studies suggest that TC may be a biomarker of suicide risk in patients with MDD [16]. However, the relationship between blood lipids and suicide is also controversial. Several recent studies have found no links between triglyceride levels, LDL, total cholesterol, and suicide attempts after controlling for suicide diagnosis and method [17]. According to a meta-analysis, cholesterol levels in patients with MDD who attempted suicide and those who did not attempt suicide were similar to healthy controls [18]. However, in China, no studies have examined whether the incidence of suicide attempts is higher in patients with MDD with dyslipidemia compared with those without dyslipidemia.

Patients with MDD at different ages of onset have different clinical features. According to the Sequential Treatment Alternatives for Depression Relief (STAR*D) study, MDD women whose symptoms began age 18 had a longer duration of disease, longer current episodes, more frequent episodes, higher suicidal tendencies, and more severe symptoms [19]. Previous studies have shown that pre-adult-onset patients with MDD have more suicidal tendencies than adult-onset patients with MDD [20]. Results from a study of Chinese patients with MDD showed that these early-onset patients were more likely to feel lonely and unemployed, more likely to have atypical psychotic depressive episodes, and more likely to have features of bipolar disorder compared with late-onset patients [21]. However, the differences in the incidence of suicide attempts and their associated factors among patients with MDD with dyslipidemia at different ages of onset are unclear.

Therefore, the purposes of our current study were 1) to explore the differences in suicide attempts between patients with MDD with and without dyslipidemia; and 2) to determine the incidence of suicide attempts and associated factors in patients with MDD with and without dyslipidemia at different ages of onset.

Methods

Participants

This was a cross-sectional study designed and conducted by the Department of Psychiatry of the First Hospital of Shanxi Medical University. Eligible patients were recruited from 2015 to 2017. The inclusion criteria applied in this study were as follows: (1) MDD diagnosis confirmed by two clinically experienced psychiatrists according to the Structured Clinical Interview for DSM-IV (SCID); (2) age between 18 and 60 years; (3) HAMD-17 score greater than or equal to 24; (4) first episode without any previous medication or psychotherapy; and (5) Han Chinese ethnicity. The following exclusion criteria were established: (1) other Axis I disorders other than MDD; (2) comorbid severe physical illnesses; (4) substance and drug abuse or dependence, except for nicotine; (5) pregnant or breastfeeding women; (6) those patients with bipolarity currently diagnosed by two research psychiatrists based on SCID, as well as those with a history of bipolar disorder; (7) those patients on lipid-lowering medications or any other medications that could have impacted their lipid metabolism.

This study was approved by the Institutional Review Board of the First Hospital of Shanxi Medical University. The patients meeting criteria for inclusion and exclusion signed an informed consent form and were allowed to withdraw at any time from this study voluntarily.

The sample size was determined by the use of the formula, n = Z2p(1-p)/d2. n = number of sample size; Z = 95% confidence interval equal to 1.96; d = 0.05 (5%), marginal error; p = expected prevalence, equal to 0.2014 according to a previous study [22]. This provided an estimate for the 247 patients in the sample. Out of a total of 1796 screened individuals, only those patients who satisfied the inclusion and exclusion criteria were enrolled in our study. 78 patients were excluded for the following reasons: (1) They were a pregnant or breastfeeding (n = 10). (2) They had a substance use disorder (n = 9), a severe personality disorder (n = 15), a severe physical illness (n = 9), refused to participate in the study (n = 21), were unable to be interviewed due to an acute clinical condition (n = 5), and had other unspecified reasons (n = 9). Finally, the sample size to be included in our study was 1718, which was significantly larger than the required sample size (n = 247), indicating that our sample size had sufficient power.

Clinical measurements

Professionally trained researchers used self-designed questionnaires to collect socio-demographic data on participants, including marital status, age, sex, education, duration of disease, and age at onset of MDD. We also collected patients' systolic and diastolic blood pressure, height, and weight, and calculated their body mass index (BMI). The research nurse measured systolic and diastolic blood pressures in the participant's left arm using an Omron Hem digital monitor with the participant seated in a quiet position. According to previous studies [23, 24] 45 years was used as the early-adulthood onset and mid-adulthood onset for MDD. Patients were classified as early-adulthood onset when their onset was younger than 45 years of age, and mid-adulthood onset when their onset were older than or equal to 45 years of age.

The HAMD-17, HAMA, PANSS positive subscale, and CGI were used to assess depression, anxiety, and psychotic symptoms, and illness severity, respectively. Patients with a total score of 24 on the HAMD have severe depressive symptoms [25]. The 17-item HAMD scale had reliability coefficients between 0.88 to 0.99 and validity coefficients of 0.94 or higher [26]. The HAMA has 14 items on a 5-point scale from 0 (no symptoms) to 4 (very severe symptoms) [27]. The total HAMA score reflects the severity of the patient's anxiety symptoms. It is the measure of anxiety that is most often used in the study of depression [28]. Positive symptoms were evaluated using the PANSS positive subscale. Patients were considered to have psychotic symptoms when the positive symptom subscale had a score of 15 or above. The PANSS scale had reliability coefficients of 0.73 to 0.83 and validity coefficients of 0.77 to 0.89 [29]. Prior to the start of the study, these psychiatrists received clinical research training in the assessment of the PANSS, HAMD, HAMA, and CGI. The inter-rater correlation coefficient for HAMD, HAMA and PANSS total scores between the two psychiatrists were 0.85, 0.84 and 0.82, respectively.

All patients with MDD were interviewed face-to-face in a quiet setting in terms of their suicide attempts. Based on previous research on suicide [30], all patients were asked: "Have you attempted suicide in your lifetime?" If patients answered "yes," they were labeled as suicide attempters, and if they answered "no," they were labeled as non-suicide attempters. For those suicide attempters, we continued to ask them about the number of suicide attempts, the manner of each attempt, and the approximate date of attempted suicide.

Physical and biochemical parameters measurements

Blood samples were collected from all participants between 6 and 8 a.m. after an overnight fast. Then blood samples were immediately transported to the laboratory center at the hospital to measure the following biomarker parameters: blood glucose, TC, triglycerides (TG), HDL, and LDL, as well as thyroid stimulating hormone (TSH), free triiodothyronine 3 (FT3), free thyroxine 4 (FT4), thyroid peroxidase antibody (TPOAb), and anti-thyroglobulin (TgAb).

The definition of dyslipidemia was based on the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults' final report (NCEP-ATP III) [31]. We also referenced the 2016 Chinese guidelines for the prevention and treatment of dyslipidemia in adults [32]. Dyslipidemia was defined as a combination of TG, LDL-C, and TC expressed as ≥ 2.3, ≥ 3.4, and ≥ 6.2 mmol/L, respectively.

Statistical analysis

We used SPSS 25.0 for statistical analysis. We used chi-square tests to examine categorical variables. When continuous variables conformed to a normal distribution, analysis of variance (ANOVA) was used. When continuous variables did not conform to a normal distribution, the Mann–Whitney U test was used. We conducted univariate analyses to identify the differences in variables related to suicide attempts in individuals who have MDD with dyslipidemia of early adult onset and mid-adulthood onset. We used Bonferroni correction for multiple comparisons. Those significantly different variables between these groups with and without a history of suicide attempts were then entered into a logistic regression analysis (backward: Wald) to examine the variables for suicide attempts. Furthermore, we used the area under the receiver operating characteristic (AUCROC) to identify key parameters in the ability to distinguish between individuals with MDD comorbid dyslipidemia who attempted suicide and those who did not. A consistency statistic between 0.7 and 0.8 was considered usually acceptable. We used P < 0.05 (two-tailed) as the level of significance.

Results

Prevalence of suicide attempts among patients with MDD with comorbid dyslipidemia by age of onset.

The prevalence of comorbid dyslipidemia in patients with MDD was 61% (1048/1718). Furthermore, the incidence of suicide attempts was 23.4% (245/1048) in patients with MDD with comorbid dyslipidemia, which was higher compared with MDD without dyslipidemia (101/670, 15.1%; 2 = 17.52, P < 0.001, OR = 1.42, 95% CI: 1.19–1.69). In addition, among patients with MDD with comorbid dyslipidemia, the incidence of suicide attempts was 22.2% (170/765) for early adult onset and 26.5% (75/283) for mid-adulthood onset, without significant difference (χ2 = 2.112, P = 0.162). Among patients with MDD without dyslipidemia, the incidence of suicide attempts was 14.6% (72/493) for early adult onset and 16.3% (29/177) for mid-adulthood onset, without significant difference (χ2 = 0.322, P = 0.570).

Clinical characteristics and biochemical indicators of suicide attempters and non-attempters in dyslipidemia patients with MDD with early-adulthood onset and mid-adulthood onset.

Table 1 shows that among early-adulthood onset patients with MDD with dyslipidemia, suicide attempters had higher PANSS positive symptom, suspicion/persecution, CGI, hallucinatory behavior, CGI, HAMD and HAMA scores, longer duration of disease, higher systolic and diastolic blood pressure (BP), as well as high serum levels of TPOAb, TC, LDL-C, TSH, and TgAb, but lower HDL levels compared with non-suicide attempters (all P < 0. 01). All these significances passed Bonferroni correction (all corrected p < 0.05), except for duration of disease (Bonferroni corrected p > 0.05).

Table 1 Socio-demographics and clinical characteristics in patients with and without suicide attempts in early adulthood onset
Full size table

As shown in Table 2, among mid-adulthood onset patients with MDD with dyslipidemia, suicide attempters had higher PANSS positive symptom, CGI, HAMD, and HAMA scores, higher systolic and diastolic blood pressure, as well as high serum levels of TPOAb, TC, LDL, TSH, and TgAb, but lower HDL levels compared with non-suicide attempters (all P < 0. 01). All these significances passed Bonferroni correction (all corrected p < 0.05), except for diastolic blood pressure (Bonferroni corrected p > 0.05).

Table 2 Socio-demographics and clinical characteristics in patients with and without suicide attempts in mid-adulthood onset
Full size table

Factors associated with suicide attempts in early-adulthood onset and mid-adulthood onset MDD with dyslipidemia

We entered variables with significant differences in univariate analysis into logistic regression (backward: Wald) to find factors associated with suicide attempts in patients with MDD with dyslipidemia at different ages of onset. Table 3 shows the following correlates of suicide attempts in dyslipidemia patients with MDD with early-adulthood onset: HAMA score (B = 0.182, P < 0.0001, OR = 1.200), CGI (B = 1.022, P < 0.0001, OR = 2.778), and TPOAb (B = 0.002, P = 0.009, OR = 1.002). In addition, AUCROC showed the following values for each risk factor: 0.77 for HAMA, 0.59 for hallucinatory behavior, 0.63 for suspicion/persecution, 0.73 for CGI, and 0.69 for systolic blood pressure. Finally, the combination of HAMA, hallucinatory behavior, suspicion/persecution, and CGI was ≥ 0.8 (Fig. 1).

Table 3 Factors associated with suicide attempts in patients with comorbid dyslipidemia in early adulthood onset
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Fig. 1
figure 1

The discriminatory capacity of related factors for patients with suicide attempts in early adulthood onset. The area under the curve of the HAMA score, hallucinatory behavior, suspiciousness/persecution, CGI score, systolic BP, and the combination of these three factors were 0.77, 0.59, 0.63, 0.73, 0.69, and 0.84, respectively

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Table 4 shows the following correlates of suicide attempts in dyslipidemia patients with MDD with mid-adulthood onset: HAMA score (B = 0.182, p < 0.0001, OR = 1.200), CGI (B = 1.022, p < 0.0001, OR = 2.778), and TPOAb (B = 0.002, p = 0.009, OR = 1.002). AUCROC showed the following values for each risk factor: 0.73 for HAMA, 0.679 for TPOAb, and 0.73 for CGI. The combination of HAMA, TPOAb, and CGI was 0.79 (Fig. 2).

Table 4 Factors associated with suicide attempts in patients with comorbid dyslipidemia in in mid-adulthood onset
Full size table
Fig. 2
figure 2

The discriminatory capacity of related factors for patients with suicide attempts in mid-adulthood onset. The area under the curve for the HAMA score, TPOAB score, and CGI score, as well as their combination, were 0.73, 0.68, and 0.79, respectively

Full size image

Discussion

To our knowledge, our study is the first to investigate the frequency and influencing factors of suicide attempts among first-episode untreated patients with MDD with comorbid dyslipidemia in a Chinese Han population. The major discoveries of our study were that the proportion of suicide attempts was higher in both early adulthood-onset and mid-adulthood-onset patients with MDD with comorbid dyslipidemia than in patients with MDD without comorbid dyslipidemia. Among MDD comorbid dyslipidemia, the percentages of suicide attempts reached 22.2% for early adulthood onset and 26.5% for mid-adulthood onset. Suicide attempt factors differed between early and mid-adulthood onset patients with MDD with dyslipidemia.

Few studies have been published on the frequency of suicide attempts in patients with MDD with dyslipidemia. In this study, the prevalence of comorbid dyslipidemia in MDD patients was 61%, which was higher than that in the Han Chinese population without MDD or any psychiatric illness (42.4%) [33]. Also, we observed a higher frequency of suicide attempts in patients with MDD with comorbid dyslipidemia than in those without comorbid dyslipidemia in both early adulthood and mid-adulthood onset. The prevalence of comorbid dyslipidemia is higher in patients with MDD than in the general population for the following reasons: First, patients with MDD have reduced activity and exercise. Some patients have binge eating habits, resulting in an increased proportion of obese and overweight patients [34]. These poor lifestyles eventually lead to abnormal blood lipid levels. Secondly, antidepressants or antipsychotics can affect metabolism, leading to adverse effects such as weight gain and dyslipidemia [35]. However, the patients included in this study were all first-time untreated patients.

Our study found higher levels of TC, LDL, and HDL, but no differences in TG in suicide attempters among patients with MDD with comorbid dyslipidemia. These findings were discovered in patients with MDD onset in both early and mid-adulthood. The relationship between suicide attempts and dyslipidemia has been extensively studied, but the findings are inconsistent. For example, Enrico Capuzzi et al. found that low cholesterol, LDL, and HDL levels were associated with violent suicide [36]. Adrea Aguglia et al. revealed that lower serum cholesterol predicted higher suicide mortality [37]. A meta-analysis reported that lower total cholesterol levels were associated with suicidal ideation, which is partially consistent with the results of the present study [38]. In a Mexican population, Marcela Segoviano-Mendoza et al. identified that relatively low cholesterol levels correlated with suicide among those suffering from MDD [39]. In contrast, the findings of Subin Parker et al. did not provide evidence to support the use of biological indicators such as total serum cholesterol to predict the likelihood of suicide in individuals with severe mental illness [40]. The different results of these studies may be due to differences in the people who took part, the ways they were evaluated, and what was considered dyslipidemia.

In our study, among early-adulthood onset patients with MDD with comorbid dyslipidemia, suicide attempters had higher HAMA scores, CGI scores, and TPOAb levels than non-suicide attempters, which was confirmed by further logistic regression analysis, suggesting that CGI, HAMA, and TPOAb were independent correlates of suicide attempts in patients with early adult-onset MDD with dyslipidemia. Also, we observed that HAMA, CGI, and TPOAb were independent correlates of suicide attempts in patients with mid-adulthood onset patients with MDD with dyslipidemia. Several studies have explored the association between individual anxiety levels and suicide attempts in patients with MDD [41]. Previous studies have consistently concluded that the severity of anxiety in patients with MDD increases suicide attempts. For example, Baek et al. reported that patients with anxious depression were more likely to have more suicidal thoughts and attempts than patients without anxious depression [42]. Based on a WHO mental health survey of national or representative epidemiological interviews in 24 countries, Kessler et al. found that patients with MDD with anxiety symptoms reported higher suicide attempts during the one-year follow-up period [43]. Also, some investigations have demonstrated that patients with MDD with comorbid anxiety are more likely to attempt suicide. Recently, Zhou et al. found that the HAMA score was an independent risk indicator for suicide attempts in patients with MDD with comorbid anxiety [30].

We noted an independent positive association between the CGI score and suicide attempts in patients with MDD with dyslipidemia of both early-adulthood onset and mid-adulthood onset. Gang Ye's study is consistent with our study showing that CGI is an independent risk factor for suicide attempts in patients with MDD [44]. The relationship between CGI and suicide attempts may be explained by the following factors: First, the CGI score represents the severity of the disease [45]. Suicide attempts are one of the basic symptoms that constitute the symptom cluster in patients with MDD [46]. The more pronounced the patient's suicide attempts, suicidal ideation, and suicidal behavior, the higher the CGI score. Second, some researchers have found that anxiety and depression are associated with worse symptoms and more unfavorable treatment outcomes in patients with MDD [41]. Hence, the higher the levels of anxiety and suicidal ideation in patients with MDD, the higher the CGI level.

Our study showed that TPOAb was an independent risk factor for suicide attempts in patients with MDD with dyslipidemia of early- and mid-adulthood onset. Previous studies have also agreed that TPOAb levels in patients with MDD increase suicidality. For example, Shen Yanmei et al. found that TPOAb was associated with a 2.1-fold increased risk of suicide attempts in patients with MDD [47]. Chen S. Wang et al. found that TPOAb was associated with the number of suicide attempts in patients with MDD with glucose dysfunction [48]. The following reasons may explain the correlation between TPOAb and suicide attempts in patients with MDD. First, a population-based survey in Denmark found that TPOAb levels increased the frequency of suicide attempts in the general population [49]. Second, TPO antigens reflect the presence or increased risk of thyroid immune disorders such as Graves' disease and Hashimoto's disease. Michael E et al. noted that autoimmune disorders are a risk factor for mood disorders [50]. Detlef Degner et al. found that TPOAb levels are strongly associated with MDD [51].

In early-adulthood onset patients with MDD with dyslipidemia, three additional factors were independently associated with suicide attempts: suspicion/persecution, systolic blood pressure, and hallucinatory behavior. However, this is not the case for mid-adulthood onset patients with MDD. All of these variances can be explained by the following possible causes: First, a previous study found greater cardiovascular burden in patients with MDD with early adult onset [52]. Dargeld et al. found that emotional hyperreactivity in patients with MDD in early adulthood predicted the risk of suicide in patients with MDD through a machine learning approach [53].Patients who are emotionally hyperactive tend to have higher cardiometabolic disturbances [54]. When they become agitated and attempt suicide, they often exhibit elevated systolic blood pressure but fail to meet the diagnostic criteria for hypertension. Second, an earlier age of onset with psychotic symptoms may be characteristic of bipolar depression [55]. Compared to patients with unipolar depression, patients with bipolar depression are more hyperemotional and more likely to exhibit emotional instability [56]. When patients with bipolar depression are emotionally unstable and have psychotic symptoms such as suspicion and hallucinatory behavior, they are more likely to make suicide attempts [57]. This may partly explain the fact that suspicion/persecution and hallucinatory behavior are independent risk factors for MDD patients with early adult onset, in contrast to MDD with mid-adulthood onset.

The biological mechanisms underlying the increase in suicide attempts in patients with MDD with dyslipidemia are not fully understood. It has been hypothesized that the 5-hydroxytryptamine (5-HT) system may be influenced in some way by lipids. Higher levels of peripheral lipids may alter the viscosity of lipids in neuronal membranes, which in turn affects 5-HT levels [58]. Sequence variants of the 5-HT receptor (HTR5A) have been shown to be associated with high plasma lipid levels [59]. Serotonergic system dysfunction has been extensively linked to suicidal behavior and suicide [60]. Studies of 5HIAA ( a key metabolite of 5HT) in the CSF of suicidal individuals provide the primary evidence establishing the relationship between 5-HT and suicide [61]. According to a meta-analysis, 5-HIAA levels were lower in patients who attempted suicide than in those who did not [62].

Our study has several limitations. First, because this was a cross-sectional survey, we could not clarify the causal relationship between the risk factors and suicide attempts in patients with MDD with combined dyslipidemia. We need well-designed cohort follow-up studies to explore this causal relationship. On the other hand, given that it was a cross-sectional study, there was a possibility of recall bias among participants, which may have some impact on the accuracy of the results of this study. Second, the patients in our study were all Han Chinese, and the findings lacked extrapolation. Therefore, validation in different countries and ethnic groups is needed. Third, we only used one simple question to assess suicide, but did not use a structured suicide assessment scale, such as the Columbia Suicide Severity Assessment Scale, to assess the severity of suicide in this study. Thus, this approach was susceptible to recall bias and, at the same time, did not measure suicide in a quantitative way. More studies are needed to explore the variables associated with the severity of suicide attempts. Finally, we excluded patients with co-morbid substance use disorders, physical illnesses and other illnesses from this study, which limited the generalizability of the findings in this study.

In conclusion, this study showed that the incidence of suicide attempts was significantly higher in first-episode untreated patients with MDD with dyslipidemia than in those without dyslipidemia. HAMA score, suspicion/persecution, CGI score, TPOAb, systolic blood pressure, and hallucinatory behavior were risk factors for suicide attempts in early-adulthood onset MDD with dyslipidemia. HAMA score, CGI score, and TPOAb were risk factors for suicide attempts in mid-adulthood onset patients with MDD with dyslipidemia. However, due to the limitations of the cross-sectional design and the lack of structured evaluation tools to assess suicide, future studies should use a prospective cohort design to confirm these findings.

Availability of data and materials

The data that support the findings of this study are available on request from the corresponding author upon reasonable request.

Abbreviations

ANOVA:

Analysis of variance

AUCROC:

Area under the receiver operating characteristic

BMI:

Body mass index

BP:

Blood pressure

CGI:

Clinical global impression severity scale

DSM-IV:

Diagnostic and statistical manual of mental disorders, Fourth edition

FT3:

Free triiodothyronine

FT4:

Free thyroxine

HAMD-17:

Hamilton depression scale-17 items

HAMA:

Hamilton anxiety Scale

HDL:

High-density lipoprotein cholesterol

LDL:

Low-density lipoprotein cholesterol

MDD:

Major depressive disorder

NCEP:

National cholesterol education program

NCEP-ATP III:

Treatment of high blood cholesterol in adults' final report (NCEP-ATP III)

PANSS:

Positive and negative syndrome scale

STAR*D:

Sequential treatment alternatives for depression relief (STAR*D)

SCID:

Structured clinical interview for DSM-IV (SCID)

SPSS:

Statistical package for the social sciences

TC:

Total cholesterol

TG:

Triglyceride

TgAb:

Anti-thyroglobulinand

TPOAb:

Thyroid peroxidases antibody

TSH:

Thyroid stimulating hormone

References

  1. Macias-Cortes ED, Llanes-Gonzalez L, Aguilar-Faisal L, Asbun-Bojalil J. Is metabolic dysregulation associated with antidepressant response in depressed women in climacteric treated with individualized homeopathic medicines or fluoxetine? The HOMDEP-MENOP Study Homeopathy. 2017;106(1):3–10.

    Article  Google Scholar 

  2. Maes M, Smith R, Christophe A, Vandoolaeghe E, Van Gastel A, Neels H, Demedts P, Wauters A, Meltzer HY. Lower serum high-density lipoprotein cholesterol (HDL-C) in major depression and in depressed men with serious suicidal attempts: relationship with immune-inflammatory markers. Acta Psychiatr Scand. 1997;95(3):212–21.

    Article  CAS  Google Scholar 

  3. Lasserre AM, Glaus J, Vandeleur CL, Marques-Vidal P, Vaucher J, Bastardot F, Waeber G, Vollenweider P, Preisig M. Depression with atypical features and increase in obesity, body mass index, waist circumference, and fat mass: a prospective, population-based study. JAMA Psychiat. 2014;71(8):880–8.

    Article  Google Scholar 

  4. Vogelzangs N, Beekman AT, van Reedt Dortland AK, Schoevers RA, Giltay EJ, de Jonge P, Penninx BW. Inflammatory and metabolic dysregulation and the 2-year course of depressive disorders in antidepressant users. Neuropsychopharmacology. 2014;39(7):1624–34.

    Article  CAS  Google Scholar 

  5. von Zimmermann C, Winkelmann M, Richter-Schmidinger T, Muhle C, Kornhuber J, Lenz B. Physical Activity and Body Composition Are Associated With Severity and Risk of Depression, and Serum Lipids. Front Psychiatry. 2020;11:494.

    Article  Google Scholar 

  6. Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, Sen S, Mata DA. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. JAMA. 2016;316(21):2214–36.

    Article  Google Scholar 

  7. Jolly T, Trivedi C, Adnan M, Mansuri Z, Agarwal V. Gambling in patients with major depressive disorder is associated with an elevated risk of Suicide: Insights from 12-years of Nationwide inpatient sample data. Addict Behav. 2021;118:106872.

    Article  Google Scholar 

  8. Mortality GBD. Causes of Death C: Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1459–544.

    Article  Google Scholar 

  9. Zhong BL, Chiu HF, Conwell Y. Rates and characteristics of elderly suicide in China, 2013–14. J Affect Disord. 2016;206:273–9.

    Article  Google Scholar 

  10. Barateau L, Lopez R, Chenini S, Pesenti C, Rassu AL, Jaussent I, Dauvilliers Y. Depression and suicidal thoughts in untreated and treated narcolepsy: Systematic analysis. Neurology. 2020;95(20):e2755–68.

    Article  Google Scholar 

  11. Kulak-Bejda A, Bejda G, Lech M, Waszkiewicz N. Are Lipids Possible Markers of Suicide Behaviors? J Clin Med. 2021;10(2):333.

    Article  CAS  Google Scholar 

  12. Eidan AJ, Al-Harmoosh RA, Al-Amarei HM. Estimation of IL-6, INFgamma, and Lipid Profile in Suicidal and Nonsuicidal Adults with Major Depressive Disorder. J Interferon Cytokine Res. 2019;39(3):181–9.

    Article  CAS  Google Scholar 

  13. Shaker NM, Sultan M, Mohamed MY, Helal SA. Abd El Moneam MHE: Lipid Profile and Impulsivity in Suicidal Patients with Major Depressive Disorder. Arch Suicide Res. 2021;25(3):641–56.

    Article  Google Scholar 

  14. Baek JH, Kang ES, Fava M, Mischoulon D, Nierenberg AA, Yu BH, Lee D, Jeon HJ. Serum lipids, recent suicide attempt and recent suicide status in patients with major depressive disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2014;51:113–8.

    Article  CAS  Google Scholar 

  15. Zhou S, Zhao K, Shi X, Sun H, Du S, Miao X, Chen J, Yang F, Xing M, Ran W, et al. Serum Lipid Levels and Suicide Attempts Within 2 Weeks in Patients With Major Depressive Disorder: Is There a Relationship? Front Psychiatry. 2021;12:676040.

    Article  Google Scholar 

  16. Capuzzi E, Bartoli F, Crocamo C, Malerba MR, Clerici M, Carra G. Recent suicide attempts and serum lipid profile in subjects with mental disorders: A cross-sectional study. Psychiatry Res. 2018;270:611–5.

    Article  CAS  Google Scholar 

  17. da Graca CM, Nardin P, Buffon A, Eidt MC, Antonio Godoy L, Fernandes BS, Goncalves CA. Serum triglycerides, but not cholesterol or leptin, are decreased in suicide attempters with mood disorders. J Affect Disord. 2015;172:403–9.

    Article  Google Scholar 

  18. Li H, Zhang X, Sun Q, Zou R, Li Z, Liu S. Association between serum lipid concentrations and attempted suicide in patients with major depressive disorder: A meta-analysis. PLoS ONE. 2020;15(12):e0243847.

    Article  CAS  Google Scholar 

  19. Zisook S, Rush AJ, Albala A, Alpert J, Balasubramani GK, Fava M, Husain M, Sackeim H, Trivedi M, Wisniewski S. Factors that differentiate early vs. later onset of major depression disorder. Psychiatry Res. 2004;129(2):127–40.

    Article  Google Scholar 

  20. van Noorden MS, Minkenberg SE, Giltay EJ, den Hollander-Gijsman ME, van Rood YR, van der Wee NJ, Zitman FG. Pre-adult versus adult onset major depressive disorder in a naturalistic patient sample: the Leiden Routine Outcome Monitoring Study. Psychol Med. 2011;41(7):1407–17.

    Article  Google Scholar 

  21. Hu C, Geng Y, Feng Y, Wang G, Ungvari GS, Chiu HF, Kilbourne AM, Lai KY, Si TM, Zheng QW, et al. Demographic and clinical differences between early- and late-onset major depressions in thirteen psychiatric institutions in China. J Affect Disord. 2015;170:266–9.

    Article  Google Scholar 

  22. Ma YJ, Wang DF, Yuan M, Zhang XJ, Long J, Chen SB, Wu QX, Wang XY, Patel M, Verrico CD, et al. The prevalence, metabolic disturbances and clinical correlates of recent suicide attempts in Chinese inpatients with major depressive disorder. BMC Psychiatry. 2019;19(1):144.

    Article  Google Scholar 

  23. Park SC, Hahn SW, Hwang TY, Kim JM, Jun TY, Lee MS, Kim JB, Yim HW, Park YC. Does age at onset of first major depressive episode indicate the subtype of major depressive disorder?: the clinical research center for depression study. Yonsei Med J. 2014;55(6):1712–20.

    Article  Google Scholar 

  24. Li H, Huang Y, Zang X, Zhu Z, Yang M, Lang XE, Wu K, Wu F, Zhang XY. The relationship between overweight and thyroid function in first-episode, untreated Chinese patients with major depressive disorder with different ages of onset. J Affect Disord. 2021;294:932–8.

    Article  Google Scholar 

  25. Carrozzino D, Patierno C, Fava GA, Guidi J. The Hamilton Rating Scales for Depression: A Critical Review of Clinimetric Properties of Different Versions. Psychother Psychosom. 2020;89(3):133–50.

    Article  Google Scholar 

  26. Sun XY, Li YX, Yu CQ, Li LM. Reliability and validity of depression scales of Chinese version: a systematic review. Zhonghua Liu Xing Bing Xue Za Zhi. 2017;38(1):110–6.

    CAS  Google Scholar 

  27. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol. 1959;32(1):50–5.

    Article  CAS  Google Scholar 

  28. Lamers F, van Oppen P, Comijs HC, Smit JH, Spinhoven P, van Balkom AJ, Nolen WA, Zitman FG, Beekman AT, Penninx BW. Comorbidity patterns of anxiety and depressive disorders in a large cohort study: the Netherlands Study of Depression and Anxiety (NESDA). J Clin Psychiatry. 2011;72(3):341–8.

    Article  Google Scholar 

  29. Aboraya A, Nasrallah HA. Perspectives on the Positive and Negative Syndrome Scale (PANSS): Use, misuse, drawbacks, and a new alternative for schizophrenia research. Ann Clin Psychiatry. 2016;28(2):125–31.

    Google Scholar 

  30. Zhou Y, Ren W, Sun Q, Yu KM, Lang X, Li Z, Zhang XY. The association of clinical correlates, metabolic parameters, and thyroid hormones with suicide attempts in first-episode and drug-naive patients with major depressive disorder comorbid with anxiety: a large-scale cross-sectional study. Transl Psychiatry. 2021;11(1):97.

    Article  CAS  Google Scholar 

  31. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486–97.

    Article  Google Scholar 

  32. Joint committee for guideline revision. 2016 Chinese guidelines for the management of dyslipidemia in adults. J Geriatr Cardiol. 2018;15(1):1–29.

  33. Opoku S, Gan Y, Yobo EA, Tenkorang-Twum D, Yue W, Wang Z, Lu Z. Awareness, treatment, control, and determinants of dyslipidemia among adults in China. Sci Rep. 2021;11(1):10056.

    Article  CAS  Google Scholar 

  34. Mills JG, Thomas SJ, Larkin TA, Deng C. Overeating and food addiction in Major Depressive Disorder: Links to peripheral dopamine. Appetite. 2020;148:104586.

    Article  Google Scholar 

  35. Franch Pato CM, Molina Rodriguez V, Franch Valverde JI. Metabolic syndrome and atypical antipsychotics: Possibility of prediction and control. Rev Psiquiatr Salud Ment. 2017;10(1):38–44.

    Article  Google Scholar 

  36. Capuzzi E, Caldiroli A, Capellazzi M, Tagliabue I, Auxilia A, Ghilardi G, Buoli M, Clerici M. Exploring the role of serum lipid profile and neutrophil-to-lymphocyte ratio in violent suicide attempters: a cross sectional study. CNS Spectr. 2022;27(3):362–8.

    Article  Google Scholar 

  37. Aguglia A, Solano P, Parisi VM, Asaro P, Caprino M, Trabucco A, Amerio A, Amore M, Serafini G. Predictors of relapse in high lethality suicide attempters: a six-month prospective study. J Affect Disord. 2020;271:328–35.

    Article  CAS  Google Scholar 

  38. Sankaranarayanan A, Pratt R, Anoop A, Smith A, Espinoza D, Ramachandran P, Tirupati S. Serum lipids and suicidal risk among patients with schizophrenia spectrum disorders: Systematic review and meta-analysis. Acta Psychiatr Scand. 2021;144(2):125–52.

    Article  CAS  Google Scholar 

  39. Segoviano-Mendoza M, Cardenas-de la Cruz M, Salas-Pacheco J, Vazquez-Alaniz F, La Llave-Leon O, Castellanos-Juarez F, Mendez-Hernandez J, Barraza-Salas M, Miranda-Morales E, Arias-Carrion O, et al. Hypocholesterolemia is an independent risk factor for depression disorder and suicide attempt in Northern Mexican population. BMC Psychiatry. 2018;18(1):7.

    Article  Google Scholar 

  40. Park S, Yi KK, Na R, Lim A, Hong JP. No association between serum cholesterol and death by suicide in patients with schizophrenia, bipolar affective disorder, or major depressive disorder. Behav Brain Funct. 2013;9:45.

    Article  Google Scholar 

  41. Choi KW, Kim YK, Jeon HJ. Comorbid Anxiety and Depression: Clinical and Conceptual Consideration and Transdiagnostic Treatment. Adv Exp Med Biol. 2020;1191:219–35.

    Article  CAS  Google Scholar 

  42. Baek JH, Heo JY, Fava M, Mischoulon D, Nierenberg A, Hong JP, Roh S, Jeon HJ. Anxiety symptoms are linked to new-onset suicidal ideation after six months of follow-up in outpatients with major depressive disorder. J Affect Disord. 2015;187:183–7.

    Article  Google Scholar 

  43. Kessler RC, Sampson NA, Berglund P, Gruber MJ, Al-Hamzawi A, Andrade L, Bunting B, Demyttenaere K, Florescu S, de Girolamo G, et al. Anxious and non-anxious major depressive disorder in the World Health Organization World Mental Health Surveys. Epidemiol Psychiatr Sci. 2015;24(3):210–26.

    Article  CAS  Google Scholar 

  44. Ye G, Li Z, Yue Y, Wu Y, Yang R, Wang H, Wu S, Zhou Y, Zhao X, Lv X, et al. Suicide attempt rate and the risk factors in young, first-episode and drug-naive Chinese Han patients with major depressive disorder. BMC Psychiatry. 2022;22(1):612.

    Article  CAS  Google Scholar 

  45. Turkoz I, Fu DJ, Bossie CA, Sheehan JJ, Alphs L. Relationship between the clinical global impression of severity for schizoaffective disorder scale and established mood scales for mania and depression. J Affect Disord. 2013;150(1):17–22.

    Article  Google Scholar 

  46. Otte C, Gold SM, Penninx BW, Pariante CM, Etkin A, Fava M, Mohr DC, Schatzberg AF. Major depressive disorder. Nat Rev Dis Primers. 2016;2:16065.

    Article  Google Scholar 

  47. Shen Y, Wu F, Zhou Y, Ma Y, Huang X, Ning Y, Lang X, Luo X, Zhang X. Association of thyroid dysfunction with suicide attempts in first-episode and drug naive patients with major depressive disorder. J Affect Disord. 2019;259:180–5.

    Article  CAS  Google Scholar 

  48. Chen SW, Li X, Lang X, Li J, Zhang XY: Metabolic parameters and thyroid hormones in relation to suicide attempts in patients with first-episode and drug-naive major depressive disorder with comorbid glucose disturbances: a large cross-sectional study. Eur Arch Psychiatry Clin Neurosci 2022.

  49. Ferlov-Schwensen C, Brix TH, Hegedus L. Death by Suicide in Graves’ Disease and Graves’ Orbitopathy: A Nationwide Danish Register Study. Thyroid. 2017;27(12):1475–80.

    Article  Google Scholar 

  50. Benros ME, Waltoft BL, Nordentoft M, Ostergaard SD, Eaton WW, Krogh J, Mortensen PB. Autoimmune diseases and severe infections as risk factors for mood disorders: a nationwide study. JAMA Psychiat. 2013;70(8):812–20.

    Article  Google Scholar 

  51. Degner D, Haust M, Meller J, Ruther E, Reulbach U. Association between autoimmune thyroiditis and depressive disorder in psychiatric outpatients. Eur Arch Psychiatry Clin Neurosci. 2015;265(1):67–72.

    Article  Google Scholar 

  52. Zhong Y, Pham S, Porta G, Douaihy A, Marsland A, Brent D, Melhem NM. Increased burden of cardiovascular risk among youth suicide attempters. Psychol Med. 2020;52:1–9.

    Google Scholar 

  53. Dargel AA, Roussel F, Volant S, Etain B, Grant R, Azorin JM, M’Bailara K, Bellivier F, Bougerol T, Kahn JP, et al. Emotional hyper-reactivity and cardiometabolic risk in remitted bipolar patients: a machine learning approach. Acta Psychiatr Scand. 2018;138(4):348–59.

    Article  CAS  Google Scholar 

  54. Baltrusch HJ, Stangel W, Titze I. Stress, cancer and immunity New developments in biopsychosocial and psychoneuroimmunologic research. Acta Neurol (Napoli). 1991;13(4):315–27.

    CAS  Google Scholar 

  55. McIntyre RS, Calabrese JR. Bipolar depression: the clinical characteristics and unmet needs of a complex disorder. Curr Med Res Opin. 2019;35(11):1993–2005.

    Article  Google Scholar 

  56. Vazquez GH, Lolich M, Cabrera C, Jokic R, Kolar D, Tondo L, Baldessarini RJ. Mixed symptoms in major depressive and bipolar disorders: A systematic review. J Affect Disord. 2018;225:756–60.

    Article  Google Scholar 

  57. Guillaume S, Courtet P, Samalin L. Bipolar depression and suicidal behavior. Encephale. 2011;37(Suppl 3):S169-172.

    Article  Google Scholar 

  58. Sarkar P, Mozumder S, Bej A, Mukherjee S, Sengupta J, Chattopadhyay A. Structure, dynamics and lipid interactions of serotonin receptors: excitements and challenges. Biophys Rev. 2020;13(1):101–22.

    Article  Google Scholar 

  59. Coryell W: Do Serum Cholesterol Values and DST Results Comprise Independent Risk Factors for Suicide? In: The Neurobiological Basis of Suicide. edn. Edited by Dwivedi Y. Boca Raton (FL); 2012.

  60. Pandey GN. Biological basis of suicide and suicidal behavior. Bipolar Disord. 2013;15(5):524–41.

    Article  CAS  Google Scholar 

  61. Zhang Y, Smith EM, Baye TM, Eckert JV, Abraham LJ, Moses EK, Kissebah AH, Martin LJ, Olivier M. Serotonin (5-HT) receptor 5A sequence variants affect human plasma triglyceride levels. Physiol Genomics. 2010;42(2):168–76.

    Article  CAS  Google Scholar 

  62. Hoertel N, Cipel H, Blanco C, Oquendo MA, Ellul P, Leaune E, Limosin F, Peyre H, Costemale-Lacoste JF. Cerebrospinal fluid levels of monoamines among suicide attempters: A systematic review and random-effects meta-analysis. J Psychiatr Res. 2021;136:224–35.

    Article  Google Scholar 

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Acknowledgements

We would like to express our deepest appreciation to the patients who decided to take part in this research. We would like to express our gratitude to the staff members who took part in this research for their assistance and support. We would like to express our gratitude to all who have contributed financially to our research.

Funding

This work was supported by: High level Clinical Key Specialties in Guangdong Province Grant (Shenzhen Supporting Construction Funds) (SZGSP013); Guangxi Zhuang Autonomous Region Health and Health Commission Self-financing Project (Z20200901).

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Author notes

  1. Yang Jiang and Yaoyao Lu contributed equally to this work, and they should be regarded as joint first author.

Authors and Affiliations

  1. Guangxi Zhuang Autonomous Region Brain Hospital, Guangxi Liuzhou, 545005, China

    Yang Jiang & Yaoyao Lu

  2. Department of Psychosomatic Disorders, Shenzhen Mental Health Center/Shenzhen KangNing Hospital, Shenzhen, 518000, Guangdong, China

    Yi Cai

  3. Department of General Medicine, Anhui Medical University, He Fei, 230601, China

    Chengjiang Liu

  4. CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, 100101, China

    Xiang-Yang Zhang

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  1. Yang Jiang
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Contributions

Study Design: Xiangyang Zhang; Analysis the data: Yang Jiang, Yaoyao Lu; Manuscript preparation and writing: Yang Jiang, Yaoyao Lu, Yi Cai, Chengjiang Liu; Manuscript revision: Xiangyang Zhang. The author(s) read and approved the fnal manuscript.

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Correspondence to Xiang-Yang Zhang.

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Ethics approval and consent to participate

This study was conducted at the psychiatric clinic department of a general hospital in Taiyuan, Shanxi Province, China. The protocol and informed consent for this study were approved by the Institutional Review Board of the First Clinical Medical College, Shanxi Medical University (No. 2016-Y27). Each participant was given a thorough explanation of the study protocol and procedures by a psychiatrist or research coordinator, and written informed consent was obtained. All of the methods were done in accordance with the National Institute of Health's Declaration of Helsinki.

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The authors declare that they have no competing interests.

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Jiang, Y., Lu, Y., Cai, Y. et al. Prevalence of suicide attempts and correlates among first-episode and untreated major depressive disorder patients with comorbid dyslipidemia of different ages of onset in a Chinese Han population: a large cross-sectional study. BMC Psychiatry 23, 10 (2023). https://doi.org/10.1186/s12888-022-04511-z

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BMC Psychiatry

ISSN: 1471-244X

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