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An Independent Association Between Anxiety Disorders and Suicidal Behavior
In Session With Gordon Asmundson, PhD:
An Independent Association Between Anxiety Disorders and Suicidal Behavior
Gordon Asmundson, PhD, RD Psych
Department of Psychology, University of Regina, Canada
First published in Psychiatry Weekly, Volume 8, Issue
24, on December 2, 2013
Q: What is the general consensus of the literature concerning anxiety disorders and suicidal thoughts and behavior?
A: Although somewhat mixed, the literature has typically indicated that suicidal ideation and behavior in people with anxiety disorders are a product of comorbid depression. Those conclusions have been drawn on the basis of large nationally representative samples wherein people with various anxiety disorders plus suicidal thoughts and behaviors are identified and then compared to people without anxiety disorders. In this statistical scenario, the variance in suicidal thoughts and behaviors attributed to other factors, such as substance abuse, depression, gender, and age is handled statistically and removed, potentially leading to an adjustment bias.
Using a statistical approach called propensity score matching (PSM), which simulates a case-control study, we tested the independent associations between anxiety disorders and suicidal thoughts and behavior, without the potential adjustment bias that can occur in the aforementioned linear statistical approach. We included subjects with anxiety disorders who participated in the National Comorbidity Survey Replication (NCS-R) and the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). These surveys provided the large samples and broad range of variables needed to do the analysis.
Q: Did the PSM approach reveal an independent association between anxiety disorders and suicidality?
A: Yes. This study, at least at the time it was published, was the first to show that each of the anxiety disorders are independently associated with suicidal thoughts and suicide attempts—beyond the effects of co-occurring mental disorders. The findings were similar for data from the NCS-R and the NESARC.
When we compared those who were diagnosed with an anxiety disorder with unmatched controls without an anxiety disorder, all of the anxiety disorders showed a substantial increase in the odds of suicidal ideation and attempts.
When subjects were matched as closely as possible using the PSM approach—for example, person 1 with anxiety disorder A plus mild depression vs person 2 without anxiety but with mild depression—the odds of suicidal thoughts and suicide attempts in the context of an anxiety disorder were still approximately two times greater and 2–4 times greater, respectively, than in the absence of an anxiety disorder, depending on the specific disorder.
These findings demonstrate that suicidal ideation and suicidal attempts are independently associated with anxiety disorders over and above depression. The clinician needs to be aware that patients presenting for treatment of an anxiety disorder may be suicidal, even when comorbid depression is absent or of minimal severity. An assumption that suicide in anxiety disorders is largely an epiphenomenon of comorbid depression could lead to mistakenly identifying such a patient as an unlikely risk for suicide.
Disclosure: Dr. Asmundson reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest.
Reference:
Thibodeau MA, Welch PG, Sareen J, Asmundson GJG. Anxiety disorders are independently associated with suicide ideation and attempts: propensity score matching in two epidemiological samples. Depress Anxiety. 2013;30:947-954.