INTRODUCTION- Suicidal behavior is a leading cause of death and disability worldwide. Fortunately, recent developments in suicide theory and research promise to meaningfully advance knowledge [1]and prevention. For the goal of improved detection and treatment of suicidal individuals to be achieved, we need to develop a detailed understanding of the origin, mechanisms [2]and outcomes of inammation in suicidal behaviour. C-reactive protein (CRP) is an acute-phase inammatory protein synthesized by hepatic Kupffer cells signalling other [3]body cells for destruction by the complement system. Inammation has been linked with a potential vital role in suicidality, among which hs-CRP play an important role. Suicidal ideation and attempt in context of depression is very common. Many studies have demonstrated an association between suicidal behaviour and inammatory markers 4-10primarily CRP. However, the caveats of most studies was that they evaluated the CRP in patients demonstrating suicidal behaviour but not in settings of depression, leading to a bias and variations due to controls having different pathophysiology making it difcult to differentiate the altered inammatory states that could be attributed to suicidality in depression or other causes. Most of the studies have not differentiated between suicidal attempt and ideation since both can inuence CRP levels acutely and chronically. Our study is a pioneer research in comparing hsCRP levels in depression patients with suicidal attempt and with suicidal ideation. In the present study, we explore a clinical inammatory marker (CRP) in psychiatric patients hospitalized in an acute adult inpatient facility following suicidal attempt and ideation. We hypothesized that patients hospitalized in a “real world” adult inpatient population following a recent suicidal attempt will display higher CRP values than those with suicidal ideation. METHODOLOGY- The present study was conducted at Department of Psychiatry, M.G.M Medical College, Indore. This is a cross-sectional comparative study conducted between January 2018 to December 2018. After obtaining the Institutional Review Board (scientic and ethical) approval, 50 consecutive subjects (25 each in depression with suicidal attempt and depression with suicidal ideation group) who attended in-patient treatment from the Psychiatry Department of a Tertiary Care Medical College were taken. INCLUSION CRITERIA Patients aged 18–65 years, both genders, who satised the 11ICD diagnostic criteria for research-10 (ICD DCR-10) criteria for Depression (F32) or RDD (F33), without psychotic symptoms were included. As per Diagnostic and Statistical Manual of Mental Disorders (DSM-V) active suicidal attempt is a self-initiated sequence of behaviours by an individual who at the time of initiation, expected the set of actions would lead to his or her own death. The speciers include current- not more than 12 months since last attempt and in early remission- 12-24 months since last attempt. While the suicidal ideation group has never attempted suicide but have ideas of suicide. Only those patients who were drug naïve or treatment free for more than 3 months before the onset of current episode and subjects/informants who gave written informed consent were taken. EXCLUSION CRITERIA Any other psychiatric comorbidity (schizoaffective, bipolar affective disorder, organic mood disorder). Current use of anti- psychotics , anti-depressant, mood stabilizers, or drug free < 3 months. Patients with history of mental retardation, seizure disorder, permanent neurological decits, cognitive impairment and affective illness secondary to general medical condition or psychoactive substance use (except tobacco) were excluded. We also excluded patients with poor physical health and those with informants who cannot provide adequate information. Subjects were taken from Dept of psychiatry, MGM Medical College- MY Hospital and Mental Hospital Indore fullling the A COMPARATIVE STUDY OF INFLAMMATORY MARKER HIGHLY SENSITIVE C-REACTIVE PROTEIN BETWEEN DEPRESSION PATIENTS WITH SUICIDAL ATTEMPT AND DEPRESSION PATIENTS WITH SUICIDAL IDEATION Original Research Paper Rastogi P Dept. Of Psychiatry MGM MC Indore M.P 452001 India X 105GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Psychiatry BACKGROUND: Suicidal ideation and attempt in context of depression is very common. Many studies have demonstrated an association between suicidal behaviour and inammatory markers primarily CRP. We explore a clinical inammatory marker (CRP) in psychiatric patients hospitalized in an acute adult inpatient facility following suicidal attempt and ideation AIMS: To compare hsCRP levels between depression patients with suicidal attempt and suicidal ideation. Methodology: Comparison of 25 depression patients with suicidal attempt and 25 depression patients with suicidal ideation was done, diagnosis as per ICD10. Hamilton Depression Rating Scale (HDRS-17), Beck Scale for Suicidal Ideation (BSSI), Suicide behaviour Questionnaire- Revised (SBQ-R), were applied for assessment of depression and suicidality. Highly sensitive CRP was measured using autoanalyzer. RESULTS: hsCRP levels were signicantly high in depression patients with suicidal attempt (6.11 mg/dl) than depression with suicidal ideation (2.14 mg/dl). Duration of illness, HAM-D, BSSI & SBQ-R scores correlated positively with hsCRP levels. CONCLUSION: Depression with suicidal attempt patients demonstrated a statistically higher hs-CRP levels than depression with suicidal ideation. Patients of depression with suicidal attempt have a strong positive correlation between hs-CRP levels and HAM-D, BSSI & SBQ-R scores. ABSTRACT KEYWORDS : Suicide; Depression; C-reactive Protein; Inammatory Marker Mudgal V* Dept. Of Psychiatry MGM MC Indore M.P 452001 India*Corresponding Author Pal V. S Dept. Of Psychiatry MGM MC Indore M.P 452001 India Lohokare R Dept. Of Biochemistry MGM MC Indore M.P 452001 India VOLUME-8, ISSUE-12, DECEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra 106 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS inclusion criteria. After complete description of the study to the subjects, written informed consent was obtained from all participants. A detailed physical examination was done to rule out major medical or neurological illness. Socio- demographic data was collected. After that clinical assessment of patient group was done using Hamilton 12Depression Rating Scale (HAM-D), Beck Scale for Suicidal 13 14Ideation (BSSI), Suicide Behaviour Questionnaire (SBQ-R). Blood samples of all groups were drawn after explaining the procedure and were collected in a clot activator (red top) tube at MY Hospital Indore Dept. of biochemistry. Post which serum was processed from the sample via centrifuge machine and the serum was analysed for hs-CRP with Automated analyser using Immunoturbidimetry method. Results were analysed using SPSS 23. RESULTS- Table 1- Sociodemographic variables of the patients In comparison to the depression with suicidal ideation the depression with suicidal attempt group had younger age of onset (28.64 years), more male (56%), unmarried (32%), Hindu faith (80%), literates, low socioeconomic (76%), unemployed (66%), nuclear family (64%) subjects. About a quarter (24%) of patients had family history of suicidal attempt in the attempt group which is higher than ideation group (16%). Table 2. Description of duration of illness (months) in study participants in depression patients with suicidal attempt and depression with suicidal ideation Depression patients attempting suicide had a mean duration of illness as 6.32 ± 2.32 months while depression with suicidal ideation group had a mean duration of 4.84 ± 2.51 months. The minimum duration for attempt group was 3 months while that for ideation group was 2 months, while maximum duration for attempt and ideation group was 12 and 11 months respectively, this duration is when the patient presented to the O.P.D and could have been more. Table 3. Description of age of onset of depression (years) in study participants in depression patients with suicidal attempt and depression with suicidal ideation Suicidal attempt group had mean age of onset at 28.24 ± 9.33 years while ideation group had onset at 37.04 ± 12.733 years. The minimum age of onset for both the case and control group was 18 years while maximum for attempt group was 54 years while that of ideation group was 65 years. Table 4. Clinical characteristics of depression patients with suicidal attempt and depression with suicidal ideation (continuous variables) HAM-D scores showed a higher mean 23.92 ± 6.35 in the suicidal attempt group while the ideation group mean was 16.80 ± 5.87, the t test demonstrated statistical signicance. Beck's scale for suicidal ideation showed a higher mean of 22.92 ± 7.44 in the suicidal attempt group in comparison to 16.48 ± 4.08 as mean for ideation group, the t test demonstrated statistical signicance. The Suicide behaviour questionnaire revealed mean scores of 12.20 ± 3.22 and 8.60 ± 2.21 for attempt and ideation group respectively with a statistical signicance of t test for higher mean SBQ score for attempt group. Table 5. Comparison of hs-CRP between depression pati ents with suicidal attempt and suicidal ideation VOLUME-8, ISSUE-12, DECEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Depression with suicidal attempt (N=25) Depression without suicidal ideation (N=25) Age(mean) in years 28.64 years 35.52 years Males Females 14 (56%) 11 (44%) 12 (48%) 13 (52%) Marital status in %: Married 56% 68% Unmarried 32% 16% Divorced 4% 4% Widowed 4% 4% Remarried 4% 8% Religion in %: Hindu 80% 62% Muslim 20% 38% Education in %: Illiterate 16% 20% thPrimary (5 ) 28% 36% thMiddle(8 ) 20% 20% High School 16% 8% Inter 8% 8% Diploma/Graduate/Post graduate Professional 12% 8% Socioeconomic Low 76% 72% Middle 22% 24% High 2% 4% Occupation Employed 34% 46% Unemployed 66% 54% Family type Nuclear 64% 44% Extended/ Joint. 36% 56% Locality Urban 64% 68% Rural 36% 32% Family history Positive 19 (76%) 21 (84%) Negative 6 (24%) 4 (16%) N Minimum Maximum Mean Std. Deviation Suicidal attempt patients 25 3 12 6.32 2.322 Suicidal ideation patients 25 2 11 4.84 2.511 N Minimum Maximum Mean Std. Deviation Suicidal attempt patients 25 18 54 28.24 9.333 Suicidal ideation patients 25 18 65 37.04 12.733 Variables Suicidal attempt patients Mean± SD N=25 Suicidal ideation patients Mean± SD N=25 t value p value HAM-D SCORES 23.92 ± 6.35 16.80 ± 5.87 4.11 .001 BECK'S SSI SCORES 22.92 ± 7.44 16.48 ± 4.08 3.79 0.001 SBQ-R SCORES 12.20 ± 3.22 8.60 ± 2.21 4.59 0.001 hs-CRP (mg/L) Suicidal attempt patients (N=25) Suicidal ideation Patients (N=25) Mean 6.11 2.14 N 25 25 *statistically signicant Table 5 shows comparison of hs-CRP levels between depression patient with suicidal attempt and ideation. The attempt group had a mean hs-CRP value of 6.11 ± 6.09 mg/L which is considered as high value as per our criteria for cut off (≥3mg/L), while ideation group had a mean of 2.14 ± 2.10 mg/L. Suicidal attempt patient group has shown higher hs- CRP levels than ideation patient group of depression which was statistically signicant. Table 6. Severity of depression in depression patients with suicidal attempt and suicidal ideation Table 6 displays depression severity as per ICD-10 criteria. Severe depression was 76% in suicidal attempt patients and 40% in suicidal ideation patients. About 24% patients were in the moderate depression category belonging to the attempt group while 40% ideation subjects had moderate depression. 20% patients had mild depression with suicidal ideation while there were no patients in the suicidal attempt group who had mild depression. Table 7. comparison of hs-CRP with severity of depression between depression patients with suicidal attempt and ideation Table 7 show comparison of hs-CRP within depression with suicidal behaviour group. The attempt group had the highest mean hs-CRP value 7.04 ± 6.68 mg/L while ideation group had 3.53 ± 2.33 mg/L hs-CRP in severe depression. In moderate depression, the attempt group had a greater mean in comparison to ideation group. T test revealed no statistical difference in means of hs-CRP as per severity of depression in the intragroup comparison. Table 8. Chi square test for hs-CRP samples (low & high) between depression with suicidal attempt and suicidal ideation Pearson chi-square value = 8.11 , p= 0.004 Table 8 describes the high and low hs-CRP counts which is dened by a cut off of 3mg/L as per literature and methodology in depression patients with suicidal attempt and depression patients with suicidal ideation. The chi square test was statistically signicant implying that depression patients with suicidal attempt have more hs-CRP samples in high group than depression patients with suicidal ideation. Cramer's v = .403, moderate effect size Table 9. Correlation of hs-CRP with HAM-D scores in patients of depression with suicidal attempt and depre ssion with suicidal ideation **. Correlation is signicant at the 0.01 level Table 9 displays Pearson correlation between hsCRP and HAM-D scores. There is a statistically signicant strong positive correlation between HAM-D scores and hs-CRP levels in suicidal attempt group, while the suicidal ideation group also had a strong positive correlation between HAM-D scores and hs-CRP. Table 10. Correlation of hs-CRP with SBQ-R scores in patients of depression with suicidal attempt and depression with suicidal ideation *. Correlation is signicant at the 0.05 level Table 10 displays Pearson correlation between hsCRP and SBQ-R scores. There is a statistically signicant medium positive correlation between SBQ-R scores and hs-CRP levels in suicidal attempt group, while the suicidal ideation group also had a medium positive correlation between SBQ-R scores and hs-CRP. Table 11. Correlation of hs-CRP with BSSI scores in patients of depression with suicidal attempt and depression with suicidal ideation **. Correlation is signicant at the 0.01 level *. Correlation is signicant at the 0.05 level Table 11 displays pearson correlation between hsCRP and BSSI scores. There is a statistically signicant strong positive correlation between BSSI scores and hs-CRP levels in suicidal attempt group, while the suicidal ideation group had a medium positive correlation between HAM-D scores and hs- CRP. X 107GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS VOLUME-8, ISSUE-12, DECEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Std. Deviation 6.09 2.10 Std. Error of Mean 1.21 0.43 Minimum .27 .12 Maximum 26.80 6.76 Range 26.53 6.64 t value 3.07 p value 0.005* Depression severity Suicidal Attempt N=25 Suicidal Ideation N=25 Mild 0 (0%) 5 (20%) Moderate 6 (24%) 10 (40%) Severe 19 (76%) 10 (40%) hs-CRP (mg/L)Suicidal attempt patients (N=25) hs-CRP (mg/L)Suicidal ideation patients (N=25) t value p value Mild depression - .81 ± .66 - - Moderate depression 3.16 ± 1.91 2.04 ± 2.01 0.94 0.37 Severe depression 7.04 ± 6.68 3.53 ± 2.33 2.06 0.05 hs-CRP result Total hs-CRP high (value >3mg/L) hs-CRP low (value ≤ 3mg/L) Suicidal Attempt Count 16 9 25 Expected count 11.0 14.0 25.0 Suicidal Ideation Count 6 19 25 Expected count 11.0 14.0 25.0 Total Count 22 28 50 Expected count 22.0 28.0 50.0 Pearson chi-square 8.11 p value 0.004 Cramer's V 0.403 HAM-D suicidal attempt HAM-D suicidal ideation hs-CRP r p r p .519** .008 .735** .001 SBQ-R suicidal attempt SBQ-R suicidal ideation hs-CRP r p r p .483* .015 .311 .130 BSSI suicidal attempt BSSI suicidal ideation hs-CRP r p r p .512** .009 .456* .022 VOLUME-8, ISSUE-12, DECEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra DISCUSSION- The sociodemographic parameters (Table 1) revealed the mean age of depression with suicidal attempt was 33.08 ± 11.9 years while that of depression with suicidal ideation group was 34.20 ± 10.3 years, this implies that suicidality 15, 16appears earlier in presence of depression. The number of female patients were higher in the depression without suicidal behaviour. group (58%) than depression with suicidal behaviour group. Our results suggest that males have higher suicidal behaviour than females. The married subjects were higher in depression with suicidal behaviour group (68%) than depression without suicidal behaviour (64%) groups. Our results suggest that being married might have protective effect on suicidal behaviour due to better social and 17, 18interpersonal support. The depression with suicidal behaviour group had higher preponderance of (76%) Hindu subjects which is in agreement of the local geographical 16distribution of the religion. Most participants in both depression with suicidal behaviour (32%) and depression without suicidal behaviour (32%) group were literate till primary education, depression without suicidal behaviour group had more percentage of illiterates (22%), Previous studies found that poorly educated subjects were more 19vulnerable to suicidal attempts. Low socio-economic income groups were found to be the majority in both depression with suicidal behaviour (74%) and depression without suicidal behaviour groups (76%). In terms of sociodemographic variables studies have shown that depression is more 20, 21common in subjects from poor economic background. The distribution of depression with suicidal behaviour group (66%) and depression without suicidal behaviour (62%) sample were urban dwelling in majority, while about one third sample 22in both groups belonged to rural background. The depression with suicidal behaviour group had higher composition of nuclear family (66%) than depression without 22suicidal behaviour group (54%). Patients attempting suicide had a mean duration of illness as 6.32 ± 2.32 months, suicidal ideation group had a mean duration of 4.84 ± 2.51 months (Table 2). These ndings are 23similar to the mean duration of depression in most literature. Therefore, we suggest the depression with suicidal behaviour patients presented to the health-care settings later as compared to depression without suicidal behaviour patients whereas the suicidal ideation subgroup presented earlier in comparison to the suicidal attempt subgroup. Since majority of suicidal attempt patients were in the severe depression category the above nding can be attributed to severe psychomotor retardation in severe depression and poor interpersonal interaction in suicide attempters. All the samples of our study were identied with major depression as per inclusion criteria and the mean age of all 50 subjects was 32.6 ± 11.9 years, similar mean age have been 10, 22, 24found in multiple previous studies. The mean age of onset in the suicidal attempt subgroup was 28.24 ± 9.33 years while in the ideation subgroup was 37.04 ± 12.70 years (Table 3), suggesting that suicidal attempt patients develop depression at an earlier age in comparison to suicidal ideation counterparts. Hence, young impressionable age is another risk factor for suicidal attempt. Our results are in concordance with previous the studies where in one 73% of the patients with 25suicidal behaviour were <30 years of age, and in another study age at <25 years was reported as being a signicant 19risk factor for suicidal attempt. The mean HAM-D scores in suicidal attempt subgroup (Table 4) were higher 23.92 ± 6.35 than the suicidal ideation subgroup was 16.80 ± 5.80, suggesting attempt can be an indicator for severe depression since suicidal attempt patients were in the very severe category of depression as per HAM-D 12scale, and that suicidal ideation alone does not warrant the diagnosis of severe depression. As per literature severe depression was found to be associated with suicidal attempt one study found severe depression as one of the factors signicantly associated with suicide, (OR=2.20, 95% 26CI=1.05–4.60). In another study it was seen that nding of severe depression was associated with a sensitivity of 87.3% 27, 28and specicity of 63% for suicide attempt. The suicidal attempt group had a mean BECK'S SSI Score of 22.92 ± 7.44 in comparison to 16.48 ± 4.08 as mean for ideation group (Table 4), the student's t-test demonstrated statistical signicance. As the BECK'S SSI relates positively with the suicidal behaviour the suicidal attempt group had a higher mean score. SBQ-R scores more than 8 are suggestive 13of suicidal behaviour which is seen in our sample population. The SBQ-R mean scores of 12.20 ± 3.22 and 8.60 ± 2.21 for attempt and ideation group (Table 4) respectively with a statistical signicance of t test for higher mean SBQ-R score in 14the attempt group. Comparison of hs-CRP levels between subgroups of depression patient with suicidal attempt and ideation (Table 5) the attempt group had a higher mean hs-CRP (6.11 ± 6.09 mg/L) value than ideation group (2.14 ± 2.10 mg/L). Suicidal attempt patient group has shown statistically signicant high mean hs-CRP than ideation patient group of depression. To the best of our knowledge no study had replicated the above results comparing suicidal attempt with suicidal ideation in context of hs-CRP. However, in a previous study conducted in 2015 no signicant difference in CRP levels between high vs 4low suicidal ideation was reported. Comparison of depression patients with suicidal attempt and ideation revealed severe depression was 76% in suicidal attempt patients and 40% in suicidal ideation patients (Table 6) which is in agreement with most guidelines which states suicidal attempt is an indicator of severe depression. However, moderate and severe depression made up for 80% of patients in having suicidal ideation. On evaluating hs-CRP mean as per severity of depression (Table 7) we found a statistically signicant difference in means of hs-CRP cases amongst mild, moderate and severe depression. The depression with suicidal attempt group had the highest mean hs-CRP value 7.04 ± 6.68 mg/L while ideation group had 3.53 ± 2.33 mg/L hs-CRP in severe depression. In moderate depression, the attempt group had a greater mean in comparison to ideation group. T test revealed no statistical difference in means of hs-CRP as per severity of depression in the intragroup comparison. Chi square test was applied in the suicidal attempt and ideation patients (Table 8) the high and low hs-CRP counts which is dened by a cut off of 3mg/L as per literature and methodology in depression patients with suicidal attempt and depression patients with suicidal ideation. The chi square test was statistically signicant implying that depression patients with suicidal attempt have more hs-CRP samples in high group than depression patients with suicidal ideation. The Cramer's v score was .403 which is suggestive of a moderate effect size. There is a statistically signicant strong positive correlation ®= 0.51) between HAM-D scores and hs-CRP levels in suicidal attempt group, while the suicidal ideation group also had a strong positive correlation (r= 0.73) between HAM-D scores and hs-CRP (Table 9). In previous literature it was found 29 that HAM-D scores to be correlated positively with hs-CRP. in another study it was found that individuals with higher 30depression scores have higher levels of hs-CRP. 108 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS VOLUME-8, ISSUE-12, DECEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra There is a statistically signicant medium positive correlation ®= 0.48) between SBQ-R scores and hs-CRP levels in suicidal attempt group, while the suicidal ideation group also had a medium positive correlation (r= 0.31) between SBQ-R scores and hs-CRP (Table 10). There is a statistically signicant strong positive correlation ®= 0.51) between BSSI scores and hs-CRP levels in suicidal attempt group, while the suicidal ideation group had a medium positive correlation (r= 0.45) between HAM-D scores and hs-CRP (Table 11). There are a few limitations to our study design like there is a lack of longitudinal follow-up which could be utilized to compare hs-CRP scores before and after intervention. Inammatory marker hs-CRP could be confounded by other inammatory conditions despite strict inclusion criteria. Sample size and study duration can attribute to factors limiting the study. CONCLUSION- Depression patients with suicidal attempt have more hs-CRP high (≥3mg/L) samples than depression patients with suicidal ideation. There is a strong positive correlation between HAM- D scores and hs-CRP levels in suicidal attempt group, while the suicidal ideation group also had a strong positive correlation. Moderate positive correlation was found between SBQ-R scores and hs-CRP levels in suicidal attempt and ideation group. 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