Letters to the Editor

Functional Neural Basis of Suicidal Behavior in Depression

TO THE E DITOR: In their study, published online March 17 and in the June 2008 print issue of the Journal, Fabrice Jollant, M.D., Ph.D., et al. (1) reported differences in the orbitofrontal cortex activation pattern among euthymic patients with recurrent depression, with and without past suicidal acts. Differences in this activation pattern among euthymic patients were compared with those among healthy comparison subjects. These differences were assessed following the presentation of angry, happy, or neutral faces. Orbitofrontal cortex dysfunction is described as a contributing factor to the core characteristics of borderline personality disorder (2), particularly impulsivity (3). In addition, comorbid depressive disorder is common among individuals with borderline personality disorder (4). Dr. Jollant et al. did not assess axis II disorders but rather personality traits for which data were reportedbut not provided in the article to be without significant difference. Considering the relatively low sample size and Bonferroni correction for multiple testing, influences of personality traits could have been underestimated as a result of such methodological issues. Furthermore, no data regarding whether suicidal acts were attempted during a depressive episode were provided, which could have helped to differentiate between depressive and impulsive suicidality. Data pertaining to the severity of past depressive episodes in the three study groups could have also helped to elucidate this issue.
References
1. Jollant F, Lawrence NS, Giampietro V, Brammer MJ, Fullana MA, Drapier D, Courtet P, Phillips ML: Orbitofrontal cortex response to angry faces in men with histories of suicide attempts. Am J Psychiatry 2008; 165:740748 2. Silbersweig D, Clarkin JF, Goldstein M, Kernberg OF, Tuescher O, Levy KN, Brendel G, Pan H, Beutel M, Pavony MT, Epstein J, Lenzenweger MF, Thomas KM, Posner MI, Stern E: Failure of frontolimbic inhibitory function in the context of negative emotion in borderline personality disorder. Am J Psychiatry 2007; 164: 18321841 3. Berlin HA, Rolls ET, Iversen SD: Borderline personality disorder, impulsivity, and the orbitofrontal cortex. Am J Psychiatry 2005; 162:23602373 4. Zanarini MC, Frankenburg FR, Dubo ED, Sickel AE, Trikha A, Levin A, Reynolds V: Axis I comorbidity of borderline personality disorder. Am J Psychiatry 1998; 155:17331739

subjects without a history of suicidal acts in response to angry faces may have reflected between-group differences in borderline personality disorder or related personality traits, notably impulsivity. We did not assess borderline personality disorder, since in the study of vulnerability to suicidal behavior it has been shown that personality traits may be more relevant than full axis II disorders (1). Of note, many scores were very close between subjects with and without a history of suicidal acts (e.g., mean motor impulsivity score: 14.3 [SD=6.5] versus 14.8 [SD=6.3], respectively), suggesting that both groups were well-matched on certain measures. Regarding personality traits, we do agree with the statistical comments made by Drs. Schulte-Herbrggen and Roepke. The personality question is of major importance to the conceptualization of suicidal behavior. Many studies have shown that vulnerability to suicidal acts is associated with heritable personality traits (1, 2). The main concept is that these personality traits constitute clinical aspects of the vulnerability to suicidal actstraits that may overlap with borderline personality disorder as well as other disorders (3). Therefore, it would not be surprising if higher activity in the orbitofrontal cortex in response to angry faces was linked to both a history of suicidal acts, as we suggested, and also impulsivity or affective lability. These issues should be further investigated among our study sample. To answer Drs. Schulte-Herbrggen and Roepkes proposal, all suicidal acts in our study sample were carried out during a major depressive episode. However, it may not be relevant to distinguish impulsive (nondepressive state [theoretically], impulsivity trait linked) from nonimpulsive (depressive state [theoretically], nonimpulsivity trait linked) acts, since it has previously been reported that impulsivity trait and impulsivity of the suicidal act are largely dissociated (4). Impulsive acts may be committed during a depressive episode by nonimpulsive individuals. Last, we did not assess the severity of past depressive episodes. This assessment should be conducted in future studies.
References
1. Brent DA, Mann JJ: Family genetic studies, suicide, and suicidal behavior. Am J Med Genet C Semin Med Genet 2005; 133:13 24 2. Brezo J, Paris J, Turecki G: Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completions: a systematic review. Acta Psychiatr Scand 2006; 113:180206 3. Mann JJ, Waternaux C, Haas GL, Malone KM: Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 1999; 156:181199 4. Baca-Garcia E, Diaz-Sastre C, Garcia Resa E, Blasco H, Braquehais Conesa D, Oquendo MA, Saiz-Ruiz J, de Leon J: Suicide attempts and impulsivity. Eur Arch Psychiatry Clin Neurosci 2005; 255:152156

OLAF SCHULTE-HERBRGGEN, M.D. STEFAN ROEPKE, M.D. Berlin, Germany

The authors report no competing interests. This letter (doi: 10.1176/appi.ajp.2008.08040489) was accepted for publication in May 2008.

Dr. Jollant Replies

TO THE EDITOR : We thank Drs. Schulte-Herbrggen and Roepke for raising issues that we would like to clarify. They suggest that our results of higher activation of the orbitofrontal cortex among subjects with past suicidal acts relative to
Am J Psychiatry 165:9, September 2008

FABRICE JOLLANT, M.D., PH.D. Montpellier, France

The authors disclosures accompany the original article. This letter (doi: 10.1176/appi.ajp.2008.08040489r) was accepted for publication in May 2008.
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