Increased Risk ofAttempted SuicideAmong AgingHolocaust Survivors

EDITOR: Barak’s article1 is afirst. It is a landmark contribu-

tion to both suicidology and Holo-caust studies. Hopefully, it willstimulate further investigation ofthis extremely important topic. Re-markably, the risk of attempted orcompleted suicide in survivorshardly drew comment in the psychi-atric literature. Furthermore, theiroccurrence in Jews either before theHolocaust or during it was hardlydescribed. Rather, the subject wasleft to scholars in the humanities, no-tably in the field of history ratherthan in the medical sciences.

Historical studies, notably Luc-jan Dobroszycki’s The Chronicle ofthe Lodz Ghetto, 1941–1944,2 foundthat the risk of completed suicidein Jews directly exposed to the Na-zis was as much as 10 times that ofthe local gentile population. Whatof the suicide risk to Holocaust sur-vivors to Israel? Israel received thelargest contingent of Holocaustsurvivors, probably as many asthree-fourths of a million souls.Not surprisingly, a much higherproportion of this group than thehost population found their wayinto Israel’s mental hospitals. How-ever, the relationship between theirsuicidality and their Holocaust ex-perience went virtually unre-corded. Statistics for completedsuicide in Israel only got off theground in the late 1960s. To myknowledge, these statistics werenever analyzed vis-a-vis the Holo-caust. Their deaths, however,merely swelled the suicide groupstatistics. Barak is the first to seri-

ously explore suicidality in Holo-caust survivors. He discovered atleast three times the risk of at-tempted suicide. He is to be highlycommended for revealing thesefacts.

Paul Brown, F.R.A.N.Z.P.The Pierre Janet Centre, St. KildaEast, Australia

Reference1. Barak Y, Aizenberg D, Szor H, et al: In-

creased risk of attempted suicide amongaging holocaust survivors. Am J Geriatr Psy-chiatry 2005; 13:701–704

2. Dobroszycki L: The Chronicle of the LodzGhetto 1941–1944. New Haven, CT, YaleUniversity Press, 1984

Bipolar andDepressive Types ofSchizoaffectiveDisorder in Old Age

EDITOR: Although Post1

pointed out that elders withschizoaffective (SA) disorder areseverely ill, often have a history ofsuicide attempts, and can be refrac-tory to antipsychotic treatment,there has been relatively little sub-sequent study of this population.Furthermore, although Post didnot distinguish bipolar (BP) fromdepressive (DEP) type SA disorderin elders, studies in younger pa-tients have suggested differencesbetween these types in clinical fea-tures, including history of suicideattempt2,3 and in pharmacologictreatment approaches.4 Therefore,we conducted a retrospective chartreview of clinical features andtreatment in geriatric patients withSA disorder. Our aims were first, to

assess the proportion of BP- andDEP-type patients, and second, toexamine whether these groups dif-fered in history of suicide attemptand in prior treatment with moodstabilizers.

Patients were studied who wereaged 60 years or older and wereconsecutively admitted to a univer-sity psychiatric hospital, and had aDiagnostic and Statistical Manual ofMental Disorders, Fourth Edition(DSM-IV) diagnosis of schizoaffec-tive disorder at discharge assignedby the team of treating cliniciansusing information obtained fromclinical interview and from the pa-tients’ family members, caregivers,and medical records; the diagnosiswas confirmed by chart review ofthis documentation. Patients wereexcluded who had a history of sub-stance abuse within one month be-fore the admission; acute medicalillness based on medical history,physical examination, and routinelaboratory tests; or mental retarda-tion. Patients were characterized asBP or DEP type by DSM–IV crite-ria. History of suicide attempt wasrecorded. History of standingpharmacotherapy was noted.

The mean age of the study sam-ple (N�60) was 68.7 years (stan-dard deviation [SD]: 7.0 years). Thepatients were predominantly fe-male (78.3%) and white (80.0%);only 6.7% of patients were His-panic and 13.3% of patients wereblack. Most had at least one priorhospitalization (70.0%). The major-ity of patients had BP type SA dis-order (Table 1). SA-BP and SA-DEPpatients overlapped in age (mean:68.5 years, SD: 6.2 years; and 69.0years, SD: 4.4 years, respectively),sex distribution (76.9% and 81.0%female, respectively), race (76.9%and 85.7% white, respectively), ed-

Am J Geriatr Psychiatry 14:4, April 2006382

LETTERS