Evolution and characteristics of the use of valproate in women of childbearing age with bipolar disorder: Results from the FACE-BD cohort

BACKGROUND

Valproate is associated with teratogenic and neurodevelopmental effects. Several agencies have restricted the conditions of its prescription in bipolar disorders (BD). We aimed to assess the evolution of valproate prescription and the clinical profile of BD women of childbearing age receiving valproate.

METHODS

Based on a large national cohort, we included all BD women 16-50 years old. Sociodemographic, clinical and pharmacological data were recorded. Logistic regression analyses were used to describe variables associated with valproate prescription.

RESULTS

Of the 1018 included women 16-50 years old, 26.9% were treated with valproate with a mean daily dosage of 968 mg. The prevalence of BD women using valproate was 32.6% before May 2015 and 17.3% after May 2015 (p<0.001), the date of French regulatory publication of restriction of valproate prescription. The multivariate analysis revealed that the inclusion period after May 2015 (OR=0.54, CI 95% 0.37-0.78, p=0.001), the age lower than 40 years (OR=0.65, CI 95% 0.43-0.98, p=0.040) and the number of lifetime mood episodes (OR=0.98, CI 95% 0.95-0.99, p=0.040) were the variables negatively associated with the use of valproate.

LIMITATIONS

Study could be underpowered to determine a clinical profile associated with valproate prescription.

CONCLUSIONS

The regulatory change in BD women of childbearing age had a significant impact on valproate prescription, even if the prescription rate remains high. Important efforts are needed to help clinicians and patients to improve quality of care in BD women of childbearing age.

Compulsory admissions of patients with mental disorders: State of the art on ethical and legislative aspects in 40 European countries

Background.

Compulsory admission procedures of patients with mental disorders vary between countries in Europe. The Ethics Committee of the European Psychiatric Association (EPA) launched a survey on involuntary admission procedures of patients with mental disorders in 40 countries to gather information from all National Psychiatric Associations that are members of the EPA to develop recommendations for improving involuntary admission processes and promote voluntary care.

Methods.

The survey focused on legislation of involuntary admissions and key actors involved in the admission procedure as well as most common reasons for involuntary admissions.

Results.

We analyzed the survey categorical data in themes, which highlight that both medical and legal actors are involved in involuntary admission procedures.

Conclusions.

We conclude that legal reasons for compulsory admission should be reworded in order to remove stigmatization of the patient, that raising awareness about involuntary admission procedures and patient rights with both patients and family advocacy groups is paramount, that communication about procedures should be widely available in lay-language for the general population, and that training sessions and guidance should be available for legal and medical practitioners. Finally, people working in the field need to be constantly aware about the ethical challenges surrounding compulsory admissions.

Cognitive modelling to assess decision-making impairments in patients with current depression and with/without suicide history

It has been reported that decision making is impaired in suicide attempters. Decision making is a complex process and little is known about its different components. Yet, this information would help to understand the functioning of suicidal minds. In this study, the Prospect Valence-Learning (PVL) computational model was applied to the Iowa Gambling Task (IGT) to investigate and compare decision-making components in patients with affective disorder and with/without history of suicide attempts and in healthy controls. To this aim, 116 inpatients with current major depressive episode (among whom 62 suicide attempters) and 38 healthy controls were recruited. Decision-making performance was measured using the IGT. The Bayesian computational PVL model was applied to compare the feedback sensitivity, loss aversion, learning/memory, and choice consistency components of decision making in the different groups. Depressive symptomatology was assessed using the Beck Depression Inventory short form (BDI-SF). The total IGT net score and the loss aversion and learning/memory scores were lower in suicide attempters than in healthy controls. The choice consistency score was low in all patients (with/without suicide history) compared with healthy controls. Moreover, patients with high BDI score showed a positive relationship between the choice consistency score and suicide attempt. These findings suggest that decision-making impairment in depressed patients with and without suicidal history might be the result of underlying problems in feedback processing and task learning, which influence the building of long-term strategies. All these impairments should be targeted in therapeutic strategies for suicidal patients.

Suicidal ideation and affect lability in single and multiple suicidal attempters with Major Depressive Disorder: An exploratory network analysis

INTRODUCTION

A better understanding of the specific contribution of risk factors to suicidal behavior could arise from analyzing suicidal ideation (SI) in clinical samples, and comparing single versus multiple suicide attempters through contemporary methods allowing complex and dynamical analyses of multiple and simultaneously interacting suicide risk factors.

METHOD

We explored associations among suicidal ideation (SI), affect lability and other suicide risk factors in 323 suicidal attempters diagnosed with major depressive disorder (MDD). We analyzed the network structure and centrality of the total sample, and compared single versus multiple attempters and subjects with low and high suicidal ideation.

RESULTS

SI was connected with anxiety (trait) and hopelessness. Central nodes for global and specific groups were affect lability (from anxiety to depression), anxiety as a trait, and harm avoidance. We observed some specific differences between clinical profiles of repeaters and non-repeaters and significant network density between high and low SI.

LIMITATIONS

Because our cross-sectional design, we cannot establish casual relationships among variables. We only examined associations at group level but not at single subject level.

CONCLUSIONS

Affect lability (mainly the shifts from anxiety to depression) and trait anxiety were central in each estimated network. These symptoms might be suitable targets for early detecting and treating suicidal patients.

Actualité sur le risque suicidaire et les sels de lithium

Le traitement au long cours des troubles de l’humeur conduit à une diminution marquée de la mortalité, notamment par suicide, de ces patients dont le risque suicidaire est majeur. Les données s’accumulent depuis 40 ans pour proposer que le lithium bénéficie d’un effet suicide, lui conférant une place à part dans l’arsenal thérapeutique. En effet, le lithium présente un effet préventif des conduites suicidaires dans le trouble bipolaire comme dans le trouble unipolaire. Cet effet semble indépendant de son efficacité thymorégulatrice et supérieur à ce qui est observé avec les anticonvulsivants. Les mécanismes d’action du lithium continuent d’être étudiés tant ils sont complexes. Les pistes se multiplient pour envisager que le lithium agisse sur différents traits de vulnérabilité suicidaire ou qu’il puisse corriger des anomalies cérébrales associées au suicide. Les travaux scientifiques, de la molécule à l’épidémiologie, concourent à proposer le lithium en première ligne pour lutter contre le risque suicidaire des patients souffrant de troubles thymiques. Il est alors envisageable de recourir au lithium dans une perspective dimensionnelle, pour traiter le risque suicidaire, l’impulsivité et l’agressivité, et ce, indépendamment du traitement thymorégulateur choisi pour le patient.

Decision making and vulnerability to suicidal behaviour in elderly

Suicide is a major public health concern, especially for older adults, who have higher rates of completed suicide than any other age group in most countries of the world. However, understanding suicidal behaviour remains a challenging task particularly among the elders who have been poorly studied. Decision making has been recently found to be altered in suicide attempters under 65.To test wether decision making would be a neuropsychological trait of vulnerability to suicidal behaviours, the authors used the Iowa Gambling Task to investigate normothymic non demented elders with a history of suicidal behaviour (N = 35) and compared it to decision making in non suicide attempters with a past history of depression (N = 52) and comparison subjects (N = 43). The data also were compared to those of similar groups of younger normothymic subjects. Moreover, the old suicidal patients were assessed according to the age at the onset of suicidal behaviour (before or after 60).Old suicide attempters did not significantly differ from the other aged groups and according to the age of first suicidal behaviour. Old suicide attempters presented better performances than that of younger suicidal patients.Vulnerability to suicidal behaviour in older people may proceed from cognitive processes which are different from the ones involved in suicidal vulnerability of younger subjects. These results are preliminary and further studies are needed to explore vulnerability cognitive patterns to suicide among elders.

La sensibilité aux stress sociaux chez les suicidants. Observation écologique

La démonstration de l’efficacité des soins basés sur le recontact, comme l’observation qu’un geste suicidaire suit régulièrement un événement de vie stressant, notamment dans le domaine social, suggèrent que les stress sociaux conduisant à l’exclusion sociale occupent un rôle central dans la survenue des conduites suicidaires. Les nouvelles technologies de la communication, à l’aide de Smartphones, permettent l’évaluation in vivo des patients à risque suicidaire. Non seulement, l’évaluation répétée du risque suicidaire dans l’environnement naturel du sujet n’est pas délétère pour les sujets, mais en outre, ce type d’innovation apporte des informations de grand intérêt pour suivre les séquences environnementales conduisant à la génération des idées de suicide. Ainsi, nous avons observé dans une étude d’évaluation écologique instantanée que les stress sociaux et eux-seuls, prédisent la survenue ultérieure d’idées de suicide. Ainsi, les individus vulnérables au suicide pourraient être particulièrement sensibles au stress sociaux. À ce titre, les études d’imagerie cérébrale démontrent l’existence d’anomalies cérébrales chez les suicidants lors de paradigmes d’exclusion sociale. Par ailleurs, les études récentes avancent la possibilité d’une inflammation chronique modérée dans les conduites suicidaires. Ainsi, divers marqueurs de l’inflammation, dont la CRP plasmatique et les taux de cytokines centraux et périphériques ont été associés aux conduites suicidaires. Il se trouve que les stress sociaux sont des inducteurs particulièrement puissants de cytokines pro-inflammatoires, en faisant intervenir des régions cérébrales également impliquées dans la vulnérabilité suicidaire (insula antérieure, cortex cingulaire antérieur). Nous formulons l’hypothèse que les sujets vulnérables aux conduites suicidaires présenteraient une réponse inflammatoire et algique exagérée aux stress sociaux.

Sleep quality and emotional reactivity cluster in bipolar disorders and impact on functioning

Objective:

Bipolar disorders (BD) are characterized by sleep disturbances and emotional dysregulation both during acute episodes and remission periods. We hypothesized that sleep quality (SQ) and emotional reactivity (ER) defined clusters of patients with no or abnormal SQ and ER and we studied the association with functioning.

Method:

We performed a bi-dimensional cluster analysis using SQ and ER measures in a sample of 533 outpatients patients with BD (in remission or with subsyndromal mood symptoms). Clusters were compared for mood symptoms, sleep profile and functioning.

Results:

We identified three clusters of patients: C1 (normal ER and SQ, 54%), C2 (hypo-ER and low SQ, 22%) and C3 (hyper-ER and low SQ, 24%). C1 was characterized by minimal mood symptoms, better sleep profile and higher functioning than other clusters. Although highly different for ER, C2 and C3 had similar levels of subsyndromal mood symptoms as assessed using classical mood scales. When exploring sleep domains, C2 showed poor sleep efficiency and a trend for longer sleep latency as compared to C3. Interestingly, alterations in functioning were similar in C2 and C3, with no difference in any of the sub-domains.

Conclusion:

Abnormalities in ER and SQ delineated three clusters of patients with BD and significantly impacted on functioning.

Risk of Suicide Mortality Among Cancer Patients: A Meta-Analysis of Observational Studies

Introduction

Suicide rates among patients with cancer are higher than ones in the general population.

Objective

This meta-analysis aims to estimate the suicide risk in patients with cancer.

Methods

We searched Medline, PsycINFO, and the Cochrane library to identify articles published before July 1, 2016, examining the association between suicide [death (SD), attempt (SA), ideation (SI)] and any form of diagnosed cancer.

Results

We initially identified 4880 records and after unsuitable studies were removed, our search yielded 102 publications of which 14 were used in the meta-analyses. Patients with cancer had higher risk of SD (seven studies, 247.869 participants; odds ratio [OR] = 1.52, 95% CI = 1.22–1.89, P = 0.0002) compared with those without cancer (among case-control studies focused on SD versus living controls). Among studies focused on SD versus other deaths, patients with cancer had higher risk of SD (two studies, 23.839 participants; OR = 1.53, 95% CI = 1.03–2.27, P = 0.03). No difference has been detected for risk of SA (four studies, 8.147.762 participants) and for SI (two studies, 37.879 participants).

Since publication bias was detected, the “trim and fill” method was applied. The majority of the included studies have a high quality at the STROBE statement.

Conclusion

The assessment of suicide risk in this population is crucial.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Borderline personality disorder and childhood maltreatment: A genome-wide methylation analysis

Early life adversity plays a critical role in the emergence of borderline personality disorder (BPD) and this could occur through epigenetic programming. In this perspective, we aimed to determine whether childhood maltreatment could durably modify epigenetic processes by the means of a whole-genome methylation scan of BPD subjects. Using the Illumina Infinium® Human Methylation 450 Bead Chip, global methylation status of DNA extracted from peripheral blood leucocytes was correlated to the severity of childhood maltreatment in 96 BPD subjects suffering from a high level of child adversity and 93 subjects suffering from major depressive disorder (MDD) and reporting a low rate of child maltreatment. Several CpGs within or near the following genes (IL17RA, miR124-3, KCNQ2, EFNB1, OCA2, MFAP2, RPH3AL, WDR60, CST9L, EP400, A2ML1, NT5DC2, FAM163A and SPSB2) were found to be differently methylated, either in BPD compared with MDD or in relation to the severity of childhood maltreatment. A highly relevant biological result was observed for cg04927004 close to miR124-3 that was significantly associated with BPD and severity of childhood maltreatment. miR124-3 codes for a microRNA (miRNA) targeting several genes previously found to be associated with BPD such as NR3C1. Our results highlight the potentially important role played by miRNAs in the etiology of neuropsychiatric disorders such as BPD and the usefulness of using methylome-wide association studies to uncover such candidate genes. Moreover, they offer new understanding of the impact of maltreatments on biological processes leading to diseases and may ultimately result in the identification of relevant biomarkers.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Adherence to treatment guidelines in clinical practice for using electroconvulsive therapy in major depressive episode

BACKGROUND

ECT is the most effective treatment of major depressive episode (MDE) but remains a neglected treatment. The French Society for Biological Psychiatry and Neuropsychopharmacology aimed to determine whether prescribing practice of ECT followed guidelines recommendations.

METHODS

This multicenter, retrospective study included adult patients with major depressive disorder (MDD) or bipolar disorder (BD), who have been treated with ECT for MDE. Duration of MDE and number of lines of treatment received before ECT were collected. The reasons for using ECT, specifically first-line indications (suicidality, urgency, presence of catatonic and psychotic features, previous ECT response, patient preference) were recorded. Statistical comparisons between groups used standard statistical tests.

RESULTS

Seven hundred and forty-five individuals were included. The mean duration of MDE before ECT was 10.1 months and the mean number of lines of treatment before ECT was 3.4. It was significantly longer for MDD single episode than recurrent MDD and BD. The presence of first-line indications for using ECT was significantly associated to shorter duration of MDE (9.1 vs 13.1 months, p<0.001) and lower number of lines of treatment before ECT (3.3 vs 4.1, p<0.001).

LIMITATIONS

This is a retrospective study and not all facilities practicing ECT participated that could limit the extrapolation of the results.

CONCLUSION

Compared to guidelines, ECT was not used as first-line strategy in clinical practice. The presence of first-line indications seemed to reduce the delay before ECT initiation. The improvements of knowledge and access of ECT are needed to decrease the gap between guidelines and clinical practice.

Somatic assessment of one hundred inpatients in a psychiatric crisis unit: A retrospective observational study

OBJECTIVES

Compared to the general population, psychiatric patients are more exposed to physical illness but have reduced access to care.

METHODS

We conducted a descriptive study in Montpellier between November 2011, 2nd and December 2012, 21st. Every Wednesday and Friday, the last two inpatients admitted in the psychiatric post-emergency unit of the University Hospital of Montpellier were assessed by a general practitioner and included in the study. This unit takes care of suicidal patients suffering from mood and/or personality disorders. The general practitioner assessed lifetime somatic history, current somatic comorbidities and medical follow-up for non-psychiatric issues.

RESULTS

One hundred patients were included. The sample consisted of 81% women with a mean age of 43 years (18-79 years). The majority of patients had a lifetime history of somatic disease (96%) and was followed by a general practitioner (99%). Six patients had no met general practitioner for at least one year. Dyslipidemia was reported in 32 patients, among those only one patient was on lipid-lowering drug (96.88%). Among patients with impaired dental condition, 29 (55.77%) had not met a dentist for at least one year. Among those with impaired near visual acuity and/or impaired distance visual acuity, 19 (65.52%) had not met an ophthalmologist for at least one year.

CONCLUSION

Although detected, somatic comorbidities seem outsourced in psychiatric patients. Greater awareness among different health professionals about the medical care of such patients could improve healthcare management and life expectancy.

[Suicidal risk during the first psychotic episode]

Suicide is the most common cause of early mortality during the course of schizophrenia. The most recent data in the literature show that the risk of suicide is greater at the beginning of the course of schizophrenia. The risk of suicide during the first year is 12 times higher than that of the general population. Specifically, 2-5 % of people with first-episode psychosis will die by suicide in long-term follow-up studies. Regarding the presence of suicidal ideation that are a major factor of suicide in subjects suffering from psychotic disorders, their prevalence remains extremely worrying, since they are substantial and persistent. Consequently, suicide prevention should be a major and immediate objective in the management of the disease, as soon as the diagnosis has been made. Suicidal ideas are a potential precursor to the evolution towards acting out. Their evolution must be specifically assessed in each individual. Indeed, in the influential Danish OPUS study the authors reported heterogeneity in suicidal ideations in young patients with first episode of psychosis and identified three prototypical trajectories of suicidal ideations over the first 2 years in treatment. Particularly, nearly 40 % of patients with first-episode psychosis have persisting suicidal thoughts over the initial treatment period. Consequently, the authors recommend routine screening for suicidality when providing treatment for first-episode psychosis. The main risk factors for suicidal behavior in patients with a first episode are classical ones. Previous research has suggested that, in addition to young age and early course of illness, other important clinical predictors of suicide in individuals with schizophrenia include presence of depressive symptoms and misuse of substances, which are very common conditions in these patients. Lack of social support, loss, rejection, stigma, insight, fear of future losses, are all negative experiences experienced by patients starting a psychotic disorder. Negative connotations of the diagnosis of psychotic disorders, feelings of being trapped that can be directly related to feeling a burden can lead to suicidal crisis in these individuals. Then, the painful experience of the disease and its consequences associated with self-stigmatization and social rejection may induce hopelessness and suicidal thoughts in these young subjects. The quality of the insight and its evolution may worsen the depressive experience and suicidal risk and they therefore also require to be measured regularly. Thus, the clinical evaluation of patients entering psychosis should focus on those dimensions that are not directly related to the psychotic symptoms. At the precise evaluation of each patient must be associated personalized measures of prevention. It is now proposed that prevention strategies targeting suicidal behaviour in first-episode psychosis should not be universal. On a more general level, evidence-based data to support specific care programs are still lacking, and only few data are in favor of integrated care in patients presenting with first episode. It should also be kept in mind that the risk of suicide is extraordinarily high for all psychiatric patients during the first few months after discharge from hospital. This should encourage caregivers to offer intensive follow-up programs to their patients and to embrace recontact and follow-up initiatives using the tools of e-health. Last, programs for the early detection of schizophrenia seem to be beneficial for the prevention of suicide in these subjects.

Impact of bipolar disorder on eating disorders severity in real-life settings

BACKGROUND

Comorbidity of bipolar disorder (BD) and eating disorders (ED) is common and increases the course and severity of BD. However, the impact of comorbid BD on the clinical profile of ED patients remains unclear. Most studies have focused on patients primarily assessed for BD and data on patients with a primary diagnosis of ED are sparse. We investigated the association between a dual diagnosis and severity in terms of clinical, neuropsychological dimensions and daily functioning.

METHOD

Two hundred and sixty-one patients with ED were consecutively recruited. BD was screened with the MINI and further confirmed in the French expert centre network. The severity of ED symptoms was assessed with the EDE-Q and EDI-2, daily functioning with the FAST. The neurocognitive assessment targeted attention, set-shifting and decision-making.

RESULTS

Forty-nine patients screened positive for BD, but diagnosis was confirmed in only thirty patients (11.5% of the cohort). After multiple adjustments, comorbidity was associated with greater severity on the total score and three subscales of the EDE-Q and on four of the ten dimensions of the EDI-2. Comorbid BD was associated with lower daily functioning but not with lower neuropsychological performance.

LIMITATIONS

Sample referred to specialist clinics not large enough to authorize an analysis by subtype and cross-sectional evaluation.

CONCLUSION

The association between ED and BD increases ED severity for most of these core features. It negatively impacts daily functioning. The results also highlight issues about the validity of screening tools to detect BD in patients with ED.

Polymorphism A118G of opioid receptor mu 1 (OPRM1) is associated with emergence of suicidal ideation at antidepressant onset in a large naturalistic cohort of depressed outpatients

Antidepressants have been the object of an international controversy for about thirty years. Some patients are inclined to develop suicidal ideation (SI) at antidepressant onset; this phenomenon is known as Treatment Emergent Suicidal Ideation (TESI), and it has conducted regulatory bodies to prompt warnings on antidepressants. Since, few studies have explored the pharmacogenomics of TESI. Given the growing body of evidence connecting the opioidergic system with suicidal behavior (particularly mu opioid receptor (MOR)), we decided to examine the relationship between two genetic polymorphisms (SNPs) in the opioidergic system and TESI in a sample of 3566 adult depressed outpatients. General practitioners and psychiatrists throughout France followed participants for 6 weeks after an initial prescription of tianeptine, an antidepressant treatment with mu agonism. Suicidal ideation was assessed with the item 10 of the Montgomery-Asberg Depression Rating Scale (item dedicated to SI) at baseline, and after 2 weeks, 4 weeks and 6 weeks. We analysed rs1799971 from the OPRM1 gene and rs105660 from the OPRK1 gene. Within the sample, 112 patients reported TESI while 384 did not. We found a significant association between AA genotype of rs1799971 and TESI even after adjustment for potential cofounders (OR = 1.93, 95% CI = [1.07; 3.49]; p-value = 0.03). On the other hand there were no significant association between rs1799971 and rs105560 with worsening of suicidal ideation or lifetime suicide attempts. Nevertheless, our results suggest a possible involvement of opioidergic system in TESI.

Clinical guidelines for the management of depression with specific comorbid psychiatric conditions French recommendations from experts (the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental)

BACKGROUND

Recommendations for pharmacological treatments of major depression with specific comorbid psychiatric conditions are lacking.

METHOD

The French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental developed expert consensus guidelines for the management of depression based on the RAND/UCLA Appropriatneness Method. Recommendations for lines of treatment are provided by the scientific committee after data analysis and interpretation of the results of a survey of 36 psychiatrist experts in the field of major depression and its treatments.

RESULTS

The expert guidelines combine scientific evidence and expert clinician's opinion to produce recommendations for major depression with comorbid anxiety disorders, personality disorders or substance use disorders and in geriatric depression.

CONCLUSION

These guidelines provide direction addressing common clinical dilemmas that arise in the pharmacologic treatment of major depression with comorbid psychiatric conditions.

[Social pain at the core of suicidal behavior]

BACKGROUND

Intolerable pain is often reported in suicide notes. Moreover, the frequency of life events preceding a suicidal act is high, especially interpersonal difficulties. Such adversity is the source of psychological or social pain.

METHODS

We propose a narrative review to discuss the role of pain in the suicidal process while having a focus on social ties.

RESULTS

Using Ecological Momentary Assessment in suicide attempters it has been shown that being alone increased suicidal ideation while being with close others significantly reduced this risk. At a neuroanatomical level, suicidal vulnerability is associated with dysfunctional insula activation during social exclusion, a region involved in social and physical pain processing. Social pain elicited by social exclusion or devaluation shares common neurobiological patterns with physical pain. It is also an exemplar of psychological pain. Despite the complexity of its definition, higher psychological pain levels are associated with suicidal ideation and acts. Finally, intense physical pain or chronic pain are strong risk factors of suicidal ideation and act. Interestingly, suicide notes often report the existence of an intolerable pain. Presence of psychological pain and difficulties in communication predict the lethality and seriousness of suicide attempts. Moreover, presence of psychological pain is associated with more impulsive choices in suicidal patients, suggesting that a suicidal act is a means to escape intolerable suffering despite negative long-term consequences (i.e. death). Analgesics are usually used to get relief from pain but are also frequently involved in suicidal overdoses. It has been shown that opioid analgesics are associated with an increased risk of suicide. Higher consumption of opioid analgesics has been shown in suicidal patients in comparison to patients with history of depression but no suicidal act and healthy controls whereas non-suicidal patients were those reporting higher presence of pain in comparison to healthy controls. It may suggest that opioids are being used by suicidal patients to get relief from psychological/social pain rather than from physical pain. Involvement of opioidergic system in suicidal process opens new therapeutic strategies. Recently, the time-limited, short-term use of very low dosages of sublingual buprenorphine (vs. placebo) was associated with decreased suicidal ideation and mental pain in severely suicidal patients without substance abuse. In a randomized controlled trial comparing a 7-week acceptance and commitment therapy (ACT) versus relaxation group, as adjunct to treatment as usual for adult outpatients suffering from a current suicidal behavior disorder, ACT has shown its effectiveness in reducing suicidal ideation and psychological pain. Evidence indicates that maintaining contact either via letter, postcard or telephone with at-risk adults following discharge from care services after a suicide attempt can reduce reattempt risk. Based on these results, a preventive program of recontact for suicide attempters, VIGILANS, has been developed in France in usual care.

CONCLUSION

The approach of the suicidal issue by the angle of pain and social disconnection offers new advances to improve clinical assessment, to identify new biological pathways involved in suicidal risk, and to propose innovative therapeutic and preventive actions.

Examining relationships between psychotic experiences and suicidal ideation in adolescents using a network approach

BACKGROUND

Suicide is one of the leading causes of death in young individuals. Timely and adequate identification of individuals with suicidal ideation could prevent from suicidal behavior. Psychotic experiences (PE) have been shown to increase levels of suicidal ideation (SI) in the general population. Therefore, detailed investigation of the relationship of PE and SI is relevant. However, the exact nature of the relationship between these two phenomena remains unclear. Understanding psychopathology as a complex network of interacting symptoms could be helpful to elucidate specific associations existing between PE and SI.

METHOD

A specific type of network analysis, the Ising model, was used to examine connections between dichotomized questions on psychotic experiences and suicidal ideation in a cross-sectional study with 1685 adolescents from the general population aged 13-18 years.

RESULTS

SI was mostly connected to the PE domains perceptual anomalies (PA) and bizarre experiences (BE), which have higher strength values in the network. Central nodes within these domains, as indexed by higher centrality measures (strength and betweenness) were: auditory experiences (PA1: hearing voices when you are alone), persecutory ideation (BE1: feelings of being persecuted; BE2: conspiracy against you), and social anxiety (SANX) (SANX1: I cannot get close to people).

CONCLUSIONS

Suicidal ideation is differentially connected to specific psychotic experiences. Auditory PE, persecutory ideation, and social anxiety symptoms could play a central role in the interconnectedness of the two constructs.

Emotional hyper-reactivity and cardiometabolic risk in remitted bipolar patients: a machine learning approach

OBJECTIVE

Remitted bipolar disorder (BD) patients frequently present with chronic mood instability and emotional hyper-reactivity, associated with poor psychosocial functioning and low-grade inflammation. We investigated emotional hyper-reactivity as a dimension for characterization of remitted BD patients, and clinical and biological factors for identifying those with and without emotional hyper-reactivity.

METHOD

A total of 635 adult remitted BD patients, evaluated in the French Network of Bipolar Expert Centers from 2010-2015, were assessed for emotional reactivity using the Multidimensional Assessment of Thymic States. Machine learning algorithms were used on clinical and biological variables to enhance characterization of patients.

RESULTS

After adjustment, patients with emotional hyper-reactivity (n = 306) had significantly higher levels of systolic and diastolic blood pressure (P < 1.0 × 10^-8 ), high-sensitivity C-reactive protein (P < 1.0 × 10^-8 ), fasting glucose (P < 2.23 × 10^-6 ), glycated hemoglobin (P = 0.0008) and suicide attempts (P = 1.4 × 10^-8 ). Using models of combined clinical and biological factors for distinguishing BD patients with and without emotional hyper-reactivity, the strongest predictors were: systolic and diastolic blood pressure, fasting glucose, C-reactive protein and number of suicide attempts. This predictive model identified patients with emotional hyper-reactivity with 84.9% accuracy.

CONCLUSION

The assessment of emotional hyper-reactivity in remitted BD patients is clinically relevant, particularly for identifying those at higher risk of cardiometabolic dysfunction, chronic inflammation, and suicide.

[French Society for Biological Psychiatry and Neuropsychopharmacology and Fondation FondaMental task force: Formal Consensus for the management of treatment-resistant depression]

Major depression represents among the most frequent psychiatric disorders in the general population with an estimated lifetime prevalence of 16-17%. It is characterized by high levels of comorbidities with other psychiatric conditions or somatic diseases as well as a recurrent or chronic course in 50 to 80% of the cases leading to negative repercussions on the daily functioning, with an impaired quality of life, and to severe direct/indirect costs. Large cohort studies have supported that failure of a first-line antidepressant treatment is observed in more than 60% of patients. In this case, several treatment strategies have been proposed by classical evidence-based guidelines from internationally recognized scientific societies, referring primarily on: I) the switch to another antidepressant of the same or different class; II) the combination with another antidepressant of complementary pharmacological profile; III) the addition of a wide range of pharmacological agents intending to potentiate the therapeutic effects of the ongoing antidepressant medication; IV) the association with appropriate psychological therapies; and, V) the use of non-invasive brain stimulation techniques. However, although based on the most recently available data and rigorous methodology, standard guidelines have the significant disadvantage of not covering a large variety of clinical conditions, while currently observed in everyday clinical practice. From these considerations, formalized recommendations by a large panel of French experts in the management of depressed patients have been developed under the shared sponsorship of the French Association of Biological Psychiatry and Neuropsychopharmacology (AFPBN) and the Fondation FondaMental. These French recommendations are presented in this special issue in order to provide relevant information about the treatment choices to make, depending particularly on the clinical response to previous treatment lines or the complexity of clinical situations (clinical features, specific populations, psychiatric comorbidities, etc.). Thus, the present approach will be especially helpful for the clinicians enabling to substantially facilitate and guide their clinical decision when confronted to difficult-to-treat forms of major depression in the daily clinical practice. This will be expected to significantly improve the poor prognosis of the treatment-resistant depression thereby lowering the clinical, functional and costly impact owing directly to the disease.

Tianeptine is associated with lower risk of suicidal ideation worsening during the first weeks of treatment onset compared with other antidepressants: A naturalistic study

Worsening of suicidal ideation during the first weeks of antidepressant treatment is a poorly understood phenomenon that prompted regulatory bodies to issue specific warnings. To better understand the causes of this phenomenon, this study compared the risk of suicidal ideation worsening in patients taking different types of antidepressant medications. To this aim, 4017 depressed adult outpatients were followed by general practitioners and psychiatrists throughout France for 6 weeks after prescription of an antidepressant treatment. The main study outcomes were to monitor changes (worsening or improvement) in suicidal ideation between baseline (treatment onset) and the study end (week 6) and to determine the remission rates according to the treatment type. Depression severity was assessed with the patient-administered Hospital Anxiety and Depression Scale and suicidal ideation with the 9-item Montgomery-Asberg Depression Rating Scale and the Hopelessness Scale. Use of tianeptine, a mu-opioid receptor agonist was significantly associated with a lower risk of suicidal ideation worsening compared with other antidepressants in the first 6 weeks of treatment. Conversely, remission rates were not significantly affected by the treatment type. Our results highlight a potential interest of opioid agonists to reduce the risk of worsening of suicidal ideation at antidepressant initiation.

Collaborative meta-analysis finds no evidence of a strong interaction between stress and 5-HTTLPR genotype contributing to the development of depression

The hypothesis that the S allele of the 5-HTTLPR serotonin transporter promoter region is associated with increased risk of depression, but only in individuals exposed to stressful situations, has generated much interest, research and controversy since first proposed in 2003. Multiple meta-analyses combining results from heterogeneous analyses have not settled the issue. To determine the magnitude of the interaction and the conditions under which it might be observed, we performed new analyses on 31 data sets containing 38 802 European ancestry subjects genotyped for 5-HTTLPR and assessed for depression and childhood maltreatment or other stressful life events, and meta-analysed the results. Analyses targeted two stressors (narrow, broad) and two depression outcomes (current, lifetime). All groups that published on this topic prior to the initiation of our study and met the assessment and sample size criteria were invited to participate. Additional groups, identified by consortium members or self-identified in response to our protocol (published prior to the start of analysis) with qualifying unpublished data, were also invited to participate. A uniform data analysis script implementing the protocol was executed by each of the consortium members. Our findings do not support the interaction hypothesis. We found no subgroups or variable definitions for which an interaction between stress and 5-HTTLPR genotype was statistically significant. In contrast, our findings for the main effects of life stressors (strong risk factor) and 5-HTTLPR genotype (no impact on risk) are strikingly consistent across our contributing studies, the original study reporting the interaction and subsequent meta-analyses. Our conclusion is that if an interaction exists in which the S allele of 5-HTTLPR increases risk of depression only in stressed individuals, then it is not broadly generalisable, but must be of modest effect size and only observable in limited situations.