Suicide

Practitioner Experiences Responding to Suicide Risk for Survivors of Human Trafficking in the Philippines

Human trafficking survivors experience elevated suicide risk in comparison to the general population. Anti-trafficking service providers in the Philippines have identified capacity building in suicide prevention as a critical priority given the insufficient number of trained mental health professionals and lack of culturally adapted evidence-based interventions in the Philippines. We conducted a focused ethnography exploring the experiences of non-mental health professionals working in the anti-human trafficking sector in the Philippines in responding to suicidality among survivors of human trafficking (n = 20). Themes included: emotional burden on service providers, manifestations of stigma regarding suicide, lack of clarity regarding risk assessment, lack of mental health services and support systems, transferring responsibility to other providers, and the need for training, supervision, and organizational systems. We discuss implications for training service providers in the anti-human trafficking sector, as well as cultural adaptation of suicide prevention interventions with human trafficking survivors in the Philippines.

Leisure sedentary time and suicide risk among young adolescents: Data from 54 low- and middle-income countries

BACKGROUND

The dose-response association between sedentary time and suicidal ideation and planning among adolescents is unclear. This study examined the association between leisure sedentary time and suicidal ideation, planning and attempts among adolescents in low- and middle-income countries (LMICs).

METHODS

We used the most recent data (2009-2016) from the Global School-based Student Health Survey (GSHS) in 54 LMICs. Leisure sedentary time and suicidal ideation, planning and attempts were assessed using a standardized questionnaire. A total of 146,345 young adolescents aged 12-15 years were included.

RESULTS

Among adolescents in the 54 LMICs, the prevalence of suicidal ideation was 14.8%, planning was 14.5%, and attempts was 13.0%. Compared with those who had less than 1 h/day of sedentary time, those who had 3, 4 h/day sedentary time were at higher odds ratio (OR) of suicidal ideation OR=1.21 (95% confidence interval (CI) =1.14-1.29), planning OR=1.15 (95%CI=1.07-1.22) and attempts OR=1.17 (95%CI=1.09-1.26), and those who had more than 8 h/day sedentary time were at OR=1.58 (95%CI=1.44-1.72), OR=1.44 (95%CI=1.31-1.58) and OR=1.27 (95%CI=1.16-1.40), respectively.

LIMITATIONS

Suicidal behaviors and sedentary time were assessed by a self-reported questionnaire, which might be prone to recall bias.

CONCLUSIONS

Higher amounts of leisure sedentary time are associated with suicidal ideation, planning and attempts among adolescents. Adolescents should spend less than 2 h/day of their sedentary time to reduce the likelihood of suicide.

Suicide and self-injury outcomes for patients with comorbid psychiatric and physical health conditions

Suicide is a transdiagnostic public health issue that affects nearly all psychiatric disorders, individuals without a mental health diagnosis, and individuals with physical health issues. We assessed the relationship between these variables and suicide outcomes using a novel epidemiological research paradigm. Data were collected from the National Trauma Data Bank. Participants included patients admitted to trauma units for suicide and self-injury (n = 13,422). Patients were classified to one of four comorbid condition groups: no comorbidity, comorbid physical condition, comorbid major psychiatric condition, or multimorbidity (comorbid physical and psychiatric conditions). Multivariable logistic regression measured associations between comorbid condition and mortality and multivariable linear regression measured associations between comorbidity and injury severity. Mortality in patients with physical health comorbidity was not significant, but patients with psychiatric comorbidity or multimorbidity had significantly lower mortality than patients without either. No association between injury severity and comorbidity was detected. There were no differences in suicide mortality for individuals with a physical health comorbidity, but mortality was lower for individuals with a comorbid major psychiatric illness or multimorbidity. Since physical health conditions and psychiatric illness are associated with eventual suicide mortality, prevention strategies could target these populations at trauma units for suicide and self-injury admissions.

Revisiting evidence of primary prevention of suicide among adult populations: A systematic overview

BACKGROUNDS

Primary prevention of suicidal behaviors in the general population is required to interrupt the trend of self-inflicted deaths worldwide. We reviewed the evidence of the efficacy of primary prevention of suicide among the adult population.

METHODS

This is an overview of systematic reviews. We searched PubMed, EMBASE, Scopus, PsycINFO, and Cochrane databases to identify articles on suicide prevention strategies in non-clinical populations. For the purpose of overview, only systematic reviews were eligible. Primary outcomes: The outcomes of the present study were changes in the number of suicide death or suicide behaviors. Two reviewers assessed the methodological quality and the risk of bias of included studies.

RESULTS

From the initial 2,315 records, 32 articles met inclusion criteria. Evidence of reduction of suicide-related outcomes was detected, but of small magnitude. Most multicomponent prevention programs were delivered to specific populations, comprising strategies such as restriction to lethal means, educational programs, and gatekeeper training. Means restriction was the single intervention that showed some evidence of individual efficacy in reducing suicide. There is evidence that poor quality of media reporting is related with increasing suicide and better-quality reports could help suicide prevention. Most of the included SRs were of critically-low methodological quality.

LIMITATIONS

Publication bias, reporting bias, study designs, outcome definition and article overlap across studies are the main concerns.

CONCLUSIONS

Multicomponent programs and means restriction have indicated a reduction of suicide rates, mainly in specific populations. There is insufficient evidence to recommend a widespread implementation of suicide primary prevention in the general population.

Exploring dissociation as a facilitator of suicide risk: A translational investigation using virtual reality

Research shows that suicidal behavior is not a result of a single cause or single event, but instead is an interaction of facilitators. One potential facilitator that needs further exploration is dissociation. Dissociation has been consistently linked to suicidal behavior, and theories have posited that dissociation increases the possibility of a suicidal act via intensified disconnect from the body. However, these theories do not indicate whether dissociation is a facilitator of suicide risk by increasing suicidal ideation and attempt behaviors. Additionally, unique considerations of working with suicidal individuals have caused suicide research to lag behind research where laboratory manipulation is possible. Virtual Reality (VR) technology is potentially a useful new translational approach to studying suicide causes. Undergraduate students (n = 145) completed a dissociation induction task and then decided whether to engage in a virtual suicide option. Results showed that those who reported higher dissociation scores also reported higher suicide risk and indicated that certain facets of dissociation (i.e., depersonalization and derealization) significantly predicted engaging in virtual suicide. Results indicate that dissociation should be considered as a factor in the assessment and treatment of suicide risk. Limitations include that this used an uncommon suicide attempt method (i.e., jumping), and engaging in VR suicide is not the same as engaging in actual suicide or suicidal behaviors. However, VR may recreate certain sensations and situations one might experience when engaging in a suicide attempt and thus should be considered assessing and treating suicide risk.

Community suicide rates and related factors within a surveillance platform in Western Kenya

BACKGROUND

Suicide is an important contributor to the burden of mental health disorders, but community-based suicide data are scarce in many low- and middle-income countries (LMIC) including Kenya. Available data on suicide underestimates the true burden due to underreporting related to stigma and legal restrictions, and under-representation of those not utilizing health facilities.

METHODS

We estimated the cumulative incidence of suicide via verbal autopsies from the Health and Demographic Surveillance System (HDSS) in Kisumu County, Kenya. We then used content analysis of open history forms among deaths coded as accidents to identify those who likely died by suicide but were not coded as suicide deaths. We finally conducted a case-control study of suicides (both verbal autopsy confirmed and likely suicides) compared to accident-caused deaths to assess factors associated with suicide in this HDSS.

RESULTS

A total of 33 out of 4306 verbal autopsies confirmed suicide as the cause of death. Content analysis of a further 228 deaths originally attributed to accidents identified 39 additional likely suicides. The best estimate of suicide-specific mortality rate was 14.7 per 100,000 population per year (credibility window = 11.3 - 18.0). The most common reported method of death was self-poisoning (54%). From the case-control study interpersonal difficulties and stressful life events were associated with increased odds of suicide in both confirmed suicides and confirmed combined with suspected suicides. Other pertinent factors such as age and being male differed depending upon which outcome was used.

CONCLUSION

Suicide is common in this area, and interventions are needed to address drivers. The twofold increase in the suicide-specific mortality rate following incorporation of misattributed suicide deaths exemplify underreporting and misclassification of suicide cases at community level. Further, verbal autopsies may underreport suicide specifically among older and female populations.

Early psychiatric referral after attempted suicide helps prevent suicide reattempts: A longitudinal national cohort study in South Korea

INTRODUCTION

Although people who attempted suicide tend to repeat suicide attempts, there is a lack of evidence on the association between psychiatric service factors and suicide reattempt among them.

METHODS

We used a nationwide, population-based medical record database of South Korea to investigate the use of psychiatric services before and after the index suicide attempt and the association between psychiatric service factors after the index suicide attempt with the risk of suicide reattempt.

RESULTS

Among 5,874 people who had attempted suicide, the all-cause mortality within 3 months after the suicide attempt was 11.6%. Among all subjects who attempted suicide, 30.6% of them had used psychiatric services within 6 months before the suicide attempt; 43.7% of them had used psychiatric services within 3 months after the suicide attempt. Among individuals who had visited clinics following attempted suicide, the cumulative incidence of suicide reattempt over a mean follow-up period of 5.1 years was 3.4%. About half of suicide reattempts occurred within 1 year after the index suicide attempt. Referral to psychiatric services within 7 days was associated with a decreased risk of suicide reattempt (adjusted hazard ratio, 0.51; 95% confidence intervals, 0.29-0.89).

CONCLUSION

An early psychiatric referral within 1 week after a suicide attempt was associated with a decreased risk of suicide reattempt.

Sleep architecture and emotional inhibition processing in adolescents hospitalized during a suicidal crisis

BACKGROUND

Suicide is the second leading cause of death in adolescents. Sleep disturbances could alter inhibitory processes and contribute to dangerous behaviors in this critical developmental period. Adolescents in suicidal crisis have been shown to have lighter sleep compared to healthy controls. Additionally, suicidal adolescents have lower neural resources mobilized by emotionally charged inhibition processing. The present exploratory study aimed to determine how sleep architecture in suicidal adolescents may relate to inhibition processing in response to emotional stimuli.

METHODS

Ten adolescents between 12 and 17 years of age with a diagnosis of major depressive disorder and who attempted suicide were recruited while hospitalized for a suicidal crisis in a psychiatric inpatient unit. Event-related potentials (ERPs) were recorded prior to bedtime during a Go/NoGo task involving pictures of sad, happy, and neutral faces. Polysomnography was then recorded throughout the night. Pearson correlations were conducted to investigate how inhibition performance and ERP parameters reflecting inhibition processing (i.e., P3d and N2d derived from difference waveform calculated as NoGo minus Go trials) relate to sleep architecture.

RESULTS

Poorer inhibition accuracy in response to emotional stimuli was significantly correlated with shorter REM sleep latency, higher REM sleep, and more frequent nocturnal awakenings. The P3d in response to sad faces was negatively correlated with NREM2 sleep and positively correlated with NREM3 sleep. No such association with the P3d was found for happy or neutral stimuli. There were no significant correlations for the N2d.

CONCLUSION

Altered sleep in adolescents with depression who are in a suicidal crisisis associated with behavioral inhibition difficulties and fewer neural resources mobilized by inhibitory processes in emotionally charged contexts. This highlights the importance of addressing sleep disturbances while managing suicidal crises in adolescents.

Catalytic Reaction Model of Suicide

Suicide is a devastating outcome of unresolved issues that affect mental health, general wellbeing and socioeconomic stress. The biology of suicidal behavior is still poorly understood, although progress has been made. Suicidal behavior runs in families and genetic studies have provided initial glimpses into potential genes that contribute to suicide risk. Here, we attempt to unify the biology and behavioral dimensions into a model that can guide research in this area. The proposed model envisions suicidal behavior as a catalytic reaction that may result in suicide depending on the conditions, analogously to enzyme catalysis of chemical reactions. A wide array of substrates or reactants, such as hopelessness, depression, debilitating illnesses and diminished motivation can mobilize suicidal thoughts and behaviors (STBs), which can then catalyze the final step/act of suicide. Here, we focus on three biological substrates in particular: threat assessment, motivation to engage in life and impulsivity. Genetic risk factors can affect each of these processes and tilt the balance toward suicidal behavior when existential crises (real or perceived) emerge such as loss of a loved one, sudden changes in social status or serious health issues. Although suicide is a uniquely human behavior, many of the fundamental biological processes are evolutionarily conserved. Insights from animal models may help to shape our understanding of suicidal behavior in man. By examining counterparts of the major biological processes in other organisms, new ideas about the role of genetic risk factors may emerge along with possible therapeutic interventions or preventive measures.

Characteristics of Korean students advised to seek psychiatric treatment before death by suicide

INTRODUCTION

Suicide is the leading cause of death among adolescents in Korea. Psychiatric disorders are well-known risk factors for suicide, but the proportion of children and adolescents who died by suicide and who had received psychiatric treatment is low. This study aims to examine how many school students who died by suicide were advised by their school to seek psychiatric treatment before their death and to characterize their clinical characteristics.

METHODS

We analyzed data collected by the Ministry of Education of Korea for all students who died by suicide between 2016 and 2020. Students were grouped according to whether or not they were advised to seek psychiatric treatment by their school-based on mental health screening and teachers' judgments. Sociodemographic characteristics (sex, educational stage, family structure, and socioeconomic status), suicide-related characteristics (place of suicide, suicide method, suicide note, previous self-harm, and previous suicide attempt), emotional and behavioral status, school life and personal, and family problems were compared between the two groups.

RESULTS

Analysis was conducted for 544 students, 110 (20.2%) of whom were advised to seek psychiatric treatment by their school before their death. This group had a higher proportion of girls; poorer attendance; higher frequency of depression, anxiety, impulsivity, and social problems; personal problems (appearance, friend-related, and mental and physical health problems); family problems (mental health problems of family, bad relationship with parents, and conflict of parents); and higher incidence of self-harm or suicide attempts (P < 0.001) than the other group.

CONCLUSION

Teachers seem to advise psychiatric treatment when mental health problems are revealed at school. It showed distinctive clinical characteristics between the two groups. Preventing suicide among students requires the attention and effort not only of schools, but also of families, communities, and mental health professionals.

Relation of perceived discrimination with depression, insomnia and post-traumatic stress in COVID-19 survivors

The study's objective was to study the association of perceived discrimination with depression, insomnia and post-traumatic stress in people recovered from coronavirus disease (COVID-19) in Santa Marta, Colombia. COVID-19 survivors were invited to participate. The authors measured perceived discrimination related to COVID-19 (COVID-19 Perceived Stigma Scale), depression (PHQ-9), insomnia (Athens Insomnia Scale), and post-traumatic stress (Brief Davidson Trauma Scale). Three hundred thirty COVID-19 survivors participated in the research; the participants were between 18 and 89 years; 61.52% were females. 32.12% of the participants reported high perceived discrimination; 49.70%, depression; 60.61%, insomnia; and 13.33% post-traumatic stress. After adjusting for age, gender, and income, depression, insomnia, and post-traumatic stress were associated significantly with discrimination perceived by COVID-19. Perceived discrimination is a social stressor that affects the psychological well-being of people recovered from COVID-19. In the follow-up of this group of patients, it is important to consider the impact of perceived discrimination on psychological well-being.

Identification of Sex-Specific Plasma Biomarkers Using Metabolomics for Major Depressive Disorder in Children and Adolescents

BACKGROUND

Children and adolescents are at a high risk of major depressive disorder (MDD) with known sex differences in epidemiology. However, there are currently no objective laboratory-based sex-specific biomarkers available to support the diagnoses of male and female patients with MDD.

METHODS

Here, a male set of 42 cases and 27 healthy controls (HCs) and a female set of 42 cases and 22 HCs were recruited. This study investigated the sex differences of plasma metabolite biomarkers in young patients with MDD by the application of ultra-high-performance liquid chromatography equipped with quadrupole time-of-flight mass spectrometry.

RESULTS

The metabolic profiles showed clear separations in both male and female sets. In total, this study identified 57 male-related and 53 female-related differential metabolites. Compared with HCs, both male and female subjects with MDD displayed four significantly altered pathways. Notably, biliverdin was selected as an independent diagnostic male-specific biomarker with an area under the receiver operating characteristic curve of 0.966, and phosphatidylcholine (10:0/14:1) was selected as a female-specific biomarker, achieving an area under the curve (AUC) of 0.957.

CONCLUSION

This metabolomics study may aid in the development of a plasma-based test for the diagnosis of male and female children and adolescents with MDD, as well as give new insight into the pathophysiology of sex differences in children and adolescents with MDD.

Validation of the Hamilton Depression Rating Scale (HDRS) in the Tunisian dialect

OBJECTIVES

The Hamilton Depression Rating Scale (HDRS) is one of the most frequently used depression assessment scales. In Tunisia, psychiatrists commonly use this scale in a Tunisian dialect. However, to the best of our knowledge, this scale has never been validated in Tunisia. This study aims to investigate the reliability and the validity of the HDRS among Tunisian patients who have been hospitalised for a suicide attempt. A secondary objective is to describe the sociodemographic characteristics of the study population.

STUDY DESIGN

This is a cross-sectional study performed in the emergency department.

METHODS

Patients who were hospitalised for a suicide attempt were eligible for inclusion in this study. The Tunisian version of the HDRS was developed using a forward-backward translation procedure. Psychometric properties of the Tunisian version of the HDRS were tested, including (i) construct validity with a confirmatory one-factor analysis; (ii) internal validity with Pearson correlations and Cronbach alpha coefficients; and (iii) external validity by correlations with the Patient Health Quality-9 (PHQ-9) scale. We used the Receiver-Operating Characteristic (ROC) curve to analyse the correlation between the total HDRS score and the presence of depression according to the PHQ-9.

RESULTS

In total, 101 participants were enrolled in this study. The principal component analysis (PCA) type factor analysis with varimax rotation found a high-grade correlation between HDRS individual items and the total score. The total variance, explained by five factors, was 64.4%. Cronbach's standardised alpha coefficient was 0.86 for the overall scale. Correlations between the total HDRS score and the PHQ-9 score, and its various items, were significant. The ROC curve analysis showed good sensitivity (80.8%) and specificity (91.1%).

CONCLUSION

The Tunisian version of the HDRS is an acceptable instrument to screen depression in individuals who have attempted suicide.

Suicide and Suicide Attempts Among Asylum-Seekers in Denmark

OBJECTIVE

There are concerns that asylum-seekers are at increased risk of suicide attempt and suicide mortality. Yet, largescale nationwide studies are limited. Our aim was to examine whether asylum-seekers in Denmark had higher rates of suicide attempt and suicide when compared to the general population.

METHODS

A retrospective cohort design was used. Data on asylum-seekers and the general population living in Denmark during 2009-2019 were obtained from the Immigration services and national registers. Indirect standardization was applied to adjust for differences with respect to age group and sex and Incidence Rate Ratios (IRR) with 95% confidence intervals were calculated.

RESULTS

In a population of 78,666 asylum-seekers, a total of 601 suicide attempts and 9 suicides were recorded. The rate of suicide attempt was 842.0 per 100,000 person-years for asylum-seekers and 92.3 per 100,000 person-years for the general population. When adjusting for differences related to age group and sex, an IRR of 8.5 (95% CI: 7.6-9.5) was found for suicide attempt between 2014-2019. The IRR for suicide attempt unaccompanied minors between 2015 and 2019 was 5.8 (95% CI: 4.3-7.5) when adjusting for age group. We did not find an elevated rate of suicide among asylum-seekers (IRR: 1.6, 95% CI: 0.6-3.5).

CONCLUSIONS

Asylum-seekers were found to have higher rates of suicide attempt than the general population in Denmark. This also applied to unaccompanied minors. Our study emphasizes the need for awareness and preventive measures targeting mental health and suicidal behavior among asylum-seekers.HIGHLIGHTSAsylum-seekers had an 8-fold higher rate of suicide attempt than the general population.The suicide attempt rate for asylum-seekers reached its lowest levels during recent years.Unaccompanied minors had a 5-fold higher frequency of suicide attempt when compared to peers in the general population.We did not find elevated rates of death by suicide among asylum-seekers. No suicide deaths were recorded among unaccompanied minors.

Prevalence and correlates of suicidal behaviors in the Taiwan Psychiatric Morbidity Survey

BACKGROUND/PURPOSE

Suicide is a huge global health burden. High suicide rates with a low prevalence of major depressive disorder were reported in East Asia. This study aimed to investigate the prevalence of suicidal behaviors in relation to the demographic characteristics and major depressive disorder in Taiwan.

METHODS

This study was based on the Taiwan Psychiatric Morbidity Survey, conducted between 2003 and 2005, a survey of common psychiatric disorders in a nationally representative sample of non-institutionalized civilians aged 18 or above. Demographic data, major depressive disorder, and suicidal behaviors were ascertained by a face-to-face interview using the paper version of the World Mental Health Survey Composite International Diagnostic Interview.

RESULTS

According to the total sample of 10,135 participants, the lifetime prevalence of suicidal ideation, plans and attempts was 7.52% (S.E = 0.46%), 1.31% (S.E. = 0.16%) and 1.29% (S.E. = 0.16%), respectively. Among suicide ideators, the conditional probability of making a suicide plan was 17.39% (S.E. = 1.92%), and a suicide attempt 17.16% (S.E. = 2.15%). Age ≤ 40, female sex, and major depressive disorder were related to a higher risk of suicidal behaviors in the general population; the former two were associated with further developing suicide attempts and the latter one developing plans among ideators.

CONCLUSION

Despite low prevalence, major depressive disorder remained a significant risk factor for suicidal behaviors in Taiwan.

Relationship between chronic exposure to ambient air pollution and mental health in Korean adult cancer survivors and the general population

Background

Although a significant association between air pollution and mental health has been identified, few studies have addressed this relationship based on cancer diagnosis. This study investigated whether associations between long-term air pollution and mental health conditions differ based on whether the individual has been diagnosed with cancer.

Methods

Nationally representative data were used and a total of 38,101 adults were included in the analyses. We assessed mental health factors such as perceived stress, depressive symptoms, and suicidal ideation, and analyzed the associations between these factors and individuals’ annual average exposure to air pollutants, including particulate matter with an aerodynamic diameter ≤ 10 μm (PM₁₀), nitrogen dioxide, sulfur dioxide, and carbon monoxide.

Results

Compared with the general population, PM₁₀ exposure in cancer survivors predicted a higher risk of depressive symptoms (odds ratio [OR] =1.34; 95% confidence interval [CI] = 1.06–1.69) and suicidal ideation (OR = 1.29; 95% CI = 1.01–1.64). Notably, the statistically significant relationship between PM₁₀ exposure and suicidal ideation in cancer survivors disappeared after further adjustment for depressive symptoms (p = 0.3103). This pattern was also observed in the result of propensity score-matched analysis for comparison between cancer survivors and the general population.

Conclusions

This study provides the first evidence that cancer survivors with depressive symptoms may be more susceptible to suicidal ideation in the context of persistent PM₁₀ exposure.

Prediction of recurrent suicidal behavior among suicide attempters with Cox regression and machine learning: a 10-year prospective cohort study

BACKGROUND

Research on predictors and risk of recurrence after suicide attempt from China is lacking. This study aims to identify risk factors and develop prediction models for recurrent suicidal behavior among suicide attempters using Cox proportional hazard (CPH) and machine learning methods.

METHODS

The prospective cohort study included 1103 suicide attempters with a maximum follow-up of 10 years from rural China. Baseline characteristics, collected by face-to-face interviews at least 1 month later after index suicide attempt, were used to predict recurrent suicidal behavior. CPH and 3 machine learning algorithms, namely, the least absolute shrinkage and selection operator, random survival forest, and gradient boosting decision tree, were used to construct prediction models. Model performance was accessed by concordance index (C-index) and the time-dependent area under the receiver operating characteristic curve (AUC) value for discrimination, and time-dependent calibration curve along with Brier score for calibration.

RESULTS

The median follow-up time was 7.79 years, and 49 suicide attempters had recurrent suicidal behavior during the study period. Four models achieved comparably good discrimination and calibration performance, with all C-indexes larger than 0.70, AUC values larger than 0.65, and Brier scores smaller than 0.06. Mental disorder emerged as the most important predictor across all four models. Suicide attempters with mental disorders had a 3 times higher risk of recurrence than those without. History of suicide attempt (HR = 2.84, 95% CI: 1.34-6.02), unstable marital status (HR = 2.81, 95% CI: 1.38-5.71), and older age (HR = 1.51, 95% CI: 1.14-2.01) were also identified as independent predictors of recurrent suicidal behavior by CPH model.

CONCLUSIONS

We developed four models to predict recurrent suicidal behavior with comparable good prediction performance. Our findings potentially provided benefits in screening vulnerable individuals on a more precise scale.

Depression Following Operative Treatments for Achilles Ruptures and Ankle Fractures

BACKGROUND

The sudden and debilitating nature of lower extremity injuries can trigger mood disturbances, including major depressive disorder.

METHODS

This prospective study enrolled patients undergoing operative repair of ankle fractures and Achilles ruptures and followed them for 1 year postoperatively. The validated Patient Health Questionnaire (PHQ-9) for depressive symptoms was administered at the preoperative visit and at postoperative weeks 1, 2, 4, 8, 16, 24, 32, 40, and 52. PHQ-9 is scored 0 to 27, with higher values indicating greater depression symptoms.

RESULTS

Fifty-eight patients completed 1 year of follow-up. The mean PHQ-9 score was 2.7 (range, 0-20) at the preoperative visit, peaked at postoperative week 1 (4.9; range, 0-16), and reached its low at postoperative week 52 (0.8; range, 0-7). Cumulative incidences of depressive symptoms during the first year following surgery were 51.7% for at least mild depression, 22.4% for at least moderate depression, and 6.9% for severe depression. A history of mental health disorder and the inability to work during the period of postoperative immobilization were independently associated with greater depressive symptoms.

CONCLUSION

The majority of patients undergoing operative treatment of Achilles ruptures and ankle fractures develop postoperative symptoms of mild to moderate depression that normalize after several months. Patients with a history of mental health disorder or who cannot work while immobilized postoperatively are at greatest risk.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Prevalence and correlates of multiple suicide attempts among adolescents aged 12-15 years from 61 countries in Africa, Asia, and the Americas

Suicide is the fourth leading cause of death worldwide in young people aged 15-19 years. However, little is known about the correlates of multiple suicide attempts in adolescents, especially from a global perspective. Therefore, the aim of the present study was to investigate the association of putative physical, behavioral, and social correlates with multiple suicide attempts among adolescents aged 12-15 years from 61 countries. Data from the Global school-based Student Health Survey (2009-2017) were analyzed. Multiple suicide attempts was classified as having attempted suicide at least twice in the past 12 months. Multivariable logistic regression analyses were conducted to assess the potential correlates. Data on 162,994 adolescents [mean (SD) age 13.8 (0.9) years; 50.8% boys] were analyzed. The overall prevalence of multiple suicide attempts was 4.4% [range 1.2% (Laos) to 13.8% (Ghana)]. Among those who had attempted suicide at least once in the past 12 months, in the overall sample, food insecurity, smoking, alcohol consumption, cannabis use, amphetamine use, sedentary behavior, sexual intercourse, sleep problems, loneliness, no close friends, and bullying victimization were all independently associated with higher odds for multiple suicide attempts although some regional differences were observed. Our study results indicate potential target factors that could be addressed amongst those who had attempted suicide in the past to reduce future suicide attempts and possibly completed suicides. Furthermore, it is possible that region-specific interventions are necessary.

Over-the-counter analgesics use is associated with pain and psychological distress among adolescents: a mixed effects approach in cross-sectional survey data from Norway

BACKGROUND

Over-the-counter analgesics (OTCA) such as Paracetamol and Ibuprofen are frequently used by adolescents, and the route of administration and access at home allows unsupervised use. Psychological distress and pain occur simultaneously and are more common among females than among males. There is a dynamic interplay between on-label pain indications and psychological distress, and frequent OTCA use or misuse can exacerbate symptoms. No studies have to date provided an overview of frequent OTCA use in a larger population-based study. The current study used survey data to explore associations between and the relative predictive value of on-label pain indication and measures of psychological distress, together with sex differences for weekly OTCA use.

METHODS

This study included 349,528 adolescents aged 13-19. The data was collected annually between January 2014 and December 2018 as part of the Norwegian Young Data survey. Performance analysis was conducted to explore the relative roles and associations between on-label pain indication and psychological distress in weekly OTCA use. A mixed-effects logistic regression model was used to explore the unique contributions from four domains of on-label pain indication and psychological distress as measured by a combined measure of anxiety and depression (HSCL-10) and peer-bullying involvement as victims or bullies.

RESULTS

Thirty percent of females and 13 % of males use OTCA weekly. Headache is the strongest on-label pain predictor of weekly OTCA use, followed by abdominal pain. Depression and anxiety are the strongest psychological predictor of weekly OTCA use, and higher symptom levels and being female increase the strength of this association. Anxiety and depression also predict weekly OTCA use after controlling for physiological pain.

CONCLUSIONS

Sex, pain and anxiety and depression are inter-correlated and strong predictors of frequent OTCA use. Frequent OTCA use in the context of psychological distress may be a form of self-medication that can exacerbate symptoms and decrease psychosocial function. Longitudinal studies that explore causal trajectories between frequent on-label OTCA use and psychological distress are required. OTCA use among adolescents, and particularly among females, with anxiety and depression should be administered with caution and closely monitored.

Household food insecurity, income loss, and symptoms of psychological distress among adults following the Cyclone Amphan in coastal Bangladesh

INTRODUCTION

Cyclone Amphan swept into Bangladesh's southwestern coast at the end of May 2020, wreaking havoc on food security and economic stability, as well as possibly worsening mental health. We studied the prevalence of post-cyclone stressors in adults following the cyclone and its association with symptoms of psychological distress.

METHODS

We conducted a cross-sectional study in a coastal district of Bangladesh. A five-item brief symptom rating scale was used to measure the symptoms of psychological distress. Household food insecurity was measured using the USAID Household Food Insecurity Access Scale questionnaire. We estimated adjusted prevalence ratios (aPRs) using robust log-linear models adjusted for potential confounders.

RESULTS

A total of 478 adults (mean [SD] age, 37.0[12.6] years; 169[35.4%] women) participated in the study. The prevalence of moderate-to-severe psychological symptoms and suicidal ideation was 55.7% and 10.9%, respectively. Following the cyclone, 40.8% of the adults reported severe food insecurity, and 66% of them reported moderate-to-severe mental health symptoms. Also, 54.4% of women and 33.7% of men reported severe food insecurity in the households. Moreover, 25.5% of respondents reported no income or a significant income loss after the cyclone, and 65.5% of them had moderate-to-severe psychological symptoms. Also, 13.8% of respondents reported housing displacement because of severely damaged houses, and 68.2% of them reported moderate-to-severe psychological symptoms. The high prevalence of mental health symptoms was found in women (aPR = 1.41, 95% CI = 1.06-1.82), people with severe food insecurity (aPR = 1.63, 95% CI = 1.01-2.64), and people who lost jobs or lost a major income source (aPR = 1.25, 95% CI = 1.02-1.54).

CONCLUSION

Following cyclone Amphan, many low-income individuals saw their income drop drastically while others were unemployed and living with severe food insecurity. The result suggests gender inequalities in food-security after the cyclone. Immediate action is needed to ensure household food-security for reducing the burden of mental illness. Rising opportunities of paid-jobs and decreasing income-loss, especially for the poor people, can have a protective impact on psychological distress. However, due to the high prevalence of severe psychological symptoms, long-term mental health services are required among the population of coastal Bangladesh.

Using the integrated motivational-volitional (IMV) model of suicidal behaviour to differentiate those with and without suicidal intent in hospital treated self-harm

Self-harm is a major public health concern. In order to respond to self-harm effectively, it is important to understand the factors associated with self-harm with and without suicidal intent. To this end, we investigated psychological factors selected from the Integrated Motivational-Volitional (IMV) model of suicidal behaviour in individuals who had recently been admitted to hospital for self-harm, with the aim of examining the characteristics of those who expressed intent to die versus those without suicidal intent. Individuals (n = 500, 60.6% female) admitted to two hospitals in central Scotland following self-harm with (suicide attempt [SA] group, n = 336) or without (non-suicidal self-harm [NSSH] group, n = 164) suicidal intent completed a range of psychological measures. Over half of the participants reported previous episodes of self-harm (SA, n = 239, 71.1%; NSSH, n = 91, 55.5%). Univariate analyses revealed that the SA and NSSH groups differed on some of the psychological measures with higher depressive symptoms, defeat, entrapment, acquired capability and impulsivity in the SA compared to the NSSH group. In the multivariate model, suicidal ideation, defeat, internal entrapment and perceived burdensomeness independently differentiated between the groups. These findings highlight the complex profiles of individuals presenting at hospital with self-harm and emphasise the need to investigate differences between subtypes of self-harm in order to support individuals optimally. Applying frameworks such as the IMV model to further understanding of self-harm might assist in the development of targeted psychological interventions to reduce risk of repeat self-harm or suicide.

Suicide mortality rates in farm-related occupations and the agriculture industry in the United States

BACKGROUND

Studies suggest that agricultural workers and rural residents may have an elevated suicide risk. However, suicide is relatively rare, and rural and farming populations have significantly declined, limiting their representation in national surveys. Many studies have inadequate samples for meaningful analysis.

METHODS

We pooled 29 years of data from the Mortality-Linked National Health Interview Survey, 1986-2014, then measured suicide mortality in groups including agriculture workers, and variation in suicide across rural and urban areas. Exposure variables indicated whether participants worked in a farm-related occupation or industry, or lived in a rural area. We used survey-weighted Poisson regression to estimate suicide mortality rates and rate ratios.

RESULTS

Age-adjusted suicide mortality rate per 100,000 was: 22.3 for farmers and farm managers; 21.6 for farmworkers; 28.7 in farming, forestry, and fishing; 15.3 across all other occupations; 16.1 among rural residents. Among farmworkers, age-adjusted rates were 28.3 in rural areas, 17.1 in urban areas (not significantly different). The age-adjusted suicide mortality rate ratio (RR) comparing workers in the agriculture, forestry, and fishery industries to those in all other industries was 1.34 (95% confidence interval, [CI]: 1.05-1.72) (not statistically significant after further adjustment for demographic characteristics). Age-adjusted results were consistent with a higher suicide risk for workers in forestry and fishing than in all other occupations (RR: 1.88, 95% CI: 0.79-4.46).

CONCLUSION

Workers in agriculture, forestry, and fishing may have an elevated suicide risk. National surveys should consider oversampling of rural residents, who have increased morbidity and mortality risks.

Clinical features and psychiatric comorbidities in military veterans with schizophrenia with or without suicidality

Suicide is currently among the leading causes of death among individuals with schizophrenia. Reducing mortality from suicide remains a major clinical challenge in the care of veterans with schizophrenia. There is a need to increase our understanding of what elevates suicide risk in veterans with schizophrenia as a first step towards the future development of suicide prevention interventions. This study compared demographic and clinical features of military veterans with schizophrenia with vs. without suicidality to determine specific risk factors for suicidality. The sample consisted of two groups of veterans with schizophrenia: suicide ideators and/or attempters (SIA) and individuals without a history of suicidal ideation or attempts (no-SIA). Participants were interviewed using the Structured Clinical Interview for DSM-5 Axis I disorders (SCID-I), Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Hamilton Depression Rating Scale (HDRS), and Schizotypal Personality Questionnaire (SPQ). In bivariate analyses, the PANSS-Positive Symptom scores, PANSS-General Psychopathology scores, HDRS total score, HDRS-Paranoid symptoms item score, and SPQ total scores were higher among SIA compared with no-SIA patients. In this unique clinical sample of veterans with schizophrenia, SIA patients were more likely to have mood disorders, post-traumatic stress disorder (PTSD), and/or alcohol use disorder in comparison to the no-SIA group. Logistic regression analysis indicated that the HDRS total score and presence/absence of comorbid mood disorder drive the difference between the groups. These results indicate that suicide risk assessment in veterans with schizophrenia should include identifying individuals with comorbid mood disorders/symptoms, PTSD, alcohol use disorder, marked positive symptoms, and schizotypal features.

The Health and Productivity Burden of Depression in South Korea

OBJECTIVES

Major depression in South Korea, which remains under-diagnosed and under-treated, increases the risk of premature death, and reduces quality of life and work productivity. The aim of this study was to quantify the depression-related health and productivity loss in South Korea in terms of life-years lost and productivity-adjusted life-years (PALYs) lost.

METHOD

Age and sex-specific life table models simulated follow-up of South Koreans with depression aged 15 to 54 years, until 55 years. Depression was defined as major depression. Inputs were drawn from national datasets and published sources. Models were constructed for the cohort with depression and repeated assuming they had no depression. Differences in total deaths, years of life, and PALYs represented the impact of depression. PALYs were ascribed a financial value equivalent to total gross domestic product (GDP) divided by the number of equivalent full-time workers (KRW81,507,146 or USD74,748). All outcomes were discounted by 3% per annum.

RESULTS

In 2019, there were more than 500,000 people aged 15-54 years with major depression in South Korea. We predicted that until this cohort reached age 55 years, and assuming 22.2% of people with depression are treated, depression led to 12,000 excess deaths, more than 55,000 discounted years of life lost and 1.6 million discounted PALYs lost, equating to KRW133 trillion (USD122 billion) in lost GDP. Applying treatment-related response and remission rates of 11.8% and 42.1%, respectively, and a non-response/non-remission rate of 46.1%, increased the total number of PALYs lost by almost 6.0%.

CONCLUSIONS

Our study highlights the considerable productivity loss attributable to depression among South Koreans over their working lifetime. Better prevention and treatment of depression is needed for long-term economic gains.

Childhood Psychological Maltreatment and Depression among Chinese Adolescents: Multiple Mediating Roles of Perceived Ostracism and Core Self-Evaluation

Previous studies have primarily focused on the separate mediating role of interpersonal context or personal characteristics in the relationship between childhood psychological maltreatment and depression, neglecting the combined effects, which have limited ecological validity. Therefore, this study investigated the multiple mediating roles of perceived ostracism and core self-evaluation in the relationship between childhood psychological maltreatment and depression. A total of 1592 Chinese adolescents (51.1% boys), ranging in age from 11 to 15 years (M = 13.23, SD = 0.96), completed a self-report questionnaire regarding demographics, psychological maltreatment, perceived ostracism, core self-evaluation and depression. A multiple mediation model was tested using Model 6 of the PROCESS macro. After controlling for the variables of gender and age, the results indicated that perceived ostracism and core self-evaluation parallelly and sequentially mediated the link between psychological maltreatment and depression. The multiple mediation model could account for 55% of the total effect. In conclusion, the current study helps us better understand the mechanisms of depression caused by psychological maltreatment, and contributes to preventing and intervening in depression among Chinese adolescents.

Integrative Community Therapy - interventive strategies in the reduction of depression symptoms in adolescents: A quasi-experimental study

This study aimed to evaluate the effects of Integrative Community Therapy on depression symptoms in adolescents in the school context. This is a quantitative, quasi-experimental, pre-, and post-test study that compared depression scores before and after the Integrative Community Therapy intervention was applied, conducted with 56 adolescent students. The guidelines recommended by the Standards for Quality Improvement Reporting Excellence were used to present this study. The instruments used for data collection were the following: Participants' characterization, Economic Classification, and the Children's Depression Inventory. This depression inventory was applied before and after the intervention was carried out. Most of the participants presented depressive symptoms (53.6%). Girls presented higher depression scores and were more likely to develop depression; to be working proved to be a protective factor for depression and adolescents with depression symptoms presented a higher proportion of suicidal ideation. The analysis of the depression variable indicated a reduction of the scores in the post-intervention period; however, in the gender analysis, there was a reduction in the depression scores only for the girls. The Integrative Community Therapy was an effective intervention in reducing depression scores, being a relevant strategy for healthcare services and schools in assisting adolescents to deal with their emotions, mitigate psycho-emotional suffering, and contribute as a support tool in the context of vulnerabilities inherent to the process of becoming an adolescent.

Thirty Years of Publications in Suicidology: A Bibliometric Analysis

A quantitative assessment of publications in suicidology has not been conducted yet. Web of Science was used to identify publications on suicidal behavior between 1989 and 2018. 41,276 items were retrieved. Over 30 years, the number of annual publications has been multiplied by 6. Psychiatry and psychology were the dominant research areas. Three-quarters of all publications were produced by high-income countries. A significant gap between male and female researchers persisted over time. Reported funding was largely public with a significant share from the private sector. Overall, suicidology appears as a dynamic field of research. This study also underlines two priorities: bridging the gender gap and encourage research in low- and middle-income countries where 80% of suicides occur.

Correlates of Suicidality Among A Community-Based Cohort of Women Sex Workers: The Protective Effect of Social Cohesion

Suicide is a critical public health concern globally. Sex workers experience a disproportionate burden of social and health inequities driven by forms of violence, stigma, and criminalization, yet empirical research on suicidality is limited. This study longitudinally investigated the burden and socio-structural correlates of recent suicidality among women sex workers in Vancouver, Canada. Data (2010-2017) were drawn from a community-based, prospective cohort of cis and trans women sex workers across Metro Vancouver. Women completed biannual interviewer-administered questionnaires, and correlates of suicidality in the last 6 months were analyzed using bivariate and multivariable logistic regression with generalized estimating equations (GEE). Of 867 women at baseline, 48% (n = 413) reported lifetime suicidality, 16% (n = 141) reported suicidality in the last 6 months, and 29% reported suicidality at some point during the study. In multivariable analysis, factors independently associated with suicidality included physical/sexual childhood abuse (adjusted odds ratio [AOR]: 2.99; 95% confidence interval [CI] = [1.75, 5.10]), mental health issues (depression/anxiety/posttraumatic stress disorder; AOR = 2.19; 95% CI = [1.63, 2.95]), intimate partner violence (AOR: 2.11; 95% CI = [1.60, 2.80]), physical/sexual client violence (AOR: 1.82; 95% CI = [1.33, 2.50]), and homelessness (AOR: 1.44; 95% CI = [1.10, 1.89]). Older age (AOR: 0.97; 95% CI = [0.95, 0.99]) and higher social cohesion (AOR: 0.88; 95% CI = [0.78, 0.99]) were significantly associated with reduced odds of suicidality. Findings reveal key socio-structural correlates of suicidality among sex workers including experiences of historical and interpersonal violence, trauma/mental health issues, and homelessness. Strengthening social cohesion may have a protective effect on suicidality. Trauma-informed community-led structural interventions tailored to sex workers are urgently needed alongside a legal framework that enables collectivization and connectedness.

Prevalence of Suicidality in the European General Population: A Systematic Review and Meta-Analysis

OBJECTIVE

To conduct a systematic review and meta-analysis of the prevalence and variability in suicidality in the general adult population of Europe between 2008 and 2017.

METHODS

Studies containing original data on suicidality were identified in five electronic databases. Point, 12-month and lifetime prevalences were calculated for various types of suicidality. Pooled prevalence rates were calculated using a random effects model. Subgroup analysis and multivariate meta-regression were also performed.

RESULTS

We identified 24 papers containing original data, which provided 97 prevalence rates for suicidality. The pooled point prevalence rate was 3.96% (2.37-5.56), pooled 12-month prevalence 2.9% (1.49-4.32), and pooled lifetime prevalence 5.55% (4.31-6.79). The subgroup analysis showed that lifetime prevalence figures for wishing to be dead and suicidal ideation were higher in areas with a population of less than 3,849 inhabitants and in Eastern Europe. Finally, the multivariate meta-regression showed differences with respect to the period and type of suicidality, lower and upper age thresholds, population size, and study area.

CONCLUSION

Our data showed that approximately 21% of European individuals have wished to be dead at some point during their lifetime. Studies like this are necessary to highlight the need for efforts to prevent and intervene in suicidality.

Self-Harm History, Anxiety-Depression, Severity of Disease, and Insight Are Significantly Associated With Suicide Risk in Forensic Psychiatric Inpatients of China

Background: Forensic psychiatric patients have higher suicide risk than the general population. This study aimed to evaluate the extent of suicide risk and to explore the associated factors in forensic psychiatric inpatients in China. Methods: We conducted a cross-sectional study from 1st November, 2018 to 30th January, 2019 in the Forensic Psychiatric Hospital of Hunan Province, China. Patient's information on socio-demographic, clinical, and criminological characteristics was collected. The suicidality subscale of the MINI-International Neuropsychiatric Interview (M.I.N.I.), the Brief Psychiatric Rating Scale (BPRS), and the Severity of Illness of Clinical Global Impressions Scale (CGI-SI) were used to measure present suicide risks, psychiatric symptoms, and the severity of the patient's disease, respectively. Binary logistic regression models were used to examine factors associated with suicide risk. Results: Twenty-one percent (84/408) of the forensic psychiatric inpatients reported suicide risk. Logistic regression analysis suggested that self-harm history (OR:3.47, 95% confidence interval CI: 1.45-8.33), symptoms of anxiety-depression (OR:1.15, 95% CI:1.04-1.27), and more severe mental disorder (OR:1.42, 95% CI:1.08-1.87) were associated with elevated suicide risk, while insight disorder (OR:0.81, 95% CI:0.65-0.99) was related to decreasing suicide risk. Conclusion: The study supplied useful clinical information to recognize high suicide risk in forensic psychiatric inpatients and may aid the development of valuable strategies for preventing and reducing suicide events.

Medically Serious Suicide Attempts in Personality Disorders

Medically serious suicide attempts (MSSA) represent a subgroup of clinically heterogeneous suicidal behaviors very close to suicides. Personality disorders (PD) are highly prevalent among them, together with affective and substance use disorders. However, few studies have specifically analyzed the role of PD in MSSA. These suicide attempts (SA) are usually followed by longer hospitalization periods and may result in severe physical and psychological consequences. The aim of this study is to compare the profile of MSSA patients with and without PD. MSSA were defined according to Beautrais 'criteria, but had to remain hospitalized ≥48 h. Overall, 168 patients from two public hospitals in Barcelona were evaluated during a three-year period. Mean hospital stay was 23.68 (standard deviation (SD) = 41.14) days. Patients with PD (n = 69) were more likely to be younger, female, make the first and the most serious SA at a younger age, reported recent stressful life-events and more frequently had previous suicide attempts compared to those without PD. However, no differences were found with regards to comorbid diagnoses, current clinical status, features of the attempt, or their impulsivity and hopelessness scores. Therefore, focusing on the subjective, qualitative experiences related to MSSA among PD patients may increase understanding of the reasons contributing to these attempts in order to improve prevention strategies in the future.

Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder

BACKGROUND

Many studies have recently been conducted to assess the antidepressant efficacy of glutamate modification in mood disorders. This is an update of a review first published in 2015 focusing on the use of glutamate receptor modulators in unipolar depression.

OBJECTIVES

To assess the effects - and review the acceptability and tolerability - of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with unipolar major depressive disorder.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020.  We did not apply any restrictions to date, language or publication status.

SELECTION CRITERIA

Double- or single-blinded randomised controlled trials (RCTs) comparing ketamine, memantine, esketamine or other glutamate receptor modulators with placebo (pill or saline infusion), other active psychotropic drugs, or electroconvulsive therapy (ECT) in adults with unipolar major depression.

DATA COLLECTION AND ANALYSIS

Three review authors independently identified studies, assessed trial quality and extracted data. The primary outcomes were response rate (50% reduction on a standardised rating scale) and adverse events. We decided a priori to measure the efficacy outcomes at different time points and run sensitivity/subgroup analyses. Risk of bias was assessed using the Cochrane tool, and certainty of the evidence was assessed using GRADE.

MAIN RESULTS

Thirty-one new studies were identified for inclusion in this updated review. Overall, we included 64 studies (5299 participants) on ketamine (31 trials), esketamine (9), memantine (5), lanicemine (4), D-cycloserine (2), Org26576 (2), riluzole (2), atomoxetine (1), basimglurant (1), citicoline (1), CP-101,606 (1), decoglurant (1), MK-0657 (1), N-acetylcysteine (1), rapastinel (1), and sarcosine (1). Forty-eight studies were placebo-controlled, and 48 were two-arm studies. The majority of trials defined an inclusion criterion for the severity of depressive symptoms at baseline: 29 at least moderate depression; 17 severe depression; and five mild-to-moderate depression. Nineteen studies recruited only patients with treatment-resistant depression, defined as inadequate response to at least two antidepressants. The majority of studies investigating ketamine administered as a single dose, whilst all of the included esketamine studies used a multiple dose regimen (most frequently twice a week for four weeks). Most studies looking at ketamine used intravenous administration, whilst the majority of esketamine trials used intranasal routes. The evidence suggests that ketamine may result in an increase in response and remission compared with placebo at 24 hours odds ratio (OR) 3.94, 95% confidence interval (CI) 1.54 to 10.10; n = 185, studies = 7, very low-certainty evidence). Ketamine may reduce depression rating scale scores over placebo at 24 hours, but the evidence is very uncertain (standardised mean difference (SMD) -0.87, 95% CI -1.26 to -0.48; n = 231, studies = 8, very low-certainty evidence). There was no difference in the number of participants assigned to ketamine or placebo who dropped out for any reason (OR 1.25, 95% CI 0.19 to 8.28; n = 201, studies = 6, very low-certainty evidence). When compared with midazolam, the evidence showed that ketamine increases remission rates at 24 hours (OR 2.21, 95% CI 0.67 to 7.32; n = 122,studies = 2, low-certainty evidence). The evidence is very uncertain about the response efficacy of ketamine at 24 hours in comparison with midazolam, and its ability to reduce depression rating scale scores at the same time point (OR 2.48, 95% CI 1.00 to 6.18; n = 296, studies = 4,very low-certainty evidence). There was no difference in the number of participants who dropped out of studies for any reason between ketamine and placebo (OR 0.33, 95% CI 0.05 to 2.09; n = 72, studies = 1, low-certainty evidence). Esketamine treatment likely results in a large increase in participants achieving remission at 24 hours compared with placebo (OR 2.74, 95% CI 1.71 to 4.40; n = 894, studies = 5, moderate-certainty evidence). Esketamine probably results in decreases in depression rating scale scores at 24 hours compared with placebo (SMD -0.31, 95% CI -0.45 to -0.17; n = 824, studies = 4, moderate-certainty evidence). Our findings show that esketamine increased response rates, although this evidence is uncertain (OR 2.11, 95% CI 1.20 to 3.68; n = 1071, studies = 5, low-certainty evidence). There was no evidence that participants assigned to esketamine treatment dropped out of trials more frequently than those assigned to placebo for any reason (OR 1.58, 95% CI 0.92 to 2.73; n = 773, studies = 4,moderate-certainty evidence). We found very little evidence for the remaining glutamate receptor modulators. We rated the risk of bias as low or unclear for most domains, though lack of detail regarding masking of treatment in the studies reduced our certainty in the effect for all outcomes.

AUTHORS' CONCLUSIONS

Our findings show that ketamine and esketamine may be more efficacious than placebo at 24 hours. How these findings translate into clinical practice, however, is not entirely clear. The evidence for use of the remaining glutamate receptor modulators is limited as very few trials were included in the meta-analyses for each comparison and the majority of comparisons included only one study. Long term non-inferiority RCTs comparing repeated ketamine and esketamine, and rigorous real-world monitoring are needed to establish comprehensive data on safety and efficacy.

Suicide in primary care: How to screen and intervene

Suicide is significant public health concern within the United States. Research results are mixed about the effectiveness of universal screening and interventions with patients who are at-risk for suicide. Primary care is a logical intervention point to mitigate risk among patients in each of these areas. The Department of Veterans Affairs and Department of Defense have developed comprehensive guidelines for the assessment and management of suicidal patients. This approach involves specific screening tools, risk stratification by categories and interventions used by clinicians to help reduce risk levels in their patients. This article aims to provide a model, built on the principles of these guidelines, which primary care physicians can use to identify, assess and intervene with patients who are at-risk for suicide.

Sharp force fatalities: Differentiating homicide from suicide through a retrospective review (2012-2019) of autopsy findings in Lisbon (Portugal)

Sharp force fatalities may have a homicidal, suicidal or accidental manner of death. To aid in such differentiation this study aimed to identify medico-legal elements which were predictors of a given manner of death as well as to describe the characteristics of these deaths. A retrospective review was performed on all homicides and suicides due to sharp force injury admitted at the South Branch of the National Institute of Legal Medicine and Forensic Sciences between January 2012 and December 2019. Deaths with a performed external examination or forensic autopsy and with available demographic, circumstantial or necroscopic information were included. Each case was reviewed to collect said information and inferential analysis was employed with both parametric and non-parametric tests as well as binary logistic regression to identify independent predictors, with significance defined at α = 0.05. A total of 57 homicides and 20 suicides were identified, with the obtained demographic and circumstantial profile of the homicide victim being that of a young foreign male whose body was found outside home, with no weapon nearby and without a known psychiatric background. Homicides presented more prominently stab wounds, with these being conspicuous on the thorax and neck. Conversely suicides notably presented cut wounds, being critically present in the neck and upper limbs. Oblique thoracic stab wounds conveyed a homicidal death. Other findings that suggested homicide included the presence of clothing damage, additional traumatic lesions and injured lungs or bone/cartilage. Toxicologically, alcohol presence was associated with homicides while psychiatric drugs suggested suicide. The logistic regression identified the presence of additional traumatic lesions (OR 14.8, p = 0.032) and the absence of lethal neck (OR 0.109, p = 0.043) and lethal upper limb (OR 0.022, p = 0.015) wounds as independent autopsy predictors of a homicidal death. However, no single feature is infallible in establishing manner of death. To achieve a cogent conclusion, all investigative elements must be considered while attending to the specifics of each case.

Borderline personality disorder and adolescent suicide attempt: the mediating role of emotional dysregulation

BACKGROUND

Emotional dysregulation seems to be a core feature of Borderline Personality Disorders (BPD). In addition, recent research in the adolescent population has shown that suicidal behaviours have been associated with maladaptive strategies of emotion regulation.

METHODS

This study examined the relative contributions of emotional dysregulation to suicide attempt history in a clinical sample of borderline adolescents. Data were analyzed from 85 participants of the Collaborative European Research Network on Borderline Personality Disorder. Participants completed measures of BPD traits and symptoms, suicide behaviours, emotional dysregulation, attachment styles and lifetime depressive disorders.

RESULTS

In an SEM model, lifetime depressive disorders and insecure attachment styles have a significant direct effect on lifetime suicide attempt, but only lifetime depressive disorders have an indirect effect through emotion dysregulation. The results suggest that emotional dysregulation has a mediating role in suicide attempts among BPD adolescents.

CONCLUSIONS

These findings call for the development of interventions targeting the role of emotion dysregulation in effectively predicting and preventing suicidality in borderline adolescents.

Substance use disorders and suicidality in youth: A systematic review and meta-analysis with a focus on the direction of the association

BACKGROUND

Reviews and meta-analyses suggest that substance use and suicidality (i.e., suicidal ideations and attempts) are associated in youth, but the direction of this association remains unclear. Theoretically, the secondary psychiatric disorder hypothesis (SPDH) posits that substance use leads to suicidality, while the secondary substance use disorder hypothesis (SSUDH) posits that suicidality leads to substance use. To clarify these associations, this meta-analysis systematically reviewed studies that examined the prospective associations between SUDs and suicidality in youth (age 25 and younger) and compared results according to the direction of the association.

METHODS

Web of Science, Embase, PsycINFO, PubMed, Medline and ProQuest Dissertations & Theses Global were searched from inception to March 8, 2020, and 55 effect sizes from 23 samples were included and analyzed using a three-level meta-analysis.

RESULTS

SUDs significantly predicted subsequent suicidality (OR = 2.16, 95%CI 1.57-2.97), suicidality significantly predicted subsequent SUDs (OR = 2.16, 95%CI 1.53-3.04), and these effect sizes did not differ (p = 0.49).

CONCLUSIONS

Considering that 65% of reviewed studies only examined the SPDH, this review highlights that more attention should be given to the SSUDH, and that studies should examine bidirectional associations between SUDs and suicidality across time. Clinically, because SUDs and suicidality were found to influence each other, results suggest that mental health and SUDs should ideally be detected and treated early, and that co-occurring disorders should be assessed and treated concomitantly.

Mechanisms Underlying the Anti-Suicidal Treatment Potential of Buprenorphine

Death by suicide is a global epidemic with over 800 K suicidal deaths worlwide in 2012. Suicide is the 10th leading cause of death among Americans and more than 44 K people died by suicide in 2019 in the United States. Patients with chronic pain, including, but not limited to, those with substance use disorders, are particularly vulnerable. Chronic pain patients have twice the risk of death by suicide compared to those without pain, and 50% of chronic pain patients report that they have considered suicide at some point due to their pain. The kappa opioid system is implicated in negative mood states including dysphoria, depression, and anxiety, and recent evidence shows that chronic pain increases the function of this system in limbic brain regions important for affect and motivation. Additionally, dynorphin, the endogenous ligand that activates the kappa opioid receptor is increased in the caudate putamen of human suicide victims. A potential treatment for reducing suicidal ideation and suicidal attempts is buprenorphine. Buprenorphine, a partial mu opioid agonist with kappa opioid antagonist properties, reduced suicidal ideation in chronic pain patients with and without an opioid use disorder. This review will highlight the clinical and preclinical evidence to support the use of buprenorphine in mitigating pain-induced negative affective states and suicidal thoughts, where these effects are at least partially mediated via its kappa antagonist properties.

Suicidal behavior in individuals accused or convicted of child sex abuse or indecent image offenses: Systematic review of prevalence and risk factors

OBJECTIVE

An emerging body of research indicates that child sex abuse (CSA) offenders are at high risk of suicide when their offenses come to light and that those accused of accessing indecent images of children (IIOC) are at particular risk.

METHODS

We conducted a systematic review and narrative synthesis on suicide rates and risk factors in this population of offenders. A keyword search of bibliographic databases (PsycINFO, Ovid, MEDLINE, Embase, PILOTS, SCIE, the Cochrane Central Register of Controlled Trials [CENTRAL] and CINAHL) was conducted.

RESULTS

Eighteen articles were included in the review, with eleven studies meeting criteria for quality assessment. The risk of suicide in perpetrators of CSA and IIOC might be over 100 times that of the general population, although estimates vary widely between studies. Several complex, interlinking factors were identified as associated with risk, including shame, unique demographic characteristics of the offenders, absence of prior criminal contact, and the impact of a criminal investigation.

CONCLUSIONS

The review identified factors that may have practical, clinical, and operational implications in the prevention of suicide in CSA and IIOC perpetrators. Exploring the impact of the investigation itself on suicide risk, including potential operational strategies and clinical input to reduce risk, should be a priority.

The Effect of Meteorological, Pollution, and Geographic Exposures on Death by Suicide: A Scoping Review

Suicide is a significant public health concern worldwide and in the United States. Despite the far-reaching impact of suicide, risk factors are still not well understood and efforts to accurately assess risk have fallen short. Current research has highlighted how potentially modifiable environmental exposures (i.e., meteorological, pollution, and geographic exposures) can affect suicide risk. A scoping review was conducted to evaluate the strength of the historical and current literature on the environment’s effect on suicide and suicide risk. Three databases (i.e., Medline, Embase, and PsychInfo) were reviewed to identify relevant studies and two authors independently reviewed studies considering pre-determined inclusion criteria. A total of 46 meteorological studies were included as well as 23 pollution studies and 12 geographic studies. Descriptive statistics, including counts, percentages, review of studies’ sample size (minimum, maximum, median, and interquartile range), were calculated using Excel and SAS 9.4. Overall, strong evidence supports that exposure to sunlight, temperature, air pollution, pesticides, and high altitude increases suicide risk, although effect sizes range from very small to small.

Suicide and Associations with Air Pollution and Ambient Temperature: A Systematic Review and Meta-Analysis

Given health threats of climate change, a comprehensive review of the impacts of ambient temperature and ar pollution on suicide is needed. We performed systematic literature review and meta-analysis of suicide risks associated with short-term exposure to ambient temperature and air pollution. Pubmed, Scopus, and Web of Science were searched for English-language publications using relevant keywords. Observational studies assessing risks of daily suicide and suicide attempts associated with temperature, particulate matter with aerodynamic diameter ≤10 μm (PM₁₀) and ≤2.5 mm (PM_2.5), ozone (O₃), sulfur dioxide (SO₂), nitrogen dioxide (NO₂), and carbon monoxide (CO) were included. Data extraction was independently performed in duplicate. Random-effect meta-analysis was applied to pool risk ratios (RRs) for increases in daily suicide per interquartile range (IQR) increase in exposure. Meta-regression analysis was applied to examine effect modification by income level based on gross national income (GNI) per capita, national suicide rates, and average level of exposure factors. In total 2274 articles were screened, with 18 studies meeting inclusion criteria for air pollution and 32 studies for temperature. RRs of suicide per 7.1 °C temperature was 1.09 (95% CI: 1.06, 1.13). RRs of suicide per IQR increase in PM_2.5, PM₁₀, and NO₂ were 1.02 (95% CI: 1.00, 1.05), 1.01 (95% CI: 1.00, 1.03), and 1.03 (95% CI: 1.00, 1.07). O₃, SO₂, and CO were not associated with suicide. RR of suicide was significantly higher in higher-income than lower-income countries (1.09, 95% CI: 1.07, 1.11 and 1.20, 95% CI: 1.14, 1.26 per 7.1 °C increased temperature, respectively). Suicide risks associated with air pollution did not significantly differ by income level, national suicide rates, or average exposure levels. Research gaps were found for interactions between air pollution and temperature on suicide risks.

A systematic review of controlled studies of suicidal and self-harming behaviours in adolescents following bereavement by suicide

BACKGROUND

Research suggests that being exposed to the suicide of others increases risk of subsequent suicidal or self-harming thoughts or behaviours. What is less clear is whether this applies to adolescents, and if the risk exceeds that following other causes of death, which has implications on suicide prevention approaches. This study aimed to systematically review the evidence on adolescent bereavement experiences by different causes to address this gap.

METHODS

A comprehensive literature search using four databases (MEDLINE, PsycInfo, Web of Science, and Embase) identified 21 studies which measured suicidal or self-harm outcomes among bereaved adolescents aged between 12 to 18 years old. The literature was screened, data was extracted using pre-piloted forms, and risk of bias was assessed using versions of the Newcastle-Ottawa Scale; a proportion of papers were double extracted and assessed for bias. The review has been registered with PROSPERO (CRD42016051125).

RESULTS

A narrative synthesis of the literature demonstrated divergent findings depending on the outcome being measured. Suicide bereavement appears to be strongly associated with suicide mortality among parentally bereaved youth, while self-harm or non-fatal suicide attempts (either presenting to hospital or self-reported) showed mixed evidence. Suicidal ideation was not uniquely associated with suicide bereavement. An exploration of circumstances surrounding the death, characteristics of the person who died, and characteristics of the young person across each outcome measure suggested that earlier experiences of loss, shorter timeframes following the death, and maternal death are associated with particularly elevated risk of suicidal outcomes.

CONCLUSIONS

Findings suggest that suicide loss is associated with subsequent suicide, and may be associated with non-fatal self-harm. A detailed account of the risk and protective factors surrounding suicide bereavement among young people is crucial to understand the pathways through which suicidal behaviours develop. Researchers, policy makers and practitioners with an interest in suicide prevention will benefit from clarity around the needs of young bereaved individuals.

Anticipatory, Relief-Oriented and Permissive Beliefs in Patients with Suicidal Behaviors: An Exploratory Case-Control Study

OBJECTIVE

The objective is to propose a specific understanding of decision-making in suicidal behavior by using a psychometric instrument, namely the Suicidal Ambivalence Scale (SAS). The SAS, initially used in addictive disorders, allows to distinguish 3 types of thoughts: first anticipatory beliefs [A] (positive expectations regarding behavior); second relief-oriented beliefs [R] (aim to reduce the feeling of suffering) and finally, permissive beliefs [P] (authorize the passage to the act). In addictions disorders, these thoughts favor craving and the act of consumption. We make the hypothesis that the processes of suicidal thoughts function similarly to thought processes in addiction and that all thoughts [A, S and P] are significantly more present in suicidal patients.

METHODS

120 suicidal crisis patients and 161 healthy controls were compared on clinical dimensions (levels of depression, hopelessness). Anticipatory, relief-oriented and permissive beliefs were evaluated with the suicidal ambivalence scale.

RESULTS

Patients have statistically more of beliefs in favor of suicidal behavior to compared healthy controls (t = 2.375, p = 0.019, d = 0.57), more particularly, anticipatory and permissive beliefs. Conversely, patients have statistically less of protective thoughts against the suicidal behavior to compared healthy controls (t = 2.195, p = 0.03, d = 0.499).

CONCLUSION

This study showed the role of anticipatory, relief-oriented and permissive beliefs in the suicidal crisis and the need to create a simple and easy to use clinical tool for more accurate assessments of beliefs in patients with the suicidal crisis.

Suicide-related calls to a national crisis chat hotline service during the COVID-19 pandemic and lockdown

BACKGROUND

A COVID-19 pandemic-related rise in suicide rates has been predicted due to social isolation, fear, uncertainty, economic turndown and grief. Detecting an increase in suicide rates is difficult in the absence of real-time data. Alternative data sources for such trends in psychopathology and suicidal behavior must be sought.

METHODS

Data from a national chat-based crisis hotline for the first half of 2019 (pre-COVID-19), were compared to data from the first half of 2020 (during COVID-19). Chat sessions were classified by content and demographics and the data compared between the two time periods.

OUTCOME

Total chats (n = 6756) were 48% higher during COVID-19 (p < .05). Suicide-related chat (SRC) number was also higher, although the proportion relative to all chats was slightly lower during COVID-19, compared to pre-COVID-19 (p < .05). SRCs increased during the COVID-19 lockdown. The number of severe SRCs resulting in urgent police intervention, increased during the lockdown (April-May 2020) compared with the same period in 2019 (p = .04). Issues of anxiety were higher in 2020 (19.4%) vs. 2019 (16.5%) (p < .00001) while issues of depression were lower (22.4% vs 33%, respectively) (p < .00001). The overall use of chats among adults aged >50 yrs increased during COVID-19 and likewise, the rate of SRCs in this age-group increased 30-fold in this period when compared to pre-COVID-19 (p < .00001). SRCs included more women than men (p < .0001) in both pre-COVID-19 and during the COVID-19 period, when the proportion of women increased from 62% in 2019 to 73% during COVID-19 (p < .0001).

INTERPRETATION

The rise in total chats, SRCs and SRCs resulting in police action, commenced during lockdown and was ameliorated by end of the lockdown, indicating that distress created by the lockdown was more impactful than mourning deaths of loved ones, fear and uncertainty, because all these factors persisted beyond the end of the lockdown. Older populations were probably more distressed due to greater risk and less adaptability to isolation, social media and staying home. More calls by women may reflect women's better help-seeking capacity. The increase in SRCs indicates the potential for more suicides and the need for bolstering mental health services and reach-out to older people during pandemic lock-downs.

Testing the Integrated Motivational-Volitional Model of Suicidal Behavior in Chinese Adolescents

The integrated motivational-volitional model of suicidal behavior (IMV; O'Connor & Kirtley, 2018) integrates some key factors of suicidal behavior (e.g., defeat and entrapment) to explain the development of suicidal ideation and suicidal attempts. This study aimed to empirically test this model in a sample of Chinese adolescents. A number of 1,239 Chinese adolescents (679 girls; M_age = 14.07, SD = 1.54) completed self-report questionnaires. Results showed that defeat was associated with entrapment, which, in turn, was related to suicidal ideation and suicidal attempts. In addition, the relationship between entrapment and suicidal ideation was significant at high levels of thwarted belongingness and perceived burdensomeness, and low levels of resilience. These findings support the application of the IMV model in Chinese adolescents, and might help mental health organizations and educational agencies formulate effective suicidal prevention programs geared toward Chinese adolescents.

A Bayesian multilevel analysis of the longitudinal associations between relationship quality and suicidal ideation and attempts among youth with bipolar disorder

BACKGROUND

Youth with bipolar disorder (BD) are at high risk for suicidal thoughts and behaviors and frequently experience interpersonal impairment, which is a risk factor for suicide. Yet, no study to date has examined the longitudinal associations between relationship quality in family/peer domains and suicidal thoughts and behaviors among youth with BD. Thus, we investigated how between-person differences - reflecting the average relationship quality across time - and within-person changes, reflecting recent fluctuations in relationship quality, act as distal and/or proximal risk factors for suicidal ideation (SI) and suicide attempts.

METHODS

We used longitudinal data from the Course and Outcome of Bipolar Youth Study (N = 413). Relationship quality variables were decomposed into stable (i.e., average) and varying (i.e., recent) components and entered, along with major clinical covariates, into separate Bayesian multilevel models predicting SI and suicide attempt. We also examined how the relationship quality effects interacted with age and sex.

RESULTS

Poorer average relationship quality with parents (β = -.33, 95% Bayesian highest density interval (HDI) [-0.54, -0.11]) or friends (β = -.33, 95% HDI [-0.55, -0.11]) was longitudinally associated with increased risk of SI but not suicide attempt. Worsening recent relationship quality with parents (β = -.10, 95% HDI [-0.19, -0.03]) and, to a lesser extent, friends (β = -.06, 95% HDI [-0.15, 0.03]) was longitudinally associated with increased risk of SI, but only worsening recent relationship quality with parents was also associated with increased risk of suicide attempt (β = -.15, 95% HDI [-0.31, 0.01]). The effects of certain relationship quality variables were moderated by gender but not age.

CONCLUSIONS

Among youth with BD, having poorer average relationship quality with peers and/or parents represents a distal risk factor for SI but not suicide attempts. Additionally, worsening recent relationship quality with parents may be a time-sensitive indicator of increased risk for SI or suicide attempt.