Suicidal behaviors in patients with rheumatic diseases: a narrative review

Mental health, COVID-19 burden and quality of life of kidney transplant recipients two years after the COVID-19 pandemic

Introduction

Few studies have evaluated the psychological distress of COVID-19 in kidney transplantation and the psychological impact that the COVID-19 pandemic has had on kidney transplant recipients is not yet well understood. The present study aimed to investigate the change in symptom burden and health-related quality of life in the two years after initial assessment, by outlining the change over time of symptoms at 12 and 24 months of follow-up.

Methods

This is a follow-up study. We performed a study published in 2021 (phase 1 of COVID-19); of the 89 kidney transplant recipients evaluated in this study, 60 completed the 12 months follow-up (March 2021 June 2021, phase 2 of COVID-19) and 57 completed the 24 months follow-up (March 2022 June 2022, post COVID-19). The same tools as in previous study were administered: the ad hoc questionnaire on emotional state and psychophysical well-being during COVID-19, the Middlesex Hospital Questionnaire (MHQ) to provide a simple and rapid quantification of the psychological and somatic symptoms and the Short Form Health Survey 36 (SF-36) was used to assess health-related quality of life.

Results

Compared to the first and second phase of COVID-19, the mean score of quality of life variables were higher in the post COVID-19 phase; thus the recipients physical health, mental health and their perception of their general health improved. Regarding the psychopathology variables the levels of Anxiety, Depression and Phobia in the Post COVID-19 phase decreased, while the Somatization score was higher. Lastly, burden of COVID-19 scores in the third phase, significantly decreased.

Discussion

Our study highlights a significant association between mental health and the burden of COVID-19 pandemic in kidney transplant recipients. This study showed, a significant worsening, over time, of some specific symptoms, such as somatization and phobias. However, the results showed that depressive symptoms improved during the study period. Long-term monitoring of kidney transplant recipients therefore remains fundamental. These results confirmed the need to provide integrated multidisciplinary services to adequately address the long-term effects of the COVID-19 pandemic on the mental health of the most vulnerable subjects.

Predicting comorbid mental health difficulties in people with autoimmune arthritis

Little is known about variables impacting the association between mental health difficulties and autoimmune conditions. This study investigates whether, age of onset, adverse childhood experiences (ACEs), and 'illness invisibility' predict comorbid mental health difficulties in people with autoimmune arthritis. Participants with autoimmune arthritis (N = 209) were recruited via social media platforms. Age of onset of arthritis and the temporal order of mental health difficulties (if applicable) were collected alongside a measure of personality and ACEs. A novel measure of illness invisibility was developed for this study. A cross-sectional mixed-subject design was utilised. 53.5% of the sample endorsed lifetime mental health difficulties. Logistic regression analyses revealed participants with a younger age of onset of arthritis had significantly higher odds of developing a mental health problem (OR 0.93, 95% CI 0.90-0.96). Independently, Illness Invisibility, endorsed by 89.9% of participants, significantly predicted postmorbid mental health difficulties (OR 1.08, 95% CI 1.01-1.19). Adverse Childhood Experiences were frequently endorsed within the sample with 37.8% reporting ≥ 3 cumulative ACEs. Every unit increase in ACEs increased the odds of having comorbid mental health difficulties (OR 1.27, 95% CI 1.09-1.47). Young people who are diagnosed with autoimmune arthritis maybe more likely to experience subsequent mental health difficulties. The 'invisibility' of their illness and exposure to ACEs also is associated with their risk for mental health complications. These findings highlight the importance of mental health screening for young people being investigated for arthritis and interdisciplinary care, especially for young people.

Comparison of advanced glycation end products concentration in the skin among patients with rheumatic diseases, with and without comorbid depression: a case-control study

Patients with rheumatic diseases suffer depression at a far greater rate than the general population. Aside from evident mental health degradation, in this group of patients depression can often lead to failures in the treatment of the basic disease. The aim of the study was to assess the concentration of advanced glycation end-products (AGE) in the skin autofluorescence (SAF) exam in patients with select rheumatic diseases depending on depression concomitance. 139 patients with rheumatic diseases were enrolled into the study-43 (39F/4 M) patients with RA, 31 (24F/7 M) patients with PsA, 27 (22F/5 M) patients with SLE and 38 (33F/5 M) patients with SSc. In all patients, the concentration of AGE was assessed using the AGE Reader device (DiagnOptics BV Groningen, The Netherlands). The Beck Depression Inventory II was used to assess depression in the patients. Patients who scored 14 points or more in the BDI-II were diagnosed with depression. In the studied group, depression was identified in 73 (53%) patients-25 with RA, 21 with PsA, 11 with SLE and 16 with SSc. Mean SAF in patients with depression was 2.8 ± 0.4, and in the group with no depression-2.2 ± 0.5 (p < 0.001). The study results indicate that in the course of rheumatic diseases, the presence of depression may influence the increase in AGE concentration in the skin. Therefore, evaluating AGE levels in the skin may be clinically relevant as it can help identify patients who may be at risk of developing depression.

Insights into suicidal behavior among psoriatic arthritis patients: A systematic review and a genetic linkage disequilibrium analysis

OBJECTIVES

To systematically assess the magnitude of suicidal behavior among PsA patients and identify associated risk factors. Also identify common genes or coinherited single nucleotide polymorphisms (SNPs) implicated in suicidal behavior and PsA.

METHODS

Based on the PRISMA guidelines, we conducted a systematic literature review of the online databases PubMed/Medline, Web of Science, and EMBASE from inception to May 2022. Full-text original articles that describe suicidal behavior in PsA patients were eligible. All registered genome-wide association study (GWAS) data in the GWAS catalog database for PsA and psychiatric traits, such as suicidal behavior, and depression, were downloaded for further analysis.

RESULTS

A total of 48 articles were identified, and 6 were relevant to the study question .Among the 122,160 PsA patients, 700 had suicidal behavior (0,57%). The range of age in one study was between 30 and 49 years, and 64% of PsA patients with suicidal behavior were female. Among 13,899 PsA patients 74 had suicidal ideation (0.53%) and 125 suicide attempts occurred (0.9%). In two studies, among 17,383 patients, 13 complete suicides occurred (0.07%). A genetic haplotype on chromosomal region 6p21.1, spanning from 29,597,596 to 32,251,264 Mb, contains predisposing SNPs for PsA and depression. 6p21.1-6p21.3 is the chromosomal region containing the HLA genes of classes I, II and III.

CONCLUSION

Suicide behavior in PsA patients was associated with depression and other psychiatric comorbidities. Further evidence supports a genetic origin, at least partly. Awareness of these findings can help clinicians to recognize suicide behavior and prevent suicide attempts.

Vitamin D in Depression: A Potential Bioactive Agent to Reduce Suicide and Suicide Attempt Risk

Suicide is one of the leading causes of death worldwide. According to the World Health Organization (WHO), every year, more than 700 thousand people die from this cause. Therefore, suicide is a public health issue. The complex interaction between different factors causes suicide; however, depression is one of the most frequent factors in people who have attempted suicide. Several studies have reported that vitamin D deficiency may be a relevant risk factor for depression, and vitamin D supplementation has shown promising effects in the adjunctive treatment of this mood disorder. Among the beneficial mechanisms of vitamin D, it has been proposed that it may enhance serotonin synthesis and modulate proinflammatory cytokines since low serotonin levels and systemic inflammation have been associated with depression and suicide. The present narrative review shows the potential pathogenic role of vitamin D deficiency in depression and suicide and the potential benefits of vitamin D supplementation to reduce their risk.

Suicide risk after head and neck cancer diagnosis in Taiwan: A retrospective cohort study

BACKGROUND

The diagnosis of head and neck cancer (HNC) may lead to exhaustion and depression. Therefore, the suicide risk of patients with HNC is high. This study aimed to understand the suicide risk of patients with HNC in Taiwan compared with patients with other-cancer and general population during the period from 2010 to 2019.

METHODS

A total of 74,495 patients with HNC were compared against the other two cohort consisting 148,878 patients with other-cancer and 595,512 individual without cancer by age, sex, and index year from the Taiwan National Health Insurance Research Database. The multivariate Cox proportional hazard regression analysis was performed to estimate the risk of all-cause or suicide mortality.

RESULTS

Compared to the non-cancer group, the all-cause mortality risk of the HNC group (the adjusted hazard ratio (aHR), 7.72; 95 % confidence interval (CI), 7.60-7.83) is lower than that of the other-cancer group (aHR, 8.87; 95 % CI, 8.77-8.98). However, the suicide mortality risk compared with non-cancer group in the HNC group (aHR, 3.89; 95 % CI, 3.46-4.37) is much higher than other-cancer group (aHR, 1.86; 95 % CI, 1.64-2.10). HNC only has the seventh highest all-cause mortality risk, but HNC has the second highest suicide mortality risk. Men always have a higher suicide mortality risk than women. Middle-aged patients (age 50-60 years) have the highest suicide mortality risk, whereas younger patients (age < 40 years) have the lowest suicide mortality risk.

LIMITATIONS

In this study, some factors and information needed were limited to the existing database; thus, preventing recall bias was difficult.

CONCLUSIONS

This study indicates that patients with HNC did not have a higher risk of all-cause mortality than patients with other cancers. However, the risk of suicide mortality in patients with HNC was higher than that of patients without cancer and patients with other cancers in Taiwan.

Correlation Between Sleep Electroencephalogram, Brain-Derived Neurotrophic Factor, AVPR1B Gene Polymorphism, and Suicidal Behavior in Patients with Depression

The purpose of this article was to investigate the level of serum brain-derived neurotrophic factor and its relationship with suicidal symptoms and severity in mentally ill suicide attempt patients, and to explore the possible role of serum brain-derived neurotrophic factor (BDNF) in the occurrence of psychotic suicidal behavior. A retrospective analysis was performed on patients with depression in the neurology department of a hospital. General physical examination, neurological specialist examination, and cranial magnetic resonance imaging (MRI) examination were performed on any selected group. We applied the 24-item Hamilton Depression Scale, Hamilton Anxiety Scale, and Mini-Intelligence Mental State Scale, and performed polysomnography and electroencephalography (EEG) monitoring to conduct statistical analysis on sleep indicators. The amplitude of low-frequency fluctuation (ALFF) values of the right frontal gyrus, left posterior cerebellar lobe, right anterior cerebellar lobe, and right occipital lingual gyrus of the patient group were significantly lower than those of the control group. The ReHo values of the right superior parietal lobule, the left precuneus, and the right occipital lingual gyrus were significantly higher than those of the control group. The genotype and allele frequency distribution of FKBP5, AVPR1B, and CRHR2 gene SNPs had no significant difference between the case group and the control group (P > 0.05). The ReHo value of the precuneus is significantly correlated with the proportion of N3 sleep, and the dysfunction of the precuneus or default network may be related to the altered sleep structure in patients with depression. The GT and TT genotypes at rs9324924 of the NR3C1 gene are associated with suicide attempts.

[Suicide prevention: How to act?]

Although being complex, suicide is a phenomenon considered as preventable, and its prevention has been made as a public health priority. Some interventions to prevent suicide have been evaluated, such as the education of the healthcare workers, especially in the suicidal assessment (suicidal risk and suicidal emergency/dangerousness), the diagnosis and management of common mental disorders, the care provided after a suicide attempt, the restriction access to common means of suicide, the use of websites to educate the public, or the appropriate reports of suicide in media. Other interventions, even not rigorously evaluated, are implemented in France as in many parts of the world. It is the case of interventions among identified high-risk groups. To be efficient, prevention programs should simultaneously include different strategies targeting several known risk factors for suicide. Clinicians play a crucial role in the suicide prevention strategies.

Mental Comorbidity in Rheumatic Diseases

In this review, we summarise the most relevant studies in a PubMed Search term “mental disorders and rheumatic disease” in the last 15 years. Mental disorders such as depression and anxiety are common in people with rheumatic diseases. Treating these comorbidities can improve the patientʼs quality of life. The high prevalence of symptoms of psychiatric disorders is a challenge for rheumatologists, especially with regard to the differentiation of possible psychiatric components in rheumatological diseases. Screening for psychiatric problems in patients with rheumatic diseases should be evaluated as soon as possible, as these can have a major influence on the perception of pain and physical functioning status from the outset. Mental health disorders are seen as a risk factor for poor patient outcomes, as patients may not adhere to medical treatments. The potential side effects of biological agents can increase patient anxiety and affect adherence to therapy. Therefore, interdisciplinary care would be of great advantage in the treatment of rheumatic patients with psychological comorbidities.

Beyond Rheumatoid Arthritis Evaluation: What are We Missing?

Rheumatoid Arthritis (RA) is a chronic inflammatory autoimmune systemic disease that preferentially affects small and large joints with a progressive course and can become deforming and disabling. In recent years, much progress has been made in the evaluation of inflammation and disease activity, however, there are other factors that have a high impact on the quality of life of these patients, such as depression, anxiety, fatigue, sleep disorders, suicidal behavior, fibromyalgia, sexual activity, sarcopenia, frailty, cachexia and obesity that are not always evaluated by rheumatologists. This review shows that the evaluation and timely detection of these aspects in patients with RA could interfere with the prognosis and improve their quality of life.

Suicidal Behavior in Fibromyalgia Patients: Rates and Determinants of Suicide Ideation, Risk, Suicide, and Suicidal Attempts-A Systematic Review of the Literature and Meta-Analysis of Over 390,000 Fibromyalgia Patients

Background: Suicide is a leading cause of death worldwide, affecting ~800,000 people every year. Fibromyalgia is an extremely prevalent rheumatic disease with a predisposition for comorbid anxiety and depression, which are known risk factors for suicidal behavior. Suicidality and relevant risk factors for suicidal behavior have not been thoroughly studied in patients with fibromyalgia. Objectives: To investigate the risk of suicidal ideation and attempts in patients with fibromyalgia. Methods: A systematic review and meta-analysis was conducted and reported according to the "Preferred Reporting Items for Systematic reviews and Meta-analyses" (PRISMA) standards. Also, the gray literature was extensively searched. Results: Thirteen studies were included in the present systematic review and meta-analysis, including 394,087 fibromyalgia patients. Sample size ranged from 44 to 199,739 subjects, mean age ranged from 45.8 to 54.5 years while the female percentage with fibromyalgia ranged from 17.1 to 100.0%. The overall suicide ideation prevalence was 29.57% (95%CI 1.84-72.07), with an OR 9.12 of (95%CI 1.42-58.77), ranging from 2.34 (95%CI 1.49-3.66) to 26.89 (95%CI 5.72-126.42). Pooled suicide attempt prevalence was 5.69% [95%CI 1.26-31.34], with an OR of 3.12 [95%CI 1.37-7.12]. Suicide risk was higher with respect to the general population with an OR of 36.77 (95%CI 15.55-96.94), as well as suicide events with an HR of 1.38 (95%CI 1.17-1.71). Determinants of suicidality were found to be: employment status, disease severity, obesity and drug dependence, chronic pain and co-morbidities, in particular depression, anxiety, poor sleep, and global mental health. However, in some cases, after adjusting for psychiatric conditions, the threshold of statistical significance was not achieved. Conclusion: Fibromyalgia patients are particularly prone to suicide, in terms of ideation, attempt, risk and events, warranting a pre-emptive screening of their mental health status. Given the few studies available, the high amount of heterogeneity, the evidence of publications bias and the lack of statistical significance when adjusting for underlying psychiatric co-morbidities, further high-quality studies should be conducted. Clinical Trial Registration: ClinicalTrial.gov, identifier 10.17605/OSF.IO/Y4BUE.

The Relationship Between Anxiety, Depression, Suicidal Ideation and Quality of Life in Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic disease and many patients with RA experience lifelong anxiety and depression. The aim of this study is to provide an assessment of anxiety, depression, suicidal ideation, disease activity and quality of life in patients with RA. Fifty patients were included in the study. Hospital Anxiety and Depression Scale (HADS), Short Form Health Survey (SF-36), Beck Scale for Suicide Ideation (BSSI) and Disease Activity Score (DAS-28) were applied. A statistically negative correlation was found between HADS-A and HADS-D scores and all subscales of SF-36. There was a statistically negative correlation between the DAS-28 score and the subscales of the SF-36 except mental health and bodily pain. Suicidal ideation was associated with anxiety and depression and BSSI scores of patients suffering from anxiety and depression are higher than the patients not suffering from anxiety and depression. There was a statistically negative correlation between BSSI and the subscales of SF-36 excepting physical role. This study indicated that anxiety, depression, quality of life, disease activity and suicidal ideation are related to each other in patients with RA. The presence of concomitant anxiety and depression may lead to suicide and poor quality of life and may worsen the prognosis of the RA.

Quality of life, depression, and psychosocial mechanisms of suicide risk in prostate cancer

INTRODUCTION

Prostate cancer (PCa) is the most common non-cutaneous cancer in men and is usually identified at a stage at which prolonged survival is expected. Therefore, strategies to address survivorship and promote well-being are crucial. This study's aim was to better understand suicidal behavior in PCa patients by examining psychosocial mediators (i.e., depression, psychache, perceived burdensomeness [PB], thwarted belongingness [TB]) in the relationship between quality of life (PCa-QoL) and suicide risk.

METHODS

Four hundred and six men with PCa (Median age 69.35 years, standard deviation 7.79) completed an online survey on various psychosocial variables associated with suicide risk. A combined serial/parallel mediation model tested whether depression, in serial with both psychache and PB/TB, mediated the relationship between PCa-QoL and suicide risk.

RESULTS

Over 14% of participants' self-reports indicated clinically significant suicide risk. Poorer PCa-QoL was related to greater depression, which was related to both greater psychache and PB/TB, which was associated with greater suicide risk. The serial mediation effect of depression and psychache was significantly stronger than that of depression and PB/TB. PCa-QoL did not predict suicide risk through depression alone, showing that depressive symptoms affect suicide risk through psychache and PB/TB.

CONCLUSIONS

Given the alarming estimate of individuals at risk for suicide in this study, clinicians should consider patients with poorer PCa-QoL and elevated depression for psychosocial referral or management. Psychache (i.e., psychological pain) and PB/TB (i.e., poor social fit) may be important targets for reducing suicide risk intervention beyond the impact of depression alone.

Pain appraisal and quality of life in 108 outpatients with rheumatoid arthritis

Individual differences in emotional functioning, pain appraisal processing, and perceived social support may play a relevant role in the subjective experience of pain. Due to the paucity of data regarding individuals with Rheumatoid Arthritis (RA), the present study aimed to examine pain intensity, emotional functioning (psychological distress and alexithymia), pain appraisal (pain beliefs, pain catastrophizing, and pain-related coping strategies) and social support, and their relationships with the health-related quality of life (HRQoL) in patients with RA. Data were collected from 108 female patients diagnosed with RA. Clinically relevant levels of depressive and anxiety symptoms assessed by the HADS subscales were present in 34% and 41% of the patients, respectively, and about 24% of them exhibited the presence of alexithymia. The results of hierarchical multiple regression analyses showed that pain intensity, alexithymia, the maladaptive beliefs regarding the stability of pain and the coping strategy of guarding explained 54% of the variance in the physical component of HRQoL (p < 0.001). Depression subscale of the HADS, alexithymia, the coping strategy of resting, and the rumination factor of pain catastrophizing significantly explained 40% of the variance in the mental component of HRQoL (p < 0.001). The present findings provide evidence regarding the importance of emotional functioning and pain appraisal in the negative impact of RA on patients' quality of life. These findings provide additional evidence for the biopsychosocial model of chronic pain, further supporting the complex interaction between emotional, cognitive, and behavioral processes in patients with chronic pain.

Relationship of Depression Scores and Ranges in Women Who Suffer From Fibromyalgia by Age Distribution: A Case-Control Study

BACKGROUND

Fibromyalgia may be defined as a chronic widespread pain condition that generates a functional impairment with various symptoms, such as depression.

PURPOSE

The main aim of this research was to compare the Beck Depression Inventory (BDI) scores and depression ranges in women who suffered from fibromyalgia with respect to healthy controls, overall and by age distributions.

METHODS

A case-control observational study was performed. Two hundred women with a mean age of 58.61 ± 15.65 years old were recruited. The women were divided into case (women with fibromyalgia) and control (healthy women) groups. The BDI scores and depression ranges were collected.

RESULTS

The depression ranges and BDI scores mean ± SD showed statistically significant differences (p < .001) between participants with fibromyalgia (19.30 ± 11.21 points; moderate depression) and healthy controls (6.37 ± 5.35 points; no depression). Regarding the age distributions, statistically significant differences were shown between fibromyalgia and control groups for adults (p < .001; 19.06 ± 6.55 vs. 4.69 ± 4.48 points) and older adults (p = .001; 20.25 ± 13.79 vs. 7.63 ± 5.47 points), respectively. ANOVA of the BDI scores with two factors and interaction (fibromyalgia presence and age distribution) determined no interaction between the two factors (p = .534) and statistically significant differences of BDI scores for fibromyalgia presence (p < .001; R2  = 35.50%), but not for age distribution (p = .144).

LINKING EVIDENCE TO ACTION

Measurable differences in higher BDI scores and depression ranges were shown in women who suffered from fibromyalgia with respect to healthy controls, regardless of age distribution. Greater probabilities (odds ratio = 15.88) of suffering from some level of depression (according to BDI scores) were found in women with fibromyalgia in comparison with healthy women. Although these findings did not seem to be influenced by age distribution, interventions targeting depression in practice, research, policy, management, or education must equally include adult and older adult women who suffer from fibromyalgia.

Perceived burdensomeness, thwarted belongingness and suicidal ideation in patients with fibromyalgia and healthy subjects: a cross-sectional study

Perceived burdensomeness and thwarted belongingness are key factors in the development of suicidal behaviors that have been frequently observed among patients with fibromyalgia. The aim of the present study was to compare these two factors in patients with fibromyalgia with and without suicidal ideation and healthy subjects. Secondary objectives were to evaluate the relationship between these two factors and the secondary variables included in the study, such as depression, sleep quality or the degree of marital adjustment. Perceived burdensomeness and thwarted belongingness were assessed with the Interpersonal Needs Questionnaire, depression and suicidal ideation with the Patients Health Questionnaire-9, suicidal risk with the Plutchik Suicide Risk scale, sleep with the Insomnia Severity Index, and marital adjustment with the Locke-Wallace Marital Adjustment scale. Questionnaire scores were compared with the Kruskal-Wallis test. 49 healthy subjects, 38 patients with fibromyalgia without suicidal ideation and 15 patients with fibromyalgia and suicidal ideations were included. Perceived burdensomeness scores were significantly higher in patients with suicidal ideation than in patients without suicidal ideation and controls; thwarted belongingness scores were significantly higher in patients with suicidal ideation than in controls. Marital adjustment was also significantly poor in patients with suicidal ideation than in patients without suicidal ideation and controls. Among patients with fibromyalgia, perceived burdensomeness seems to be strongly related with suicidal ideation, whereas thwarted belongingness seems to play a less relevant role at this respect. Poor marital adjustment could be related with depression.