Predictors of suicidal ideation in depressive primary care patients

Food Insecurity and Suicidal Ideation: Results from a National Longitudinal Study of Military Veterans

OBJECTIVE

Research examining social determinants of suicide risk in veterans suggests a potential link between food insecurity and subsequent suicidal ideation in military veterans. The objective of this study is to investigate, if and how, food insecurity predicts subsequent suicidal ideation in a nationally representative longitudinal survey of veterans.

METHODS

A national longitudinal survey was analyzed of participants randomly drawn from over one million U.S. military service members who served after September 11, 2001. N = 1,090 veterans provided two waves of data one year apart (79% retention rate); the final sample was representative of post-9/11 veterans in all 50 states and all military branches.

RESULTS

Veterans with food insecurity had nearly four times higher suicidal ideation one year later compared to veterans not reporting food insecurity (39% vs 10%). In multivariable analyses controlling for demographic, military, and clinical covariates, food insecurity (OR = 2.37, p =.0165) predicted suicidal ideation one year later, as did mental health disorders (OR = 2.12, p = .0097). Veterans with both food insecurity and mental health disorders had a more than nine-fold increase in predicted probability of suicidal ideation in the subsequent year compared to veterans with neither food insecurity nor mental health disorders (48.5% vs. 5.5%).

CONCLUSION

These findings identify food insecurity as an independent risk marker for suicidal ideation in military veterans in addition to mental disorders. Food insecurity is both an indicator of and an intervention point for subsequent suicide risk. Regularly assessing for food insecurity, and intervening accordingly, can provide upstream opportunities to reduce odds of suicide among veterans.

Dorsolateral prefrontal activation in depressed young adults with and without suicidal ideation during an emotional autobiographical memory task: A fNIRS study

OBJECTIVE

Previous studies have proved that there is a strong association between dorsolateral prefrontal cortex and mood symptoms. This study aimed at using functional near-infrared spectroscopy technology to invest brain activity in dlPFC of depressed individuals with and without suicidal ideation during emotional autobiographical memory test, and to understand their differences in brain cognitive mechanisms. It is helpful to improve our ability to predict and subsequently to prevent suicide.

METHODS

85 young adults participated in the study by a simple random sampling method, with health control (34participants), depression with suicidal ideation (17participants), and depression without suicidal ideation (34participants). The average oxyhemoglobin in dlPFC of subjects during EAMT was collected by a 53-channel fNIRS imaging device.

RESULTS

A marginal significant difference was found between three groups in left dlPFC and right dlPFC. Post hoc analysis revealed that: (1) under negative emotion, depression without suicidal ideation group had higher activation than healthy control group in left dlPFC. (2) under positive emotion, depression with suicidal ideation group had lower activation than healthy control in right dlPFC.

CONCLUSIONS

Results indicated that the depressed individuals with suicidal ideation had some deficits in executive function in right dlPFC, while the depressed adults without suicidal ideation may have mechanism of resource compensatory recruitment in left dlPFC and the dlPFC abnormality involved in the pathophysiology, may localize within left hemisphere. The depressed individuals with and without suicidal ideation had the different mechanisms in dlPFC and fNIRS can be a neuroimaging biomarker characterizing or predicting suicidality in depressed individuals.

Social Group Identification as a Predictor of Pretreatment Suicidal Ideation and Intent in those Receiving cCBT: Evidence from a Scottish Primary Care Sample

Suicidal ideation and intent are strongly linked with suicidal attempts and completions; however, no study to date has explored the predictors of ideation and intent within a sample receiving computerized cognitive behavioral therapy (cCBT) as an intervention for mild to moderate depression. The current study investigates the impact of social group identification and socioeconomic deprivation, together with a number of important clinical and demographic factors, on suicidal ideation and intent within a Scottish primary care sample. Participants (N = 1062) were recruited from referrals to a cCBT program, "Beating the Blues" (BtB), over a 33-month period. Participants completed three versions of the group identifications scale (GIS), one for each of three groups: family, community, and a social group of choice. Single-item questions on suicidal ideation and intent were delivered through the BtB program, and demographic and clinical information were collected on commencing BtB. More severe psychological distress, fewer group identifications, younger age, and being male, all significantly predicted the presence of suicidal ideations, however only greater severity of psychological distress was associated with more serious suicidal intent. These results provide valuable insight into factors associated with suicidal ideation and intent within a clinical population from a psychosocial, psychopharmacological, and demographic perspective.

Effectiveness of mindfulness-based cognitive therapy against suicidal ideation in patients with depression: A systematic review and meta-analysis

BACKGROUND

Mindfulness-based cognitive therapy (MBCT) can effectively prevent relapse of major depression, but there is currently insufficient evidence for efficacy against suicidal ideation during depressive episodes. We thus conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing MBCT to treatment as usual (TAU) for suppression of suicidal ideation in patients with current depression.

METHODS

We systematically searched PubMed, Embase, Cochrane, CNKI, and Wan Fang databases for RCTs published in English or Chinese between January 1, 2000, and August 30, 2021. Pooled data were compared between MBCT and TAU groups using a random-effects model.

FINDINGS

Seven RCTs with a total of 479 participants were included. Suicidal ideation and general depression scores were significantly improved following MBCT compared to TAU [Suicidal Ideation: standard mean difference (SMD) = -0.33, 95 % CI, -0.56 to -0.10; Depression: SMD = -0.96, 95%CI, -1.54 to -0.38].

INTERPRETATION

Mindfulness-based cognitive therapy is an effective intervention for reducing depressive symptoms and suicidal ideation in depressed patients.

TRIAL REGISTRATION

This meta-analysis was conducted in accordance with PRISMA guidelines and registered at PROSPERO https://www.crd.york.ac.uk/PROSPERO/ (CRD42021285016).

Internalized Homophobia and Suicide Ideation Among Sexual Minority Adults: The Serial Mediation of Core Self-Evaluations and Depression

Internalized homophobia (IH) is the endorsement of negative attitudes and stereotypes about sexual minority individuals among those who are LGBQ + . However, although IH is associated with suicide ideation, the underlying mechanisms of this association are relatively understudied. To address this limitation, this research investigates Core Self-Evaluation (CSE; one's fundamental evaluations about themselves, their own abilities, and their own control) and depression as underlying mechanisms associating IH with suicide ideation. CSE comprises four traits: self-esteem, locus of control, emotional stability, and generalized self-efficacy. An online survey was completed by 404 sexual minority adults (Mean_age = 27.42 years, %Female = 51.50, %Male = 30.40, %Trans Female = 3.2, %Trans Male = 5.4). Participants were recruited via Prolific, an online crowdsourcing platform. Four serial mediation analyses examined the direct and indirect effects of IH on suicide ideation via each CSE trait and depression symptoms. Results showed support for the CSE-depression mediated pathway. Self-esteem, emotional stability, and general self-efficacy (but not locus of control) mediated the relationship between IH and suicide ideation via depression symptoms. Across three serial mediations, greater IH was associated with lower (1) self-esteem, (2) emotional stability, and (3) self-efficacy; lower self-esteem, emotional stability, and self-efficacy were associated with greater reported depression symptoms, which were then associated with greater suicide ideation. This research has implications for understanding the underlying mechanisms that associate IH with poor mental health among sexual minority adults. Studying the social and psychological mechanisms can help develop therapeutic interventions that target suicide ideation and promote positive self-evaluations among sexual minority individuals.

Predictive Modeling for Suicide-Related Outcomes and Risk Factors among Patients with Pain Conditions: A Systematic Review

Suicide is a leading cause of death in the US. Patients with pain conditions have higher suicidal risks. In a systematic review searching observational studies from multiple sources (e.g., MEDLINE) from 1 January 2000–12 September 2020, we evaluated existing suicide prediction models’ (SPMs) performance and identified risk factors and their derived data sources among patients with pain conditions. The suicide-related outcomes included suicidal ideation, suicide attempts, suicide deaths, and suicide behaviors. Among the 87 studies included (with 8 SPM studies), 107 suicide risk factors (grouped into 27 categories) were identified. The most frequently occurring risk factor category was depression and their severity (33%). Approximately 20% of the risk factor categories would require identification from data sources beyond structured data (e.g., clinical notes). For 8 SPM studies (only 2 performing validation), the reported prediction metrics/performance varied: C-statistics (n = 3 studies) ranged 0.67–0.84, overall accuracy(n = 5): 0.78–0.96, sensitivity(n = 2): 0.65–0.91, and positive predictive values(n = 3): 0.01–0.43. Using the modified Quality in Prognosis Studies tool to assess the risk of biases, four SPM studies had moderate-to-high risk of biases. This systematic review identified a comprehensive list of risk factors that may improve predicting suicidal risks for patients with pain conditions. Future studies need to examine reasons for performance variations and SPM’s clinical utility.

Improving Suicide Prevention in Primary Care for Differing Levels of Behavioral Health Integration: A Review

Importance

Suicide prevention implementation in primary care is needed due to the increasing rate of suicide in the past few decades, particularly for young and marginalized people. Primary care is the most likely point of contact for suicidal patients in the healthcare system. Attention to the level of medical integration with behavioral health is vital to suicide prevention and is applied throughout this review.

Methods

A narrative review was performed.

Observations

Many interventions help improve suicide prevention care. PCP education, screening, safety planning/lethal means reduction, care transitions, psychotherapy, and medication management are all evidence-based strategies. Additionally, the pragmatic topics of financing suicide prevention, supporting providers, enacting suicide postvention, and preparing for future directions in the field at each level of primary care/behavioral health integration are discussed.

Conclusions and Relevance

The findings are clinically relevant for practices interested in implementing evidence-based suicide prevention strategies by attending to the behavioral health/medical interface. Leveraging the patient/provider relationship to allow for optimal suicide prevention care requires clinics to structure provider time to allow for emotionally present care. Defining clear roles for staff and giving attention to provider well being are also critical factors to supporting primary care-based suicide prevention efforts.

The prevalence of painful physical symptoms in major depressive disorder: A systematic review and meta-analysis of observational studies

BACKGROUND

Painful physical symptoms (PPS) are common in patients with major depressive disorder (MDD), but their prevalence has been mixed. This is a systematic review and meta-analysis of the pooled prevalence of PPS in MDD patients.

METHODS

Systematic literature searches were independently conducted in major databases (PubMed, EMBASE, PsycINFO and Web of Science). Data analyses were conducted using a random-effects model.

RESULTS

A total of 20 studies with 53,852 patients were included. The overall prevalence of PPS in MDD patients was 55.2% (95%CI: 47.9-62.3%), with a point prevalence of 64.2% (95%CI: 53.2-73.8%) and a 12-month prevalence of 57.0% (95%CI: 23.9-84.8%). No significant publication bias was found in this meta-analysis.

CONCLUSION

PPS are common in MDD patients. Considering the negative impact of PPS on daily functioning, effective preventive measures and routine screening should be conducted for MDD patients, and timely treatments should be offered to those in need. Registration number: CRD42020179471.

Suicidal Thoughts in Patients With Cancer and Comorbid Major Depression: Findings From a Depression Screening Program

BACKGROUND

Major depression is found in around ten percent of patients attending cancer clinics. One of the symptoms of major depression, defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), is "thoughts of death or suicide." To implement depression screening programs for patients with cancer, we need to know the prevalence not only of this broadly defined symptom but also of more specific suicidal thoughts, as only the latter clearly indicates the need for specialist psychiatric assessment and management of suicide risk.

METHODS

We analyzed data from a routine 2-stage depression screening program that operated in 3 UK cancer centers, linked with demographic and clinical data obtained from a national cancer registry. We included data on 2217 patients with common cancers and comorbid, interview-diagnosed, major depression. We determined the percentage of patients with (a) the DSM-IV symptom "thoughts of death or suicide" and (b) suicidal thoughts, defined as an affirmative response to the question "have you had thoughts of ending your life?" We investigated the associations of patients' demographic and clinical characteristics with each of these using logistic regression models.

RESULTS

We found that 641 of 2217 (29%) of patients had the DSM symptom "thoughts of death or suicide" and 207 of 2217 (9%) had suicidal thoughts. Of the demographic and clinical characteristics that we studied, none had statistically significant associations with having the DSM symptom. Only younger age and primary cancer were associated with having suicidal thoughts.

CONCLUSIONS

We found that almost one-third of patients with cancer and comorbid major depression have the DSM symptom "thoughts of death or suicide." However, only a third of the patients with this symptom report suicidal thoughts. These findings suggest that around one in ten patients found by a screening program to have major depression will have suicidal thoughts requiring a psychiatric assessment. The staffing of depression screening programs should be designed with these data in mind.

Suicidal Ideation and Its Associated Factors Among Patients with Major Depressive Disorder at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia

BACKGROUND

Suicidal ideation is thinking about suicide/serving as the agent of one's own death. Patients with a major depressive disorder are the highest group which are affected by suicidal ideation. It is a pre-condition for suicide attempts and to commit suicide among major depressive patients. Suicidal behavior and major depressive disorder have been becoming the main attention in recent years. In Ethiopia, there is limited knowledge of suicidal ideation among major depressive disorder patients and the factors of suicidal ideation are also limited.

OBJECTIVE

This study assessed the prevalence of suicidal ideation and its associated factors among major depressive disorder patients at Amanuel Mental Specialized Hospital, Ethiopia.

METHODS

A cross-sectional study was conducted from March 1-30, 2019. A total of 337 major depressive disorder patients were successfully interviewed using structured and pre-tested questionnaires. A systematic random sampling technique was applied. Logistic regression was applied to identify factors of suicidal ideation. Statistical significance was considered at P-value < 0.05.

RESULTS

In this study, the prevalence of suicidal ideation among major depressive disorder patients was 48.4%. Being female (AOR 2.4, 95% CI=1.40, 4.25), family history of suicide (AOR 3.2, 95% CI=1.26, 8.11), and having poor social support (AOR 4.2, 95% CI=2.29, 7.59) were significantly associated with suicidal ideation among patients with major depressive disorder.

CONCLUSION

The prevalence of suicidal ideation among major depressive disorder patients was relatively high. Hence, due attention should be given to the screening of suicidal ideation for all patients with major depressive disorder to initiate timely interventions.

Depression, Acquired Capability for Suicide, and Attempted Suicide

OBJECTIVE

The study sought to replicate, with a community sample and different measures of the critical variables, the finding of Chu et al. (Cognitive Therapy and Research, 2016, 40, 22) in a military sample that suicide attempts were more frequent for those reporting higher numbers of depressive episodes if acquired capability for suicide (ACS) was also high.

METHOD

An online survey (N = 251) collected data on episodes and severity of depression, number of suicide attempts, and a questionnaire measure of ACS.

RESULTS

The interaction effect reported by Chu et al. (Cognitive Therapy and Research, 2016, 40, 22) was replicated, but depended on using the Fearlessness of Death component of ACS and the number and not the severity of depressive episodes.

CONCLUSION

The moderating effect of ACS on the relation between depression and suicide attempts can be demonstrated beyond a military and predominately male sample. Limitations of the study are noted.

Effects of awareness material featuring individuals with experience of depression and suicidal thoughts on an audience with depressive symptoms: Randomized controlled trial

BACKGROUND AND OBJECTIVE

Suicide prevention plans support individuals with personal experience of mental disorders and suicidality to provide their narratives of coping in the media. The evidence how such portrayals impact on individuals with similar symptoms is limited and there are concerns about unwanted side effects.

METHODS

This was a double-blinded randomized controlled online trial conducted from August to November 2018. N = 158 young adults aged 18-24 with current depressive symptoms and suicidal thoughts were randomized to watch a short film featuring a young individual with personal experience of depression and suicidality (n = 81), or a thematically unrelated control film (n = 77) with similar stylistic elements. Questionnaire data were collected before and immediately after exposure and analysed with ANOVA. The primary outcome was suicidal ideation; secondary outcomes were depressed mood and help-seeking intentions. We also tested the moderating effects of the degree of depressive symptoms on the effects.

RESULTS

Depressed mood was significantly lower, with small-to medium effect size, in the intervention group compared to the control group (F(1,111) = 4.13, P < .05, η_p² = .036). There was no effect on suicidal ideation or help-seeking intentions in the total sample. Participants screening positive for moderately severe depression or higher experienced an increase in suicidal ideation in the control group.

LIMITATIONS

Self-reported variables in an online setting.

CONCLUSIONS

Videos featuring personal experience of coping with depression appear safe for young individuals with similar or higher symptoms of depression and suicidal ideation on the short run, and might have some benefits.

TRIAL REGISTRATION

German Clinical Trial Registry, DRKS00015095 (registration date: 2018-07-16).

Psychosocial protective factors and suicidal ideation: Results from a national longitudinal study of veterans

BACKGROUND

This study investigates the empirical association between psychosocial protective factors and subsequent suicidal ideation in veterans.

METHODS

We conducted a national longitudinal survey in which participants were randomly drawn from over one million U.S. military service members who served after September 11, 2001. Data were provided by a total of 1090 veterans representative of all 50 states and all military branches in two waves of data collection one year apart (79% retention rate).

RESULTS

In chi-square analyses, psychosocial protective factors at wave 1 (employment, meeting basic needs, self-care, living stability, social support, spirituality, resilience, and self-determination) were significantly related to lower suicidal ideation at wave 2. In multivariable analyses controlling for covariates at wave 1 including suicidal ideation, the total number of protective factors endorsed at wave 1 significantly predicted reduced odds of suicidal ideation at wave 2. In multivariable analysis examining individual risk and protective factors, again controlling for covariates, results showed that money to cover basic needs and higher psychological resilience at wave 1 were associated with significantly lower odds of suicidal ideation at wave 2.

LIMITATIONS

The study measured the link between psychosocial protective factors and suicidal ideation but not suicide attempts, which would be an important next step for this research.

CONCLUSIONS

The results indicate that psychosocial rehabilitation and holistic approaches targeting financial well-being, homelessness, resilience, self-care, social support, spirituality, and work may offer a promising avenue in both veteran and non-veteran populations for treatment safety planning as well as suicide risk management and prevention.

Are wishes for death or suicidal ideation symptoms of depression in older adults?

OBJECTIVE

Clinicians may question whether thoughts of being better off dead are normal consequences of aging or symptoms of depression. We examine whether thoughts of suicide are as strongly linked to depression severity in older adults as they are in other age groups.

METHODS

Cross-sectional cohort study. Participants included 509,945 outpatients >18 years old from four large integrated healthcare systems in the Mental Health Research Network who completed 1.2 million Patient Health Questionnaires (PHQ) and had data to calculate Charlson Comorbidity Index scores from 2010 through 2012. The PHQ8 estimated depression severity, while suicidal ideation was measured using the 9th item of the PHQ. Data were abstracted from a Virtual Data Warehouse.

RESULTS

In older adult patients, suicidal ideation was strongly associated with depression severity. Older adults who had at least moderately-severe depression (PHQ8 ≥15) were 48 times more likely (95% CI: 42.8-53.8) to report suicidal ideation than those with minimal or mild symptoms of depression (PHQ8 <10) after adjustment for all other variables in the model, including medical comorbidity burden.

CONCLUSIONS

Depression severity was by far the strongest predictor of suicidal ideation in older adult patients. Older patients with suicidal ideation should be screened for depression.

Investigation of a Suicide Ideation Risk Profile in People With Co-occurring Depression and Substance Use Disorder

Disengagement from services is common before suicide, hence identifying factors at treatment presentation that predict future suicidality is important. This article explores risk profiles for suicidal ideation among treatment seekers with depression and substance misuse. Participants completed assessments at baseline and 6 months. Baseline demographics, psychiatric history, and current symptoms were entered into a decision tree to predict suicidal ideation at follow-up. Sixty-three percent of participants at baseline and 43.5% at follow-up reported suicidal ideation. Baseline ideation most salient when psychiatric illness began before adulthood, increasing the rate of follow-up ideation by 16%. Among those without baseline ideation, dysfunctional attitudes were the most important risk factor, increasing rates of suicidal ideation by 35%. These findings provide evidence of factors beyond initial diagnoses that increase the likelihood of suicidal ideation and are worthy of clinical attention. In particular, providing suicide prevention resources to those with high dysfunctional attitudes may be beneficial.

The Interactive Effect of Major Depression and Nonsuicidal Self-Injury on Current Suicide Risk and Lifetime Suicide Attempts

This study examined the main and interactive effects of MDD and lifetime nonsuicidal self-injury (NSSI) on current suicide risk and past suicide attempts. We predicted that individuals with a history of NSSI and current MDD would be at greater suicide risk than those with either risk factor alone. An interaction between lifetime MDD and NSSI was hypothesized for past suicide attempts. 204 substance dependent inpatients completed self-report measures and a diagnostic interview. Patients with both a history of NSSI and current MDD, relative to all other groups, had the greatest suicide risk. No support was found for the lifetime MDD by NSSI interaction.

CONCLUSION

Findings suggest the relevance of both NSSI and MDD in suicide risk.

Suicidal ideations, plans and attempts in primary care: cross-sectional study of consultants at primary health care system in Morocco

Introduction

The aim of the study is to estimate the prevalence of suicidal ideation among Moroccan consultants in primary health care system.

Methods

We conducted a cross sectional survey in three health care centers in two cities of Morocco to estimate the prevalence of suicidal ideation, plan and suicide attempts among 396 consultants in the primary health care system, using the Mini International neuropsychiatric interview. Patients were 18 years and older, without known psychiatric or chronic somatic disease. Statistical analysis was performed by the SPSS 13.0 software.

Results

The prevalence of suicidal ideation was 5.3%, and 2.7% of the patients planned their suicide and 1.2% tried to commit suicide. The multivariate analysis did not demonstrate significant association.

Conclusion

Suicidal ideation, plan and suicide attempts are prevalent in primary health care patients, but they are still under diagnosed. An adequate training of physicians and the establishment of education programs is essential to reduce the rate of suicide.

Reasons for living and hope as the protective factors against suicidality in Chinese patients with depression: a cross sectional study

BACKGROUND

The risk factors of suicidal ideation and attempts have been discussed in many researches. Few studies have examined reasons for living and hope as protective factors against suicide in a clinical population. It is unclear if these factors help to reduce suicide rates in patients with depression. The study aimed to assess the role of reasons for living and hope in the identification and reduction of suicidality and explore the influence of reasons for living or hope in the transition from suicidal ideation to suicide attempts.

METHODS

Patients with depression (N = 115) completed the Beck Depression Inventory, Reasons for Living Inventory, and Adult Suicidal Ideation Questionnaire.

RESULTS

There were significant correlations among depression, hope, total reasons for living, and suicidal ideation and attempts. Further, after controlling for depression, reasons for living and hope had significant main effects on suicidal ideation. Hope also had a significant predictive effect in the transition of suicidal ideation to suicide attempt.

CONCLUSIONS

We concluded that reasons for living and hope may protect against suicidal ideation and attempts in patients with depression. Especially hope could reduce the possibility of suicide attempt.

Characteristics of suicidal outpatients with mood, anxiety and somatoform disorders: The role of childhood abuse and neglect

BACKGROUND

The most prevalent psychiatric disorders are mood, anxiety and somatoform (MAS) disorders which show high mutual comorbidity, childhood trauma and elevated risk of suicidality. So far, no studies have compared suicide risk in a secondary care population with comorbid MAS disorders. This gap was taken as starting point for the study.

AIMS

In comparing suicidal and non-suicidal MAS patients, the following was examined: suicide risk in the three disorder groups, socio-demographic and clinical characteristics, occurrence of childhood trauma types and contribution of childhood trauma to suicidality.

METHODS

This cross-sectional study compared suicidal (n = 316) versus non-suicidal comorbid MAS outpatients (n = 929) by means of the Mini-International Neuropsychiatric Interview Plus (MINI-Plus), Brief Symptom Inventory (BSI), Short Form Health Survey 36 (SF-36), Dimensional Assessment of Personality Pathology-Short Form (DAPP-SF) and Childhood Trauma Questionnaire (CTQ).

RESULTS

Compared to non-suicidal MAS patients, suicidal MAS patients mostly had mood disorders (single/comorbid), multiple diagnoses, worse functioning, more personality pathology (self-harm) and more childhood neglect and abuse.

CONCLUSION

Especially (comorbid) depressed patients are at risk for suicide, and routine screening and monitoring of childhood trauma and suicidality in them are recommended, along with the timely deployment of appropriate trauma-focused psychotherapy.

Suicidality in primary care patients who present with sadness and anhedonia: a prospective European study

BACKGROUND

Sadness and anhedonia (loss of interest in activities) are central symptoms of major depression. However, not all people with these symptoms meet diagnostic criteria for major depression. We aimed to assess the importance of suicidality in the outcomes for primary care patients who present with sadness and anhedonia.

METHOD

Cohort study of 2,599 unselected primary care attenders in six European countries followed up at 6 and 12 months.

RESULTS

1) In patients with sadness and/or anhedonia who were not depressed at entry to the study, suicide plans (OR = 3.05; 95 % CI = 1.50-6.24; p = 0.0022) and suicide attempts (OR = 9.08; 95 % CI = 2.57-32.03; p = 0.0006) were significant predictors of developing new onset depression at 6 or 12 months. 2) In patients with sadness and/or anhedonia who met CIDI criteria for major depression at entry, suicidal ideation (OR = 2.93; 95 % CI = 1.70-5.07; p = 0.0001), suicide plans (OR = 3.70; 95 % CI = 2.08-6.57; p < 0.0001), and suicide attempts (OR = 3.33; 95 % CI = 1.47-7.54; p = 0.0040) were significant predictors of persistent depression at 6 or 12 months.

CONCLUSIONS

Three questions on suicidality could help primary care professionals to assess such patients more closely without necessarily establishing whether they meet criteria for major depression.

Prevalence of Depression and Depression Care for Populations Registered in Primary Care in Two Remote Cities in the Brazilian Amazon

Background

The prevalence of depression has been widely studied in high-income countries and in large cities of low-income countries; however, little is known about the prevalence and treatment gap of depression in remote areas of the Amazonian region in Brazil.

Objectives

The objectives of this study are to estimate the prevalence of depression in adults registered with the Family Health Strategy in two remote cities in the Brazilian Amazon and to investigate the proportion of individuals with depression that received mental health care.

Methods

This is a cross-sectional study of an adult population registered with primary care clinics in the cities of Coari and Tefé, State of Amazon, Brazil. Depression was defined as a score of ≥10 on the Patient Health Questionnaire-9. Depression care was evaluated by asking participants with depression if they received antidepressants and/or had been seen by a health professional at a community mental health center in the three months prior to the interview. Poisson regression was used to examine the unadjusted and adjusted associations between depression and exposure variables.

Results

The overall prevalence of depression was 19.1% (95% CI: 17.2–21.1), with 22.2% (95% CI: 19.3–25.0) among women and 16.0% (95% CI: 13.4–18.5) among men. The prevalence of depression in Coari and Tefé were 18.3% (CI 95% 15.7–21.0) and 19.9% (95% CI:17.2–22.7), respectively. Being a woman, lacking social support, increasing exposure to stressful life events and having a higher number medical comorbidities were consistently associated with depression. Lower educational attainment and income, tobacco use, and risky alcohol use were also associated with depression in the unadjusted analyses. Only 11.5% of those with depression were receiving antidepressants and/or visited the mental health care facility during the three months prior to the interview.

Conclusion

Approximately one in five adults in our sample had depression. A high proportion of participants presented indicators of social disadvantage and other risk factors previously associated with depression worldwide. There was a large treatment gap for depression in the Amazonian region, which demonstrates the need for innovative models of depression care in primary care settings in Brazil

Electronic protocol for suicide risk management in research participants

OBJECTIVE

To describe an electronic, telephone-delivered, suicide risk management protocol (SRMP) that is designed to guide research staff and safely triage study participants who are at risk for self-harm.

METHODS

We tested the SRMP in the context of the NIH-funded randomized clinical trial "Bypassing the Blues" in which 302 patients who had undergone coronary artery bypass graft surgery (CABG) were screened for depression and assessed by telephone 2-weeks following hospital discharge and at 2-, 4-, and 8-month follow-up. We programmed the SRMP to assign different risk levels based on patients' answers from none to imminent with action items for research staff keyed to each of them. We describe frequency of suicidal thinking, SRMP use, and completion of specific steps in the SRMP management process over the 8-month follow-up period.

RESULTS

Suicidal ideation was expressed by 74 (25%) of the 302 study participants in 139 (13%) of the 1069 blinded telephone assessments performed by research staff. The SRMP was launched in 103 (10%) of assessments, and the suicidal risk level was classified as moderate or high in 10 (1%) of these assessments, thereby necessitating an immediate evaluation by a study psychiatrist. However, no hospitalizations, emergency room visits, or deaths ascribed to suicidal ideation were discovered during the study period.

CONCLUSION

The SRMP was successful in systematically and safely guiding research staff lacking specialty mental health training through the standardized risk assessment and triaging research participants at risk for self-harm.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT00091962 (http://clinicaltrials.gov/ct2/show/NCT00091962?term=rollman+cabg&rank=1).

Suicide risk in primary care: identification and management in older adults

The National Strategy for Suicide Prevention (2012) has set a goal to reduce suicides by 20% within 5 years. Suicide rates are higher in older adults compared to most other age groups, and the majority of suicide completers have visited their primary care physician in the year before suicide. Primary care is an ideal setting to identify suicide risk and initiate mental health care. We review risk factors for late-life suicide; methods to assess for different levels of suicidality; and recent research developments regarding both effective assessment and management of suicide risk among older primary care patients. We highlight that broader scale screening of suicide risk may be considered in light of findings that suicidality can occur even in the absence of major risk factors like depression. We also highlight collaborative care models targeting suicide risk, and recent innovative interventions that aim to prevent the development of suicidal ideation and suicidal behavior.

The pain suicidality association: a narrative review

OBJECTIVES

The objective of this narrative review was to examine recent evidence and, when necessary, past evidence on the association between pain and suicidality.

DESIGN

Fifty-eight research reports were found on this topic, which had not previously been reviewed. These reports were divided into groups by whether they addressed suicide ideation (SI), suicide attempts (SAs), or suicide completion (SC), and what population they represented (acute pain patients [APPs], chronic pain patients [CPPs], other than APPs/CPPs) and whether they controlled for relevant confounders. Information as to whether the results of these studies supported/did not support the association of pain and suicidality was abstracted. For each group of studies (above), a vote counting method was utilized to determine the overall percentage of studies supporting/not supporting the association of pain and suicidality. According to this percentage, the consistency of the data supporting this association was rated according to Agency for Healthcare Research and Quality guidelines.

RESULTS

The following groups of studies received an A consistency rating (consistent evidence from multiple studies): SI, SA, and SC for other than APPs/CPPs; and SI, SA, and SC for CPP prevalence greater than an appropriate control group. Also, a subgroup of the SI, SA, and SC studies for other than APPs/CPPs had controlled for behavioral issues (potential confounders). These three subgroups also received an A consistency rating. The 58 studies also identified a number of new predictor variables for SI, SA, and SC in CPPs.

CONCLUSIONS

These studies solidify the evidence for an association between pain and SI, SA, and SC in both CPPs and other than APPs/CPPs.

[Risk Factors for Suicidal Ideation in Patients with Depressive Disorders in Colombia]

INTRODUCTION

Suicidal ideation is a poor prognostic factor in patients with depression, due to the risk of suicide attempt or completed suicide. However, it is a relatively unexplored aspect in the Colombian population. It is important to identify the associated factors in order to develop appropriate treatment strategies.

OBJECTIVE

To identify risk factors for suicidal ideation in patients with major depressive disorder between 18 and 65 years in 5 Colombian cities.

METHODS

Data from 295 patients diagnosed with major depressive disorder were used from the Study of the Economic Burden of Depression in Colombia. The association between the clinical and psychosocial variables with the presence of suicidal ideation was assessed using two-level hierarchical models.

RESULTS

Female sex was a factor associated with a lower risk of suicidal ideation. Factors associated with the presence of suicidal ideation include unemployment, smoking and alcohol use in the past 30 days, mental health perceived as fair or poor, diagnosis of double depression, inpatient treatment, low income, unemployment, and a major financial crisis in the last 2 years.

CONCLUSIONS

Suicidal ideation is highly prevalent in patients with major depressive disorder. Risk factors associated with both the clinical and psychosocial domain must be carefully evaluated during risk assessment of patients with this diagnosis.

Prevalence and correlates of smoking status among veterans affairs primary care patients with probable major depressive disorder

In an attempt to guide planning and optimize outcomes for population-specific smoking cessation efforts, the present study examined smoking prevalence and the demographic, clinical and psychosocial characteristics associated with smoking among a sample of Veterans Affairs primary care patients with probable major depression. Survey data were collected between 2003 and 2004 from 761 patients with probable major depression who attended one of 10 geographically dispersed VA primary care clinics. Current smoking prevalence was 39.8%. Relative to nonsmokers with probable major depression, bivariate comparisons revealed that current smokers had higher depression severity, drank more heavily, and were more likely to have comorbid PTSD. Smokers with probable major depression were also more likely than nonsmokers with probable major depression to have missed a health care appointment and to have missed medication doses in the previous 5months. Smokers were more amenable than non-smokers to depression treatment and diagnosis, and they reported more frequent visits to a mental health specialist and less social support. Alcohol abuse and low levels of social support were significant concurrent predictors of smoking status in controlled multivariable logistic regression. In conclusion, smoking prevalence was high among primary care patients with probable major depression, and these smokers reported a range of psychiatric and psychosocial characteristics with potential to complicate systems-level smoking cessation interventions.

Physicians' characteristics associated with exploring suicide risk among patients with depression: a French panel survey of general practitioners

Background

General practitioners (GPs) have a key role to play in suicide prevention, but the rates at which they question patients with depression about suicidal thoughts and plans are rather low. Little is known about GPs' characteristics associated with such inquiries. Our objectives were to describe GPs' attitudes, perceived barriers, and self-reported practices in this questioning of these patients and to analyze factors associated with these practices.

Methodology

This cross-sectional survey was conducted among participants in a panel of randomly selected French GPs (1249/1431 participated: 87.3%). GPs were interviewed with a standardized questionnaire covering their professional and personal characteristics, attitudes, and practices in exploring the suicide risk of their patients with depression. We built a suicide inquiry score by summing the responses to 5 items and used a multiple linear regression analysis to explore the characteristics associated with this score.

Principal Findings

Most GPs reported inquiring about the presence of suicidal ideation often or very often; less than 30% reported that they frequently explored signs of a specific suicide plan. The mean suicide inquiry score was 12.4 (SD, 2.9; range, 5–20). False ideas, such as thinking that patients who report suicidal ideas do not often commit suicide, were frequent (42.3%). Previous continuing medical education on suicide, participation in a formal mental health network, and patients who committed suicide in the past 5 years were associated with a higher score. Reluctance to question patients about suicide and perception of insufficient skill were associated with a lower score.

Conclusions/Significance

This study showed great variability in French GPs' practices in exploring suicide risk in patients with depression. Interventions aiming at improving GPs' initial training and continuing medical education in suicide and/or depression, and their collaboration with mental health specialists should be developed, and their impacts assessed.

Suicidality in primary care patients with somatoform disorders

OBJECTIVE

To examine rates of suicidality in primary care patients with somatoform disorders and to identify factors that might help to understand and manage active suicidal ideation in these patients.

METHODS

We conducted a cross-sectional study screening 1645 primary care patients. In total, 142 patients fulfilled the criteria for a somatoform disorder. Suicidality and illness perceptions were assessed in these patients.

RESULTS

Of the 142 patients, 23.9% had active suicidal ideation during the previous 6 months; 17.6% had attempted to commit suicide in the past, the majority after onset of the somatoform symptoms. We tested two models with suicidal ideation as a dependent variable. In the first model, comorbid symptoms of depression (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.03-1.33) and previous suicide attempts (OR= 3.02, 95% CI = 1.06-8.62) were significantly associated with suicidal ideation. Comorbid symptoms of anxiety did not yield significance. Illness perceptions and age of onset of the symptoms were then added to this model to test the role of somatoform-specific factors in addition to previous factors. In the complete model, comorbid symptoms of depression (OR = 1.15, 95% CI = 1.00-1.32) and dysfunctional illness perceptions (OR = 1.06, 95% CI = 1.01-1.11) were independently associated with active suicidal ideation, whereas the other factors did not yield significance.

CONCLUSIONS

According to our data, suicidality seems to be a substantial problem in primary care patients with somatoform disorders. Dysfunctional illness perceptions may play a vital role in the understanding and management of active suicidal ideation in these patients, in addition to more established factors.

Incidental treatment effects of CBT on suicidal ideation and hopelessness

BACKGROUND

Depression and alcohol misuse are among the most prevalent diagnoses in suicide fatalities. The risk posed by these disorders is exacerbated when they co-occur. Limited research has evaluated the effectiveness of common depression and alcohol treatments for the reduction of suicide vulnerability in individuals experiencing comorbidity.

METHODS

Participants with depressive symptoms and hazardous alcohol use were selected from two randomised controlled trials. They had received either a brief (1 session) intervention, or depression-focused cognitive behaviour therapy (CBT), alcohol-focused CBT, therapist-delivered integrated CBT, computer-delivered integrated CBT or person-centred therapy (PCT) over a 10-week period. Suicidal ideation, hopelessness, depression severity and alcohol consumption were assessed at baseline and 12-month follow-up.

RESULTS

Three hundred three participants were assessed at baseline and 12 months. Both suicidal ideation and hopelessness were associated with higher severity of depressive symptoms, but not with alcohol consumption. Suicidal ideation did not improve significantly at follow-up, with no differences between treatment conditions. Improvements in hopelessness differed between treatment conditions; hopelessness improved more in the CBT conditions compared to PCT and in single-focused CBT compared to integrated CBT.

LIMITATIONS

Low retention rates may have impacted on the reliability of our findings. Combining data from two studies may have resulted in heterogeneity of samples between conditions.

CONCLUSIONS

CBT appears to be associated with reductions in hopelessness in people with co-occurring depression and alcohol misuse, even when it is not the focus of treatment. Less consistent results were observed for suicidal ideation. Establishing specific procedures or therapeutic content for clinicians to monitor these outcomes may result in better management of individuals with higher vulnerability for suicide.

Suicidal ideation in German primary care

OBJECTIVE

To examine suicidal ideation in a sample of German primary care patients.

METHODS

We conducted a cross-sectional study and included 1455 primary care patients who visited 1 of 41 general practitioners (GPs) working at 19 different sites. Suicidal ideation and psychopathology were assessed with the Patient Health Questionnaire (PHQ) in an anonymous screening together with health care utilization.

RESULTS

One hundred seventy-one (11.8%) of 1455 patients endorsed the suicidal ideation item of the PHQ. These patients were significantly younger, more often female and unmarried, suffered more often from psychopathology and reported more health care utilization than patients without suicidal ideation. Patients with the highest frequency of suicidal ideation also talked more often routinely about psychosocial problems with their GP, used more often medication against their complaints and searched more often for a psychotherapist than other suicidal ideators. Yet, these patients were not more likely to be in psychotherapy at the time of the screening.

CONCLUSION

Our data suggest that suicidal ideation is a common phenomenon in primary care, which is independently associated with psychopathology in terms of depression, anxiety and somatoform complaints. Psychosocial support from GPs and medication seem to be easier available for primary care patients with suicidal ideation than psychotherapy, independent of the severity of the suicidal ideation.

Characteristics, management, and depression outcomes of primary care patients who endorse thoughts of death or suicide on the PHQ-9

BACKGROUND

With increasing emphasis on integrating behavioral health services, primary care providers play an important role in managing patients with suicidal thoughts.

OBJECTIVE

To evaluate whether Patient Health Questionnaire-9 (PHQ-9) Item 9 scores are associated with patient characteristics, management, and depression outcomes in a primary care-based mental health program.

DESIGN

Observational analysis of data collected from a patient registry.

PARTICIPANTS

Eleven thousand fifteen adults enrolled in the Mental Health Integration Program (MHIP).

INTERVENTIONS

MHIP provides integrated mental health services for safety-net populations in over 100 community health centers across Washington State. Key elements of the team-based model include: a disease registry; integrated care management; and organized psychiatric case review.

MAIN MEASURES

The independent variable, suicidal ideation (SI), was assessed by PHQ-9 Item 9. Depression severity was assessed with the PHQ-8. Outcomes included four indicators of depression treatment process (care manager contact, psychiatric case review, psychotropic medications, and specialty mental health referral), and two indicators of depression outcomes (50 % reduction in PHQ-9 score and PHQ-9 score < 10).

KEY RESULTS

SI was common (45.2 %) at baseline, with significantly higher rates among men and patients with greater psychopathology. Few patients with SI (5.4 %) lacked substantial current depressive symptoms. After adjusting for age, gender, and severity of psychopathology, patients with SI received follow-up earlier (care manager contact HR = 1.05, p < 0.001; psychiatric review HR = 1.02, p < 0.05), and were more likely to receive psychotropic medications (OR = 1.11, p = 0.001) and specialty referral (OR = 1.23, p < 0.001), yet were less likely to achieve a PHQ-9 score < 10 (HR = 0.87, p < 0.001).

CONCLUSIONS

Suicidal thoughts are common among safety-net patients referred by primary care providers for behavioral health care. Scores on Item 9 of the PHQ-9 are easily obtainable in primary care, may help providers initiate conversations about suicidality, and serve as useful markers of psychiatric complexity and treatment-resistance. Patients with positive scores should receive timely and comprehensive psychiatric evaluation and follow-up.

Heart rate variability in patients with fully remitted major depressive disorder

OBJECTIVE

Cardiac autonomic dysregulation has been reported in major depressive disorder (MDD), but scarce studies investigated that in fully remitted MDD.

METHODS

To examine cardiac autonomic function in remitted MDD, 470 unmedicated individuals with a diagnosis of MDD earlier in life and 462 healthy volunteers, aged 18-65 years, were recruited for a case-control analysis. Cardiac autonomic function was evaluated by measuring heart rate variability (HRV) parameters. Frequency-domain indices of HRV were obtained. The obtained results were evaluated in association with personality traits assessed by the Tridimensional Personality Questionnaire.

RESULTS

In patients with remitted MDD, no differences in RR intervals and all frequency-domain indices of HRV could be detected as compared with controls. Stratified analyses by the presence of a history of suicide ideation (the SI+ vs. the SI-subgroup) revealed decreased cardiac vagal control in the SI+ subgroup. The correlation analysis revealed an inverse relation between HRV levels and the harm avoidance score (which has been suggested to be associated with serotonergic activity), mainly attributable to the robust association in the SI+ subgroup.

CONCLUSION

Our study shows that cardiac autonomic dysregulation is not shown in remitted MDD patients as a whole but is limited to the subgroup of remitted MDD patients with a history of suicidal ideation. In view of the higher risk for cardiac complications in these vulnerable individuals, one might consider the treatment to restore their autonomic function.

Suicidal ideation and the subjective aspects of depression

BACKGROUND

Suicidal ideation is common in depression, but only moderately related to depression severity - in part because certain clusters of symptoms, such as those related to core mood disturbance, have a differential relationship to suicidal thinking.

METHODS

400 medication free participants with current major depression were assessed with either or both the Hamilton Depression Rating Scale (HDRS, n=396) and Beck Depression Inventory (BDI, n=366), and the Scale for Suicide Ideation (SSI). Depression rating scales were decomposed into symptoms clusters previously reported (Grunebaum et al., 2005), in order to evaluate their association to suicidal thinking.

RESULTS

Correlations between overall depression severity ratings and the measure of suicidal ideation were modest, and reduced when specific items assessing suicidal thinking on these depression scales were removed. Symptom clusters assessing Psychic Depression (HDRS), Subjective Depression (BDI), and Self-Blame (BDI) were the strongest correlates of suicidal ideation; other somatic and vegetative symptoms had little or no association to suicidal ideation. Severity of these symptom clusters effectively discriminated those with (SSI>0) and without (SSI=0) ideation; severity of these symptom clusters was less strongly associated with the severity of ideation once ideation was present.

LIMITATIONS

This is a cross-sectional study, and the dynamic relationship between changes in the severity of various depressive symptoms and change in suicidal thinking remains to be explored.

CONCLUSIONS

Depression severity is moderately associated with suicidal ideation, and accounted for primarily by core mood disturbance symptoms and self-punitive thinking. These associations may explain why suicide risk might remain high during treatment even though somatic and vegetative symptoms improve.

Self-perceived Difficulties With Suicidal Patients in A Sample of Italian General Practitioners

Background

Suicidal behaviours are relatively common among primary care patients, but suicide ideation seems to be poorly detected by GPs. The purpose of the present study is to investigate the frequency of issues related to suicidal behaviour in GPs’ setting and to inquire the level of difficulties perceived by physicians when dealing with suicidal patients.

Methods

A survey on 88 GPs in Rovigo (Italy) has been conducted through the use of a self-administered questionnaire inquiring about suicidal behaviour in patients, personal history and outside professional lives.

Results

Four out of 5 doctors have encountered at least a case of suicide in their professional career, and 3 out of 4 recorded at least a case of suicide attempt in a working year. The frequency of personal history of suicidal ideation/behaviour was 2.3%. One third of GPs have come into contact with suicides or suicide attempts outside the professional setting. Sixty one per cent of doctors admitted difficulties in exploring suicidal ideation, but tended to ascribe it to a reluctant attitude of patients.

Conclusions

The study underscores GPs’ need of being helped in the difficult task of recognising suicidal patients.

Keywords

General practitioner; Suicide ideation; Suicide; Suicide attempt

Associations between Overall and Abdominal Obesity and Suicidal Ideation among US Adult Women

Obesity is associated with increased risks for mental disorders. This study examined associations of obesity indicators including body mass index (BMI), waist circumference, and waist-height ratio with suicidal ideation among U.S. women. We analyzed data from 3,732 nonpregnant women aged ≥20 years who participated in the 2005-2008 National Health and Nutrition Examination Survey. We used anthropometric measures of weight, height, and waist circumference to calculate BMI and waist-height ratio. Suicidal ideation was assessed using the Item 9 of the Patient Health Questionnaire-9. Odds ratios with 95% conference intervals were estimated using logistic regression analyses after controlling for potential confounders. The age-adjusted prevalence of suicidal ideation was 3.0%; the prevalence increased linearly across quartiles of BMI, waist circumference, and waist-height ratio (P for linear trend <0.01 for all). The positive associations of waist circumference and waist-height ratio with suicidal ideation remained significant (P < 0.05) after adjustment for sociodemographics, lifestyle-related behavioral factors, and having either chronic conditions or current depression. However, these associations were attenuated after both chronic conditions and depression were entered into the models. Thus, the previously reported association between obesity and suicidal ideation appears to be confounded by coexistence of chronic conditions and current depression among women of the United States.