Predictors of relapse in high lethality suicide attempters: a six-month prospective study

Effectiveness of early and intensive intervention on suicide prevention: CARS programme

The aim of this study was to evaluate the outcomes of the Programme for Management of Suicidal Behaviour and Suicide Prevention (CARS). Individuals treated in the emergency department of University Hospital Marqués de Valdecilla for suicidal thoughts or attempts (N = 401) between 1-March-2016 and 31-December-2018 were considered. No randomization by patients or groups was performed. Student's t-test, chi-square and repeated measure analysis of variance were used. Kaplan-Meier survival function and Cox proportional hazard regression models were employed to estimate the risks of relapse. Outcome of those who voluntary enrol CARS were compared with treatment as usual (TAU) at 6- and 12-months follow-up. The results indicate a significant reduction and delayed occurrence of suicidal behaviour over a 12-month follow-up period with the CARS programme compared to TAU, along with a decreased frequency of hospital admissions. CARS programme demonstrates a substantial impact, significantly reducing the risk of recurrent suicidal behaviour by 35.5 % and the risk of repeated suicidal attempts by 47.2 % at the 12-month follow-up. The programme exhibits a dual protective effect, diminishing suicidal behaviour and fostering improved long-term outcomes. In conclusion, CARS effectively reduced suicidal behaviour recurrence, achieving significant decreases in suicidal thoughts, plans and attempts.

Risk factors of suicide re-attempt: A two-year prospective study

BACKGROUND

History of suicide attempt (SA) is the strongest predictor of a new SA and suicide. It is primordial to identify additional risk factors of suicide re-attempt. The aim of this study was to identify risk factors of suicide re-attempt in patients with recent SA followed for 2 years.

METHODS

In this multicentric cohort of adult inpatients, the median of the index SA before inclusion was 10 days. Clinicians assessed a large panel of psychological dimensions using validated tools. Occurrence of a new SA or death by suicide during the follow-up was recorded. A cluster analysis was used to identify the dimensions that best characterized the population and a variable "number of personality traits" was created that included the three most representative traits: anxiety, anger, and anxious lability. Risk factors of re-attempt were assessed with adjusted Cox regression models.

RESULTS

Among the 379 patients included, 100 (26.4 %) re-attempted suicide and 6 (1.6 %) died by suicide. The two major risk factors of suicide re-attempt were no history of violent SA and presenting two or three personality traits among trait anxiety, anger and anxious lability.

LIMITATIONS

It was impossible to know if treatment change during follow-up occur before or after the re-attempt.

DISCUSSION

One of the most important predictors of re-attempt in suicide attempters with mood disorders, was the presence of three personality traits (anger, anxiety, and anxious lability). Clinicians should provide close monitoring to patients presenting these traits and proposed treatments specifically targeting these dimensions, especially anxiety.

Risk factors for suicide reattempt: a systematic review and meta-analysis

BACKGROUND

Suicide is one of the main external causes of death worldwide. People who have already attempted suicide are at high risk of new suicidal behavior. However, there is a lack of information on the risk factors that facilitate the appearance of reattempts. The aim of this study was to calculate the risk of suicide reattempt in the presence of suicidal history and psychosocial risk factors and to estimate the effect of each individual risk factor.

METHODS

This systematic review and meta-analysis were conducted following the PRISMA-2020 guidelines. Studies on suicide reattempt that measured risk factors were searched from inception to 2022. The risk factors studied were those directly related to suicide history: history of suicide prior to the index attempt, and those that mediate the transition from suicidal ideation to attempt (alcohol or drug misuse, impulsivity, trauma, and non-suicidal self-injury).

RESULTS

The initial search resulted in 11 905 articles. Of these, 34 articles were selected for this meta-analysis, jointly presenting 52 different effect sizes. The pooled effect size across the risk factors was significant (OR 2.16). Reattempt risk may be increased in presence of any of the following risk factors: previous history, active suicidal ideation, trauma, alcohol misuse, and drug misuse. However, impulsivity, and non-suicidal self-injury did not show a significant effect on reattempt.

CONCLUSION

Most of the risk factors traditionally associated with suicide are also relevant when talking about suicide reattempts. Knowing the traits that define reattempters can help develop better preventive and intervention plans.

Prevalence and related factors of first-time suicide attempts in the past 14 days in Chinese adult patients with first-episode drug-naïve major depressive disorder

Background

This study aimed to identify socio-demographic, physiologic, and psychologic related factors of the first-time suicide attempt (FSA) in the past 14 days in Chinese adult patients with first-episode drug-naïve (FEDN) major depressive disorder (MDD).

Methods

A total of 1718 adult patients with FEDN MDD were enrolled in this cross-sectional survey. Depression, anxiety symptoms, and suicide attempts were assessed. Additionally, biological samples were collected and measured, while Logistic regression analysis was employed to explore the risk factors for FSA in the past 14 days among FEDN MDD patients.

Results

Among suicide attempters, 12.11% (208 out of 1718) reported experiencing FSA in the past 14 days. Logistic regression analysis showed that the risk factors for FSA included more severe anxiety symptoms (OR=1.37, 95%CI: 1.28-1.48, p<0.001), higher levels of total cholesterol (TC) (OR=1.42, 95%CI: 1.13-1.77, p=0.003), and elevated thyroid-stimulating hormone (TSH) (OR=1.13, 95%CI: 1.03-1.25, p=0.01). The regression model exhibited good discriminatory power for FSA with an area under the curve (AUC) of 0.82.

Conclusion

FEDN MDD patients with more severe anxiety and higher levels of TSH and TC are more likely to develop FSA in the past 14 days. These factors are risk factors for short-term (in the past 14 days) FSA and may serve as indicators for early intervention.

ASSIP vs. Crisis Counseling for Preventing Suicide Re-attempts: Outcome Predictor Analysis of a Randomized Clinical Trial Data

OBJECTIVE

Knowledge of the effectiveness and limits of the suitability of brief interventions in suicide prevention is greatly needed. We investigated subgroup differences and predictors for suicide re-attempts within a clinical trial population recruited for a brief intervention to prevent re-attempts.

METHODS

Consenting adult patients receiving treatment for a suicide attempt in Helsinki City general hospital emergency rooms in 2016-2017 (n = 239) were randomly allocated to (a) the Attempted Suicide Short Intervention Program (ASSIP) or (b) Crisis Counseling (CC). Participants also received their usual treatment. Information on primary outcome repeat attempts and secondary outcomes was collected via telephone and from medical and psychiatric records for 2 years. As proportions of re-attempts did not differ significantly between ASSIP and CC (29.2 vs. 35.2%), patients were pooled and predictors for suicide re-attempts were analyzed using Kaplan-Meier and logistic regression analyses.

RESULTS

Re-attempts were predicted by participants' younger age (OR 0.965 [0.933-0.998]), previous suicide attempts (OR 2.437 [1.106-5.370]), psychiatric hospitalization in the year preceding baseline (OR 3.256 [1.422-7.458]), and clinical diagnosis of a personality disorder (OR 4.244 [1.923-9.370]), especially borderline personality disorder (OR 5.922 [2.558-13.709]).

CONCLUSIONS

Within a population of suicide attempters consenting to a brief intervention trial, the risk of re-attempt was strongly predicted by subjects' young age, history of previous attempts, psychiatric hospitalizations, and personality disorder, particularly borderline personality disorder. The composition of treated populations with regard to these characteristics may strongly influence the observed success of brief interventions. Their potential as moderators of treatment effectiveness and as indicators of the utility of brief interventions warrants further investigation.HIGHLIGHTSDuring the 2-year follow-up, 32% of trial participants reattempted suicide.Rates of reattempts varied and were strongly predicted by clinical subgroup.Subgroup composition may strongly influence brief interventions' observed outcome.

Evening Chronotype and Suicide: Exploring Neuroinflammation and Psychopathological Dimensions as Possible Bridging Factors-A Narrative Review

A chronotype is generally defined as the variability of the phase angle of entrainment, while the latter reflects the relationship between the timing of a certain rhythm (e.g., the sleep-wake cycle) and the timing of an external temporal cue. Individuals can be placed on a spectrum from "morning types" (M types) to "evening types" (E types). E-chronotype has been proposed as a transdiagnostic risk factor for psychiatric conditions, and it has been associated with psychopathological dimensions. Eveningness seems to be correlated with both suicidal ideation (SI) and suicidal behavior (SB) through several possible mediating factors. Immunological alterations have also been linked to later chronotypes and SI/SB. This narrative review aims to summarize the evidence supporting the possible association between chronotypes and suicide and the eventual mediating role of neuroinflammation and several psychopathological dimensions. A search of the literature (2003-2023) was conducted using various databases: PUBMED, EMBASE, Scopus, UpToDate, PsycINFO, and Cochrane Library. English-language articles were collected and screened for eligibility. Despite the apparent absence of a direct correlation between E-chronotype and suicidality, E-chronotype promotes a chain of effects that could be involved in an increased risk of SB, in which with neuroinflammation possibly plays an intriguing role and some psychopathological dimensions may stand out.

Clinical characteristics of suicidal behavior in first hospitalization and drug-naïve patients with major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is a major and common cause of suicide. The purpose of this article is to report the clinical characteristics and patterns of co-morbid suicidal behavior (SB) in first hospitalized and drug-naïve MDD patients.

METHODS

A total of 345 patients with first hospitalization and drug-naïve MDD with SB were included in this study, while 183 patients without SB were included as a control group. We collected socio-demographic, general clinical data and common biochemical indicators of all participants and assessed their clinical symptoms.

RESULTS

Compared to patients without SB, MDD with SB had more severe clinical symptoms and worse metabolic indicators. Duration of disease, depressive symptom scores, and thyroid stimulating hormone (TSH) levels was risk factors for SB and its number.

CONCLUSIONS

MDD patients with SB suffered more severe clinical symptoms and worse metabolic indicators, and risk factors for SB in this population were identified, which may provide beneficial insight and reference for clinical prevention and intervention of SB in MDD patients.

The Recovery from Attempting Suicide

A positive trajectory of life after an attempted suicide is extremely limited in research despite its advantage of aiding salutary outcomes. A systematic review of the qualitative research was conducted to explore the impact the attempt of taking your own life has had on your life and your work, to discover what changes participants have made to move toward a life worth living, and to understand how people can help better support individuals from attempted suicide attempts. A comprehensive search of online articles identified thirteen eligible studies. Three themes emerged: (1) rediscovering a life of meaning (2) contextual factors that facilitate a life worth living (3) internal changes. Limitations were discussed along with recommendations for future research.

Psychiatric Treatment and Repeat Suicide Attempts Among Adults With Substance Use, by HIV Status, United States, 2014-2020

OBJECTIVES

The association among psychiatric treatment history, HIV, and suicide reattempts among people starting treatment for substance use is not well understood. The objective of this study was to describe, by HIV status, the risk and protective factors associated with suicide reattempts among adults seeking treatment for substance use.

METHODS

The study included 340 390 US adult residents aged ≥18 years in the Addiction Severity Index-Multimedia Version network from January 1, 2014, through December 31, 2020. We used adjusted logistic regression models to estimate strength of association between prior psychiatric treatment, HIV status, and sociodemographic factors and suicide reattempts within 30 days of treatment evaluation.

RESULTS

Adults who had been prescribed psychiatric medication were less likely to have a recent suicide reattempt (adjusted odds ratio [aOR] = 0.8; 95% CI, 0.7-0.8) than adults with no prescription history. Adjusted models found similar protective effects between psychiatric treatment and suicide reattempts among adults reporting abuse, mental illness, injection drug use, and limited activity because of a medical condition. Conversely, the following were associated with recent suicide reattempts: being male (aOR = 1.4; 95% CI, 1.3-1.5), having a high school education/GED (General Educational Development) or less (aOR = 1.2; 95% CI, 1.1-1.2), being single (aOR = 1.2; 95% CI, 1.1-1.3), experiencing a pain problem (aOR = 1.2; 95% CI, 1.2-1.3), and not being referred to substance use treatment by court (aOR = 3.4; 95% CI, 3.2-3.7).

CONCLUSIONS

A history of prescribed psychiatric medication is significantly associated with a reduced risk for suicide reattempts among adults seeking substance use treatment. Clinicians should consider incorporating mental health and suicide assessments into substance use treatment plans.

Sociodemographic and Clinical Correlates Associated with the Frequent Service Users in an Italian Psychiatric Emergency Department

BACKGROUND

The aim of the present study is to identify the main sociodemographic and clinical correlates associated with frequent service users (FSUs) in an Italian psychiatric emergency department.

METHODS

This study is an observational and prospective clinical investigation. All subjects (N = 549) consecutively admitted to the Psychiatric Inpatient Unit of the IRCCS Ospedale Policlinico San Martino ((Genoa, Italy) were recruited over a period of 18 months.

RESULTS

On average, FSUs were more likely to be single (75.0% vs. 64.0, p = 0.001), younger (38.79 years ± 14.68 vs. 45.94 years ± 16.94, p = 0.028), with an earlier onset (20.15 years ± 7.22 vs. 29.33 years ± 15.96, p < 0.001), and longer length of hospitalisation (13.65 days ± 12.40 vs. 9.89 ± 10.15, p = 0.006) compared to non-FSUs. While bipolar disorder was the most common primary diagnosis in both FSUs and non-FSUs, cluster B personality disorder was particularly elevated in FSUs (30.3% vs. 10.4%, p < 0.001). Furthermore, FSUs were more prone to substance use disorder (63.6% vs. 40.0%, p < 0.001), particularly cannabis (45.5% vs. 15.3%, p < 0.001), cocaine (33.3% vs. 10.4%, p < 0.001), and heroin (19.7% vs. 5.8%, p < 0.001), and were more likely to have non-suicidal self-injuries (21.2% vs. 6.8%, p < 0.001). FSUs were significantly more likely to be discharged against medical advice (18.2% vs. 5.6%, p < 0.001) or to have at least one escape attempt from the psychiatric ward (12.1% vs. 0.8%, p < 0.001).

CONCLUSIONS

Specific clinical and social profiles of patients who repeatedly utilised the services of a psychiatric emergency department have been identified. Our findings can be used to develop suitable structures to support and reintegrate FSUs into society and work life.

Prevalence of suicide attempts and correlates among first-episode and untreated major depressive disorder patients with comorbid dyslipidemia of different ages of onset in a Chinese Han population: a large cross-sectional study

BACKGROUND

Patients with dyslipidemia are at increased risk for suicide, especially those with major depressive disorder (MDD). Few studies have investigated the independent effects of suicide attempts on comorbid dyslipidemia in patients with MDD. Moreover, there are no comparisons of differences in factors associated with suicide attempts among patients with MDD with dyslipidemia at different ages of onset. The aim of this study was to investigate the prevalence of suicide attempts and associated variables in first episode and untreated patients with MDD with comorbid dyslipidemia at different ages of onset.

METHODS

We recruited 1718 patients with first-episode untreated MDD in this study. Demographical and clinical data were collected, and lipid profiles, thyroid function, and blood glucose levels were measured. The Hamilton Depression Scale 17 (HAMD-17), Hamilton Anxiety Scale (HAMA), Clinical Global Impression Severity Scale (CGI), and Positive and Negative Syndrome Scale (PANSS) positive subscale were assessed for depression, anxiety and illness severity, as well as psychotic symptoms, respectively.

RESULTS

The percentage of patients with MDD with comorbid dyslipidemia was 61% (1048/1718). Among patients with MDD with comorbid dyslipidemia, the incidence of suicide attempts was 22.2% (170/765) for early adulthood onset and 26.5% (75/283) for mid-adulthood onset. Independent factors associated with suicide attempts in early adulthood onset patients with MDD with dyslipidemia were as follows: HAMA score (B = 0.328, P < 0.0001, OR = 1.388), Suspicion /persecution (B = -0.554, P = 0.006, OR = 0.575), CGI (B = 0.878, P < 0.0001, OR = 2.406), systolic blood pressure (B = 0.048, P = 0.004, OR = 1.049), hallucinatory behavior (B = 0.334, P = 0.025, OR = 1.397), and TPOAb (B = 0.003, p < 0.0001, OR = 1.003). Independent factors associated with suicide attempts in mid-adulthood onset patients with MDD with comorbid dyslipidemia were as follows: HAMA score (B = 0.182, P < 0.0001, OR = 1.200), CGI (B = 1.022, P < 0.0001, OR = 2.778), and TPOAb (B = 0.002, P = 0.009, OR = 1.002).

CONCLUSION

Our findings suggest an elevated risk of suicide attempts in patients with MDD with comorbid dyslipidemia. The incidence of suicide attempts was similar in the early- and mid-adulthood onset subgroups among patients with MDD with dyslipidemia, but the factors associated with suicide attempts were different in these two subgroups.

Overall goal of Cognitive-Behavioral Therapy in Major Psychiatric Disorders and Suicidality: A Narrative Review

Cognitive-behavioral therapy (CBT) is a form of psychological treatment that is based on the underlying assumption that mental disorders and psychological distress are maintained by cognitive factors, that is, that general beliefs about the world, the self, and the future contribute to the maintenance of emotional distress and behavioral problems. The overall goal of CBT is to replace dysfunctional constructs with more flexible and adaptive cognitions. The most relevant cognitive-behavioral techniques in clinical practice are: i. Cognitive Restructuring (also known as the ABCDE method) is indicated to support patients dealing with negative beliefs or thoughts. The different steps in the cognitive restructuring process are summarized by the letters in the ABCDE acronym that describe the different stages of this coaching model: Activating event or situation associated with the negative thoughts, Beliefs and belief structures held by the individual that explain how they perceive the world which can facilitate negative thoughts, Consequences or feelings related to the activating event, Disputation of beliefs to allow individuals to challenge their belief system, and Effective new approach or effort to deal with the problem by facilitating individuals to replace unhelpful beliefs with more helpful ones. ii. Problem-Solving (also known as SOLVE) to raise awareness for specific triggers, and evaluate and choose more effective options. Each letter of the SOLVE acronym identifies different steps of the problem-solving process: Select a problem, generate Options, rate the Likely outcome of each option, choose the Very best option, and Evaluate how well each option worked. For example, a suicide attempt is reconceptualized as a failure in problem-solving. This treatment approach attempts to provide patients with a better sense of control over future emerging problems. iii. Re-attribution is a technique that enables patients to replace negative self-statements (eg, "it is all my fault") with different statements where responsibility is attributed more appropriately. Furthermore, decatastrophizing may help subjects, especially adolescents decide whether they may be overestimating the catastrophic nature of the precipitating event, and by allowing them to scale the event severity they learn to evaluate situations along a continuum rather than seeing them in black and white. iv. Affect Regulation techniques are often used with suicidal adolescents to teach them how to recognize stimuli that provoke negative emotions and how to mitigate the resulting emotional arousal through self-talk and relaxation.

C-Reactive Protein as a Potential Peripheral Biomarker for High-Lethality Suicide Attempts

The aim of the present study was to identify a cut-off of c-reactive protein (c-RP) potentially predictive of high-lethality suicide attempts (SA) in an inpatient psychiatric sample. After attempting suicide, subjects were admitted to the emergency ward of the IRCCS Ospedale Policlinico San Martino and later to the section of Psychiatry from 1 August 2013 to 31 July 2018. C-reactive protein was measured. The Area Under the Receiver Operating Characteristic (ROC_AUC) was used to assess the discriminative capacity of c-RP for high- vs. low-lethality SA, and a logistic regression was performed to detect the odds ratio, adjusted for age and sex. High-lethality suicide attempters were 133 (30.8%), while low-lethality suicide attempters were 299 (69.2%). The optimal cut-off threshold (and corresponding sensitivity and specificity values) for c-RP was 4.65 mg/L (68/71%). This cut-off corresponds to an AUC of 73.5%. An odds ratio of 4.70 was generated for current high-lethality SA after a logistic regression, adjusted for age and sex. Research on social and biological factors underlying the lethality of SA is crucial for a better understanding of this complex phenomenon. Identifying potential predictors of SA, especially those at high lethality, is essential to implement personalized preventive strategies.

Which Clinical and Biochemical Parameters Are Associated with Lifetime Suicide Attempts in Bipolar Disorder?

Introduction: Bipolar Disorder (BD) is a disabling condition with suicidal behavior as one of the most common adverse outcomes. The purpose of the present research is to investigate the relationship between lifetime suicide attempts and the clinical factors/biochemical parameters in a large sample of bipolar patients. Methods: A total of 561 patients, consecutively hospitalized for BD in Milan and Monza (Italy), were recruited. Data about the demographic and clinical variables, as well as the values of blood analyses, were collected. The groups identified according to the presence/absence of lifetime suicide attempts were compared using univariate analyses. Then, three preliminary binary logistic regressions and a final logistic regression model were performed to identify the clinical and biochemical parameters associated with lifetime suicide attempts in BD. Results: Lifetime suicide attempts in BD were predicted by a longer duration of untreated illness (DUI) (p = 0.005), absence of lifetime psychotic symptoms (p = 0.025), presence of poly-substance use disorders (p = 0.033), comorbidity with obesity (p = 0.022), a last mood episode of manic polarity (p = 0.044), and lower bilirubin serum levels (p = 0.002); higher total cholesterol serum levels showed a trend toward statistical significance (p = 0.058). Conclusions: BD patients with lifetime suicide attempts present unfavorable clinical features. Some specific biochemical characteristics of bipolar patients may represent potential markers of suicidal behavior and need to be better investigated to identify new targets of treatment in the framework of personalized medicine. These preliminary findings have to be confirmed by further studies in different clinical settings.

Associating factors of suicide and repetition following self-harm: A systematic review and meta-analysis of longitudinal studies

BACKGROUND

Longitudinal evidence for sociodemographic and clinic factors deviating risk for suicide and repetition following SH (self-harm) varied greatly.

METHODS

A comprehensive search of PubMed, Web of Science, EMBASE, and PsycINFO was conducted from January 1st, 2010 to April 5th, 2022. Longitudinal studies focusing on examining associating factors for suicide and repetition following SH were included. PROSPERO registration CRD42021248695.

FINDINGS

The present meta-analysis synthesized data from 62 studies published from Jan. 1st, 2010. The associating factors of SH repetition included female gender (RR, 95%CI: 1.11, 1.04-1.18, I²=82.8%), the elderly (compared with adolescents and young adults, RR, 95%CI: 0.67, 0.52-0.87, I²=86.3%), multiple episodes of SH (RR, 95%CI: 1.97, 1.51-2.57, I²=94.3%), diagnosis (RR, 95%CI: 1.60, 1.27-2.02, I²=92.7%) and treatment (RR, 95%CI: 1.59, 1.40-1.80, I²=93.3%) of psychiatric disorder. Male gender (RR, 95%CI: 2.03, 1.80-2.28, I²=83.8%), middle-aged adults (compared with adolescents and young adults, RR, 95%CI: 2.40, 1.87-3.08, I²=74.4%), the elderly (compared with adolescents and young adults, RR, 95%CI: 4.38, 2.98-6.44, I²=76.8%), physical illness (RR, 95%CI: 1.95, 1.56-2.43, I²=0), multiple episodes of SH (RR, 95%CI: 2.02, 1.58-2.58, I²=87.4%), diagnosis (RR, 95%CI: 2.13, 1.67-2.71, I²=90.9%) and treatment (RR, 95%CI: 1.36, 1.16-1.58, I²=58.6%) of psychiatric disorder were associated with increased risk of suicide following SH.

INTERPRETATION

Due to the substantial heterogeneity for clinic factors of suicide and repetition following SH, these results need to be interpreted with caution. Clinics should pay more attention to the cases with SH repetition, especially with poor physical and psychiatric conditions.

FUNDING

This work was supported by National Natural Science Foundation of China (NSFC) [No: 82103954; 30972527; 81573233].

Hyper/neuroinflammation in COVID-19 and suicide etiopathogenesis: Hypothesis for a nefarious collision?

Accumulating scientific and clinical evidence highlighted pathological hyperinflammation as a cardinal feature of SARS-CoV-2 infection and acute COVID-19 disease. With the emergence of long COVID-19 syndrome, several chronic health consequences, including neuropsychiatric sequelae, have gained attention from the public and medical communities. Since inflammatory mediators have also been accredited as putative biomarkers of suicidal ideations and behaviors, hyper- and neuroinflammation might share some colliding points, overlapping and being interconnected in the context of COVID-19. This review aims to provide a summary of current knowledge on the molecular and cellular mechanisms of COVID-19-associated hyper/neuroinflammation with focus on their relevance to the inflammatory hypothesis of suicide development. Subsequently, strategies to alleviate COVID-19 hyper/neuroinflammation by immunomodulatory agents (many of which at experimental stages) as well as psychopharmacologic/psychotherapeutic approaches are also mentioned. While suicide risk in COVID-19 survivors - until now little known - needs further analysis through longitudinal studies, current observations and mechanistic postulates warrant additional attention to this possibly emerging mental health concern.

Investigating Predictive Factors of Suicidal Re-attempts in Adolescents and Young Adults After a First Suicide Attempt, a Prospective Cohort Study. Study Protocol of the SURAYA Project

INTRODUCTION

Suicide is the fourth leading cause of death in youth. Previous suicide attempts are among the strongest predictors of future suicide re-attempt. However, the lack of data and understanding of suicidal re-attempt behaviors in this population makes suicide risk assessment complex and challenging in clinical practice. The primary objective of this study is to determine the rate of suicide re-attempts in youth admitted to the emergency department after a first suicide attempt. The secondary objectives are to explore the clinical, socio-demographic, and biological risk factors that may be associated with re-attempted suicide in adolescents and young adults.

METHODS

We have developed a single-center prospective and naturalistic study that will follow a cohort of 200 young people aged 16 to 25 years admitted for a first suicide attempt to the emergency department of Lyon, France. The primary outcome measure will be the incidence rate of new suicide attempts during 3 months of follow-up. Secondary outcomes to investigate predictors of suicide attempts will include several socio-demographic, clinical and biological assessments: blood and hair cortisol levels, plasma pro- and mature Brain-Derived Neurotrophic Factor (BDNF) isoforms proportion, previous infection with toxoplasma gondii, and C-Reactive Protein (CRP), orosomucoid, fibrinogen, interleukin (IL)-6 inflammatory markers.

DISCUSSION

To our knowledge, the present study is the first prospective study specifically designed to assess the risk of re-attempting suicide and to investigate the multidimensional predictive factors associated with re-attempting suicide in youth after a first suicide attempt. The results of this study will provide a unique opportunity to better understand whether youth are an at-risk group for suicide re-attempts, and will help us identify predictive factors of suicide re-attempt risk that could be translated into clinical settings to improve psychiatric care in this population.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT03538197, first registered on 05/29/2018. The first patient was enrolled 05/22/2018.

Peripheral BDNF levels in psychiatric patients with and without a history of suicide attempt: A systematic review and meta-analysis

OBJECTIVE

Psychiatric patients are at increased risk of attempting suicide. Several potential biomarkers of suicide risk have been proposed with inconsistent findings. The present paper aimed to evaluate differences in peripheral BDNF levels between psychiatric patients with and without a history of suicide attempts.

METHODS

We conducted a systematic review and meta-analysis following the PRISMA guidelines. Relevant papers published up to January 5, 2021 were identified searching the electronic databases Web of Knowledge^SM and PsycINFO. A random-effect meta-analysis was conducted using Stata 16.

RESULTS

Thirteen studies met inclusion criteria. Overall, no significant differences in BDNF levels between the two groups were found (13 studies, n = 1340, Hedge's g = -0.21, 95% CI -0.44 to 0.02). Heterogeneity was substantial (I² = 72.91%). Subgroup analyses revealed that BDNF levels were significantly reduced in plasma with medium effect size (5 studies, n = 363, Hedge's g = -0.44, 95% CI -0.86 to -0.02), but not in serum (8 studies, n = 977, Hedge's g = -0.09, 95% CI -0.33 to 0.15). No significant differences were found according to the type of diagnosis (major depressive disorder vs. other diagnoses) or the period of suicide attempt (lifetime vs. recent).

CONCLUSION

The utility of BDNF as a biomarker of suicide attempts in psychiatric patients appears limited to its plasma concentration. Although caution interpretation is needed, our findings may represent a starting point for the design of rigorous case-control studies exploring the association between neurotrophins and suicidal behaviors.

Suicide attempts are associated with activated immune-inflammatory, nitro-oxidative, and neurotoxic pathways: A systematic review and meta-analysis

BACKGROUND

Suicide attempts (SA) frequently occur in patients with mood disorders and schizophrenia, which are both accompanied by activated immune-inflammatory and nitro-oxidative (IO&NS) pathways.

METHODS

We searched PubMed, Google Scholar, and Web of Science, for articles published from inception until February 1, 2021. We included studies that compared blood biomarkers in psychiatric patients with (SA+) and without SA (SA-) and heathy controls and we combined different IO&NS biomarkers into immune, inflammatory, and neurotoxic profiles and used meta-analysis (random-effect model with restricted maximum-likelihood) to delineate effect sizes with 95% confidence interval (CI).

FINDINGS

Our search included 51 studies comprising 4.945 SA+ patients and 24.148 controls. We stratified the control group into healthy controls and SA- patients. SA+ patients showed significantly (p<0.001) increased immune activation (SMD: 1.044; CI: 0.599, 1.489), inflammation (SMD: 1.109; CI: 0.505, 1.714), neurotoxicity (SMD: 0.879; CI: 0.465, 1.293), and lowered neuroprotection (SMD: 0.648; CI: 0.354, 0.941) as compared with healthy controls. When compared with SA- patients, those with SA+ showed significant (p<0.001) immune activation (SMD: 0.290; CI: 0.183, 0.397), inflammation (SMD: 0.311; CI: 0.191, 0.432), and neurotoxicity (SMD: 0.315; CI: 0.198, 0.432), and lowered neuroprotection (SMD: 0.341; CI: 0.167, 0.515). Patients with current, but not lifetime, SA showed significant (p<0.001) levels of inflammation and neurotoxicity as compared with controls.

CONCLUSIONS

Patients with immune activation are at a higher risk of SA which may be explained by increased neurotoxicity due to inflammation and nitro-oxidative stress. This meta-analysis discovered new biomarkers of SA and therapeutic targets to treat individuals with SA.

Increased C-reactive protein concentration and suicidal behavior in people with psychiatric disorders: A systematic review and meta-analysis

OBJECTIVE

Suicide is a leading cause of death worldwide. Identifying factors associated with suicidality (suicidal ideation [SI]/suicidal behavior) could increase our understanding of the pathophysiological underpinnings of suicide and improve its prevention.

METHODS

We conducted a systematic review (PubMed/PsycInfo/Cochrane databases, up to September 2020) and random-effect meta-analysis including observational studies comparing peripheral C-reactive protein (CRP) levels in suicidal versus non-suicidal patients affected by any psychiatric disorder and healthy controls (HC). Primary outcome was the CRP standardized mean difference (SMD) between patients with high suicidality versus those with absent or low suicidality. Secondary outcomes were SMD of CRP levels between those with suicide attempt versus no suicide attempt, as well as between those with (high) versus low or absent SI. Quality of included studies was measured with Newcastle-Ottawa scale.

RESULTS

Out of initial 550 references, 21 observational studies involving 7682 subjects (7445 with mood disorders or first-episode psychosis, 237 HC) were included. A significant association of CRP levels with suicidality (SMD 0.688, 95% CI 0.476-0.9, p < 0.001) emerged. CRP levels were higher in individuals with high SI (SMD 1.145, 95% CI 0.273-2.018, p = 0.010) and in those with suicide attempt (SMD 0.549, 95%CI 0.363-0.735, p < 0.001) than non-suicidal individuals (either patients or HC). Main analyses were confirmed in sensitivity analysis (removing HC), and after adjusting for publication bias. The cross-sectional design of included studies, and the high heterogeneity of diagnosis and treatment limit the generalizability of these results. Median quality of included studies was high.

CONCLUSION

CRP is associated with higher suicidality in patients with mental disorders. Large cohort studies longitudinally monitoring CRP levels are needed to explore its longitudinal association with suicidality.

Chloroquine/Hydroxychloroquine Use and Suicide Risk: Hypotheses for Confluent Etiopathogenetic Mechanisms?

Chloroquine (CQ) and hydroxychloroquine (HCQ) are classical anti-malarial and anti-inflammatory treatments, which were used as first-line therapy at the beginning of the 2019 coronavirus disease (COVID-19) pandemic. Besides the emerging data on their lack of efficacy against COVID-19 infection, such treatments have been associated with some severe health concerns, including those of neuropsychiatric nature, such as a possible increase in suicide risk. Here we report a case of a patient with no history of psychiatric illnesses, who abruptly developed depression with melancholic features, severe suicidal ideation (SI), and attempted suicide (SA) shortly after receiving HCQ for his COVID-19 infection. The case was followed by a mini-review of the heterogeneous scientific literature on the hypothetical association between neuropsychiatric symptoms, with a focus on SI and suicidal behavior (SB, including SA and death by suicide), when CQ and HCQ are used in COVID-19, rheumatologic diseases, and malaria settings. Considering the anti-inflammatory properties of CQ and HCQ and the implications for neuroinflammation in suicide pathogenesis, the possible increase in suicide risk caused by these medications appears paradoxical and suggests that other underlying pathological trajectories might account for this eventuality. In this regard, some of these latter mechanistic postulates were proposed. Certainly the role and contribution of psycho-social factors that a COVID-19 patient had to face can neither be minimized nor excluded in the attempt to understand his suffering until the development of SI/SB. However, while this case report represents a rare scenario in clinical practice and no consensus exists in the literature on this topic, a psychiatric screening for suicide risk in patients using of CQ and HCQ could be carefully considered.

Possible Association of Cholesterol as a Biomarker in Suicide Behavior

Suicides and suicidal behavior are major causes of mortality and morbidity in public health and are a global problem. Various authors have proposed changes in lipid metabolism (total cholesterol decrease) as a possible biological marker for suicidal behavior. The objective of this study was to review the studies that have demonstrated a relationship between serum cholesterol levels and suicidal behavior and to describe the possible pathophysiological mechanisms that associate changes in cholesterol concentration and suicidal behavior. Relevant literature related to serum cholesterol levels and suicidal behavior was identified through various database searches. The data from the existing literature present the findings that relate low cholesterol levels and possible pathophysiological mechanisms (neuroinflammation, serotonergic neurotransmission), genes related to cholesterol synthesis, pharmacological treatments that alter lipid metabolism and the possible participation in suicidal behavior. Nevertheless, future research is required to describe how serum cholesterol affects cholesterol metabolism in the CNS to establish and understand the role of cholesterol in suicidal behavior.

The Need for Collective Awareness of Attempted Suicide Rates in a Warming Climate

Background: Climate factors may offer a stronger explanation of the variations in suicide rates compared with economic variables, even in the case of patients admitted involuntarily. Aims: We assessed the role of temperature as a determinant of the increased prevalence of suicide attempts (SA). Method: The sample comprised all cases of hospitalization for SA at the Psychiatric Clinic of the IRCCS Ospedale Policlinico San Martino between August 2013 and July 2018. For ambient temperature, data were provided by the Meteorological Observatory of the University of Genoa. Results: We noted a peak in suicides that was typically found in late spring and early summer due to global warming. Limitations: Other environmental/psychological factors contributing to the onset of an acute clinical event were not considered. The cross-sectional design of the study is another limitation. Conclusion: Further studies are needed to clarify the impact of climatic factors on suicide behavior and implement early intervention and preventive strategies for mental health.

Impact of the COVID-19 Pandemic on Psychiatric Admissions to a Large Swiss Emergency Department: An Observational Study

The coronavirus disease 2019 (COVID-19) pandemic is a public health emergency with profound mental health consequences. The psychiatric emergency department (ED) plays a key role during this mental health crisis. This study aimed to investigate differences in admissions at a Swiss psychiatric ED from 1 April to 15 May during a “pandemic-free” period in 2016 and a “during-pandemic” period in 2020. The study included 579 consultations at psychiatric ED in the “during-pandemic” period and 702 in the “pandemic-free” period. Sociodemographic and clinical characteristics were compared, and logistic regression analysis was performed to identify variables associated with psychiatric admissions during the pandemic. A reduction in total psychiatric ED admissions was documented during COVID-19. Logistic regression analysis predicted the independent variable (ED admission during the pandemic) and estimated odds ratio (OR) for being unmarried/not in a relationship, arrival in an ambulance, suicidal behavior, behavioral disorders and psychomotor agitation. Though only statistically significant in bivariate analysis, patients were also more likely to be involuntarily hospitalized. This picture appears to be reversed from a sociodemographic and clinical point of view to our observation of psychiatric ED consultation in 2016. These findings highlight that the reduction in psychiatric ED admissions during the pandemic seems to be associated with living alone and more severe psychopathologies, which must alert psychiatrists to ensure access to mental health care in times of pandemic.

Are Lipids Possible Markers of Suicide Behaviors?

Suicides and suicidal behaviors are very important causes of mortality and morbidity and have become a serious global problem. More than 800,000 people die from suicide every year. Previous researches have established that lipids play an important role in the pathogenesis of suicide. Moreover, lipid levels might be a biological marker of suicide. A lot of researchers have tried to identify biological markers that might be related to depressive disorder, bipolar disorder or schizophrenia and suicidal behavior. It was also important to consider the usefulness of an additional tool for prevention actions. Metabolic deregulation, particularly low total cholesterol and low-density lipoproteins-cholesterol levels may cause higher suicide risk in patients with these psychiatric disorders.

Meteorological Variables and Suicidal Behavior: Air Pollution and Apparent Temperature Are Associated With High-Lethality Suicide Attempts and Male Gender

This study analyzed the impact of meteorological variables and high-lethality suicide attempts (HLSA) to assess a potential time shift of HLSA affected by climate evolution to predict the suicide attempt cases over different periods of the year. After attempting suicide, 225 subjects were admitted to the emergency ward of the IRCCS Ospedale Policlinico San Martino and later to the psychiatric unit from March 2016 to July 2018. Socio-demographic and clinical characteristics as well as the meteorological variables were collected. The Mann-Kendall test as well as redundancy and cross-correlation analyses were performed to analyze the trends, statistically correlations, and correspondence of the trends, respectively between suicidal behaviors and climatic factors. Sixty-seven (29.8%) committed a HLSA. Our findings indicate a significant association between HLSA and male gender and apparent temperature with a strong correlation of 75% with a phase shift of -1 month. Solar radiation and air pollution (PM_2.5) have a positive correlation of 65 and 32%, respectively, with a zero-time lag. Limitations include that the data are limited to a single hospital; psychological factors, or other clinical variables that could be ruled out as a trigger have not been considered. Meteorological variables may not mirror the temperature that the patient is exposed to due to the air conditioning systems. Exploring those environmental factors associated with HLSA in a more detailed manner could lead to early intervention and prevention strategies for such distressing admissions.

Lipid and Glycemic Profiles in Patients with Bipolar Disorder: Cholesterol Levels Are Reduced in Mania

Background and Objectives: Bipolar disorder (BD) is a severe mental condition with a lifetime prevalence estimated around 2% among the general population. Due to risk factors, etiological mechanisms, and the chronic use of psychotropic medications, people with BD are frequently affected by medical comorbidities, such as metabolic syndrome (MetS), associated with altered blood levels of glucose, cholesterol, and triglycerides. Moreover, the lipid concentration may be associated with the severity of psychiatric symptoms. Materials and Methods: Five hundred and forty-two in- and outpatients (418 affected by BD and 124 affected by schizophrenia) were recruited in two Italian university hospitals. A blood examination assessing the fasting glucose, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides was performed. Results: No significant differences were found in the lipid and glycemic profiles between patients with BD and schizophrenia. When considering only the BD sample, we found that patients experiencing a manic episode had significantly lower total cholesterol, HDL, and LDL than euthymic patients. Moreover, the total and LDL cholesterol levels were significantly lower in (hypo)manic than depressed patients. Mood episodes did not influence the triglyceride and glucose levels in our sample. Conclusions: Clinicians should pay attention to blood cholesterol levels in patients with BD, as differences in concentrations may predispose them to severe medical conditions and can be associated with the onset of mood episodes.