Predictors of suicidal ideation, suicide attempt and suicide death among people with major depressive disorder: A systematic review and meta-analysis of cohort studies

Nutritional Strategies in Major Depression Disorder: From Ketogenic Diet to Modulation of the Microbiota-Gut-Brain Axis

Major depressive disorder (MDD) is a leading cause of disability worldwide. While traditional pharmacological treatments are effective for many cases, a significant proportion of patients do not achieve full remission or experience side effects. Nutritional interventions hold promise as an alternative or adjunctive approach, especially for treatment-resistant depression. This review examines the potential role of nutrition in managing MDD through addressing biological deficits and modulating pathways relevant to its pathophysiology. Specifically, it explores the ketogenic diet and gut microbiome modulation through various methods, including probiotics, prebiotics, synbiotics, postbiotics, and fecal microbiota transplantation. Numerous studies link dietary inadequacies to increased MDD risk and deficiencies in nutrients like omega-3 s, vitamins D and B, magnesium, and zinc. These deficiencies impact neurotransmitters, inflammation, and other biological factors in MDD. The gut-brain axis also regulates mood, stress response, and immunity, and disruptions are implicated in MDD. While medications aid acute symptoms, nutritional strategies may improve long-term outcomes by preventing relapse and promoting sustained remission. This comprehensive review aims to provide insights into nutrition's multifaceted relationship with MDD and its potential for developing more effective integrated treatment approaches.

Rural-urban and age differences in association between depression and suicidal attempt: a large retrospective clinical sample study in China

OBJECTIVES

To assess the association between depression and suicide attempt (SA) by age and region.

DESIGN

Cross-sectional study.

SETTING

First Affiliated Hospital of Wannan Medical College from January 2021 to January 2022.

PARTICIPANTS

Hospitalised patients.

PRIMARY OUTCOME MEASURES

SA was the primary outcome and data on SA was obtained from the electronic medical records of hospitalised patients.

METHODS AND ANALYSIS

In this study, data on inpatients of the First Affiliated Hospital of Wannan Medical College from January 2021 to January 2022 were extracted from the medical record system using the convenience sampling method. According to the exclusion criteria, 7593 eligible research subjects were obtained. Logistic regression analysis was used to assess the association between depression and SA, combining age and region. Subgroup analyses were carried out to assess the relationship between age, region and SA in depressed patients, after excluding non-depressed patients, and to inspect the interaction of age and region. Finally, further comparisons of the disparities in suicide patterns among different age groups and regional groups were made.

RESULTS

Among 7593 patients (3630 males), 655 (8.6%) patients with SA were observed. We found that depression was significantly associated with SA by age and region (all p<0.05). Specifically, depressed juveniles and adults had a higher risk of SA compared with non-depressed adults, and ORs (95% CIs) were 2.62 (1.59 to 4.30) and 1.67 (1.30 to 2.13), respectively. Furthermore, rural individuals with depression, urban individuals without depression and urban individuals with depression had a higher risk of SA compared with rural participants without depression, and ORs (95% CIs) were 1.60 (1.22 to 2.12), 1.29 (1.04 to 1.61) and 2.53 (1.83 to 3.49), respectively. In subgroup analyses, we further found that depression was strongly associated with SA in juveniles (OR 2.84, 95% CI 1.19 to 6.76, p=0.018) and urban patients (OR 1.67, 95% CI 1.15 to 2.40, p=0.006). Notably, the predominant methods of suicide among individuals with depression were the utilisation of sleeping pills or antidepressants.

CONCLUSION

Our study found individuals with depression are at higher risk of SA, especially juveniles and urban individuals. Effective integration of mental health and urban-rural services could mitigate the risk of suicide and contribute to better outcomes.

Personality Disorders and Suicide. A Systematic Review of Psychological Autopsy Studies

PURPOSE OF REVIEW

This systematic review explores the relationship between personality disorders (PDs) and lethal suicide behavior. Following PRISMA guidelines, the study examines psychological autopsy studies with suicide deaths and identified PDs. Inclusion criteria encompass studies using the psychological autopsy method, reporting PD diagnosis and suicide deaths, in English language and with no temporal restrictions. The search strategy, conducted in PubMed and Embase until December 2nd, 2023, utilized specific terms related to suicide, PD, and psychological autopsy. Quality assessment using the Newcastle Ottawa-Scale for case-control studies was employed.

RECENT FINDINGS

56 psychological autopsy studies were included in the systematic review, revealing a prevalence of PDs among suicide deaths, and emphasizing their role as significant suicide risk factors. The review underscores the impact of comorbid PDs and Axis I disorders on suicide risk, particularly if additional stressors are present. Gender differences in PD prevalence are noted, with impulsivity and alcohol abuse identified as universal risk factors. Despite extensive global data collection, limitations include potential methodological variations and biases inherent in psychological autopsy studies. This study, registered in PROSPERO (CRD42022322359), contributes essential insights into the prevalence, characteristics, and risk factors of PDs among suicide deaths.

Enhancing Transcriptomic Insights into Neurological Disorders Through the Comparative Analysis of Shapley Values

Neurological disorders such as Autism Spectrum Disorder (ASD), Schizophrenia (SCH), Bipolar Disorder (BD), and Major Depressive Disorder (MDD) affect millions of people worldwide, yet their molecular mechanisms remain poorly understood. This study describes the application of the Comparative Analysis of Shapley values (CASh) to transcriptomic data from nine datasets associated with these complex disorders, demonstrating its effectiveness in identifying differentially expressed genes (DEGs). CASh, which combines Game Theory with Bootstrap resampling, offers a robust alternative to traditional statistical methods by assessing the contribution of each gene in the broader context of the complete dataset. Unlike conventional approaches, CASh is highly effective at detecting subtle but meaningful molecular patterns that are often missed. These findings highlight the potential of CASh to enhance the precision of transcriptomic analysis, providing a deeper understanding of the molecular mechanisms underlying these disorders and establishing a solid basis to improve diagnostic techniques and developing more targeted therapeutic interventions.

Emotional Risk Factors, Rumination, and Self-Criticism in Relation to Suicidal Ideation Among Chinese Depressive Outpatients

Previous studies indicated that individuals with major depressive disorder (MDD) are at high risk of suicide, making the identification of risk factors in suicidal depressive outpatients essential for developing effective prevention and treatment strategies. This study aims to (1) identify emotional risk factors and (2) examine the relationship between cognitive markers-including rumination and self-criticism-and suicidal ideation among depressive outpatients. A total of 165 Chinese clinical outpatients with depression were recruited from local hospitals in Hong Kong. In our sample, 68% of patients with moderate depression and 87.5% of patients with severe depression reported experiencing suicidal thoughts. The results from the logistic regression revealed a significant interaction between rumination and self-critical thoughts in relation to suicidal ideation. Specifically, the ruminative patients with self-critical thoughts were more likely to have suicidal thoughts than those without self-critical thoughts. These findings align with the cognitive model of suicide, suggesting that maladaptive information processing and negative cognitive content are associated with an increased risk of suicide. The current findings have clinical implications for the future development of more specific and accurate mental health assessment, preventive programs, and psychotherapies for depressive outpatients.

Does help-seeking mediate the relationship between the masculine norm of self-reliance and suicidal thoughts among men?

PURPOSE

This study aimed to explore the relationship between the masculine norm of self-reliance and suicidal thoughts among Australian men, hypothesising that lack of help-seeking might mediate the relationship between high self-reliance and the emergence of suicidal thoughts.

METHODS

This study used data from on the Australian Longitudinal Study on Male Health 'Ten to Men', a prospective longitudinal cohort study that began in 2013/2014 with boys and men aged 10-55 years (N = 16,021) at wave 1. The focus was on men who participated in waves 1 and 2 (2013/2014, 2015/2016) and had linked administrative data. A causal mediation analysis was conducted to quantify the total effect of self-reliance at wave 1 on suicidal thoughts at wave 2, and to investigate the extent of mediation by help-seeking between waves 1 and 2.

RESULTS

High self-reliance was associated with an increased odds of suicidal thoughts (OR = 1.46, 95% CI 1.24-1.72). However, there was no significant mediating effect of a lack of help-seeking on the relationship between self-reliance and suicidal thoughts (OR = 1.00, 95% CI 0.99-1.01).

CONCLUSION

Findings suggest that highly self-reliant men are at an increased risk of experiencing suicidal thoughts; however, this relationship is not explained by lack of help-seeking. Future studies could explore other potential mechanisms to better understand why highly self-reliant men are more likely to experience suicidal thoughts.

Efficacy of racemic ketamine or esketamine monotherapy for reducing suicidal ideation in uni- or bipolar depression: a systematic review and meta-analysis

The current systematic review and meta-analysis examined the effect of racemic ketamine or esketamine on suicidal ideation in individuals with uni- or bipolar depression. We searched the MEDLINE, Embase, Central, PsycINFO, and Web of Science databases to identify randomized controlled trials that examined the effect of racemic ketamine or esketamine monotherapy on suicidal ideation (SI) in individuals with uni- or bipolar depression. The two monotherapies were compared; the primary outcome was the rate of remission of SI, and the secondary outcome was the SI score. The risk ratio was used as an effect size measure for binary variables, while the standardized mean difference was used as an effect size measure for continuous variables. Our meta-analysis included 13 randomized controlled trials involving 1,1109 individuals with uni- or bipolar depression. Patients receiving racemic ketamine monotherapy had a significantly higher acute SI remission rate than those receiving placebo or midazolam (RR = 2.06, 95% CI 1.47 to 2.91, P < 0.0001). Racemic ketamine also led to significantly lower SI scores than placebo or midazolam (SMD = -0.36, 95% CI -0.71 to -0.01, P = 0.04). The evidence for the treatment of SI with esketamine was inconsistent. The pooled effect sizes for long-term anti-SI effects did not reveal significant differences between therapies. Our study indicated the efficacy of racemic ketamine monotherapy for rapidly and transiently reducing SI in individuals with uni- or bipolar depression, but the efficacy of racemic ketamine monotherapy against long-term suicidal ideation remains unclear. There is not -sufficient evidence to support the anti-suicidal effects of esketamine monotherapy.Protocol registration: Prospero registration number: CRD42023434380.

Clinical predictors of suicidal ideation, suicide attempts and suicide death in depressive disorder: a systematic review and meta-analysis

Patients with depressive disorders are especially prone to suicide risk. Among the clinical predictors of suicidality, those specifically related to depressive disorders have not been accurately detailed. Our aim was to conduct a systematic review and meta-analysis of studies reporting longitudinal predictors of suicidal ideation, suicide attempts and suicide death within depression, including diagnostic subtypes, symptoms, clinical course, and assessment scales. A systematic search of the literature between 2001 and 2022 identified 4422 references, among which 19 studies providing 45 different predictors of suicidality met the inclusion criteria. Random effects meta-analyses were performed for 22 predictors, three for suicidal ideation, eleven for suicide attempts and eight for suicide death. Heterogeneity and publication bias were inspected through I2 tests and Egger's tests respectively. Meta-analysis results showed that severity of hopelessness predicted suicidal ideation and suicide attempts. History of suicide attempts, suicidal ideation, severe depression, and psychotic symptoms predicted subsequent suicide attempts and suicide death. Time to full remission and sleep disturbances were also found as relevant predictors of future suicide behaviours. This review specifies which predictors of suicidality within the clinical features of depression will help clinicians and policy makers to better prevent suicide risk in patients with depressive disorders. Further longitudinal studies are needed to reliably assess the predictive ability of our results and to analyse other possible clinical predictors to prevent suicidality, especially with regard to suicidal ideation.

Pediatric suicide: Review of a preventable tragedy

Concepts of suicide are explored in this issue with a focus on suicide in children and adolescents. The epidemiology of pediatric suicide in the United States is reviewed; also, risk and protective factors, as well as prevention strategies, are discussed. Suicide in the pediatric athlete and the potential protective effect of exercise are examined. In addition, this analysis addresses the beneficial role of psychological management as well as current research on pharmacologic treatment and brain stimulation procedures as part of comprehensive pediatric suicide prevention. Though death by suicide in pediatric persons has been and remains a tragic phenomenon, there is much that clinicians, other healthcare professionals, and society itself can accomplish in the prevention of pediatric suicide as well as the management of suicidality in our children and adolescents.

Neuroimaging and natural language processing-based classification of suicidal thoughts in major depressive disorder

Suicide is a growing public health problem around the world. The most important risk factor for suicide is underlying psychiatric illness, especially depression. Detailed classification of suicide in patients with depression can greatly enhance personalized suicide control efforts. This study used unstructured psychiatric charts and brain magnetic resonance imaging (MRI) records from a psychiatric outpatient clinic to develop a machine learning-based suicidal thought classification model. The study included 152 patients with new depressive episodes for development and 58 patients from a geographically different hospital for validation. We developed an eXtreme Gradient Boosting (XGBoost)-based classification models according to the combined types of data: independent components-map weightings from brain T1-weighted MRI and topic probabilities from clinical notes. Specifically, we used 5 psychiatric symptom topics and 5 brain networks for models. Anxiety and somatic symptoms topics were significantly more common in the suicidal group, and there were group differences in the default mode and cortical midline networks. The clinical symptoms plus structural brain patterns model had the highest area under the receiver operating characteristic curve (0.794) versus the clinical notes only and brain MRI only models (0.748 and 0.738, respectively). The results were consistent across performance metrics and external validation. Our findings suggest that focusing on personalized neuroimaging and natural language processing variables improves evaluation of suicidal thoughts.

The moderating role of belongingness in the contribution of depression to suicide ideation following the October 7, 2023, terrorist attack in Israel: A nationwide prospective study

INTRODUCTION

With >1300 civilians murdered, the terrorist attack of October 7 is one of the deadliest terrorist attacks in modern history. Previous research documented a sharp increase in depression in the aftermath of the attacks and the military conflict that followed. In this national prospective cohort study, we examined to what extent perceived belongingness (PB) moderates the association between depression and suicide ideation (SI) in the wake of the October 7th terrorist attack.

METHODS

A representative sample of 710 Israeli adults (of them, 362 females, 51.1 %), Jews (557, 79.9 %), and Arabs (153, 20.1 %), aged 18-85 (M = 41.01, SD = 13.72) completed questionnaires assessing depression, current SI, and perceived belongingness at two timepoints: T1 (in August 2023) and T2 (in November 2023).

RESULTS

Perceived belongingness at T1 predicted SI at T2 beyond demographic and trauma-related characteristics. Importantly, we found a significant interaction in which a PB at T1 moderated the link between depression and current SI at T2. Specifically, the level of depression at T2 contributed to current SI-T2 more strongly for individuals with low PB levels than for individuals with high PB levels.

DISCUSSION

Our study highlights the impact of PB on SI following the October 7th terrorist attack. Clinicians treating individuals coping with depression should attend to their patients' sense of belongingness, as low PB comprises a significant risk factor for current SI. Moreover, community and national initiatives that could increase levels of PB among the citizens may help to diminish suicide risk in the aftermath of the attack.

Profiles of mental illness in college students and associated factors: A latent class analysis

Mental illness among university students poses a pressing challenge for educational institutions, urging the need for strategies that foster health and mitigate mental distress, with an emphasis on preventing suicide. Our study sought to discern the profiles of mental illness among college students and explore the factors associated with them. We examined data from 918 students at a Brazilian Federal Institute, utilizing Latent Class Analysis and multinomial regression for our analyses. We identified three distinct mental illness profiles: Anxiety with Low Suicide Risk; Mental Illness with Moderate Suicide Risk; and Mental Illness with High Suicide Risk. We observed a reduced association of these profiles with religious beliefs. Conversely, there was a heightened association with cisgender women, individuals identifying as LGBTQI+, those with learning disabilities, and victims of sexual violence. Our findings underscore the importance of tailored prevention and health promotion programs to enhance student well-being. There's a compelling need to devise mental health strategies tailored to the specific needs of the identified groups, particularly students from the LGBTQI + community, survivors of sexual abuse, and those grappling with learning disabilities.

Evaluation of serum MIP-1β and MCP-2 levels in major depressive disorder: A case-control study

BACKGROUND

Major depressive disorder (MDD) is a common and debilitating mental illness characterized by persistent feelings of sadness, hopelessness, and a lack of interest in daily activities. The objective of this study was to investigate whether levels of macrophage inflammatory protein-1β (MIP-1β) and macrophage chemoattractant protein-2 (MCP-2) in the blood were associated with the pathophysiology and development of MDD compared to healthy controls (HCs).

METHODS

This case-control study was conducted involving 50 MDD patients and 38 HCs. We performed a comprehensive assessment to match age, sex, BMI, and socio-demographic profile between the groups. The study excluded participants with chronic infection, inflammatory diseases, coexisting psychiatric disorder, history of liver and kidney diseases, and individuals who are under antipsychotic medications. A professional psychiatrist diagnosed MDD patients and evaluated HCs based on the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) criteria. The severity of depression was assessed using the Hamilton Depression (Ham-D) rating scale. Commercially available enzyme-linked immunosorbent assay (ELISA) kits were used to quantify the serum MIP-1β and MCP-2 levels.

RESULTS

The results indicated elevated serum MIP-1β levels (207.73±24.24 pg/ml) in MDD patients compared to HCs (58.77±9.14 pg/ml). This difference in concentration is positively correlated with severity of disease symptoms (r = 0.451; p<0.001). Similarly, the levels of MCP-2 were found to be elevated in patients compared to controls (143.61±19.92 vs. 56.84±4.02 pg/ml; p = 0.003), with a positive correlation with the Ham-D scores (r = 0.373; p = 0.004).

CONCLUSION

According to this study, elevated levels of MIP-1β and MCP-2 may be associated with the pathophysiology and development of MDD. These increased serum MIP-1β and MCP-2 levels could be used as risk assessment tools for MDD. The present findings urge further research and the development of therapeutic and diagnostic approaches for depression.

Anxious and depressive symptoms and health-related quality of life in a cohort of people who recently attempted suicide: A network analysis

BACKGROUND

Suicide is an international health concern with immeasurable impact from the perspective of human and social suffering. Prior suicide attempts, anxious and depressive symptoms, and relatively lower health-related quality of life (HRQoL) are among the most replicated risk factors for suicide. Our goal was to visualize the distribution of these features and their interconnections with use of a network analysis approach in individuals who recently attempted suicide.

METHODS

Individuals with a recent suicide attempt were recruited from nine University Hospitals across Spain as part of the SURVIVE cohort study. Anxious and depressive symptoms, and perceived HRQoL were included in the network analysis. Network structures were estimated with the EBICglasso model. Centrality measures and bridge symptoms connecting communities were explored. Subnetworks comparing younger and older individuals, and women and men were analyzed.

RESULTS

A total of 1106 individuals with a recent suicide attempt were included. Depressed mood was the symptom with the greatest influence in the overall network, followed by anxiety symptoms such as feeling nervous, worrying, restless, and having difficulties to relax. Perceived general health was associated with increased suicidal ideation in the whole sample. Older people showed a specific connection between perceived general health and depressed mood.

LIMITATIONS

The cross-sectional design does not allow determination of established causality.

CONCLUSIONS

Depressed mood was the core network's symptom and, therefore, an important target in the management and prevention of suicide. HRQoL had more influence on the network of older populations, in which it should be a primary focus.

Longitudinal Association between Stressful Life Events and Suicidal Ideation in Adults with Major Depression Disorder: The Mediating Effects of Insomnia Symptoms

Stressful life events (SLEs) and suicidal ideation (SI) are prevalent in persons with major depression disorder (MDD). Less is known about the underlying role of insomnia symptoms in the association between SLEs and SI. This three-wave prospective cohort study sought to investigate the longitudinal association among SLEs, insomnia symptoms, and SI in persons with MDD. The study population included 511 persons with MDD (mean [SD] age, 28.7 [6.7] years; 67.1% were females). Generalized estimated equations (GEEs) were utilized to explore prospective association among exposure of SLEs, insomnia symptoms, and SI. Additionally, a structural equation model (SEM) was employed to estimate the longitudinal mediating effect of insomnia symptoms in the relationship between SLEs and SI. Our study demonstrated that cumulative SLEs were determined to be longitudinally associated with SI in persons with MDD. We further observed that the association between SLEs and SI was significantly mediated by insomnia symptoms. Clinicians assessing persons with MDD, especially those with the history of SLE, could carefully evaluate and promptly treat insomnia symptoms as part of personalized assessment of their depressive illness, thereby achieving early prevention and intervention for suicidal behaviors in persons with MDD.

Associations Between Vitamin K and Suicide Attempts in Patients with Depression: A Case-Control Study

Background

Hypovitaminosis K has been linked to depression and suicide, but epidemiological research is scarce. This study aimed to explore the association among vitamin K with depression and suicidal attempts.

Methods

This was a retrospective cross-sectional study involving 146 cases with a history of suicidal attempts and 149 subjects without a lifetime history of suicidal attempts. The levels of thyroid hormones, lipid profile, inflammatory cytokines, and vitamins were measured.

Results

Subjects who had suicidal attempts presented with a significant decrease in FT4, TC, vitamin D, and vitamin K but increased CRP levels. In these variables, vitamin K has a better diagnostic value for suicidal attempts in depressed patients, with a sensitivity of 0.842 and a specificity of 0.715. Correlation analysis suggested that vitamin K was significantly and positively related to FT4, TC, LDL, and sdLDL. Multivariate analysis showed that serum vitamin K level predicts suicidal attempts in depressive patients (OR = 0.614, P = 0.004, 95% CI 0.153-0.904). Moreover, a negative correlation between vitamin K and suicidal attempts was also noted for partial FT4, CRP, and vitamin D strata analysis.

Conclusion

Our study suggests that low vitamin K levels were correlated with suicidal attempts in patients with depression, indicating that vitamin K deficiency might be a biological risk factor for depression.

Differences in resting-state brain activity in first-episode drug-naïve major depressive disorder patients with and without suicidal ideation

Despite altered brain activities being associated with suicidal ideation (SI), the neural correlates of SI in major depressive disorder (MDD) have remained elusive. We enrolled 82 first-episode drug-naïve MDD patients including 41 with SI and 41 without SI, as well as 41 healthy controls (HCs). Resting-state functional and structural MRI data were collected. The measures of fractional amplitude of low-frequency fluctuation (fALFF) and grey matter volume (GMV) were calculated and compared. Compared with HCs, patients with SI exhibited increased fALFF values in the right rectus gyrus and left medial superior frontal gyrus, middle frontal gyrus and precuneus. Decreased GMV in the right parahippocampal gyrus, insula and middle occipital gyrus and increased GMV in the left superior frontal gyrus were detected in patients with SI. In addition, patients without SI demonstrated increased fALFF values in the right superior frontal gyrus and decreased fALFF values in the right postcentral gyrus. Decreased GMV in the left superior frontal gyrus, right medial superior frontal gyrus, opercular part of inferior frontal gyrus, postcentral gyrus, fusiform gyrus and increased left supplementary motor area, superior occipital gyrus, right anterior cingulate gyrus and superior temporal gyrus were revealed in patients with SI. Moreover, in comparison with patients without SI, increased fALFF values were identified in the left precuneus of patients with SI. However, no significant differences were found in GMV between patients with and without SI. These findings might be helpful for finding neuroimaging markers predicting individual suicide risk and detecting targeted brain regions for effective early interventions.

Diagnosis of peripartum depression disorder: A state-of-the-art approach from the COST Action Riseup-PPD

BACKGROUND

Peripartum depression (PPD) is a major depression disorder (MDD) episode with onset during pregnancy or within four weeks after childbirth, as defined in DSM-5. However, research suggests that PPD may be a distinct diagnosis. The goal of this study was to summarize the similarities and differences between PPD and MDD by synthesizing the current research on PPD diagnosis concerning different clinical features and give directions for improving diagnosis of PPD in clinical practice.

METHODS

To lay the groundwork for this narrative review, several databases were searched using general search phrases on PPD and its components of clinical diagnosis.

RESULTS

When compared to MDD, peripartum depression exhibits several distinct characteristics. PPD manifests with a variety of symptoms, i.e., more anxiety, psychomotor symptoms, obsessive thoughts, impaired concentration, fatigue and loss of energy, but less sad mood and suicidal ideation, compared to MDD. Although PPD and MDD prevalence rates are comparable, there are greater cross-cultural variances for PPD. Additionally, PPD has some distinct risk factors and mechanisms such as distinct ovarian tissue expression, premenstrual syndrome, unintended pregnancy, and obstetric complications.

CONCLUSION

There is a need for more in-depth research comparing MDD with depression during pregnancy and the entire postpartum year. The diagnostic criteria should be modified, particularly with (i) addition of specific symptoms (i.e., anxiety), (ii) onset specifier extending to the first year following childbirth, (iii) and change the peripartum onset specifier to either "pregnancy onset" or "postpartum onset". Diagnostic criteria for PPD are further discussed.

Adjunctive cariprazine as a novel effective strategy for treating major depressive disorder: A systematic review and meta-analysis

BACKGROUND

Cariprazine has been approved by the Food and Drug Administration for treating bipolar depression and as an adjunctive treatment for Major Depressive Disorder (MDD). However, it remains unclear about its pharmacological efficacy in treating MDD. Therefore, a meta-analysis was conducted to investigate the adjunctive use of cariprazine in MDD.

METHODS

Electronic databases were searched for eligible studies evaluating the efficacy and safety of cariprazine in patients with MDD up to November 15, 2023. The changes in Montgomery-Asberg Depression Rating Scale (MADRS) score and incidence of adverse events (AEs), which represents of efficacy and tolerability, are considered as the main outcomes.

RESULTS

A total of 3066 patients with MDD included in all across 5 RCTs. With regard to MADRS score, cariprazine group showed better results than control group (SMD = -0.12, 95% CI -0.19 to -0.04, P = 0.002, 5 RCTs, n = 3066). Cariprazine, meanwhile, improved the MADRS response (RR = 1.19, 95% CI 1.08 to 1.31, P = 0.0004, 5 RCTs, n = 3066). For safety outcomes, statistical difference was observed in AEs (RR = 1.26, 95% CI 1.18 to 1.35, P < 0.00001, 5 RCTs, n = 3077). The suicide ideation and SAEs showed no statistical difference between two groups.

CONCLUSION

Cariprazine demonstrated antidepressant effect as an augmentation therapy in treating MDD. Meanwhile, the tolerability of it was acceptable as an adjunctive treatment. However, studies with larger sample sizes are still needed to explore the optimal dosage.

Examining assisted suicide and euthanasia through the lens of healthcare quality

Many people on both sides of the debate to legalise physician-hastened death are motivated by compassion and a desire to provide better end of life care for others. Assisted dying may include euthanasia and/or assisted suicide (EAS). It is legal in some jurisdictions and under debate in others including Ireland. EAS is a complex, sensitive and can be an emotive issue; detailed and nuanced examination of the subject is needed. To enhance this discussion, we examine EAS through the lens of quality. In examining EAS from this stance, we consider the action, along with the outcomes, the impact of the outcomes from other jurisdictions with legalised EAS, alongside the risks and the balancing measures used, in addition to considering the intervention itself. Progressive expansion of eligibility for EAS has occurred over time in the Netherlands, Belgium and Canada. Given the complexity of assessing coercion, the risks to persons in vulnerable groups (including older persons, persons with mental health conditions and persons with disabilities), the progressive expansion of eligibility for EAS, the lack of safety and the undermining of suicide prevention strategies, the current law is most protective of persons in vulnerable groups in the interest of social justice. Person-centred and compassionate care needs be prioritised with greater access and equitable access to primary and specialist palliative care and mental health care for persons with incurable and terminal illnesses and support for caregivers allowing patients to die naturally with optimised symptom control.

Major depressive disorder with suicidal ideation or behavior in Chinese population: A scoping review of current evidence on disease assessment, burden, treatment and risk factors

BACKGROUND

Identifying and managing major depressive disorder (MDD) patients with suicidal ideation or behavior (MDSI) is critical for reducing the disease burden. This scoping review aims to map the existing evidence related to MDSI in the Chinese population.

METHOD

A scoping review was conducted to summarize the published evidence regarding epidemiology or disease burden, evaluation, diagnosis, management, and prognosis of MDSI. The search strategy imposed restriction on English or Chinese publications between 1 January 2011 and 28 February 2022.

RESULTS

Of the 14,005 identified records, 133 met the eligibility criteria and were included for analysis. The included studies were characterized as high heterogeneity in evaluation of suicidal ideation or behavior. Compared with MDD patients without suicidal ideation or behavior, MDSI patients were more likely to suffer from psychological and somatic symptoms, social function impairment, and lower quality of life. Younger age, female gender, longer disease course, and comorbid psychological or physical symptoms were consistently found to be risk factors of suicidal ideation or behavior. Relevant research gaps remain regarding comprehensive evaluation of standard clinical diagnosis, disease burden, social-cultural risk factors, and effectiveness of interventions targeting MDSI. Studies with large sample size, representative population are warranted to provide high-quality evidence.

CONCLUSIONS

MDD patients with suicidal ideation or behavior should be prioritized in treatment and resource allocation. Heterogeneity exists in the definition and evaluation of MDSI in different studies. To better inform clinical practice, it is imperative to establish a unified standard for evaluation and diagnosis of suicidal ideation or behavior among MDD population.

Patient characteristics, validity of clinical diagnoses and Outcomes Associated with Suicidality in Inpatients with Symptoms of Depression (OASIS-D): design, procedures and outcomes

BACKGROUND

Suicidality, ranging from passive suicidal thoughts to suicide attempt, is common in major depressive disorder (MDD). However, relatively little is known about patient, illness and treatment characteristics in those with co-occurring MDD and suicidality, including the timing of and factors associated with the offset, continuation or reemergence of suicidality. Here, we present the background, rationale, design and hypotheses of the Patient Characteristics, Validity of Clinical Diagnoses and Outcomes Associated with Suicidality in Inpatients with Symptoms of Depression (OASIS-D) study, an investigator-initiated, observational study, funded by Janssen-Cilag GmbH.

METHODS/RESULTS

OASIS-D is an eight-site, six-month, cohort study of patients aged 18-75 hospitalized with MDD. Divided into three sub-studies and patient populations (PPs), OASIS-D will (i) systematically characterize approximately 4500 consecutively hospitalized patients with any form of unipolar depressive episode (PP1), (ii) evaluate the validity of the clinical diagnosis of moderate or severe unipolar depressive episode with the Mini-International Neuropsychiatric Interview (M.I.N.I.) and present suicidality (at least passive suicidal thoughts) present ≥ 48 h after admission with the Sheehan-Suicide Tracking Scale (S-STS), assessing also predictors of the diagnostic concordance/discordance of MDD in around 500 inpatients (PP2), and (iii) characterize and prospectively follow for 6 months 315 inpatients with a research-verified moderate or severe unipolar depressive episode and at least passive suicidal thoughts ≥ 48 h after admission, evaluating treatment and illness/response patterns at baseline, hospital discharge, 3 and 6 months. Exploratory objectives will describe the association between the number of days with suicidality and utilization of outpatient and inpatient care services, and structured assessments of factors influencing the risk of self-injurious behavior without suicidal intent, and of continuous, intermittent or remitted suicidality during the 6-month observation period.

CONCLUSION

Despite their frequency and clinical relevance, relatively little is known about patient and treatment characteristics of individuals with MDD and suicidality, including factors moderating and mediating the outcome of both MDD and suicidality. Results of the OASIS-D study are hoped to improve the understanding of the frequency, correlates and 6-month naturalistic treatment and outcome trajectories of different levels of suicidality in hospitalized adults with MDD and suicidality.

TRIAL REGISTRATION

NCT04404309 [ClinicalTrials.gov].

Suicidal risk and protective factors in major affective disorders: A prospective cohort study of 4307 participants

BACKGROUND

Suicidal behavior is strongly associated with major affective disorders, but there is a need to quantify and compare specific risk and protective factors in bipolar disorder (BD) and major depressive disorder (MDD).

METHODS

In 4307 extensively evaluated major affective-disorder participants with BD (n = 1425) or MDD (n = 2882) diagnosed by current international criteria, we compared characteristics among those with versus without suicidal acts from illness-onset through 8.24 years of follow-up.

RESULTS

Suicidal acts were identified in 11.4 % of participants; 25.9 % were violent and 6.92 % (0.79 % of all participants) were fatal. Associated risk factors included: diagnosis (BD > MDD), manic/psychotic features in first-episodes, family history of suicide or BD, separation/divorce, early abuse, young at illness-onset, female sex with BD, substance abuse, higher irritable, cyclothymic or dysthymic temperament ratings, greater long-term morbidity, and lower intake functional ratings. Protective factors included marriage, co-occurring anxiety disorder, higher ratings of hyperthymic temperament and depressive first episodes. Based on multivariable logistic regression, five factors remained significantly and independently associated with suicidal acts: BD diagnosis, more time depressed during prospective follow-up, younger at onset, lower functional status at intake, and women > men with BD.

LIMITATIONS

Reported findings may or may not apply consistently in other cultures and locations.

CONCLUSIONS

Suicidal acts including violent acts and suicides were more prevalent with BD than MDD. Of identified risk (n = 31) and protective factors (n = 4), several differed with diagnosis. Their clinical recognition should contribute to improved prediction and prevention of suicide in major affective disorders.

Individual and Combined Effect of MAO-A/MAO-B Gene Variants and Adverse Childhood Experiences on the Severity of Major Depressive Disorder

BACKGROUND

Major depressive disorder (MDD) is a mood disorder with a high prevalence worldwide that causes disability and, in some cases, suicide. Although environmental factors play a crucial role in this disease, other biological factors may predispose individuals to MDD. Genetic and environmental factors influence mental disorders; therefore, a potential combined effect of MAO-A/MAO-B gene variants may be a target for the study of susceptibility to MDD. This study aimed to evaluate the effects of MAO-A and -B gene variants when combined with adverse childhood experiences (ACEs) on the susceptibility and severity of symptoms in MDD.

METHODS

A case-control study was performed, including 345 individuals, 175 MDD cases and 170 controls. Genotyping was performed using real-time PCR with hydrolysis probes. The analysis of the rs1465107 and rs1799836 gene variants of MAO-A and -B, respectively, was performed either alone or in combination with ACEs on the severity of depression, as determined through specific questionnaires, including DSM-IV diagnostic criteria for MDD.

RESULTS

According to individual effects, the presence of ACEs, as well as the allele G of the rs1465107 of MAO-A, is associated with a higher severity of depression, more significantly in females. Furthermore, the allele rs1799836 G of MAO-B was associated with the severity of depression, even after being adjusted by gene variants and ACEs (IRR = 1.67, p = 0.01). In males, the allele rs1799836 G of MAO-B was shown to interact with SNP with ACEs (IRR = 1.70, p < 0.001). According to combined effect analyses, the severity of depression was associated with ACEs when combined with either allele rs1465107 of MAO-A or allele rs17993836 of MAO-B, whereas SNP risk association was influenced by gender.

CONCLUSIONS

The severity of depression is related to either individual or combined effects of temperamental traits and genetic susceptibility of specific genes such as MAO-A and MAO-B.

Borderline personality disorder and depression severity predict suicidal outcomes: A six-month prospective cohort study of depression, bipolar depression, and borderline personality disorder

BACKGROUND

Suicide risk is high in patients with major depressive disorder (MDD), bipolar disorder (BD) and borderline personality disorder (BPD). Whether risk levels of and risk factors for suicidal ideation (SI) and suicide attempts (SA) are similar or different in these disorders remains unclear, as few directly comparative studies exist. The relationship of short-term changes in depression severity and SI is underinvestigated, and might differ across groups, for example, between BPD and non-BPD patients.

METHODS

We followed, for 6 months, a cohort of treatment-seeking, major depressive episode (MDE) patients in psychiatric care (original n = 124), stratified into MDE/MDD, MDE/BD and MDE/BPD subcohorts. We examined risks of suicide-related outcomes and their risk factors prospectively. We examined the covariation of SI and depression over time with biweekly online modified Patient Health Questionnaire 9 surveys and analysed this relationship through multi-level modelling.

RESULTS

Risk of SA in BPD (22.2%) was higher than non-BPD (4.23%) patients. In regression models, BPD severity was correlated with risk of SA and clinically significant SI. During follow-up, mean depression severity and changes in depression symptoms were associated with SI risk regardless of diagnosis.

CONCLUSIONS

Concurrent BPD in depression seems predictive for high risk of SA. Severity of BPD features is relevant for assessing risk of SA and SI in MDE. Changes in depressive symptoms indicate concurrent changes in risk of SI. BPD status at intake can index risk for future SA, whereas depressive symptoms appear a useful continuously monitored risk index.

Autonomic dysregulation and self-injurious thoughts and behaviours in children and young people: A systematic review and meta-analysis

Background

Self-injurious thoughts and behaviours (SITBs) have been associated with dysfunction of the Autonomic Nervous System (ANS) in children and young people, suggesting that objective ANS measures may aid assessment of suicide risk, but a systematic synthesis of this literature is currently lacking.

Methods

Following a pre-registered protocol (PROSPERO CRD42022327605), we conducted a systematic search of PubMed, Medline, Embase, PsycINFO, and Web of Science, for empirical studies published until 10th May 2022 that compared indices of ANS functioning in individuals aged 0-25 years with versus without SITBs, or reported continuous associations between ANS measures and SITBs. Study quality was assessed with the Newcastle-Ottawa Scales. Pooled effect sizes (Hedge's g) were estimated with random-effects meta-analytic models.

Results

Twenty studies (1979 participants) were included in our systematic review, with 16 included in meta-analyses. Results suggested that SITBs were associated with altered cardiac indices of arousal (g = -0.328, p < 0.001), which was driven by lower heart rate variability in individuals with SITBs (g = -0.375, p = 0.025). Overall results for electrodermal activity were not significant (g = 0.026, p = 0.857), but subgroup analyses showed increased activity in studies of individuals who engaged specifically in non-suicidal self-harm (g = 0.249, p = 0.014) but decreased activity in the remaining studies (g = -0.567, p = 0.004).

Conclusions

Our systematic review and meta-analysis found evidence of reduced parasympathetic regulation as well as more tentative evidence of altered electrodermal activity in children and young people displaying SITBs. Future longitudinal studies should test the clinical utility of these markers for detecting and monitoring suicide risk.

Suicidal Ideations in Major Depressed Subjects: Role of the Temporal Dynamics of Anhedonia

Given the limited data available in the literature, the aim of this study was to investigate the potential role played by the temporal dynamics of anhedonia (lifelong anhedonia and recent changes in anhedonia) in the occurrence of suicidal ideations in major depressed subjects. The clinical data of 285 major depressed subjects recruited from the database of the Erasme Hospital Sleep Laboratory were analyzed. A score on item nine of the Beck Depression Inventory (BDI-II) ≥1 and/or an identification during the systematic psychiatric assessment were used to determine the presence of suicidal ideations. The association between anhedonia complaints (lifelong anhedonia and recent change in anhedonia) and suicidal ideations in major depressed subjects was assessed by logistic regression analyzes. The prevalence of suicidal ideations was 39.3% in our sample of major depressed subjects. After adjusting for the main confounding factors, multivariate logistic regression analysis demonstrated that unlike lifelong anhedonia, only recent changes in anhedonia were a risk factor for suicidal ideations in major depressed subjects. Given this potential involvement of the recent change in anhedonia in the occurrence of suicidal ideations in major depressed subjects, it seems essential to better identify and adequately manage this specific form of anhedonia in order to open new perspectives for the prevention of suicide in this particular sub-population.

Reduced numbers of naïve CD4 + T cells and an altered CD4/CD8 balance in depressed common variable immune deficiency (CVID) patients. Is thymosin-α1 a possible treatment?

In the 1990's the macrophage-T-cell-theory of depression was posed stating that low grade inflammation and an abnormal T cell system destabilize the development and function of the emotional brain in such a way, that individuals become ultrasensitive to stress. Recently we gathered evidence that indeed higher frequencies of CD4+ memory T cells, lower frequencies of naive CD4 + T cells, higher frequencies of CD8 + T cells (the latter two in part elicited by Cytomegalovirus, CMV, infection) are a characteristic of Major Depressive Disorder (MDD). In MDD patients with a history of childhood trauma and severe depression monocytes are inflammatory activated. Low grade inflammation and T cell system defects have also been reported in patients with Common Variable Immune Deficiency (CVID) (next to antibody production defects). CVID patients show a higher prevalence of mild depression. The aim of this study was to determine T cell frequencies and monocyte inflammatory activation in CVID patients with and without depression. This study confirms that CVID patients have CMV independent decreases in the frequency of naïve CD4 + T cells and it de novo shows a CMV dependent increase in the expression of inflammatory genes in monocytes. CVID patients with depression are additionally characterized by a CMV independent increase in the frequency of naïve CD8 + T cells, while lacking monocyte inflammatory activation. In conclusion, depressed CVID patients have T cell abnormalities comparable to that of patients with regular MDD. These abnormalities are presently targeted by thymosin α1 in an open-label proof of concept trial.

Clinical symptoms, thyroid dysfunction, and metabolic disturbances in first-episode drug-naïve major depressive disorder patients with suicide attempts: A network perspective

BACKGROUNDS

Co-occurrence of thyroid dysfunction, metabolic disturbances, and worsening clinical symptoms in major depressive disorder (MDD) patients with suicidal attempts (SA) are common. However, their relationship in SA patients remains unexplored. We aimed to (1) determine the independent association of thyroid dysfunction, clinical symptoms, and metabolic disturbances with SA; and (2) identify their interactions in SA patients via the network approach.

METHODS

1718 FEDN MDD patients were recruited. Depressive, anxiety, and psychotic symptoms were assessed by the Hamilton Rating Scale for Depression (HAMD), the Hamilton Rating Scale for Anxiety (HAMA), and the Positive and Negative Syndrome Subscale positive subscale, respectively. The serum levels of thyroid hormones and other metabolic parameters were assessed. Logistic regression model was applied to determine the correlates of SA. Network analysis was applied to determine the interaction between thyroid dysfunction, clinical symptoms, and metabolic disturbances.

RESULTS

SA patients had significant worse metabolic disturbances, thyroid dysfunction, and clinical symptoms than non-SA patients. Thyroid peroxidases antibody, thyroid stimulating hormone (TSH), HAMD scores, HAMA scores, and systolic blood pressure was independently associated with SA. Network analysis suggested that TSH was the hub of the network, exhibiting substantial associations with metabolic disturbances, anxiety, and psychotic symptoms in SA patients.

CONCLUSIONS

Our work highlights the predominant role of serum TSH levels in the pathophysiology of SA. Regular thyroid function tests might help early detect SA. Targeting increased TSH levels may help reduce metabolic disturbances and clinical symptoms in SA patients.

Prediction of suicidal ideation among Chinese college students based on radial basis function neural network

Background

Suicide is one of the leading causes of death for college students. The predictors of suicidal ideation among college students are inconsistent and few studies have systematically investigated psychological symptoms of college students to predict suicide. Therefore, this study aims to develop a suicidal ideation prediction model and explore important predictors of suicidal ideation among college students in China.

Methods

We recruited 1,500 college students of Sichuan University and followed up for 4 years. Demographic information, behavioral and psychological information of the participants were collected using computer-based questionnaires. The Radial Basis Function Neural Network (RBFNN) method was used to develop three suicidal ideation risk prediction models and to identify important predictive factors for suicidal ideation among college students.

Results

The incidence of suicidal ideation among college students in the last 12 months ranged from 3.00 to 4.07%. The prediction accuracies of all the three models were over 91.7%. The area under curve scores were up to 0.96. Previous suicidal ideation and poor subjective sleep quality were the most robust predictors. Poor self-rated mental health has also been identified to be an important predictor. Paranoid symptom, internet addiction, poor self-rated physical health, poor self-rated overall health, emotional abuse, low average annual household income per person and heavy study pressure were potential predictors for suicidal ideation.

Conclusions

The study suggested that the RBFNN method was accurate in predicting suicidal ideation. And students who have ever had previous suicidal ideation and poor sleep quality should be paid consistent attention to.

Suicidal Ideation in Major Depressed Individuals: Role of Type D Personality

Major depressed individuals are a subpopulation at high-risk of suicide. However, despite the evidence for a particular relationship between suicidal ideation (SI) and type D personality, few studies have investigated the role played by this personality structure in the occurrence of SI in major depressed individuals. Data from 318 major depressed individuals recruited from the clinical database of the Sleep Laboratory were analysed. Suicidal ideation was considered present if the score in item 9 of the Beck Depression Inventory (BDI-II) was ≥1 and/or if they were highlighted during the systematic psychiatric assessment conducted on admission to the Sleep Laboratory. Logistic regression analyses were used to determine the risk of SI associated with type D personality in major depressed individuals. The prevalence of suicidal ideation was 38.4% in our sample of major depressed individuals. After adjusting for major confounding factors, multivariate logistic regression analyses demonstrated that type D personality was a risk factor for SI in major depressed individuals. Thus, given the potential role played by type D personality in the occurrence of SI in major depressed individuals, it seems necessary to more systematically research and adequately manage this personality structure to allow for a better prevention of suicidal behaviours in this subpopulation.

Analysis of Motives and Factors Connected to Suicidal Behavior in Patients Hospitalized in a Psychiatric Department

(1) Background: This study aimed to investigate the motives and factors connected to suicidal behavior in 121 hospitalized patients with intentional self-harm (diagnosis X 60-81 according to the ICD-10); (2) Methods: Suicidal behavior of the patient was assessed from data obtained by psychiatric examinations and by the Columbia Suicide Severity Rating Scale. Analysis of data to identify the patients’ reason and motives behind suicidal behavior in a group of patients with a suicide attempt (SA, n = 80) and patients with Non-Suicidal Self-Injurious Behavior (NSSIB, n = 41) was carried out; (3) Results: Results showed that patients with affective disorder have a 19-times higher rate of SA against other diagnoses. Patients with personality disorders have a 32-times higher rate of NSSIB than patients with other diagnoses. Living alone and the absence of social support increased the likelihood of SA. Qualitative data analysis of patients’ statements showed different themes in the justification of motives for suicidal behavior between SA and NSSIB cases. Significant differences were shown for non-communicated reasons, loneliness, social problems, extortion, and distress; (4) Conclusions: The evaluation of patients’ verbal statements by qualitative analysis during the psychiatric examination should be considered in clinical practice. It should be considered to include self-poisoning in the criteria of the Non-suicidal Self-Injury diagnostic categories.