Differences between suicide attempters and nonattempters in depressed older patients: depression severity, white-matter lesions, and cognitive functioning

Plasma Apo-E mediated corticospinal tract abnormalities and suicidality in patients with major depressive disorder

This study aims to explore the link between Apo-E, brain white matter, and suicide in patients with major depressive disorder (MDD) to investigate the potential neuroimmune mechanisms of Apo-E that may lead to suicide. Thirty-nine patients with MDD (22 patients with suicidality) and 57 age, gender, and education-matched healthy controls participated in this study, provided plasma Apo-E samples, and underwent diffusion tensor imaging scans. Plasma Apo-E levels and white matter microstructure were analyzed among the MDD with suicidality, MDD without suicidality, and HC groups using analysis of variance with post hoc Bonferroni correction and tract-based spatial statistics (TBSS) with threshold-free cluster enhancement correction. Mediation analysis investigated the relationship between Apo-E, brain white matter, and suicidality in MDD. The MDD with suicidality subgroup had higher depressive and suicide scores, longer disease course, and lower plasma Apo-E levels than MDD without suicidality. TBSS revealed that the MDD non-suicide subgroup showed significantly increased mean diffusivity in the left corticospinal tract and body of the left corpus callosum, as well as increased axial diffusivity in the left anterior corona radiata and the right posterior thalamic radiation compared to the suicidal MDD group. The main finding was that the increased MD of the left corticospinal tract contributed to the elevated suicide score, with Apo-E mediating the effect. Preliminary result that Apo-E's mediating role between the left corticospinal tract and the suicide factor suggests the neuroimmune mechanism of suicide in MDD. The study was registered on ClinicalTrials.gov (NCT03790085).

Interplay of combat deployment harassment, testosterone concentrations and post-deployment suicide risk in male veterans

OBJECTIVE

Many combat veterans exhibit suicidal ideation and behaviour, but the relationships among experiences occurring during combat deployment and suicidality are still not fully understood. In this study, we tested the hypothesis that harassment during a combat deployment is associated with post-deployment suicidality and testosterone function.

METHODS

Male combat veterans who made post-deployment suicide attempts and demographically matched veterans without a history of suicide attempts were enrolled in the study. Demographic and clinical parameters of study participants were assessed and recorded. Study participants were interviewed by a trained clinician using the Mini-International Neuropsychiatric Interview (MINI), the Deployment Risk and Resilience Inventory (DRRI) – Relationships within unit scale, the Scale for Suicidal Ideation (SSI), and the Brown–Goodwin Aggression Scale. Free testosterone levels were assessed in morning blood samples.

RESULTS

DRRI harassment scores were higher and free testosterone levels were lower among suicide attempters in comparison with non-attempters. In the whole sample, DRRI harassment scores positively correlated with SSI scores and negatively correlated with free testosterone levels. Free testosterone levels negatively correlated with SSI scores. Aggression scale scores positively correlated with DRRI harassment scores among non-attempters but not among attempters.

CONCLUSION

Our observations that harassment scores are associated with suicidality and testosterone levels, and suicidality is associated with testosterone levels may indicate that there is a link between deployment harassment, testosterone function and suicidality.

Depression in older women who died by suicide: associations with other suicide contributors and suicide methods

Suicides among older women have received little research attention. In this study based on the 2017-2019 National Violent Death Reporting System data, we examined the prevalence of depression in older female suicide decedents (N = 3,061), associations between depression and other suicide precipitants, and the associations between suicide methods and depression. Descriptive statistics and generalized linear models (GLM) for a Poisson distribution with a log link were used to examine the research questions. Of the decedents, 15.0% had depressed mood without a reported diagnosis and 41.8% had a depression diagnosis. Nearly one-half of the decedents with reported depression were receiving mental health/substance use treatment at the time of injury. The likelihood of depression was lower among those who were age 85 and older compared to those were age 65-74, but higher among those who had anxiety disorder (IRR = 1.50, 95% CI = 1.33-1.69), history of suicidal ideation (IRR = 1.22, 95% CI = 1.10-1.35), history of suicide attempt (IRR = 1.27, 95% CI = 1.14-1.41), and bereavement problems (IRR = 1.45, 95% CI = 1.27-1.65). Those who had depression were less likely to have used firearms (IRR = 0.85, 95% CI = 0.75-0.97) but more likely to have used hanging/suffocation (IRR = 1.37, 95% CI = 1.13-1.67). The findings show that gun ownership was likely an important factor for firearm use. The high prevalence of depressed mood and/or depression diagnosis among older female suicide decedents at the time of their fatal injury underscores the importance of assessing depression and providing evidence-based depression treatment as an essential suicide prevention approach.

Cross-sectional study on the psychosocial factors, the severity of depression, and coping strategies among patients attempting suicide

Background

With around 10-20 million individuals attempting suicide each year, suicide attempts have been considered a significant public health issue. A significant fraction of it is caused by depression. Life events and other psychosocial stressors were frequently linked to both depression and suicidal behavior. Coping strategies are cognitive, emotional, and behavioral approaches used to lessen and cope with the negative impacts of stressful situations.

Aim

This study aimed to find the psychosocial factors, the severity of depression, and coping strategies among patients attempting suicide.

Materials and Methods

Study design: This study was a hospital-based descriptive cross-sectional study. A total of 120 consecutive cases were selected using Patient Health Questionnaire 2 (PHQ-2) scales and assessed for severity of depression and coping strategies using the Hamilton Depression Rating Scale (HAM-D) and Coping Orientation to Problem Experienced Inventory (Brief-COPE) scales, respectively. Pearson's Chi-square or Fisher's exact test and independent-samples t-test have been performed to see the association between categorical and continuous variables. The Pearson correlation coefficient has been used to see the relationship between two continuous variables.

Results

Most of the cases (33.3%) were found to be severely depressed. Among all the cases, the majority, that is, 90.8%, were using avoidant-type coping strategies and only 9.2% were using approach-type coping strategies. A significant positive correlation between the avoidant-type coping strategy and depression and a negative correlation between the approach-type coping strategy and depression was found.

Conclusion

Patients with depression attempting suicide were found to utilize avoidant-type coping strategies to cope with life stresses. Hence, it is crucial to place greater emphasis on assessing coping strategies and focus on teaching approach-oriented coping strategies as a means to prevent suicidal attempts.

Preliminary Study of White Matter Abnormalities and Associations With the Metabotropic Glutamate Receptor 5 to Distinguish Bipolar and Major Depressive Disorders

Background

Understanding distinct neurobiological mechanisms underlying bipolar disorder (BD) and major depressive disorder (MDD) is crucial for accurate diagnosis and the discovery of novel and more effective targeted treatments. Previous diffusion-weighted MRI studies have suggested some common frontotemporal corticolimbic system white matter (WM) abnormalities across the disorders. However, critical to the development of more precise diagnosis and treatment is identifying distinguishing abnormalities. Promising candidates include more prominent frontotemporal WM abnormalities observed in BD in the uncinate fasciculus (UF) that have been associated with frontal-amygdala functional dysconnectivity, and with suicide that is especially high in BD. Prior work also showed differentiation in metabotropic glutamate receptor 5 (mGlu5) abnormalities in BD versus MDD, which could be a mechanism affected in the frontotemporal system. However, associations between WM and mGlu5 have not been examined previously as a differentiator of BD. Using a multimodal neuroimaging approach, we examined WM integrity alterations in the disorders and their associations with mGluR5 levels.

Methods

Individuals with BD (N = 21), MDD (N = 10), and HC (N = 25) participated in structural and diffusion-weighted MRI scanning, and imaging with [18F]FPEB PET for quantification of mGlu5 availability. Whole-brain analyses were used to assess corticolimbic WM matter fractional anisotropy (FA) across BD and MDD relative to HC; abnormalities were tested for associations with mGlu5 availability.

Results

FA corticolimbic reductions were observed in both disorders and altered UF WM integrity was observed only in BD. In BD, lower UF FA was associated with lower amygdala mGlu5 availability (p < .05).

Conclusions

These novel preliminary findings suggest important associations between lower UF FA and lower amygdala mGlu5 levels that could represent a disorder-specific neural mechanism in which mGluR5 is associated with the frontotemporal dysconnectivity of the disorder.

Prevalence and influencing factors of suicide in first-episode and drug-naive young major depressive disorder patients with impaired fasting glucose: a cross-sectional study

Background

An association exists between major depression disorder (MDD), suicide attempts, and glucose metabolism, but suicide attempts in young MDD patients with comorbid impaired fasting glucose (IFG) have been less well studied. The purpose of this study was to examine the prevalence and risk factors for suicide attempts in young, first-episode, drug-naive (FEDN) MDD patients with comorbid IFG.

Methods

We recruited 917 young patients with FEDN MDD, 116 of whom were judged to have combined IFG because their blood glucose was >6.0. We collected anthropological and clinical data on all of them. The Hamilton Depression Scale (HAMD) score, the Hamilton Anxiety Scale (HAMA) score and the Positive and Negative Syndrome Scale (PANSS) positive subscale score were used to assess their clinical symptoms. Blood glucose, plasma thyroid function and lipid indicators were measured.

Results

The prevalence of suicide attempts in young MDD patients with IFG was 32.8% (38/116). Furthermore, among young MDD patients with comorbid IFG, suicide attempters had more severe depression and anxiety symptoms, more comorbid psychotic symptom, higher levels of antibody of thyroid stimulating hormone and thyroid peroxidases (TPOAb), and more severe lipid metabolism disorders than those without suicide attempts. In addition, HAMA scores and TPOAb were independently associated with suicide attempts in young patients with FEDN MDD.

Conclusion

Our study suggests that young MDD patients with IFG have a high rate of suicide attempts. Some clinical symptoms and thyroid function parameters may be the risk factor for suicide attempts in young MDD patients with impaired glucose metabolism.

Developing a Multimodal Monitoring System for Geriatric Depression: A Feasibility Study

The Internet of Medical Things is promising for monitoring depression symptoms. Therefore, it is necessary to develop multimodal monitoring systems tailored for elderly individuals with high feasibility and usability for further research and practice. This study comprised two phases: (1) methodological development of the system; and (2) system validation to evaluate its feasibility. We developed a system that includes a smartphone for facial and verbal expressions, a smartwatch for activity and heart rate monitoring, and an ecological momentary assessment application. A sample of 21 older Koreans aged 65 years and more was recruited from a community center. The 4-week data were collected for each participant (n = 19) using self-report questionnaires, wearable devices, and interviews and were analyzed using mixed methods. The depressive group (n = 6) indicated lower user acceptance relative to the nondepressive group (n = 13). Both groups experienced positive emotions, had regular life patterns, increased their self-interest, and stated that a system could disturb their daily activities. However, they were interested in learning new technologies and actively monitored their mental health status. Our multimodal monitoring system shows potential as a feasible and useful measure for acquiring mental health information about geriatric depression.

Risk factors for suicidal behavior in late-life depression: A retrospective preliminary clinical study

AIM

To explore the risk factors associated with suicidal behavior (SB) using logistic regression analysis and the propensity score matching (PSM) method among Chinese patients suffering from late-life depression (LLD).

METHOD

Patient information sheets were retrieved with the International Classification of Diseases, Tenth Revision (ICD-10) code from an electronic database that comprised patient medical information. Herein, we set SB as a dependent variable, and gender, marital status, monthly income, quality of interpersonal relationships, hobbies, impulsivity, severity of depression, psychiatric symptoms or not, and having histories of smoking, drinking, major mental trauma as independent variables according to clinical experience and previous findings. For uncertain independent risk factors associated with SB generated by logistic regression analysis, PSM was performed for further verification.

RESULTS

The differences between the SB group and non-SB group for marital status, severity of depression, a history of drinking, and a history of major mental trauma were found to be statistically significant in univariate comparisons (P < 0.05); binary logistic regression analysis and PSM analysis showed that the severity of depression, a history of drinking, and a history of major mental trauma were independent risk factors associated with SB of patients with LLD with an odds ratio greater than one.

CONCLUSION

The severity of depression, a history of drinking, and a history of major mental trauma were independently associated with the occurrence of SB of patients with LLD in China. Further longitudinal and prospective studies are warranted to examine the dynamic changes of confounding risk factors. Geriatr Gerontol Int 2021; 21: 849-854.

Greater white matter hyperintensities and the association with executive function in suicide attempters with late-life depression

Late-life depression (LLD) is associated with greater risk of suicide and white matter hyperintensities (WMH), which are also found in suicide attempters regardless of age. Greater periventricular WMH are related to worse cognitive function. We investigated the spatial distribution of WMH in suicide attempters with LLD and its association with cognitive function. We recruited 114 participants with LLD (34 with history of suicide attempt and 80 without) and 47 older adult controls (individuals without LLD or history of suicide attempt). WMH were quantified by an automated segmentation algorithm and were classified into different regions. Suicide attempters with LLD had significantly higher global WMH (F3, 150 = 2.856, p = 0.039) and periventricular WMH (F3, 150 = 3.635, p = 0.014) compared to other groups. Suicide attempters with high WMH had significantly lower executive function, which could be an underlying mechanism for cognitive decline in older adults with suicidality.

Neurocognitive Effects of Combined Electroconvulsive Therapy (ECT) and Venlafaxine in Geriatric Depression: Phase 1 of the PRIDE Study

OBJECTIVE

There is limited information regarding the tolerability of electroconvulsive therapy (ECT) combined with pharmacotherapy in elderly adults with major depressive disorder (MDD). Addressing this gap, we report acute neurocognitive outcomes from Phase 1 of the Prolonging Remission in Depressed Elderly (PRIDE) study.

METHODS

Elderly adults (age ≥60) with MDD received an acute course of 6 times seizure threshold right unilateral ultrabrief pulse (RUL-UB) ECT. Venlafaxine was initiated during the first treatment week and continued throughout the study. A comprehensive neurocognitive battery was administered at baseline and 72 hours following the last ECT session. Statistical significance was defined as a two-sided p-value of less than 0.05.

RESULTS

A total of 240 elderly adults were enrolled. Neurocognitive performance acutely declined post ECT on measures of psychomotor and verbal processing speed, autobiographical memory consistency, short-term verbal recall and recognition of learned words, phonemic fluency, and complex visual scanning/cognitive flexibility. The magnitude of change from baseline to end for most neurocognitive measures was modest.

CONCLUSION

This is the first study to characterize the neurocognitive effects of combined RUL-UB ECT and venlafaxine in elderly adults with MDD and provides new evidence for the tolerability of RUL-UB ECT in an elderly sample. Of the cognitive domains assessed, only phonemic fluency, complex visual scanning, and cognitive flexibility qualitatively declined from low average to mildly impaired. While some acute changes in neurocognitive performance were statistically significant, the majority of the indices as based on the effect sizes remained relatively stable.

Prevalence and clinical correlates of psychotic depression in first-episode and drug-naïve outpatients with major depressive disorder in a Chinese Han population

BACKGROUND

Few systemic studies of psychotic depression (PD) have been conducted in first-episode and drug-naïve (FEDN) patients. This study was to examine the prevalence of PD and its clinical correlates in a large sample of FEDN outpatients with major depressive disorder (MDD) in a Chinese Han population, which to our best knowledge has not been studied.

METHODS

In this cross-sectional study, a total of 1718 FEDN MDD outpatients were recruited. All patients were rated on the positive symptom subscale of the Positive and Negative Syndrome Scale (PANSS) for psychotic symptoms, the 17-item Hamilton Depression Rating Scale (HAMD-17) for depression and Hamilton Anxiety Rating Scale (HAMA) for anxiety.

RESULTS

The prevalence of PD was 10.0% (171/1718) in MDD patients. Compared to the non-PD patients, PD patients had significantly older age, lower educational levels, higher anxiety symptom score and were more likely to attempt suicide. Further logistic regression analysis indicated that PD was associated with older age, suicide attempt and comorbid anxiety (all p < 0.05). Multiple regression analyses showed that both HAMD and HAMA total scores were significantly associated with PANSS positive symptom subscale score.

LIMITATIONS

Our cross-sectional study design does not show a direct causal relationship between psychiatric symptoms and related factors in patients with MDD.

CONCLUSIONS

Our results suggest a high prevalence of PD in MDD patients in the acute early stage in a Chinese Han population, which is associated with demographic variables and clinical symptoms.

Chronic brain stimulation rewarding experience ameliorates depression-induced cognitive deficits and restores aberrant plasticity in the prefrontal cortex

BACKGROUND

Major depressive disorder (MDD) is a multifactorial disease which often coexists with cognitive deficits. Depression-induced cognitive deficits are known to be associated with aberrant reward processing, neurochemical and structural alterations. Recent studies have shown that chronic electrical stimulation of brain reward areas induces a robust antidepressant effect. However, the effects of repeated electrical self-stimulation of lateral hypothalamus - medial forebrain bundle (LH-MFB) on depression-induced cognitive deficits and associated neurochemical and structural alterations in the prefrontal cortex (PFC) are unknown.

OBJECTIVES

We investigated the effect of chronic rewarding self-stimulation of LH-MFB in neonatal clomipramine (CLI) model of depression. During adulthood, neonatal CLI and saline administered rats were implanted with bilateral electrodes stereotaxically in the LH-MFB and trained to receive intracranial self-stimulation (ICSS) for 14 days. The rats were tested for depressive-like behaviors, learning and memory followed by estimation of PFC volumes, levels of monoamines and its metabolites in the PFC.

RESULTS

We found that chronic ICSS of LH-MFB reverses CLI-induced behavioral despair and anhedonia. Interestingly, self-stimulation normalizes the impaired novel object and location recognition memory in CLI rats. The amelioration of learning impairments in CLI rats was associated with the reversal of volume loss and restoration of monoamine metabolism in the PFC.

CONCLUSION

We demonstrated that repeated intracranial self-stimulation of LH-MFB ameliorates CLI-induced learning deficits, reverses altered monoamine metabolism and the atrophy of PFC. Our results support the hypothesis that chronic brain stimulation rewarding experience might be evolved as a potential treatment strategy for reversal of learning deficits in depression and associated disorders.

Suicide Among Persons With Dementia, Georgia, 2013 to 2016

INTRODUCTION

Findings from studies examining the relationship between dementia and suicide have been inconsistent. This study examined the characteristics, precipitants, and risk factors for suicide among persons with dementia.

METHODS

Data from the Georgia Alzheimer's Disease and Related Dementia registry were linked with 2013 to 2016 data from Georgia Vital Records and Georgia Violent Death Reporting System. Descriptive statistics were calculated and logistic regression was used to examine risk factors for suicide.

RESULTS

Ninety-one Georgia residents with dementia who died by suicide were identified. Among decedents with known circumstances, common precipitants included depressed mood (38.7%) and physical health problems (72.6%). Suicide rate among persons with dementia was 9.3 per 100 000 person-years overall and substantially higher among those diagnosed in the past 12 months (424.5/100 000 person-years). Being male, dementia diagnosis before age 65, and a recent diagnosis of dementia independently predicted suicide, but not depression or cardiovascular diseases.

CONCLUSION

Prevention strategies that identify at-risk individuals, provide support, and ensure continuity of care for persons diagnosed with dementia may help reduce suicide in this population.

Neuroimaging Studies of Suicidal Behavior and Non-suicidal Self-Injury in Psychiatric Patients: A Systematic Review

Background: With around 800,000 people taking their own lives every year, suicide is a growing health concern. Understanding the factors that underlie suicidality and identifying specific variables associated with increased risk is paramount for increasing our understanding of suicide etiology. Neuroimaging methods that enable the investigation of structural and functional brain markers in vivo are a promising tool in suicide research. Although a number of studies in clinical samples have been published to date, evidence about neuroimaging correlates for suicidality remains controversial. Objective: Patients with mental disorders have an increased risk for both suicidal behavior and non-suicidal self-injury. This manuscript aims to present an up-to-date overview of the literature on potential neuroimaging markers associated with SB and NSSI in clinical samples. We sought to identify consistently reported structural changes associated with suicidal symptoms within and across psychiatric disorders. Methods: A systematic literature search across four databases was performed to identify all English-language neuroimaging articles involving patients with at least one psychiatric diagnosis and at least one variable assessing SB or NSSI. We evaluated and screened evidence in these articles against a set of inclusion/exclusion criteria and categorized them by disease, adhering to the PRISMA guidelines. Results: Thirty-three original scientific articles investigating neuroimaging correlates of SB in psychiatric samples were found, but no single article focusing on NSSI alone. Associations between suicidality and regions in frontal and temporal cortex were reported by 15 and 9 studies across four disorders, respectively. Furthermore, differences in hippocampus were reported by four studies across three disorders. However, we found a significant lack of replicability (consistency in size and direction) of results across studies. Conclusions: Our systematic review revealed a lack of neuroimaging studies focusing on NSSI in clinical samples. We highlight several potential sources of bias in published studies, and conclude that future studies should implement more rigorous study designs to minimize bias risk. Despite several studies reporting associations between SB and anatomical differences in the frontal cortex, there was a lack of consistency across them. We conclude that better-powered samples, standardized neuroimaging and analytical protocols are needed to continue advancing knowledge in this field.

High serum levels of tenascin-C are associated with suicide attempts in depressed patients

The proteomic study reported that Tenascin-C might be a diagnostic biomarker for major depressive disorder, but clinical studies of this potential relationship are lacking. Here we examined the association between tenascin-C levels in serum and suicide attempts. Serum tenascin-C concentrations were compared among depressive patients who had not attempted suicide (n = 86), patients who had attempted it (n = 43), and healthy controls (n = 109). All participants were aged between 18 and 68 years. The association between concentration and suicide attempts was assessed by multivariate analysis after adjusting for sociodemographics, lifestyle and health indicators. Tenascin-C concentrations were higher in patients than in controls, and higher in patients who had attempted suicide than in patients who had not. Higher concentrations were associated with greater risk of attempting suicide. Among patients who had attempted suicide, tenascin-C concentrations were associated with severity of depression. Our results suggest that high tenascin-C levels in depressive patients correlate with suicide attempts and severity of depression. Tenascin-C may contribute to risk of suicide attempts in depressed patients.

The evaluation and design of a short depression screening tool in Turkish older adults

ABSTRACTIntroduction:Depression is a common and serious healthcare problem for older adults. This study aimed to determine the validity and reliability of GDS-4 and GDS-5 in Turkish, and to establish a new short-form Geriatric Depression Scale (GDS) for our population, and also determine the superiority of each short scale to another.

METHODS

A total of 437 outpatients were enrolled in the study. A researcher evaluated all participants according to the Diagnostic and Statistical Manual of Mental Disorders-fifth edition (DSM-5) diagnostic criteria, and then another researcher applied GDS-15 to all participants. We obtained the answers of short GDS forms, examined in this study, from GDS-15 forms. After Cohen's κ analysis, we compared the diagnostic value of each question for geriatric depression according to their κ values, and developed three (TGDS-3), four (TGDS-4), five (TGDS-5), and six (TGDS-6) question scales to screen geriatric depression in Turkish population.

RESULTS

A total of 437 participants were assessed. The mean age (SD) of the patients was 72.95 years (7.37).Cronbach's α values of GDS-4 and GDS-5 were 0.70. The best cut-off values were ≥5 for GDS-15 and GDS-5, and ≥1 for others.

DISCUSSION

GDS-15 is the most powerful screening scale for geriatric depression. GDS-4 and GDS-5 are not eligible for depression screening in Turkish older adults. All new short scales are valid and reliable, and TGDS-4 is a practical, less time-consuming option for daily practice.

Adapted psychotherapy for suicidal geriatric patients with depression

This debate article aims to evaluate whether current diagnostic and therapeutic options for suicidal geriatric patients with depression suffice, and which adapted strategies might be helpful. We hope to encourage clinicians to consider special approaches when treating the elderly.

BACKGROUND

Suicide in old age is a major public health problem, as the suicide rates are highest among those aged 60 years and older in most European countries. Although pharmacological treatment options are relatively easy for older patients to obtain, their access to standard psychotherapy is limited. The reasons for this are i) the widely shared attitude about the effectiveness of psychotherapy for older people and ii) the limited access to standard psychotherapy due to their immobility.

CONCLUSION

New psychotherapeutic methods need to be developed. Psychotherapy at the patient's home seems to be a new approach to accommodate that individual's personal circumstances and make effective therapy possible.

Brain structure alterations in depression: Psychoradiological evidence

Depression is the leading cause of disability around the world, but little is known about its pathology. Currently, the diagnosis of depression is made based on clinical manifestations, with little objective evidence. Magnetic resonance imaging (MRI) has been used to investigate the pathological changes in brain anatomy associated with this disorder. MRI can identify structural alterations in depressive patients in vivo, which could make considerable contributions to clinical diagnosis and treatment. Numerous studies that focused on gray and white matter have found significant brain region alterations in major depressive disorder patients, such as in the frontal lobe, hippocampus, temporal lobe, thalamus, striatum, and amygdala. The results are inconsistent and controversial because of the different demographic and clinical characteristics. However, some regions overlapped; thus, we think that there may be a "hub" in MDD and that an impairment in these regions contributes to disease severity. Brain connections contain both structural connections and functional connections, which reflect disease from a different view and support that MDD may be caused by the interaction of multiple brain regions. According to previous reports, significant circuits include the frontal-subcortical circuit, the suicide circuit, and the reward circuit. As has been recognized, the pathophysiology of major depressive disorder is complex and changeable. The current review focuses on the significant alterations in the gray and white matter of patients with the depressive disorder to generate a better understanding of the circuits. Moreover, identifying the nuances of depressive disorder and finding a biomarker will make a significant contribution to the guidance of clinical diagnosis and treatment.

The influence of thoughts of death and suicidal ideation on the course of depression in older depressed patients

OBJECTIVE

Thoughts of death are not regularly included in diagnostic instruments and rarely examined separately from thoughts of suicide. This exploratory study examined whether thoughts of death and thoughts of suicide affect the course of late-life depressive disorders.

METHODS

In 378 depressed older persons, thoughts of death and thoughts of suicide were assessed using questions from the Composite International Diagnostic Interview. After 2 years, the presence of a DSM-IV-TR diagnosis of minor or major depression or dysthymia was assessed with the Composite International Diagnostic Interview. The Inventory of Depressive Symptomatology was administered every 6 months up till 3-year follow-up.

RESULTS

Multinomial logistic regression showed that thoughts of death as well as thoughts of suicide predicted double depression at follow-up (OR = 2.14 [95% CI: 1.04-4.40] and OR = 6.47 [95% CI: 2.22-3.02], respectively), compared with patients without these thoughts. Results became non-significant when adjusted for baseline depression severity (OR = 1.17 [95% CI: 0.52-2.63] and OR = 2.57 [95% CI: 0.79-8.84], respectively). Mixed linear models showed that severity of depression was lowest in the reference group, while symptoms decreased more over time in those with either thoughts of death or suicide.

CONCLUSIONS

Patients with thoughts of death or with thoughts of suicide were more severely depressed at baseline and follow-up, with the highest risk of being depressed at follow-up for patients with thoughts of suicide. These associations could be explained by baseline depression severity. The results suggest that thoughts of death and thoughts of suicide are important risk markers in predicting the course of depression. Copyright © 2016 John Wiley & Sons, Ltd.

Biomarkers of Suicide Attempt Behavior: Towards a Biological Model of Risk

PURPOSE OF REVIEW

The rising suicide rate in the USA will not be reversed without improved risk assessment and prevention practices. To date, the best method for clinicians to assess a patient's risk for suicide is screening for past suicide attempts in the patient and their family. However, neuroimaging, genomic, and biochemical studies have generated a body of findings that allow description of an initial heuristic biological model for suicidal behavior that may have predictive value.

RECENT FINDINGS

We review studies from the past 3 years examining potential biological predictors of suicide attempt behavior. We divide findings into two major categories: (1) structural and functional brain imaging findings and (2) biochemical and genomic findings encompassing several systems, including major neurotransmitters (serotonin, catecholamines, GABA, and glutamate), the hypothalamic pituitary adrenal (HPA) axis, the inflammasome, lipids, and neuroplasticity. The biomarkers that appear promising for assessing suicide risk in clinical settings include indices of serotonergic function, inflammation, neuronal plasticity, and lipids.

Association between abnormal default mode network activity and suicidality in depressed adolescents

BACKGROUND

Suicide is the second leading cause of death among 15- to 29-year-olds in China, and 60 % of suicidal patients have a history of depression. Previous brain imaging studies have shown that depression and suicide may be associated with abnormal activity in default mode network (DMN) regions. However, no study has specifically investigated the relationship between DMN functional activity and suicidal behavior in depressed individuals. Therefore, in the present study, we directly investigated features of DMN brain activity in adolescent patients with histories of depression and attempted suicide.

METHODS

A total of 35 sex- and age-matched suicidal depressed patients were compared with 18 non-suicidal depressed patients and 47 healthy controls. We explored functional activity changes in DMN regions that could be associated with suicidal behavior by comparing resting-state functional magnetic resonance imaging (rs-fMRI) signals using independent component analysis (ICA). Scores on six clinical scales that measure depression severity (Hamilton Depression Scale (HDRS) and Beck Depression Inventory (BDI)) and suicidal traits (Barratt Impulsiveness Scale (BIS-11), Suicide Attitude Questionnaire (SAQ), Beck Hopelessness Scale (BHS), and Scale for Suicide Ideation (SSI)) were compared in the three groups.

RESULTS

Compared with the healthy controls, all of the evaluated depressed patients showed increased functional connectivity in select DMN regions. The suicidal patients showed increased connectivity in the left cerebellum and decreased connectivity in the right posterior cingulate cortex (PCC), whereas the non-suicidal depressed patients showed increased connectivity in the left superior frontal gyrus, left lingual gyrus and right precuneus and decreased connectivity in the left cerebellum. Compared to the non-suicidal patients, the suicidal patients showed increased connectivity in the left cerebellum and the left lingual gyrus and decreased connectivity in the right precuneus. No differences in the scores of any clinical scales were found between the suicidal and non-suicidal depressed patients.

CONCLUSIONS

Collectively, our results highlight the importance of the DMN in the pathophysiology of depression and suggest that suicidal behavior in depressed adolescents may be related to abnormal functional connectivity in the DMN. In particular, abnormal connectivity in the PCC/precuneus and left cerebellum might be a predictor of suicidal behavior in depressed adolescent patients.

Neurobiology of Elderly Suicide

Suicide in the elderly is an underestimated and complex issue that has mainly been explored in sociological, clinical and psychological perspectives. Suicide in non-elderly adults has been associated with diverse neurobiological alterations that may shed light on future predictive markers and more efficient preventative interventions. The aim of this paper was to review studies specifically investigating the neurobiology of elderly suicidal behaviour. We performed a systematic English and French Medline and EMBASE search until 2013. Contrary to literature about the non-elderly, we found a paucity of studies investigating the biomarkers of suicidal risk in elderly adults. Main findings were found in the neurocognitive domain. Studies generally supported the existence of cognitive deficits, notably decision-making impairment and reduced cognitive inhibition, in patients with a history of suicidal act compared to patients without such history. However, replications are needed to confirm findings. Due to several limitations including the small number of available studies, frequent lack of replication and small sample size, no firm conclusions can be drawn. The authors encourage further investigations in this field as insight in the neurobiology of these complex behaviors may limit clichés about end of life and aging, as well as improve future prevention of suicide in the elderly.

Course of cognitive impairment following attempted suicide in older adults

OBJECTIVE

Cognitive impairment has been associated with late-life suicidal behavior. Without longitudinal data it is unclear whether these are transient features of a depressive state or stable impairments. We examined longitudinally the course of cognitive impairment in older adults with depression and a history of suicide attempt.

METHODS

We investigated the persistence of cognitive impairment over time in 198 depressed older adults (age >60); 91 suicide attempters, 39 depressed individuals with suicidal ideation (ideators), and 68 non-suicidal depressed adults assessed over a 2-year period at four time points. We used linear mixed effects modeling to examine group differences in trajectories of cognitive decline over 2 years, using the Mini-Mental State Examination (MMSE), Mattis Dementia Rating Scale (DRS), and Executive Interview (EXIT).

RESULTS

Over the 2-year period, suicide attempters performed significantly worse than both suicide ideators and non-suicidal depressed older adults on the MMSE (mean difference: from ideators: -0.88, p = 0.02; from non-suicidal depressed: -1.52, p < 0.01), while on the EXIT and DRS, suicide attempters performed significantly worse than non-suicidal depressed older adults (mean difference: in EXIT: -1.75, p = 0.01; in DRS: 3.04, p < 0.01; in MMSE: 1.15, p < 0.01). Cognitive impairment in suicide attempters partly resolved, as indicated by a group × time interaction on the DRS (p = 0.039), but not the EXIT (p = 0.58) or the MMSE (p = 0.08).

CONCLUSIONS

Cognitive impairment in late-life suicidal behavior appears to involve both a stable and a state-related component.

Effect of Problem-Solving Therapy on Depressed Low-Income Homebound Older Adults' Death/Suicidal Ideation and Hopelessness

Previous study findings of psychotherapy's effect on suicide prevention have been inconsistent. This study reports the results of secondary analyses of outcome data from a short-term depression treatment on reducing death/suicidal ideation among 158 low-income homebound adults aged 50+. The treatment, in-person or telehealth problem-solving therapy (PST), compared with telephone support call, has been found effective in reducing depressive symptoms and disability among participants. Compared with support call participants, tele-PST participants, but not in-person PST participants, exhibited lower ideation ratings across the follow-up period. Effect sizes at 36 weeks were 0.31 for tele-PST and 0.17 for in-person PST. Hopelessness mediated the effect of tele-PST but not in-person PST; however, in-person PST also alleviated hopelessness, which led to lower ideation. Clinical implications of the findings are discussed.

Impulsive traits and unplanned suicide attempts predict exaggerated prefrontal response to angry faces in the elderly

OBJECTIVE

Abnormal responses to social stimuli are seen in people vulnerable to suicidal behavior, indicating possible disruptions in the neural circuitry mediating the interpretation of socioemotional cues. These disruptions have not been empirically related to psychological and cognitive pathways to suicide. In the present study of older suicide attempters, we examined neural responses to emotional faces and their relationship to impulsivity, one of the components of the suicidal diathesis.

METHODS

Using functional magnetic resonance imaging, we recorded neurohemodynamic responses to angry faces in a carefully characterized sample of 18 depressed elderly with history of suicide attempts, 13 depressed nonsuicidal patients, and 18 healthy individuals, all aged 60+. Impulsivity was assessed with the Social Problem Solving Inventory Impulsivity/Carelessness Style subscale and Barratt Impulsiveness Scale. The Suicide Intent Scale planning subscale was used to describe the degree of planning associated with the most lethal attempt.

RESULTS

Depression and history of attempted suicide were not associated with neural responses to angry faces, failing to replicate earlier studies. Higher impulsivity, however, predicted exaggerated responses to angry faces in fronto-opercular and dorsomedial prefrontal cortex (pcorr <0.05). Poorly planned suicide attempts also predicted increased fronto-opercular responses. Results were robust to effects of medication exposure, comorbid anxiety and addiction, severity of depression, burden of physical illness, and possible brain injury from suicide attempts.

CONCLUSION

Impulsive traits and history of unplanned suicide attempts partly explain the heterogeneity in neural responses to angry faces in depressed elderly. Displays of social emotion command excessive cortical processing in impulsive suicide attempters.

Suicide in older adults: the role of emotions and cognition

Suicide in older adults is a significant clinical concern. In this review of recent findings, we concentrate on the role of emotions and cognition in suicide risk and behavior in older adults. We discuss the epidemiology of suicide in older adults, integrate recent findings on non-psychotic major depression, schizophrenia and suicidal ideation, explore the relationship of emotion regulation with suicide, present recent advances on suicide in demented patients, and describe the latest developments on cognition and decision processes in suicide.

Neurobiological risk factors for suicide: insights from brain imaging

CONTEXT

This article reviews neuroimaging studies on neural circuitry associated with suicide-related thoughts and behaviors to identify areas of convergence in findings. Gaps in the literature for which additional research is needed are identified.

EVIDENCE ACQUISITION

A PubMed search was conducted and articles published before March 2014 were reviewed that compared individuals who made suicide attempts to those with similar diagnoses who had not made attempts or to healthy comparison subjects. Articles on adults with suicidal ideation and adolescents who had made attempts, or with suicidal ideation, were also included. Reviewed imaging modalities included structural magnetic resonance imaging, diffusion tensor imaging, single photon emission computed tomography, positron emission tomography, and functional magnetic resonance imaging.

EVIDENCE SYNTHESIS

Although many studies include small samples, and subject characteristics and imaging methods vary across studies, there were convergent findings involving the structure and function of frontal neural systems and the serotonergic system.

CONCLUSIONS

These initial neuroimaging studies of suicide behavior have provided promising results. Future neuroimaging efforts could be strengthened by more strategic use of common data elements and a focus on suicide risk trajectories. At-risk subgroups defined by biopsychosocial risk factors and multidimensional assessment of suicidal thoughts and behaviors may provide a clearer picture of the neural circuitry associated with risk status-both current and lifetime. Also needed are studies investigating neural changes associated with interventions that are effective in risk reduction.