The relationship between multimorbidity and suicidal ideation: A meta-analysis

Comorbid physical health burden of serious mental health disorders in 32 European countries

BACKGROUND

Mental health disorders (MHDs) are associated with physical health disparities, but underlying excess risk and health burden have not yet been comprehensively assessed.

OBJECTIVE

To assess the burden of comorbid physical health conditions (PHCs) across serious MHDs in Europe.

METHODS

We estimated the relative prevalence risk of PHCs associated with alcohol use disorders (AUD), bipolar disorder (BD), depressive disorders (DD) and schizophrenia (SZ) across working-age populations of 32 European countries in 2019 based on a targeted literature review. Excess physical health burden was modelled using population-attributable fractions and country-level prevalence data.

FINDINGS

We screened 10 960 studies, of which 41 were deemed eligible, with a total sample size of over 18 million persons. Relative prevalence of PHCs was reported in 54%, 20%, 15%, 5% and 7% of studies, respectively, for SZ, DD, BD, AUD or mixed. Significant relative risk estimates ranged from 1.44 to 3.66 for BD, from 1.43 to 2.21 for DD, from 0.81 to 1.97 for SZ and 3.31 for AUD. Excess physical health burden ranged between 27% and 67% of the total, corresponding to 84 million (AUD), 67 million (BD), 66 million (DD) and 5 million (SZ) PHC diagnoses in Europe. A 1% reduction in excess risk assuming causal inference could result in two million fewer PHCs across investigated MHDs.

CONCLUSIONS

This is the first comprehensive study of the physical health burden of serious MHDs in Europe. The methods allow for updates, refinement and extension to other MHDs or geographical areas.

CLINICAL IMPLICATIONS

The results indicate potential population health benefits achievable through more integrated mental and physical healthcare and prevention approaches.

Family function, anxiety and depression in adults with disabilities: a network analysis

Background

The prevalence of family dysfunction, anxiety and depression is high in people with disabilities due to long-term activity constraints and social difficulties. Recently, although studies have attempted to provide guidance for family therapy by focusing on the relationship between family function and negative emotions, the specific effects of improved family function during family therapy on alleviation of anxiety and depressive symptoms have been obscured. Thus, this study attempted to elucidate the impact of specific family functioning on specific symptoms of anxiety and depression through network analysis.

Methods

Family APGAR Index Questionnaire (APGAR), Generalized Anxiety Scale (GAD-7), and Patient Health Questionnaire Depression Scale (PHQ-9) were used to survey 897 adults with disabilities in Sichuan Province. Meanwhile, network analysis for studying the relationship between anxiety, depression and family functioning among the disabled via R software.

Results

The network analysis showed that (1) Nodes PHQ4 ("Energy"), APGAR3 ("Growth"), GAD1 ("Nervousness") and GAD4 ("Relaxing Trouble") were central nodes in the network model; (2) Bridge nodes linking family function, anxiety and depressive symptoms in the sample were PHQ9 ("Suicide ideation"), PHQ6 ("Worthlessness"), GAD1 ("Nervousness") and GAD5 ("Restlessness"); (3) The node APGAR5 ("Resolve") directly connects the bridge symptoms PHQ9 ("Suicide ideation") and PHQ8 ("Motor").

Conclusion

This study suggests that therapists could target the resolve of family members during family therapy to reduce suicidal ideation and enhance the level of activity of people with disabilities, thereby improving the network of anxiety and depression symptoms and alleviating negative emotions of people with disabilities.

Bridge connection between depression and anxiety symptoms and lifestyles in Chinese residents from a network perspective

Background

Lifestyle habits are vital components of the culture of mental health treatment settings. We examined the bridge connection between depressive and anxiety symptoms and lifestyles from a network perspective using a population-based study.

Methods

Face-to-face interviews were conducted with a provincially representative sample of 13,768 inhabitants from the Guangdong Sleep and Psychosomatic Health Survey based on standardized evaluation techniques. We identified the central symptoms by expected influence. The interconnection between depression and anxiety symptoms, as well as the bridge connectivity linking depression-anxiety symptoms and lifestyle factors, were assessed using the bridge centrality index. Network stability and sensibility analyses were performed using a case-dropping bootstrap procedure.

Results

The core symptom that exhibited the highest expected influence was fatigue or little energy, followed by uncontrollable worry, trouble relaxing, and sad mood in the depression-anxiety symptoms network, while guilt was the most interconnected symptom and had the highest bridge strength. Surrounding nodes of each node explained an average variance of 57.63%. Additionally, suicidal thoughts were recognized as collective bridging symptoms connecting lifestyle variables in the network integrating depression-anxiety symptoms with lifestyle factors. Current tobacco and alcohol consumption were positively associated with suicidal thoughts and irritability. Habitual diet rhythm and physical exercise frequency were linked to suicidal thoughts, guilt, and poor appetite or overeating. Suicidal thoughts, irritability, and guilt indicated the greatest connectivity with lifestyle factors. All networks had high stability and accuracy.

Conclusion

These highlighted core and bridge symptoms could serve as latent targets for the prevention and intervention of comorbid depression and anxiety. It might be crucial for clinical practitioners to design effective and targeted treatment and prevention strategies aiming at specific lifestyles and behaviors.

Multimorbidity in People with Epilepsy

Multimorbidity is an emerging priority in healthcare due to associations with the ageing population, frailty, polypharmacy, health and social care demands. It affects 60-70% of adults and 80% of children with epilepsy. Neurodevelopmental conditions are commonly seen in children with epilepsy, while cancer, cardiovascular and neurodegenerative conditions often afflict older people with epilepsy. Mental health problems are common across the lifespan. Genetic, environmental, social and lifestyle factors contribute to multimorbidity and its consequences. Multimorbid people with epilepsy (PWE) are at higher risk of depression and suicide, premature death, suffer lower health-related quality of life, and require more hospital admissions and health care costs. The best management of multimorbid PWE requires a paradigm shift from the traditional single disease-single comorbidity approach and a refocus on a person-centred approach. Improvements in health care must be informed by assessing the burden of multimorbidity associated with epilepsy, delineating disease clusters, and measuring the effects on health outcomes.

Physical multimorbidity, suicidal ideation, and suicide attempts among adults aged ≥50 years from low- and middle-income countries

OBJECTIVES

The association between physical multimorbidity and suicidal ideation or suicide attempts among older adults from low- and middle-income countries (LMICs) is largely unknown. We aimed to assess this association as well as its mediators using nationally representative data from six LMICs.

METHODS

Cross-sectional, community-based data from the Study on Global Aging and Adult Health were analyzed. A total of 11 chronic physical conditions were assessed. Self-reported information on past 12-month suicidal ideation and suicide attempts was also collected. Multivariable logistic regression and mediation analyses were conducted.

RESULTS

The final sample consisted of 34,129 adults aged ≥50 years (mean [SD] age 62.4 (16.0) years; maximum age 114 years; 52.1% females). In the overall sample, physical multimorbidity was associated with increased odds for suicidal ideation (OR = 2.99; 95% CI = 2.06-4.34) and suicide attempts (OR = 2.79; 95% CI = 1.58-4.95), with the association being stronger in males than females. The association between multimorbidity and suicidal ideation or suicide attempts was largely mediated by pain/discomfort (mediated% 33.3%-44.2%), sleep/energy (28.2%-33.8%), and mobility limitations (26.6%-34.8%).

CONCLUSIONS

Physical multimorbidity among older adults in LMICs was associated with a substantially increased risk for suicidal ideation and suicide attempts. Addressing the identified mediators in people with physical multimorbidity may aid in the prevention of suicidal ideation and suicide attempts.

Apolipoprotein E genotype, inflammatory biomarkers, and non-psychiatric multimorbidity contribute to the suicidal ideation phenotype in older age. The Salus in Apulia Study

BACKGROUND

Possible relationships between suicidal ideation and biopsychosocial predictors in older age are unclear. In the population-based Salus in Apulia Study, we investigated the relationships among biomarkers, socio-demographic, psychopathological, inflammatory and metabolic characteristics and suicidal ideation in 1252 older subjects.

METHODS

Suicidal ideation was evaluated with the brief version of the Columbia-Suicide Severity Rating Scale. Apolipoprotein E (APOE) genotype and inflammatory profile [interleukin (IL)-6, tumor necrosis factor (TNF)-α, C-reactive protein (CRP)] were evaluated. A machine learning algorithm, the Random Forest (RF), selected potential biopsychosocial factors associated to suicidal ideation.

RESULTS

Suicidal ideators accounted for 2.32 % of subjects, were female, smokers, and obese with multimorbidity. After adjusting for age, gender, education and social dysfunction, logistic regression analyses revealed that suicidal ideation was associated to late-life depression (LLD) (odds ratio:21.71,95 % confidence interval:9.22-51.14). In the full RF model, asthma was the most important contributor to suicidal ideation. In the final RF model, education, age, and mild cognitive impairment followed by gender and global cognition were considered the most important contributors. Among biomarkers, in the final RF model, IL-6 followed by TNF-α, APOE ε4 allele presence, CRP and high-density lipoprotein cholesterol contributed most to suicidal ideation.

LIMITATIONS

A relatively small number of older subjects with suicidal ideation (2.3 %); we did not distinguish between active and passive suicidal ideation.

CONCLUSIONS

Although LLD is a strong determinant of suicidal ideation, other non-psychiatric factors, i.e., serum inflammation biomarkers, APOE ε4 allele, and multimorbidity, should be taken into account when evaluating a suicidal ideation phenotype in older age.

The association of physical multimorbidity with suicidal ideation and suicide attempts in England: A mediation analysis of influential factors

BACKGROUND

Suicide is one of the most important causes of deaths in the United Kingdom, and the numbers are currently increasing.

AIM

There are numerous identified determinants of suicidality, and physical multimorbidity is potentially important but is currently understudied. Thus, this study aims to investigate the association of physical multimorbidity with suicidality.

METHODS

Cross-sectional data from the Adult Psychiatric Morbidity Survey 2007, which was conducted in England between October 2006 and December 2007 by the National Center for Social Research and Leicester University were analyzed. Respondents were asked about 20 physical health conditions, and suicidal ideation and suicide attempts were assessed.

RESULTS

Out of 7,403 individuals aged 16 years or over, the prevalence of physical multimorbidity, suicidal ideation, and suicide attempts were 35.1%, 4.3%, and 0.7%, respectively. After adjustment for potential confounders, compared to no physical conditions, 1, 2, 3, and ⩾4 conditions were associated with significant 1.79 (95% CI [1.25, 2.57]), 2.39 (95% CI [1.63, 3.51]), 2.88 (95% CI [1.83, 4.55]), and 6.29 (95% CI [4.12, 9.61]) times higher odds for suicidal ideation. Mediation analysis showed that cognitive problems (mediated percentage 39.2%) and disability (37.5%) explained the largest proportion between multimorbidity and suicidal ideation. Pain (38.0%) and cognitive problems (30.7%) explained the largest proportion between multimorbidity and suicide attempts.

CONCLUSION

In this large sample of UK adults, physical multimorbidity was associated with significantly higher odds for suicidal ideation and suicide attempts. Moreover, several potential mediators were identified, and these may serve as future targets for interventions that aim to prevent suicidality among people with physical multimorbidity.

Predictors and outcomes in primary depression care (POKAL) - a research training group develops an innovative approach to collaborative care

BACKGROUND

The interdisciplinary research training group (POKAL) aims to improve care for patients with depression and multimorbidity in primary care. POKAL includes nine projects within the framework of the Chronic Care Model (CCM). In addition, POKAL will train young (mental) health professionals in research competences within primary care settings. POKAL will address specific challenges in diagnosis (reliability of diagnosis, ignoring suicidal risks), in treatment (insufficient patient involvement, highly fragmented care and inappropriate long-time anti-depressive medication) and in implementation of innovations (insufficient guideline adherence, use of irrelevant patient outcomes, ignoring relevant context factors) in primary depression care.

METHODS

In 2021 POKAL started with a first group of 16 trainees in general practice (GPs), pharmacy, psychology, public health, informatics, etc. The program is scheduled for at least 6 years, so a second group of trainees starting in 2024 will also have three years of research-time. Experienced principal investigators (PIs) supervise all trainees in their specific projects. All projects refer to the CCM and focus on the diagnostic, therapeutic, and implementation challenges.

RESULTS

The first cohort of the POKAL research training group will develop and test new depression-specific diagnostics (hermeneutical strategies, predicting models, screening for suicidal ideation), treatment (primary-care based psycho-education, modulating factors in depression monitoring, strategies of de-prescribing) and implementation in primary care (guideline implementation, use of patient-assessed data, identification of relevant context factors). Based on those results the second cohort of trainees and their PIs will run two major trials to proof innovations in primary care-based a) diagnostics and b) treatment for depression.

CONCLUSION

The research and training programme POKAL aims to provide appropriate approaches for depression diagnosis and treatment in primary care.

Intent disclosure in late-life suicide: Age group differences in correlates and associations with suicide means

Age-adjusted suicide rates declined from 2018 to 2020. However, suicide rates among older adults, particularly males 75 and older, have continued to rise, and the evidence base for effective interventions to prevent suicide in late life remains limited. One strategy to prevent older adults' suicidal behavior is to intervene when they reveal suicide intent. Previous research found that a significant proportion of older suicide decedents disclosed their suicide intent close to the fatal incident. In this study, based on the 2017-2019 United States National Violent Death Reporting System (NVDRS) data, we examined: (1) correlates of intent disclosure among three age groups (65-74, 75-84, and 85+) of older suicide decedents (N = 17,917; 14,856 men and 3,061 women); and (2) associations of suicide means with intent disclosure and suicide contributing factors. The results show that 19.9% of all suicide decedents aged 65+ (18.7%, 21.0%, and 22.0% in the 65-74, 75-84, and 85+ age groups, respectively) disclosed their suicide intent to their partner, family/friends, and healthcare providers within a month of their death. Multivariable analyses using generalized linear models for a Poisson distribution with a log link showed that physical and mental health, substance misuse, addiction problems, and relationship/other life stressors were associated with a higher likelihood of intent disclosure in the 65-74 and 75-84 age groups. However, only physical health problems were associated with a higher likelihood of intent disclosure among those aged 85 and older. Intent disclosure was not associated with using firearms and poisoning as suicide means but with a lower likelihood of hanging or suffocation. Mental health and substance misuse problems were associated with higher odds of hanging or suffocation and poisoning, and physical health problems and male sex in the 85+ age group were associated with higher odds of firearm use. Suicide prevention strategies for those who have disclosed their suicide intent or are at risk of suicidal behavior should include more patient-centered comfort and palliative care, mental health/substance misuse/addiction treatment, and restriction of access to potential suicide means. More research on older adults who disclose suicide intent and late-life suicide prevention strategies is needed.

The relationship between secondhand smoking exposure and mental health among never-smoking adolescents in school: Data from the Global School-based Student Health Survey

BACKGROUND

There is no safe level of exposure to secondhand smoking. Adolescence is a stage of rapid psychological development and is highly susceptible to various factors that can cause some mental health problems. This study aims to estimate the prevalence of secondhand smoking exposure in never-smoking school adolescents and evaluate whether there is an association between secondhand smoking exposure and mental health.

METHODS

70 nationally representative data sets from the Global School-based Student Health Survey, conducted between 2003 and 2017, were used to estimate the prevalence of secondhand smoking exposure and evaluate whether there is an association between secondhand smoking exposure and loneliness, sleeplessness, and suicidal ideation.

RESULTS

Total 191, 613 no-smoking school adolescents (43.0% boys) were included in this analysis. The prevalence of secondhand smoking exposure ranged from 15.1% in Tajikistan to 79.6% in Timor-Leste. There was no difference in the prevalence of secondhand smoking exposure between boys and girls in most countries. After adjusted, secondhand smoking exposure was positively associated with loneliness (odds ratio 1.39, 95% CI 1.30-1.49), sleeplessness (odds ratio 1.37, 95% CI 1.28-1.47), and suicidal ideation (odds ratio 1.22, 95% CI 1.15-1.30) in never-smoking school adolescents in overall samples.

LIMITATIONS

Use of self-report measures and potentially limited generalizability.

CONCLUSIONS

Secondhand smoking exposure remains a serious public health issue among never-smoking school adolescents and its impact on adolescent mental health cannot be ignored. Stricter and more comprehensive policies and bans on secondhand smoking should be implemented, and adolescents' mental health should receive more attention.

Bridging late-life depression and chronic somatic diseases: a network analysis

The clinical presentation of late-life depression is highly heterogeneous and likely influenced by the co-presence of somatic diseases. Using a network approach, this study aims to explore how depressive symptoms are interconnected with each other, as well as with different measures of somatic disease burden in older adults. We examined cross-sectional data on 2860 individuals aged 60+ from the Swedish National Study on Aging and Care in Kungsholmen, Stockholm. The severity of sixteen depressive symptoms was clinically assessed with the Comprehensive Psychopathological Rating Scale. We combined data from individual clinical assessment and health-registers to construct eight system-specific disease clusters (cardiovascular, neurological, gastrointestinal, metabolic, musculoskeletal, respiratory, sensory, and unclassified), along with a measure of overall somatic burden. The interconnection among depressive symptoms, and with disease clusters was explored through networks based on Spearman partial correlations. Bridge centrality index and network loadings were employed to identify depressive symptoms directly connecting disease clusters and depression. Sadness, pessimism, anxiety, and suicidal thoughts were the most interconnected symptoms of the depression network, while somatic symptoms of depression were less interconnected. In the network integrating depressive symptoms with disease clusters, suicidal thoughts, reduced appetite, and cognitive difficulties constituted the most consistent bridge connections. The same bridge symptoms emerged when considering an overall measure of somatic disease burden. Suicidal thoughts, reduced appetite, and cognitive difficulties may play a key role in the interconnection between late-life depression and somatic diseases. If confirmed in longitudinal studies, these bridging symptoms could constitute potential targets in the prevention of late-life depression.