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

Having any mental health condition before the COVID-19 pandemic as a risk factor of COVID-19 contagion during the first year of pandemic: A Spanish adult cohort

Numerous studies suggest that subjects suffering from a mental health condition before the COVID-19 pandemic were at higher risk of contagion, but mostly are cross-sectional or retrospective. The BIOVAL-D-COVID-19 is a longitudinal cohort study design with 922 subjects who full filled two evaluations from an online survey of Spanish residents before and during the pandemic. Mental health conditions assessed were: Major Depressive Episode (MDE), Generalised Anxiety Disorder (GAD), Suicidal Thoughts and Behaviours (STB) and subthreshold of panic and bipolar disorder (BD). Mental health screening instruments used were: the Spanish version of the Composite International Diagnostic Interview (CIDI) version 3.0 for the evaluation of MDE, the GAD-7 scale to evaluate GAD; STB was evaluated with four items from the CIDI questionnaire. Panic Disorder and BD were screened from a modified and self-reported version of the CIDI. A bivariate plus five logistic regression models were developed for each mental health condition adjusted by socio-demographic variables; employment status; general and physical health; comorbidity; and including all previous variables and the other mental health conditions. We found in bivariate model that MDE; GAD and STB were statistically significant risk factors of contagion of COVID-19. The logistic regression models developed reveal that having a previous GAD (aOR 3.30 1.31-8.31) or STB (aOR 2.16 CI 95% 1.01-4.62) was statistically significant associated with COVID-19 contagion, independently of all variables included. MDE was not a risk factor of contagion when it was adjusted by comorbidity (aOR 0.99 CI 95% 0.47-2.09). It is recommended to detect those subjects with previous GAD or STB as vulnerable groups of infection to reduce contagion rates.

Suicide risk in patients with a current depressive episode during the COVID-19 pandemic

Introduction

The prevalence of major depressive disorder (MDD) increased during the COVID-19 pandemic. Data on suicidality in these patients during the pandemic period remain scarce. The aim of the study was to determine the prevalence and variables associated with serious suicide risk in Russian inpatients with MDD during the COVID-19 pandemic.

Methods

A cross-sectional cohort study with consecutive sampling was conducted from January 1, 2021 to December 31, 2021. All patients completed the Mini International Neuropsychiatric Interview (M.I.N.I.) (including the suicidality module), the Beck Depression Inventory, and the State-Trait Anxiety Inventory, and underwent a semi-structured interview to collect relevant demographic and clinical data. Effect sizes for all independent variables and covariates were calculated using partial eta-squared (ηp2).

Results

Of the 6757 patients with non-psychotic mental disorders assessed, 1605 (23.7%) had MDD confirmed by the M.I.N.I., of whom 17.8% were at serious risk for suicide according to the M.I.N.I. suicidality module. Factors independently associated with serious suicide risk in Russian inpatients with MDD during the pandemic were younger age (ηp2 = 0.021), greater severity of depression (0.038), higher state anxiety (0.003), and nonsuicidal self-injury (NSSI) (0.066). The same variables, except for state anxiety, were independently associated with suicide risk in the subgroup of MDD patients previously infected with SARS-CoV2.

Conclusion

In the COVID-19 pandemic, the proportion of patients with MDD at serious risk of suicide was similar to pre-pandemic data. No associations were found between suicidality in patients with MDD and COVID-related factors. Younger age, greater severity of depression, and especially NSSI were the most significant risk factors for suicide in patients with MDD during the COVID-19 pandemic.

Risk of Suicide-Related Outcomes After SARS-COV-2 Infection: Results from a Nationwide Observational Matched Cohort of US Veterans

BACKGROUND

Negative mental health-related effects of SARS-COV-2 infection are increasingly evident. However, the impact on suicide-related outcomes is poorly understood, especially among populations at elevated risk.

OBJECTIVE

To determine risk of suicide attempts and other self-directed violence (SDV) after SARS-COV-2 infection in a high-risk population.

DESIGN

We employed an observational design supported by comprehensive electronic health records from the Veterans Health Administration (VHA) to examine the association of SARS-COV-2 infection with suicide attempts and other SDV within one year of infection. Veterans with SARS-COV-2 infections were matched 1:5 with non-infected comparators each month. Three periods after index were evaluated: days 1-30, days 31-365, and days 1-365.

PARTICIPANTS

VHA patients infected with SARS-COV-2 between March 1, 2020 and March 31, 2021 and matched non-infected Veteran comparators.

MAIN MEASURES

Suicide attempt and other SDV events for the COVID-19 and non-infected comparator groups were analyzed using incidence rates per 100,000 person years and hazard ratios from Cox regressions modeling time from matched index date to first event. Subgroups were also examined.

KEY RESULTS

198,938 veterans with SARS-COV-2 (COVID-19 group) and 992,036 comparators were included. Unadjusted one-year incidence per 100,000 for suicide attempt and other SDV was higher among the COVID-19 group: 355 vs 250 and 327 vs 235, respectively. The COVID-19 group had higher risk than comparators for suicide attempts: days 1-30 hazard ratio (HR) = 2.54 (CI:2.05, 3.15), days 31-365 HR = 1.30 (CI:1.19, 1.43) and days 1-365 HR = 1.41 (CI:1.30, 1.54), and for other SDV: days 1-30 HR = 1.94 (CI:1.51, 2.49), days 31-365 HR = 1.32 (CI:1.20, 1.45) and days 1-365 HR = 1.38 (CI:1.26, 1.51).

CONCLUSIONS

COVID-19 patients had higher risks of both suicide attempts and other forms of SDV compared to uninfected comparators, which persisted for at least one year after infection. Results support suicide risk screening of those infected with SARS-COV-2 to identify opportunities to prevent self-harm.

A Prospective Multicenter Longitudinal Analysis of Suicidal Ideation among Long-COVID-19 Patients

Long coronavirus disease 19 (COVID-19) is an emerging multifaceted illness with the pathological hallmarks of chronic inflammation and neuropsychiatric symptoms. These pathologies have also been implicated in developing suicidal behaviors and suicidal ideation (SI). However, research addressing suicide risk in long COVID-19 is limited. In this prospective study, we aim to characterize SI development among long-COVID-19 patients and to determine the predictive power of inflammatory markers and long-COVID-19 symptoms-including those of psychiatric origin-for SI. During this prospective, longitudinal, multicenter study, healthy subjects and long-COVID-19 patients will be recruited from the University Hospital of Geneva, Switzerland, the University of Genova, the University of Rome "La Sapienza", and the University of San Francisco. Study participants will undergo a series of clinic visits over a follow-up period of 1 year for SI assessment. Baseline and SI-onset levels of inflammatory mediators in plasma samples, along with 12 long-COVID-19 features (post-exertional malaise, fatigue, brain fog, dizziness, gastrointestinal disturbance, palpitations, changes in sexual desire/capacity, loss/change of smell/taste, thirst, chronic cough, chest pain, and abnormal movements) will be collected for SI risk analysis. The proposed enrollment period is from 15 January 2024 to 15 January 2026 with targeted recruitment of 100 participants for each study group. The anticipated findings of this study are expected to provide important insights into suicide risk among long-COVID-19 patients and determine whether inflammation and psychiatric comorbidities are involved in the development of SI in these subjects. This could pave the way to more effective evidence-based suicide prevention approaches to address this emerging public health concern.

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

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

Microglia and Other Cellular Mediators of Immunological Dysfunction in Schizophrenia: A Narrative Synthesis of Clinical Findings

Schizophrenia is a complex psychiatric condition that may involve immune system dysregulation. Since most putative disease mechanisms in schizophrenia have been derived from genetic association studies and fluid-based molecular analyses, this review aims to summarize the emerging evidence on clinical correlates to immune system dysfunction in this psychiatric disorder. We conclude this review by attempting to develop a unifying hypothesis regarding the relative contributions of microglia and various immune cell populations to the development of schizophrenia. This may provide important translational insights that can become useful for addressing the multifaceted clinical presentation of schizophrenia.

High molar ratios of tumor necrosis factor α (TNF α) soluble receptors I and II to the TNF ligand in human plasma from male veterans with comorbid posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI)

Background and Objectives

Posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) are associated with chronic inflammation, as inferred from increased, but variable, peripheral levels of cytokines. We sought proof of concept for the notion that peripheral cytokine binding proteins and/or soluble receptors can confound measures of cytokines in those with a history of physical and psychological traumatic exposures. Efforts were focused on one of the major cytokines involved in inflammation, tumor necrosis factor-α (TNF-α).

Methods

We examined blood plasma concentrations of TNF-α, its soluble receptors (TNF-soluble receptors (sR) I and TNFsRII), and C-reactive protein (CRP-1) in a cohort of US Veterans. In a previous study, CRP-1 was shown to be reduced by probiotic anti-inflammatory treatment in this patient cohort. All participants (n = 22) were diagnosed with PTSD and had a history of mild TBI with persistent post-concussive symptoms. Exclusion criteria included medications directly targeting inflammation.

Results

Molar concentrations of soluble TNFsRI and II exceeded concentrations of the TNF-α ligand. TNFsRI, but not TNFsRII, was significantly associated with CRP-1 (Spearman Rho correlations = 0.518; p=.016 and 0.365; p = .104, respectively).

Conclusions

TNF soluble receptors may bind to and sequester free TNF-α, suggesting that only measuring ligand concentrations may not provide a fully comprehensive view of inflammation, and potentially lead to inaccurate conclusions. TNFsRI concentration may provide a better estimate of inflammation than TNF-α for those with PTSD and post-acute mTBI with post-concussive symptoms, a hypothesis that invites further testing in larger studies.

Association between Psychological, Biochemical and Personal Factors with the Inflammatory Marker High-Sensitive C Reactive Protein (Hs-CRP) in Mexican Healthy Population

In the last decades, it has been shown that inflammatory processes play a role in the development of mental and physical problems; although some studies have researched the relationship between inflammation and psychological variables, the inclusion of biochemical variables as possible confounders has been limited. Therefore, the aim of this study was to determine whether psychological variables are associated with the inflammatory marker, highly sensitive CRP (hs-CRP), after controlling for personal and biochemical variables in the Mexican population. The study was performed at the University of Guadalajara facilities, during the second half of 2022. Healthy subjects were invited to participate in the study, which consisted of the measurement of personal, psychological, and biochemical variables. We included 172 participants, 92 (52.9%) of which were women; the median (range) of age of the whole sample was 22 (18-69) years old. In the bivariate analysis, significant positive correlations were observed between hs-CRP and body mass index (BMI) and waist/hip ratio (WHR) in both sexes, together with leukocytes, uric acid, low-density lipoprotein (LDL), triglycerides, and the liver enzymes gamma glutamyl transferase (GGT) and alkaline phosphatase (ALP). In the multivariate regression analysis of the global and men's samples, anxiety was positively associated with hs-CRP, while depression and positive relations with others were negatively associated with hs-CRP. In conclusion, psychological variables influence inflammation mainly in men, and anxiety was the main contributor; in addition, positive relation with others is a variable that should be further explored as a psychological protector of inflammation in both sexes.

Suicidality and homelessness: prevalence and associated factors of suicidal behaviour among homeless young adults in Southern Ethiopia

BACKGROUND

Research indicates that homelessness is associated with an increased risk of suicide. While street homelessness is a global problem, it is a disproportionately serious concern in low- and middle-income countries such as Ethiopia. Despite their high risk of suicidal thoughts and attempts, there has been limited research on this subject among homeless young people in Ethiopia. Therefore, we assessed the prevalence and factors contributing to suicidal behaviour among homeless young people in the southern region of this country.

METHODS

We conducted a community-based cross-sectional study from 15 June to 15 August 2020 involving 798 homeless young adults in four southern Ethiopian towns and cities. The Suicide Behaviour Questionnaire-Revised (SBQ-R) was used to assess suicidal behaviour. Data were coded and entered into Epi-Data version 7 and analysed using SPSS version 20. We conducted a multivariable logistic regression analysis to identify factors associated with suicidal behaviour. Variables with a p-value of < 0.05 were considered statistically significant. An adjusted odds ratio with a 95% confidence interval was determined to indicate the association's strength.

RESULTS

The overall prevalence of suicidal behaviour among young homeless individuals was 38.2% (95% CI: 34.8%, 41.5%). The lifetime prevalence of suicidal ideation, planning and attempt was 10.7% (95% CI: 8.6-12.9%), 5.1% (95% CI: 3.6-6.6%) and 3% (95% CI: 1.9-4.3%), respectively. A longer duration of homelessness (1-2 years) (AOR = 2.244, 95% CI: 1.447-3.481), stressful life events (AOR = 1.655, 95% CI: 1.132-2.418) and the stigma associated with homelessness (AOR = 1.629, 95% CI: 1.149-1.505) were significantly associated with suicidal behaviour.

CONCLUSION

The results of our study indicate that suicide is a serious public health problem among homeless young people in southern Ethiopia. We have found associations between suicidal behaviour and stressful events, homelessness lasting for one to two years and stigma. Our study suggests that policymakers and programme planners need to develop a strategy for preventing, detecting and managing suicidal behaviour among street-dwelling homeless young adults, a vulnerable and understudied population. A community-based suicide prevention campaign is also essential for street-dwelling homeless young people in Ethiopia.

Suicidal ideation following self-reported COVID-19-like symptoms or serology-confirmed SARS-CoV-2 infection in France: A propensity score weighted analysis from a cohort study

BACKGROUND

A higher risk of suicidal ideation associated with self-report of Coronavirus Disease 2019 (COVID-19)-like symptoms or COVID-19 infection has been observed in cross-sectional studies, but evidence from longitudinal studies remains limited. The aims of this study were 2-fold: (1) to explore if self-reported COVID-19-like symptoms in 2020 were associated with suicidal ideation in 2021; (2) to explore if the association also existed when using a biological marker of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in 2020.

METHODS AND FINDINGS

A total of 52,050 participants from the French EpiCov cohort were included (median follow-up time = 13.7 months). In terms of demographics, 53.84% were women, 60.92% were over 45 years old, 82.01% were born in mainland France from parents born in mainland France, and 59.38% completed high school. COVID-19-like symptoms were defined as participant report of a sudden loss of taste/smell or fever alongside cough, shortness of breath, or chest oppression, between February and November 2020. Symptoms were self-reported at baseline in May 2020 and at the first follow-up in Autumn 2020. Serology-confirmed SARS-CoV-2 infection in 2020 was derived from Spike protein ELISA test screening in dried-blood-spot samples. Samples were collected from October 2020 to March 2021, with 94.4% collected in 2020. Suicidal ideation since December 2020 was self-reported at the second follow-up in Summer 2021. Associations of self-reported COVID-19-like symptoms and serology-confirmed SARS-CoV-2 infection in 2020 with suicidal ideation in 2021 were ascertained using modified Poisson regression models, weighted by inverse probability weights computed from propensity scores. Among the 52,050 participants, 1.68% [1.54% to 1.82%] reported suicidal ideation in 2021, 9.57% [9.24% to 9.90%] had a serology-confirmed SARS-CoV-2 infection in 2020, and 13.23% [12.86% to 13.61%] reported COVID-19-like symptoms in 2020. Self-reported COVID-19-like symptoms in 2020 were associated with higher risks of later suicidal ideation in 2021 (Relative Riskipw [95% CI] = 1.43 [1.20 to 1.69]), while serology-confirmed SARS-CoV-2 infection in 2020 was not (RRipw = 0.89 [0.70 to 1.13]). Limitations of this study include the use of a single question to assess suicidal ideation, the use of self-reported history of mental health disorders, and limited generalizability due to attrition bias.

CONCLUSIONS

Self-reported COVID-19-like symptoms in 2020, but not serology-confirmed SARS-CoV-2 infection in 2020, were associated with a higher risk of subsequent suicidal ideation in 2021. The exact role of SARS-CoV-2 infection with respect to suicide risk has yet to be clarified. Including mental health resources in COVID-19-related settings could encourage symptomatic individuals to care for their mental health and limit suicidal ideation to emerge or worsen.

Adaptor protein MyD88 confers the susceptibility to stress via amplifying immune danger signals

Increasing evidence supports the pathogenic role of neuroinflammation in psychiatric diseases, including major depressive disorder (MDD) and neuropsychiatric symptoms of Coronavirus disease 2019 (COVID-19); however, the precise mechanism and therapeutic strategy are poorly understood. Here, we report that myeloid differentiation factor 88 (MyD88), a pivotal adaptor that bridges toll-like receptors to their downstream signaling by recruiting the signaling complex called 'myddosome', was up-regulated in the medial prefrontal cortex (mPFC) after exposure to chronic social defeat stress (CSDS) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein. The inducible expression of MyD88 in the mPFC primed neuroinflammation and conferred stress susceptibility via amplifying immune danger signals, such as high-mobility group box 1 and SARS-CoV-2 spike protein. Overexpression of MyD88 aggravated, whereas knockout or pharmacological inhibition of MyD88 ameliorated CSDS-induced depressive-like behavior. Notably, TJ-M2010-5, a novel synthesized targeting inhibitor of MyD88 dimerization, alleviated both CSDS- and SARS-CoV-2 spike protein-induced depressive-like behavior. Taken together, our findings indicate that inhibiting MyD88 signaling represents a promising therapeutic strategy for stress-related mental disorders, such as MDD and COVID-19-related neuropsychiatric symptoms.

The Role of Inflammation in the Pathophysiology of Depression and Suicidal Behavior: Implications for Treatment

Depression and suicidal behavior are 2 complex psychiatric conditions of significant public health concerns due to their debilitating nature. The need to enhance contemporary treatments and preventative approaches for these illnesses not only calls for distillation of current views on their pathogenesis but also provides an impetus for further elucidation of their novel etiological determinants. In this regard, inflammation has recently been recognized as a potentially important contributor to the development of depression and suicidal behavior. This review highlights key evidence that supports the presence of dysregulated neurometabolic and immunologic signaling and abnormal interaction with microbial species as putative etiological hallmarks of inflammation in depression as well as their contribution to the development of suicidal behavior. Furthermore, therapeutic insights addressing candidate mechanisms of pathological inflammation in these disorders are proposed.

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

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

Suicide Risk in Post-COVID-19 Syndrome

Post-acute sequelae of COVID-19 include several neuropsychiatric disorders. Little is known about the relationship between post-COVID-19 syndrome and suicidality. The aim of the study was to investigate the risk of suicide in subjects with persistent post-COVID-19 syndrome. One-thousand five-hundred eighty-eight subjects were assessed in the Post-Acute Care Service at the Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS of Rome. Assessment included: (a) sociodemographic characteristics; (b) symptoms during and after COVID-19; (c) psychopathological evaluation. Participants were divided in those with (SUI) or without (NON SUI) suicide risk according to the Mini International Neuropsychiatric Interview. Additionally, subjects with SUI were split into those with high (HIGH SUI) and low (LOW SUI) suicide risk. Between-group comparisons were made with t-tests for continuous variables and χ² tests for categorical variables. SUI showed greater percentages of physical complaints during and after COVID-19, greater percentages of psychiatric history and presence of psychiatric history in relatives, greater percentages of subjects previously undergoing psychopharmacotherapy, and greater levels of anxiety, mixed depressive symptoms, general psychopathology than NON SUI. HIGH SUI showed greater number of symptoms during and after COVID-19 and higher levels of mixed depressive symptoms than LOW SUI. Percentages of subjects undergoing psychotherapy was higher in LOW SUI than HIGH SUI. Greater levels of physical complaints and psychopathology during post-COVID-syndrome might enhance the risk of committing suicide. Treatment of physical complaints and psychotherapy might reduce suicide risk.

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

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