Suicidal ideation and risk factors in primary care patients with anxiety disorders

Generalized anxiety and mild anxiety symptoms in U.S. military veterans: Prevalence, characteristics, and functioning

Generalized anxiety disorder (GAD) is a mental disorder characterized by excessive anxiety and worries that impair daily functioning. While prior work has documented the prevalence and correlates of GAD and subthreshold GAD (SGAD) in clinical samples, contemporary data on the epidemiology of anxiety symptoms are lacking, particularly in higher-risk populations such as military veterans. To address this gap, we analyzed data from a large, nationally representative sample of U.S. veterans to examine the: prevalence of probable GAD and mild anxiety symptoms measured using a brief screener; sociodemographic and military characteristics associated with anxiety symptoms; and psychiatric and functional correlates of anxiety symptoms. Results revealed that a total of 7.9% (95% confidence interval [CI] = 6.7-9.3%) and 22.1% (95%CI = 20.5-23.9%) of veterans screened positive for probable GAD and mild anxiety symptoms, respectively. Relative to veterans without anxiety symptoms, those with probable GAD and mild anxiety symptoms were younger, more likely to be female and racial/ethnic minorities, and more likely to have served 2+ deployments. Further, a "dose-response" association was observed between anxiety symptom severity and clinical correlates, with robust associations observed between probable GAD and poorer mental health, suicidal thoughts and behaviors, and functional impairment. Mild anxiety symptoms showed intermediate magnitude associations with these outcomes. Results of this study suggest that 3-of-10 U.S. veterans report anxiety symptoms. While the use of a brief screener to assess mild anxiety symptoms and probable GAD is limited, findings underscore the importance of a dimensional approach to assessing anxiety symptoms and associated clinical and functional characteristics in veterans.

Can dialectical behavior therapy skills group treat social anxiety disorder? A brief integrative review

The purposes of this brief integrative review are to identify and critically evaluate recent work in the area of Dialectical Behavior Therapy-Skills Group (DBT-SG) for Social Anxiety Disorder (SAD) with suicidal ideation (SI) and to suggest further how DBT-based skills may be applied to cognitive maintenance factors of SAD. Accordingly, we first evaluate the relevance of DBT in treating SI in other disorders. Second, we evaluate the relationship between SI and SAD, providing considerations for the complexity of comorbid disorders and presentations. Finally, we extend this knowledge to discuss considerations for the use of DBT-SG skills to target specific etiological and maintenance elements of SAD, with a focus on four themes (interpersonal effectiveness, mindfulness, emotion regulation, and distress tolerance). Overall, we conclude that DBT-SG may prove beneficial in reducing SI and symptoms in SAD that impact social and emotional functioning.

Generalized Anxiety Disorder in Canadian Adults: to what Extent Might Social Support Subdomains and Negative Social Interactions Predict Psychological Distress?

Generalized anxiety disorder (GAD) may involve persistent and unwarranted anxiety, fear, and rumination, combined with various somatic symptoms (e.g., fatigue, dizziness, muscle tension, and nausea) which may compel many to withdraw socially. While studies report an inverse relationship between social support and psychological distress among adults with GAD, those that assess the distinct influence of negative social relations, particularly by sex are limited. The primary aims of this study were to (a) assess and compare respondents with a lifetime of GAD in terms of levels of perceived social support (using the Social Provisions Scale - 10 Items (SPS-10) Scale), negative social interactions (using the Negative Social Interaction (NSI) Scale) and psychological distress (using the Kessler Psychological Distress Scale (K10)), and (b) determine whether SPS-10 subdomains and NSIs predict psychological distress. Compared with a matched sample without GAD, respondents with GAD were more likely to be single, divorced, and have lower incomes. Respondents with GAD also had lower overall SPS-10 scores, and lower scores for each subdomain (i.e., 'guidance', 'reliable alliance', 'reassurance of worth', 'attachment', and 'social integration'), and higher NSI and K10 scores. Although no difference in psychological distress was observed between men and women with GAD, men had lower SPS-10 scores (overall and for each subdomain), while women had higher NSIs scores. A subsequent hierarchical regression for respondents with GAD revealed that 'social integration' and 'reassurance of worth' predicted lower psychological distress, while higher NSI scores predicted higher psychological distress. Finding implications and future research are discussed.

Factors affecting the utilization of mental health services among undergraduate students in a Nigerian University

Under-utilization of mental health services among university students is a major public health concern. This study assessed the factors affecting the utilization of mental health services among undergraduate students.

This research was a cross-sectional survey carried out among students of Afe Babalola University, Ado-Ekiti, Nigeria. A semi-structured self-administered questionnaire was used for data collection and multi-stage sampling technique was used in sampling the participants. Utilization, attitude, and health seeking behavior were categorized into good (≥50% score), and poor (<50% score), while social support was categorized into poor (8–18), moderate (19–25), and strong (26–32). Chi-square test and Logistic regression were used to assess the relationship between the categorical variables.

450 students enrolled in this study of which 52.4% were females and mean age of 19.40 ± 1.65 years. Most students showed a good attitude (87.5%), health seeking behavior (67.8%), and poor social support (69.4%) towards mental health services. There was an association between source of information (p = 0.005), health seeking behavior (p = 0.001) and utilization of mental health services. There was also a higher likelihood for students of female gender (OR: 1.621 (1.072–2.452)) and being aged above 20 years (OR: 1.331 (0.822–2.153)) to have good utilization of mental health services.

Majority of the students showed good attitude and health seeking behavior towards mental health services but there was poor utilization as well as poor to moderate social support towards mental health services. Gender, age, attitude, source of information as well as health seeking behavior are important factors that can affect the utilization of mental health services among undergraduate students. Interventions targeted towards these factors should be done to ultimately improve utilization of mental health services among undergraduate students.

Ego-resiliency moderates the risk of depression and social anxiety symptoms on suicidal ideation in medical students

BACKGROUND

Little is known about the role of protective factors in suicidal ideation among medical students. This study aimed to examine the association between suicidal ideation and protective (self-esteem/ego-resiliency/social support) and risk (depression/social anxiety) factors.

METHODS

Data on sociodemographic factors, depression, social anxiety, self-esteem, ego-resiliency, social support, and current suicidal ideation were collected from 408 medical students. A logistic regression model was constructed to identify the independent impact of potential influencing factors on suicidal ideation. Potential moderating effects were also explored.

RESULTS

Thirty-eight participants (9.3%) reported experiencing suicidal ideation. Younger age, higher levels of depression, social anxiety, and lower levels of self-esteem, ego-resiliency, and social support were found to be significantly correlated with suicidal ideation. In the final model, higher levels of depression and social anxiety were associated with an increased risk of suicidal ideation, while higher levels of self-esteem and social support were associated with a decreased risk of suicidal ideation. Although the independent effect was not significant, the interactions of ego-resiliency with both depression and social anxiety on suicidal ideation were significant. Higher levels of ego-resiliency acted as a buffer against suicidal ideation among those with higher levels of depression or social anxiety.

CONCLUSIONS

In addition to risk factors, this study revealed the underlying protective and moderating factors of suicidal ideation among medical students. Mental health programs focusing on enhancing ego-resiliency, self-esteem, and social support may contribute to suicide prevention in medical students.

Pain, functional disability and mental disorders as potential mediators of the association between chronic physical conditions and suicidal ideation in community living older adults

OBJECTIVES

To examine the associations between chronic physical conditions and suicidal ideation and to assess whether associations are mediated by pain, anxiety, depression, post-traumatic stress syndrome (PTSS), and functional disability.

METHODS

The study sample includes 1533 older adults aged 65+ recruited in primary care clinics between 2011-2013 and participating in Quebec's Health Survey on Services "Étude sur la Santé des Aînés-Services" (ESA-S) study. Path analysis was used to assess the associations. The presence of suicidal behaviour was ascertained using 4 questions. PTSS was based on a validated scale for primary care older adults. Anxiety and depression were assessed according to DSM-IV criteria. Pain was self-reported on an ordinal scale and functional disability was based on the presence of disability in 8 dimensions of activities of daily living. The main predictors included a list of 13 physical disorders identified by diagnostic codes. Suicidal ideation was also controlled by a number of socio-demographic and psychosocial factors.

RESULTS

PTSS, depression, and functional disability mediate the association between various chronic conditions and suicidal ideation. Although pain and anxiety are associated with many physical disorders, they did not mediate the association with suicidal ideation.

CONCLUSIONS

Chronic physical disorders are associated with suicidal ideation, either directly or indirectly through PTSS, depression, and functional disability. The findings underscore the importance of early identification and management of older patients with specific chronic disorders in primary care as they may be most at risk for suicidal ideation.

Comorbid alcohol-related problems and suicidality disproportionately impact men and emerging adults among individuals with depressive symptoms

OBJECTIVE

Depressive disorders are common among adults with alcohol use disorder and with suicidality; however, demographic differences in comorbid alcohol use disorder, binge drinking, and suicidality are understudied. The objective of this study was to determine the extent to which comorbid suicidality and alcohol use disorders and comorbid suicidality and binge drinking differ by age and gender among adults with depressive symptoms.

METHOD

The sample included adults (unweighted N=29,460) in the United States who completed the 2015-2018 National Survey of Drug Use and Heath and screened positively for depression. Gender and age groups odds of alcohol use disorder only, suicidality only, and alcohol use disorder+suicidality were compared to neither problem. Similar analyses were conducted for binge drinking.

RESULTS

Men showed disproportional odds of alcohol use disorder only, all suicidality and alcohol use disorder comorbidities, and binge drinking+active suicidal ideation than women. Emerging adults showed higher odds of: passive and active suicidal ideation only and suicidality+alcohol use disorder than adults 35 and older; binge drinking only, binge drinking+passive suicidal ideation, and binge drinking+active suicidal ideation than all older adults; binge drinking+suicide planning and binge drinking+attempts than adults 50 and older.

LIMITATIONS

Because participants all reported depression symptoms either at the subclinical or clinical level, demographic differences in suicidality, alcohol use disorder, and binge drinking found in this study cannot be generalized to non-depressed samples.

CONCLUSIONS

Treatment providers should be aware of disproportionately higher odds of comorbid suicidality and alcohol use disorder, and suicidality and binge drinking among men and emerging adults.

Suicidality and Its Relation with Physical and Mental Conditions: Results from a Cross-Sectional Study of the Nationwide Primary Care Population Sample in Latvia

Background and Objectives: Physical and mental conditions are important risk factors for suicidality. However, there is no clear understanding of these relationships and the effect of co-occurrence on suicidality. We aimed to investigate the associations between current suicidality and mental disorders, physical conditions, and health-related factors in the nationwide primary care population in Latvia. Materials and Methods: A cross-sectional study was performed within the framework of the National Research Program BIOMEDICINE 2014-2017 at 24 primary care settings across Latvia in 2015. Adult patients were evaluated over one week at each facility. Socio-demographic variables, physical condition, and health-related factors were assessed on-site by trained psychiatrists. Mental disorders and suicidality were determined using the Mini International Neuropsychiatric Interview, and assessments were conducted over the telephone within two weeks after the visit to the general practitioner. Results: Of the 1485 cases, 18.6% reported suicidality. Only current depression, any anxiety disorder, any alcohol use disorder, and physical-mental multimorbidity were significantly associated with suicidality in the multivariate logistic regression analysis. Gastrointestinal diseases were associated with current depression alone (odds ratio (OR) 10.36; 95% confidence interval (CI) 2.34-45.76) and comorbid depression with any anxiety disorder (OR 7.55; 95% CI 2.15-26.49) among persons with current suicidality. Conclusions: Screening for depression, anxiety, and alcohol use disorders regularly among patients with physical illness may be important to help recognise suicidality in primary care that could improve the quality of life of patients and prevent suicides.

Suicide in primary care: How to screen and intervene

Suicide is significant public health concern within the United States. Research results are mixed about the effectiveness of universal screening and interventions with patients who are at-risk for suicide. Primary care is a logical intervention point to mitigate risk among patients in each of these areas. The Department of Veterans Affairs and Department of Defense have developed comprehensive guidelines for the assessment and management of suicidal patients. This approach involves specific screening tools, risk stratification by categories and interventions used by clinicians to help reduce risk levels in their patients. This article aims to provide a model, built on the principles of these guidelines, which primary care physicians can use to identify, assess and intervene with patients who are at-risk for suicide.

The revision of the categories of mood, anxiety and stress-related disorders in the ICD-11: a perspective from the Arab region

Background

The World Health Organization estimates that 75% of patients with mental and substance use disorders in low- and middle-income countries do not have access to the care needed. In the Arab World, approximately 100–140 million people suffer from at least one psychiatric disorder. One main criticism of classification systems has been their lack of cultural sensitivity. The International Classification of Diseases, 11th edition aims to improve clinical utility of psychiatric classification across cultures. Mood, anxiety and stress-related disorders are the most common psychiatric manifestations and the most impacted by cultural factors.

Main body

Relying on rigorous field testing, including in three Arab countries, clinically meaningful changes have been introduced in the International Classification of Diseases 11. These include new disorders such as complex post-traumatic stress disorder and prolonged grief disorder. In classifying mood episodes, the pattern of symptoms over time is emphasized. Disorders associated with anxiety provide the basis for a new grouping separate from obsessive-compulsive-related disorders. Lastly, culture and its impact are incorporated into each diagnostic grouping.

Conclusions

This latest version of the International Classification of Diseases prioritizes addressing gaps in the validity and reliability of psychiatric classification. The methodology adopted in this latest revision is encouraging and opens the way to truly global collaboration on refining psychiatric diagnoses and practice.

Association between Suicidal Ideation and Causes of Primary Care Visits: A Cross-Sectional Study to Identify Patients with Suspected Suicidal Ideation

OBJECTIVE

Suicide victims are likely to visit a primary care provider within 1 month of the suicide attempt. However, it is impossible for primary care providers to screen all patients for suicidal ideation or attempts. We, therefore, aimed to investigate potential differences in the chief diagnoses received by primary care patients with and without suicidal ideation, as this information may provide clues and predict patients at risk of suicide.

METHODS

This cross-sectional study included 1,211 Korean adults aged ≥20 years who had participated in the Korea National Health and Nutrition Examination Survey during 2014 and provided information about their histories of suicidal ideation and visits to primary care providers. Multiple logistic regression analyses were used to examine whether suicidal ideation was associated with specific diseases after controlling for age, sex, household income, education, occupation, marital status, smoking, alcohol consumption, and physical activity.

RESULTS

Among primary care patients, the sample-weighted percentage of suicidal ideation was approximately 12%. The diagnoses of neoplasm and mental disorder were associated with a higher likelihood of suicidal ideation {odds ratio (OR) [95% confidence interval (CI)] 8.32 (1.01-68.56) and 6.19 (1.72-22.33), respectively}. Notably, diseases of the musculoskeletal system and connective tissue were also associated with suicidal ideation [OR (95% CI): 1.93 (1.09-3.43)].

CONCLUSION

The observed visit patterns and correlations of certain diagnoses with suicidal ideation suggest that primary care physicians should pay attention to patients with relevant disorders, consider screening suicidal ideation, and properly consult to a psychiatrist.

Sleep Patterns and Anxiety in Children Interact to Predict Later Suicidal Ideation

Elevated levels of childhood anxiety pose risk for suicide; however, factors that accentuate this risk are unknown. Seventy-one children participated in a longitudinal study investigating anxiety and sleep in childhood (between 7-11 years) and later suicidal ideation (SI; M = 3.3 years later). Sleep was assessed via subjective reports and objective measures (actigraphy and polysomnography). Children with greater anxiety symptoms were at greater risk for later SI when sleep disturbances were present in childhood. Results suggest that sleep disruption may amplify SI risk in anxious children.

Diagnostic consequences of a new category of anxious depression and a reduced duration requirement for anxiety symptoms in the ICD-11 PHC

BACKGROUND

A new diagnosis of anxious depression (AD), characterized by both depressive and anxious symptoms at case level, has been proposed for the classification of mental disorders for primary care for ICD-11 (ICD-11 PHC). The ICD-11 PHC proposes a duration requirement for anxiety symptoms of 2 weeks, in line with the requirement for depressive symptoms. This study examined diagnostic assignment under ICD-11 PHC as compared to the previous classification, the ICD-10 PHC, and the relationship of anxiety duration to disability and suicidal ideation.

METHODS

Primary care physicians in five countries referred patients based on either perceived psychological distress or distressing somatic symptoms to a research assistant who administered a computer-guided diagnostic interview. Complete data were obtained for 2279 participants.

RESULTS

Under ICD-11 PHC 47.7% participants received a diagnosis of AD and had greater disability than other diagnostic groups. Under ICD-10 PHC, in addition to meeting requirements for depressive episode, most of these patients met requirements for either generalized anxiety disorder (41.5%) or mixed anxiety and depressive disorder (45.4%). One third of individuals diagnosed with AD had anxiety durations between 2 weeks and 3 months and presented as much disability and suicidal ideation as individuals with longer anxiety durations.

LIMITATIONS

The study was not designed to establish prevalence of these conditions.

CONCLUSION

The proposed ICD-11 PHC encourages early identification and management of significant anxiety symptoms in primary care, particularly when these co-occur with depression. This study provides support for the clinical relevance of these symptoms and the importance of early identification.

Internet-Delivered Acceptance and Commitment Therapy for Anxiety Treatment: Systematic Review

Background

Anxiety conditions are debilitating and prevalent throughout the world. Acceptance and Commitment Therapy (ACT) is an effective, acceptance-based behavioral therapy for anxiety. However, there are treatment barriers (eg, financial, geographical, and attitudinal), which prevent people from accessing it. To overcome these barriers, internet-delivered ACT (iACT) interventions have been developed in recent years. These interventions use websites to deliver ACT information and skill training exercises on the Web, either as pure self-help or with therapist guidance.

Objective

This systematic review aimed to examine the therapeutic impact of iACT on all anxiety conditions.

Methods

The EMBASE, MEDLINE, ProQuest Central, PsycINFO, Scopus, and Web of Science databases were searched up to September 2018. The titles and abstracts of remaining records after deduplication were screened by 2 authors with a total of 36 full-text articles being retained for closer inspection next to eligibility criteria. Empirical studies of all designs, population types, and comparator groups were included if they appraised the impact of iACT treatment on any standardized measure of anxiety. Included studies were appraised on methodological quality and had their data extracted into a standardized coding sheet. Findings were then tabulated, and a narrative synthesis was performed because of the heterogeneity found between studies.

Results

A total of 20 studies met inclusion criteria. There were 11 randomized controlled trials (RCTs) and 9 uncontrolled pilot studies. Participants across all studies were adults. The anxiety conditions treated were as follows: generalized anxiety disorder (GAD), social anxiety disorder (SAD), illness anxiety disorder (IAD), and general anxiety symptoms, with or without comorbid physical and mental health problems. A total of 18 studies reported significant anxiety reduction after iACT treatment. This was observed in studies that delivered iACT with (n=13) or without (n=5) therapist guidance. The average attrition rate across all included studies during the active iACT treatment phase was 19.19%. In the 13 studies that assessed treatment satisfaction, participants on average rated their iACT experience with above average to high treatment satisfaction.

Conclusions

These findings indicate that iACT can be an efficacious and acceptable treatment for adults with GAD and general anxiety symptoms. More RCT studies are needed to corroborate these early iACT findings using empirical treatments in active control groups (eg, internet-delivered cognitive behavioral therapy). This would potentially validate the promising results found for SAD and IAD as well as address the full spectrum of anxiety disorders.

Suicide risk among Veteran primary care patients with current anxiety symptoms

BACKGROUND

Although anxiety is prevalent in primary care, the association between anxiety symptoms and suicide risk remains understudied.

OBJECTIVES

This cross-sectional study aimed to (i) assess the prevalence of suicide risk among Veteran primary care patients with anxiety symptoms and (ii) compare suicide risk between patients with a positive (versus negative) depression screen.

METHODS

Participants were 182 adult primary care patients (84.6% male, Mage = 58.3 years) with current anxiety symptoms, but no psychotherapy in specialty care in the past year, at a Veterans Health Administration medical center in New York. Participants completed self-report measures of anxiety, depression and suicide risk via telephone.

RESULTS

Forty percent endorsed ≥1 suicide risk item. Suicide risk was more common among those screening positive (versus negative) for depression (50.5% versus 26.5%, χ2 (1) = 10.88; P = 0.001). Participants with a negative depression screen constituted 31% of all those with any suicide risk. Logistic regression revealed that anxiety symptom severity was not associated with suicide risk (P = 0.14) after controlling for age, sex and depression screen status (P = 0.01).

CONCLUSIONS

A substantial proportion of primary care patients with anxiety was classified as at risk for suicide, even in the absence of a positive depression screen. Primary care providers should assess suicide risk among patients with anxiety symptoms, even if the patients are not seeking specialty mental health treatment, the anxiety symptoms are not severe or do not rise to the level of an anxiety disorder, and comorbid depressive symptoms are not present.

Depressive Symptom Network Associated With Comorbid Anxiety in Late-Life Depression

Background: Depression and anxiety are the most common comorbid psychiatric disorders in the elderly. Psychiatrists have been reporting worsened depression symptoms and prognosis by comorbid anxiety symptoms. However, it is still unclear how anxiety affects the course of depression in the elderly. The aims of this study are (1) to identify the symptom network in late-life depression (LLD), and (2) to examine the role of anxiety in LLD with a network perspective. Methods: The study analyzed 776 community-based participants who were clinically diagnosed with depression and enrolled in Suwon Geriatric Mental Health Center. Network analysis was used to investigate the relationships between the symptoms of the Montgomery-Åsberg Depression Rating Scale (MADRS). The depression sample was divided into groups of low and high anxiety according to the Beck Anxiety Index. Propensity score matching (PSM) was used to minimize the effects of depression severity on the network. Network comparison test (NCT) were carried out to compare the global connectivity, global strength, and specific edge strength between the two subgroups. Results: Reported sadness, pessimistic thinking, and suicidal ideation are the core symptoms of LLD in terms of node strength. The MADRS sum score [mean (SD) 28.10 (9.19) vs 20.08 (7.11); P < .01] was much higher in the high anxiety group. The NCT before PSM showed the high anxiety group had significantly higher global strength (P < .01). However, the NCT after PSM did not reveal any statistical significance both in global structure (P = .46) and global strength (P = .26). A comparison between centrality indices showed a higher node strength of vegetative symptoms in the high anxiety group and this also remained after PSM. Conclusion: Based on the statistical analysis, anxiety worsens the severity of depression in the elderly. However, NCT after PSM revealed comorbid anxiety does not change the global structure and strength of the depression symptom network. Therefore, anxiety may affect LLD in a way of worsening the severity, rather than changing psychopathology. Additionally, the study revealed the centrality of vegetative symptoms was low in LLD but increased substantially in patients with comorbid anxiety.

Suicidal ideation in primary care patients suffering from panic disorder with or without agoraphobia

BACKGROUND

Suicidal ideation is common in patients suffering from panic disorder. The present study investigated rates of suicidal ideation and risk factors for suicidal ideation in a sample of primary care patients suffering from panic disorder with or without agoraphobia.

METHODS

A total of N = 296 patients [n = 215 (72.6%) women; age: M = 43.99, SD = 13.44] were investigated. Anxiety severity, anxiety symptoms, avoidance behavior, comorbid depression diagnosis, severity of depression, age, sex, employment status, living situation and frequency of visits at the general practitioner were considered as risk factors of suicidal ideation.

RESULTS

Suicidal ideation was experienced by 25% of the respondents. In a logistic regression analysis, depression diagnosis and depression severity emerged as significant risk factors for suicidal ideation. Anxiety measures were not associated with suicidal ideation.

CONCLUSION

Suicidal ideation is common in primary care patients suffering from panic disorder with or without agoraphobia. Individuals with greater burden of mental illness in terms of mood disorder comorbidity and depressive symptomatology are especially likely to suffer from suicidal ideation.

Age Differences in Death and Suicidal Ideation in Anxious Primary Care Patients

OBJECTIVES

The objective of this study was to examine age differences in the likelihood of endorsing of death and suicidal ideation in primary care patients with anxiety disorders.

METHOD

Participants were drawn from the Coordinated Anxiety Learning and Management (CALM) Study, an effectiveness trial for primary care patients with panic disorder (PD), generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and/or social anxiety disorder (SAD).

RESULTS

Approximately one third of older adults with anxiety disorders reported feeling like they were better off dead. Older adults with PD and SAD were more likely to endorse suicidal ideation lasting at least more than half the prior week compared with younger adults with these disorders. Older adults with SAD endorsed higher rates of suicidal ideation compared with older adults with other anxiety disorders. Multivariate analyses revealed the importance of physical health, social support, and comorbid MDD in this association.

CONCLUSIONS

Suicidal ideation is common in anxious, older, primary care patients and is particularly prevalent in socially anxious older adults. Findings speak to the importance of physical health, social functioning, and MDD in this association.

CLINICAL IMPLICATIONS

When working with anxious older adults it is important to conduct a thorough suicide risk assessment and teach skills to cope with death and suicidal ideation-related thoughts.

Psychological interventions for anxiety in adult primary care patients: A review and recommendations for future research

Anxiety symptoms are prevalent in primary care, yet treatment rates are low. The integration of behavioral health providers into primary care via the Primary Care Behavioral Health (PCBH) model offers a promising way to improve treatment options by adding a team member with the necessary skillset to deliver evidence-based psychological interventions for anxiety. We conducted a narrative review of psychological interventions for anxiety applied within adult primary care settings (k = 44) to update the literature and evaluate the fit of existing interventions with the PCBH model. The majority of studies were randomized controlled trials (RCTs; 70.5%). Most interventions utilized cognitive-behavioral therapy (68.2%) and were delivered individually, face-to-face (52.3%). Overall, 65.9% of interventions (58.6% of RCTs, 91.7% of pre-post) were effective in reducing anxiety symptoms, and 83.3% maintained the gains at follow-up. Although it is encouraging that most interventions significantly reduced anxiety, their longer formats (i.e., number and duration of sessions) and narrow symptom targets make translation into practice difficult. Methodological limitations of the research included homogenous samples, failure to report key procedural details, pre-post designs, and restrictive eligibility criteria. We offer recommendations to guide future research to improve the likelihood of successful translation of anxiety interventions into clinical practice.

Predicting suicidal ideation in primary care: An approach to identify easily assessable key variables

OBJECTIVE

To obtain predictors of suicidal ideation, which can also be used for an indirect assessment of suicidal ideation (SI). To create a classifier for SI based on variables of the Patient Health Questionnaire (PHQ) and sociodemographic variables, and to obtain an upper bound on the best possible performance of a predictor based on those variables.

METHODS

From a consecutive sample of 9025 primary care patients, 6805 eligible patients (60% female; mean age = 51.5 years) participated. Advanced methods of machine learning were used to derive the prediction equation. Various classifiers were applied and the area under the curve (AUC) was computed as a performance measure.

RESULTS

Classifiers based on methods of machine learning outperformed ordinary regression methods and achieved AUCs around 0.87. The key variables in the prediction equation comprised four items - namely feelings of depression/hopelessness, low self-esteem, worrying, and severe sleep disturbances. The generalized anxiety disorder scale (GAD-7) and the somatic symptom subscale (PHQ-15) did not enhance prediction substantially.

CONCLUSIONS

In predicting suicidal ideation researchers should refrain from using ordinary regression tools. The relevant information is primarily captured by the depression subscale and should be incorporated in a nonlinear model. For clinical practice, a classification tree using only four items of the whole PHQ may be advocated.

Effects of vilazodone on suicidal ideation and behavior in adults with major depressive disorder or generalized anxiety disorder: post-hoc analysis of randomized, double-blind, placebo-controlled trials

Treatment-emergent suicidal ideation and behavior are ongoing concerns with antidepressants. Vilazodone, currently approved for the treatment of major depressive disorder (MDD) in adults, has also been evaluated in generalized anxiety disorder (GAD). Post-hoc analyses of vilazodone trials were carried out to examine its effects on suicidal ideation and behavior in adults with MDD or GAD. Data were pooled from vilazodone trials in MDD (four studies) and GAD (three studies). The incidence of suicide-related events was analyzed on the basis of treatment-emergent adverse event reporting and Columbia-Suicide Severity Rating Scale (C-SSRS) monitoring. Treatment-emergent suicidal ideation was analyzed on the basis of a C-SSRS category shift from no suicidal ideation/behavior (C-SSRS=0) at baseline to suicide ideation (C-SSRS=1-5) during treatment. In pooled safety populations (MDD, n=2233; GAD, n=1475), suicide-related treatment-emergent adverse events occurred in less than 1% of vilazodone-treated and placebo-treated patients. Incidences of C-SSRS suicidal ideation were as follows: MDD (vilazodone=19.9%, placebo=24.7%); GAD (vilazodone=7.7%, placebo=9.4%). Shifts from no suicidal ideation/behavior at baseline to suicidal ideation during treatment were as follows: MDD (vilazodone=9.4%, placebo=10.3%); GAD (vilazodone=4.4%, placebo=6.1%). Data from placebo-controlled studies indicate little or no risk of treatment-emergent suicidal ideation or behavior with vilazodone in adults with MDD or GAD. Nevertheless, all patients should be monitored for suicidal thoughts and behaviors during antidepressant treatment.

Differential associations between Social Anxiety Disorder, family cohesion, and suicidality across racial/ethnic groups: Findings from the National Comorbidity Survey-Adolescent (NCS-A)

The proposed research seeks to introduce a novel model relating Social Anxiety Disorder (SAD) and suicide outcomes (i.e., passive suicidal ideation, active suicidal ideation, and suicide attempts) in diverse adolescents. This model posits that family cohesion is one pathway by which suicide risk is increased for socially anxious youth, and predicts that the relationships between these variables may be of different strength in Latino and White subgroups and across gender. Data from a sample of Latino (n=1922) and non-Hispanic White (hereafter referred to as White throughout) (n=5648) male and female adolescents who participated in the National Comorbidity Survey-Adolescent were used for this study. Analyses were conducted using generalized structural equation modeling. Results showed that the mediation model held for White females. Further examination of direct pathways highlighted SAD as a risk factor unique to Latinos for active suicidal ideation and suicide attempt, over and above comorbid depression and other relevant contextual factors. Additionally, family cohesion showed a strong association with suicide outcomes across groups, with some inconsistent findings for White males. Overall, it appears that the mechanism by which SAD increases risk for suicidality is different across groups, indicating further need to identify relevant mediators, especially for racial/ethnic minority youth.

Primary care assessment of patients at risk for suicide

Primary care providers (PCPs) play a crucial role caring for patients with depression, managing antidepressant therapy, and assessing patients for suicide risk. Ten percent of the more than 20 million primary care visits for depression each year involve mental health issues, and account for 62% of the antidepressants prescribed in the United States. Psychiatric disorders appear to be underrecognized and undertreated in primary care. Suicidal ideation is present in a significant percentage of depressed primary care patients but rarely discussed. This article describes the warning signs and risk factors associated with suicide and recommends screening tools that can help PCPs identify patients at risk.

Risco de suicídio e comorbidades psiquiátricas no transtorno de ansiedade generalizada

RESUMO Objetivo Investigar o risco de suicídio nos pacientes com transtorno de ansiedade generalizada (TAG). Métodos Estudo transversal com 253 pacientes dos ambulatórios de Psiquiatria, Nefrologia e Cardiologia do Hospital Universitário da Universidade Federal de Alagoas. O instrumento utilizado foi o MINI 5.0.0 (Mini-International Neuropsychiatric Interview). Resultados Os indivíduos com TAG corresponderam a 16,6% da amostra, sendo 30,8% nos pacientes entrevistados no ambulatório de psiquiatria e 11,3% nos pacientes entrevistados nos demais ambulatórios. A maioria é do sexo feminino (83,3%), casada (53,8%), sendo a média de idade de 44 (±12,2) anos. Houve comorbidade psiquiátrica em 88,1% dos entrevistados; 54,8% possuíam duas ou mais e 33,3% tinham apenas uma. A mais prevalente foi depressão maior (53,7%), seguida de distimia (21,4%) e depressão recorrente (14,6%). O risco de suicídio foi observado em 54,8% dos indivíduos com TAG. Conclusão A prevalência de TAG foi significativamente maior que na população geral, principalmente no ambulatório de psiquiatria. A maioria dos pacientes apresentou comorbidade psiquiátrica, especialmente transtornos de humor, além de risco de suicídio. O TAG mostrou elevada correlação com transtornos de humor e significativa associação com o risco de suicídio.

Pharmacologic management of comorbid post-traumatic stress disorder and addictions

BACKGROUND AND OBJECTIVES

Post-traumatic Stress Disorder (PTSD) and substance use disorders (SUD) frequently co-occur, and their combination can increase poor health outcomes as well as mortality.

METHODS

Using PUBMED and the list of references from key publications, this review article covered the epidemiology, neurobiology and pharmacotherapy of PTSD with comorbid alcohol, opiate, and cannabis use disorders. These SUD represent two with and one without FDA approved pharmacotherapies.

RESULTS

SUD is two to three times more likely among individuals with lifetime PTSD, and suicide, which is made more likely by both of these disorders, appears to be additively increased by having this comorbidity of SUD and PTSD. The shared neurobiological features of these two illnesses include amygdalar hyperactivity with hippocampal, medial prefrontal and anterior cingulate cortex dysfunction. Medications for comorbid PTSD and SUD include the PTSD treatment sertraline, often used in combination with anticonvulsants, antipsychotics, and adrenergic blockers. When PTSD is comorbid with alcohol use disorder (AUD), naltrexone, acamprosate or disulfiram may be combined with PTSD treatments. Disulfiram alone may treat both PTSD and AUD. For PTSD combined with opiate use disorder methadone or buprenorphine are most commonly used with sertraline. Marijuana use has been considered by some to be a treatment for PTSD, but no FDA treatment for this addiction is approved. Pregabalin and D-cycloserine are two innovations in pharmacotherapy for PTSD and SUD.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Comorbid PTSD and SUD amplifies their lethality and treatment complexity. Although they share important neurobiology, these patients uncommonly respond to a single pharmacotherapy such as sertraline or disulfiram and more typically require medication combinations and consideration of the specific type of SUD.

Resilience moderates the risk of depression and anxiety symptoms on suicidal ideation in patients with depression and/or anxiety disorders

BACKGROUND

Few studies have investigated the role of protective factors for suicidal ideation, which include resilience and social support among psychiatric patients with depression and/or anxiety disorders who are at increased risk of suicide.

METHODS

Demographic data, history of childhood maltreatment, and levels of depression, anxiety, problematic alcohol use, resilience, perceived social support, and current suicidal ideation were collected from a total of 436 patients diagnosed with depression and/or anxiety disorders. Hierarchical multiple logistic regression analyses were used to identify the independent and interaction effects of potentially influencing factors.

RESULTS

Moderate-severe suicidal ideation was reported in 24.5% of our sample. After controlling for relevant covariates, history of emotional neglect and sexual abuse, low resilience, and high depression and anxiety symptoms were sequentially included in the model. In the final model, high depression (adjusted odds ratio (OR)=9.33, confidence interval (CI) 3.99-21.77) and anxiety (adjusted OR=2.62, CI=1.24-5.53) were independently associated with moderate-severe suicidal ideation among risk factors whereas resilience was not. In the multiple logistic regression model that examined interaction effects between risk and protective factors, the interactions between resilience and depression (p<.001) and between resilience and anxiety were significant (p=.021). A higher level of resilience was protective against moderate-severe suicide ideation among those with higher levels of depression or anxiety symptoms.

CONCLUSIONS

Our results indicate that resilience potentially moderates the risk of depression and anxiety symptoms on suicidal ideation in patients with depression and/or anxiety disorders. Assessment of resilience and intervention focused on resilience enhancement is suggested for suicide prevention.

Life span history of non-fatal suicidal behaviours in a large sample of general practitioners' patients: data from Rovigo, Northern Italy

A survey about history of non-fatal suicidal behaviour was performed on 1,171 subjects in the waiting room of general practitioners' practices in the territory of Rovigo (Northern Italy). The mean age of interviewed subjects was 52.9 ± 17.0, with a majority of female individuals. Two and two percent admitted previous experience of non-suicidal self-injury, 4.7 % admitted having had serious suicidal thoughts/plans, and 1.8 % reported at least one suicide attempt. Compared to the rest of the sample, people with history of suicidal behaviours resulted to be of younger age (p < .05), whilst their level of well-being was poorer (p < .001). When compared to the results of the Italian arm of the European Study of the Epidemiology of Mental Disorders, carried out on general population samples, the present study produces higher rates of suicidality, despite the much higher mean age of the interviewed subjects compared to the general population.

Anxiety disorders in primary care

Anxiety disorders are the most common psychiatric condition presenting to primary care practitioners. Yet they can be easily overlooked or misdiagnosed. Patients that struggle with anxiety disorders are more likely to seek treatment from primary care providers than mental health specialists. Given the costs in terms of debilitation and associated financial burden, and increased risk of suicide, the identification and successful treatment of anxiety is imperative. By means of clinical acumen and the use of screening tools, the provider can develop expertise in recognition and effective treatment of anxiety disorders.

Suicide risk in primary care: identification and management in older adults

The National Strategy for Suicide Prevention (2012) has set a goal to reduce suicides by 20% within 5 years. Suicide rates are higher in older adults compared to most other age groups, and the majority of suicide completers have visited their primary care physician in the year before suicide. Primary care is an ideal setting to identify suicide risk and initiate mental health care. We review risk factors for late-life suicide; methods to assess for different levels of suicidality; and recent research developments regarding both effective assessment and management of suicide risk among older primary care patients. We highlight that broader scale screening of suicide risk may be considered in light of findings that suicidality can occur even in the absence of major risk factors like depression. We also highlight collaborative care models targeting suicide risk, and recent innovative interventions that aim to prevent the development of suicidal ideation and suicidal behavior.

Risk factors for suicidal behaviour in individuals on disability pension due to common mental disorders - a nationwide register-based prospective cohort study in Sweden

BACKGROUND

Common mental disorders (CMD) have become one of the leading causes for disability pension (DP). Studies on predictors of adverse health outcome following DP are sparse. This study aimed to examine the association of different socio-demographic factors and health care consumption with subsequent suicidal behaviour among individuals on DP due to CMD.

METHOD

This is a population-based prospective cohort study based on register data. All individuals aged 18-64 years, living in Sweden on 31-Dec-2004 who in 2005 were on DP due to CMD (N = 46 745) were followed regarding suicide attempt and suicide (2006-10). Univariate and multivariate hazard ratios (HR) and 95% confidence intervals (CI) for suicidal behaviour were estimated by Cox regression.

RESULTS

During the five-year follow-up, 1 046 (2.2%) and 210 (0.4%) individuals attempted and committed suicide, respectively. Multivariate analyses showed that young age (18-24 years) and low education predicted suicide attempt, while living alone was associated with both higher suicide attempt and suicide (range of HRs 1.23 to 1.68). Combined prescription of antidepressants with anxiolytics during 2005 and inpatient care due to mental diagnoses or suicide attempt (2001-05) were strongly associated with suicide attempt and suicide (range of HRs 1.3 to 4.9), while inpatient care due to somatic diagnoses and specialized outpatient care due to mental diagnoses during 2001-05 only predicted suicide attempt (HR 1.45; 95% CI: 1.3-1.7; HR 1.30; 95% CI: 1.1-1.7).

CONCLUSIONS

Along with socio-demographic factors, it is very important to consider type of previous healthcare use and medication history when designing further research or intervention aiming at individuals on DP due to CMD. Further research is warranted to investigate both characteristics of disability pension due to CMD, like duration, diagnoses and grade as well as mechanisms to subsequent suicidal behavior, taking potential gender differences into consideration.

The effect of successful and unsuccessful smoking cessation on short-term anxiety, depression, and suicidality

Research on the mental health effects of quitting smoking is limited. Smokers with mental illness appear to be at a higher risk of unsuccessful smoking cessation. Recent work suggests they are at elevated risk for post-cessation increases in anxiety, depression and suicidal ideation. The current study tested the effects of successful and unsuccessful smoking cessation on short-term psychopathology in 192 community participants. Smoking cessation outcomes were classified using expired carbon monoxide levels that were taken at quit week, 1 and 2 week follow-up and 1 month follow-up. We found no psychopathology increases in participants who successfully quit smoking. For individuals struggling to quit our results partially supported a recently proposed struggling quitters hypothesis. However, the vast majority of individuals posited to be vulnerable by the struggling quitters hypothesis did not experience clinically significant increases in psychopathology. These findings have implications for clinicians whose clients are interested in smoking cessation.