The emergence of suicidal ideation during the post-hospital treatment of depressed patients

Interactions between mood and paranoid symptoms affect suicidality in first-episode affective psychoses

BACKGROUND

Suicide prevention is a major challenge in the treatment of first-episode affective psychoses. The literature reports that combinations of manic, depressive and paranoid symptoms, which may interact, are associated with an increased risk of suicide. The present study investigated whether interactions between manic, depressive and paranoid symptoms affected suicidality in first-episode affective psychoses.

METHODS

We prospectively studied 380 first-episode psychosis patients enrolled in an early intervention programme and diagnosed with affective or non-affective psychoses. We compared intensity and presence of suicidal thoughts and occurrence of suicide attempts over a three-year follow-up period and investigated the impact of interactions between manic, depressive and paranoid symptoms on level of suicidality.

RESULTS

At 12 months follow-up, we observed a higher level of suicidal thoughts and higher occurrence of suicide attempts among the affective psychoses patients compared to non-affective psychoses patients. Combined presence of either depressive and paranoid symptoms, or manic and paranoid symptoms, was significantly associated with increased suicidal thoughts. However, the combination of depressive and manic symptoms showed a significant negative association with suicidal thoughts.

CONCLUSIONS

This study suggests that paranoid symptoms combined with either manic or depressive symptoms are associated with an increased risk of suicide in first-episode affective psychoses. Detailed assessment of these dimensions is therefore warranted in first-episode affective patients and integrated treatment should be adapted to increased suicidal risk, even if patients do not display full-blown depressive or manic syndromes.

Exploring risk factors for re-hospitalization in a psychiatric inpatient setting: a retrospective naturalistic study

BACKGROUND

The reduction of multiple psychiatric hospitalizations is an important clinical challenge in mental health care. In fact, psychiatric re-hospitalization negatively affects the quality of life and the life expectancy of patients with psychiatric disorders. For these reasons, identifying predictors of re-hospitalization is important for better managing psychiatric patients. The first purpose of the present study was to examine the readmission rate in a large sample of inpatients with a psychiatric disorder. Second, we investigated the role of several demographical and clinical features impacting re-hospitalization.  METHOD: This retrospective study enrolled 1001 adult inpatients (510 men and 491 women) consecutively admitted to the University Psychiatric Clinic, Sant'Andrea Hospital, Sapienza University of Rome between January 2018 and January 2022. To identify risk factors for psychiatric re-hospitalization, we divided the sample into 3 subgroups: the Zero-Re group which had no readmission after the index hospitalization, the One-Re group with patients re-admitted only once, and the Two-Re with at least two re-admissions.  RESULTS: The groups differed according to previous hospitalizations, a history of suicide attempts, age at onset, and length of stay. Furthermore, the results of the regression model demonstrated that the Two-Re group was more likely to have a history of suicide attempts and previous hospitalizations.

DISCUSSION

These results indicate the importance of assessing risk factors in psychiatric hospitalized patients and implementing ad hoc prevention strategies for reducing subsequent re-hospitalizations.

Esketamine Nasal Spray for Rapid Reduction of Depressive Symptoms in Patients With Major Depressive Disorder Who Have Active Suicide Ideation With Intent: Results of a Phase 3, Double-Blind, Randomized Study (ASPIRE II)

BACKGROUND

Patients with major depressive disorder (MDD) having active suicidal ideation with intent require immediate treatment.

METHODS

This double-blind study (ASPIRE II) randomized adults (aged 18-64 years) with MDD having active suicidal ideation with intent to esketamine 84 mg or placebo nasal spray twice weekly for 4 weeks, given with comprehensive standard of care (hospitalization ≥5 days and newly initiated or optimized oral antidepressant[s]). Change from baseline to 24 hours post-first dose in Montgomery-Asberg Depression Rating Scale total score (primary efficacy endpoint) was analyzed using ANCOVA. Clinical Global Impression-Severity of Suicidality-revised (key secondary endpoint) was analyzed using ANCOVA on ranks of change.

RESULTS

Of 230 patients who were randomized (115 per arm), 227 received study drug and were included in efficacy/safety analyses; 184 (80.0%) completed double-blind treatment. Greater improvement in Montgomery-Asberg Depression Rating Scale total score was observed with esketamine (mean [SD]: -15.7 [11.56]) vs placebo (-12.4 [10.43]), each with standard of care, at 24 hours (least-squares mean difference [SE]: -3.9 [1.39], 95% CI: -6.60, -1.11; 2-sided P = .006). This was also noted at the earlier (4-hour) timepoint (least-squares mean difference -4.2, 95% CI: -6.38, -1.94). Patients in both treatment groups experienced rapid reduction in Clinical Global Impression-Severity of Suicidality-revised score; the between-group difference was not statistically significant. The most common adverse events among esketamine-treated patients were dizziness, dissociation, nausea, dysgeusia, somnolence, headache, and paresthesia.

CONCLUSION

This study confirmed rapid and robust reduction of depressive symptoms with esketamine nasal spray in severely ill patients with MDD who have active suicidal ideation with intent. Trial Registration: Clinical Trials.gov identifier: NCT03097133.

Frequency of rehospitalization after hospitalization for suicidal ideation or suicidal behavior in patients with depression

This study sought to: 1. determine the frequency of rehospitalization with diagnosis of suicidal ideation or suicide attempt (SI/SA) within a year and how often patients had multiple rehospitalizations; 2. identify the time period for which the risk of rehospitalization is highest; and 3. determine the characteristics of patients with multiple rehospitalizations. We conducted a retrospective cohort study of adults with depression using 4 US health claims databases. We defined hospitalization as an inpatient or emergency room visit with codes indicating a suicide attempt or suicidal thoughts using a validated algorithm. Rates of rehospitalization with SI or SA were analyzed together and separately, including multiple re-hospitalizations with SI/SA. Across all databases 121,065 patients were hospitalized with a diagnosis of SI/SA. Rates of rehospitalization within a year ranged from 7.96% to 11.24%. The risk of rehospitalization with SI/SA is highest during the first month. Nearly 50% of rehospitalizations occurred within 3 months after initial hospitalization. Patients with rehospitalization(s) had more anxiety disorders, sleep disorders and substance use disorders than patients without. Among patients with depression hospitalized for SI/SA, rehospitalization for SI/SA within a year is not uncommon. Risk of rehospitalization with a diagnosis of SI/SA is highest during the first month.

Anxiety symptoms are linked to new-onset suicidal ideation after six months of follow-up in outpatients with major depressive disorder

BACKGROUND

Suicide risk evaluation is one of the most challenging assessments of patients with major depressive disorder (MDD). Initial risk evaluation might be insufficient in predicting emergence of suicidal ideation during the maintenance period. We aimed to elucidate factors associated with emergence or persistence of suicidal ideation 6 months after initiation of outpatient treatment in patients with MDD.

METHODS

A total of 300 participants with MDD defined by DSM-IV-TR criteria underwent face-to-face interview at baseline and follow-up phone interview at 6 months later. Severity of depression, suicidal ideation, and anxiety were evaluated.

RESULTS

Among participants who did not report any suicidal idea at baseline, 10.9% reported suicidal ideation during the 6-month phone interview, while 28.4% of participants who reported suicidal ideation at baseline reported suicidal ideation during the phone interview. No significant difference in remission rate of depression was observed between the groups, but subjects without suicidal ideation at baseline had a higher rate of symptom improvement at the 6-month phone interview. After controlling for age, sex, baseline severity of suicide risk and depression and lifetime history of suicide attempts, emergence of suicidal ideation was significantly associated with anxiety level at baseline (t=2.127, p=0.039) and severity of depression symptoms at 6 month (t=-3.028, p=0.004); persistence of suicidal ideation was associated with severity of depression symptoms at 6 month (t=-4.962, p<0.001).

LIMITATION

Follow-up evaluation was done by phone interview.

CONCLUSION

Anxiety at baseline needs to be carefully evaluated in assessing suicide risk of patients with MDD.

Risk Factors for Suicidal Ideation among College Students: 6-Month Follow-up

This study was a 6-month follow-up study examining risk factors for suicide among college students. The sample included 95 participants who also participated in the first data collection period. Online questionnaires were completed by participants from the first wave. Thirteen percent of the sample had clinically significant levels of suicidal ideation, 3.2% met the criteria for dysthymia, and 15.8% and 17.9% met the DSM-IV criteria for a diagnosis of Major Depressive Disorder and Generalized Anxiety Disorder, respectfully. About 9.5% met criteria for alcohol dependence and 16.8% met criteria for drug abuse. Overall, 23% of the variance was explained in suicidal ideation with depressive symptoms, presence of anxiety, and high relational victimization scores attributing to 15% of the variance. Results of the 6-month follow-up support prior research suggesting high correlation between Major Depressive Disorder and suicidal ideation. However, there was no correlation found between levels of suicidal ideation and Generalized Anxiety Disorders.

Psychosocial features of depression: a systematic literature review

BACKGROUND

Despite the great burden of depression on sufferers and society, there is a lack of reliable information regarding the full range of psychosocial difficulties associated with depression and their related variables. This systematic review aimed to demonstrate the utility of the International Classification of Functioning, Disability and Health (ICF) in describing the psychosocial difficulties that shape the lived experience of persons with depression.

METHODS

An electronic search that included publications from 2005 to 2010 in the MEDLINE and PsycHINFO databases was conducted to collect psychosocial outcomes. Quality of studies was also considered.

RESULTS

103 studies were included. 477 outcomes referring psychosocial difficulties were extracted and grouped into 32 ICF related categories. Emotional functions (19% of studies), followed by energy and drive (17% of studies), were the most frequent psychosocial outcomes. The onset, course, determinants, and related variables of the most important psychosocial difficulties, reported in at least 10% of studies, were described. Medication played a dual role as determinant of onset and change in some psychosocial areas, e.g. in pain, sleep, and energy and drive.

LIMITATIONS

The search was limited by year of publication and focused only on minor and major depression diagnoses: other depressive disorders were not included. Some underresearched, but relevant psychosocial areas could have not been analyzed.

CONCLUSIONS

The present systematic review provides information on the psychosocial difficulties that depressive patients face in their daily lives. Future studies on depression should include outcome instruments that cover these relevant areas in order to comprehensively describe psychosocial functioning.