Emotional distress and dysregulation as treatment targets to reduce suicide in psychosis: a scoping review

There is a pressing need for effective treatments that address the high rate of suicide observed among people with psychosis. In this scoping review we highlight two suicidogenic treatment targets that have been relatively neglected in people with psychotic disorders: emotional distress and emotion dysregulation. We review the research on these constructs in psychosis and their relationship to suicide in this population, and then make clinical recommendations based on research findings. Emotional distress and emotional dysregulation may be promising treatment targets for suicide among people with psychosis.

Reducing short term suicide risk after hospitalization: A randomized controlled trial of the Collaborative Assessment and Management of Suicidality

BACKGROUND

This study compared the "next day appointment" (NDA) use of the Collaborative Assessment and Management of Suicidality (CAMS) to treatment as usual (TAU) for individuals discharged from the hospital following a suicide-related crisis. We hypothesized that CAMS would significantly reduce suicidal thoughts and behaviors as well as improve psychological distress, quality of life/overall functioning, treatment retention and patient satisfaction.

METHODS

Participants were 150 individuals who had at least one lifetime actual, aborted, or interrupted attempt and were admitted following a suicide-related crisis. There were 75 participants in the experimental condition who received adherent CAMS and 75 participants who received TAU. Suicidal thoughts and behaviors, psychological distress, and quality of life/overall functioning were assessed at baseline and at 1, 3, 6, and 12 months post-baseline. Treatment retention and patient satisfaction were assessed at post-treatment.

RESULTS

Participants in both conditions improved from baseline to 12 months but CAMS was not superior to TAU for the primary outcomes. A small but significant improvement was found in probability of suicidal ideation at 3 months favoring TAU and amount of suicidal ideation at 12 months favoring CAMS. CAMS participants experienced less psychological distress at 12 months compared to baseline.

LIMITATIONS

The study was limited by only one research clinic, lower than expected recruitment, and imbalance of suicidal ideation at baseline.

CONCLUSIONS

All participants improved but CAMS was not more effective than TAU. The NDA clinic was feasible and acceptable to clients and staff in both conditions and future research should investigate its potential benefit.

Emotion-related impulsivity and suicidal ideation: Towards a more specific model

OBJECTIVES

Suicidal ideation is a pervasive and painful experience that varies considerably in its phenomenology. Here, we consider how one key risk variable might inform our understanding of variation in suicidal ideation: emotion-related impulsivity, the trait-like tendency towards unconstrained speech, behaviour, and cognition in the face of intense emotions. We hypothesized that emotion-related impulsivity would be tied to specific features, including severity, perceived lack of controllability, more rapidly fluctuating course, higher scores on a measure of acute suicidal affective disturbance, and more emotional and cognitive disturbance as antecedents.

METHODS

We recruited two samples of adults (Ns = 421, 221) through Amazon Mechanical Turk (MTurk), with oversampling of those with suicidal ideation. Both samples completed psychometrically sound self-report measures online to assess emotion- and non-emotion-related dimensions of impulsivity and characteristics of suicidal ideation.

RESULTS

One form of emotion-related impulsivity related to the severity, uncontrollability, dynamic course, and affective and cognitive precursors of ideation.

CONCLUSIONS

Despite limitations of the cross-sectional design and self-report measures, the current findings highlight the importance of specificity in considering key dimensions of impulsivity and suicidal ideation.

Collaborative Assessment and Management of Suicidality for Teens: A Promising Frontline Intervention for Addressing Adolescent Suicidality

This pilot open trial examined the feasibility, acceptability, and preliminary outcomes of the Collaborative Assessment and Management of Suicidality for teens (CAMS-4Teens) who presented to outpatient care with suicidal thoughts and behaviors. Participants were 22 adolescents (13-17; 59% identified as female) with clinical elevations (≥7) on the Suicidal Behaviors Questionnaire-Revised (SBQ-R). Primary outcomes were feasibility and acceptability. We also explored outcomes of suicidal thoughts and behaviors, as well as mixed effects modeling for weekly assessments of the Suicide Status Form (SSF) Core Assessment constructs. Our main implementation outcomes suggest that the intervention is acceptable, appropriate, and feasible to deliver. Clinicians were adherent to the model with high ratings of adherence. In addition, preliminary evaluation of suicidal thoughts and behaviors found a large effect size for reduction in suicidal thoughts. Benchmarking to other adolescent suicide specific interventions and the Collaborative Assessment of Management of Suicidality with adult populations provide promise that suicidal adolescent responses may be on par with established interventions. Findings from the study are preliminary in nature and intended to inform if CAMS with adolescents is a promising approach to engage and treat patient-defined "drivers" of suicide. The results suggest that a future investigation with power to detect significant change over another active intervention is warranted.

Embedding an Evidence-Based Model for Suicide Prevention in the National Health Service: A Service Improvement Initiative

Despite the improved understanding of the determinants of suicide over recent decades, the mean suicide rate within the United Kingdom (UK) has remained at 10 per 100,000 per annum, with about 28% accessing mental health services in the 12 months prior to death. In this paper, we outlined a novel systems-level approach to tackling this problem through objectively differentiating the level of severity for each suicide risk presentation and providing fast-track pathways to care for all, including life-threatening cases. An additional operational challenge addressed within the proposed model was the saturation of local crisis mental health services with approximately 150 suicidality referrals per month, including non-mental health cases. This paper discussed a service improvement initiative undertaken within a National Health Service (NHS) secondary care mental health provider's open-access 24/7 crisis and home treatment service. An organisation-wide bespoke "suicide risk triage" system utilising the Collaborative Assessment and Management of Suicidality (CAMS) was implemented across all services. The preliminary impacts on suicidality, suicide rates and service user outcomes were described.

Developing Adaptive Treatment Strategies to Address Suicidal Risk in College Students: A Pilot Sequential, Multiple Assignment, Randomized Trial (SMART)

This pilot study investigated the potential to utilize adaptive treatment strategies for treating moderate to severe suicidal risk among college students. This article will describe the unique study design and report on feasibility and acceptability findings. A 2-stage Sequential Multiple Assignment Randomized Trial (SMART) was conducted: In Stage 1, 62 suicidal college students were randomized to either a suicide-focused or a treatment-as-usual condition (4-8 weeks). Those deemed insufficient responders were re-randomized to one of two Stage 2 interventions-both suicide-focused but one comprehensive and multimodal and the other flexible and theoretically agnostic (4-16 additional weeks). Recruitment rates were high, treatment dropout levels were lower than expected for the setting, study dropouts were rare, and counselors were able to deliver suicide-focused approaches with fidelity. Treatment satisfaction was high among clients and moderately high among counselors. Findings from this pilot show that a SMART is highly feasible and acceptable to suicidal college students, counselors, and campuses.

Are There Linguistic Markers of Suicidal Writing That Can Predict the Course of Treatment? A Repeated Measures Longitudinal Analysis

The purpose of this pilot study was to predict resolution of suicidal ideation and risk over the course of therapy among suicidal outpatients (N = 144) using a novel method for analyzing Self- verses Relationally oriented qualitative written responses to the Suicide Status Form (SSF). A content analysis software program was used to extract word counts and a repeated measures longitudinal design was implemented to assess improvement over time. Patients with primarily Relationally focused word counts were more likely to have a quicker suicide risk resolution than those with more Self-focused word counts (6-7 sessions versus 17-18 sessions). Implications of these data are discussed, including the potential for enhancing treatment outcomes using this method with individuals entering treatment.

A pilot and feasibility study of the plasma and tissue pharmacokinetics of cefazolin in an immature porcine model of pediatric cardiac surgery

BACKGROUND

Surgical site infection (SSI) prevention for children with congenital heart disease is imperative and methods to assess and evaluate the tissue concentrations of prophylactic antibiotics are important to help maximize these efforts.

AIM

The purposes of this study were to determine the plasma and tissue concentrations with standard of care, perioperative cefazolin dosing in an immature porcine model of pediatric cardiac surgery, and to determine the feasibility of this model.

METHODS

Piglets (3-5 days old) underwent either median sternotomy (MS) or cardiopulmonary bypass with deep hypothermic circulatory arrest (CPB + DHCA) and received standard of care prophylactic cefazolin for the procedures. Serial plasma and microdialysis sampling of the skeletal muscle and subcutaneous tissue adjacent to the surgical site was performed. Cefazolin concentrations were measured, noncompartmental pharmacokinetic analyses were performed, and tissue penetration of cefazolin was assessed.

RESULTS

Following the first intravenous dose, maximal cefazolin concentrations in the subcutaneous tissue and skeletal muscle were similar between groups with peak tissue concentrations 15-30 min after administration. After the second cefazolin dose given with the initiation of CPB, total plasma cefazolin concentrations remained relatively constant until the end of DHCA and then decreased while muscle- and subcutaneous-unbound cefazolin concentrations showed a second peak during or after rewarming. For the MS group, 60-67% of the intraoperative time showed subcutaneous and skeletal muscle concentrations of cefazolin >16 μg·ml(-1) while this percentage was 78-79% for the CPB + DHCA group. There was less tissue penetration of cefazolin in the group that underwent CBP + DHCA (P = 0.03).

CONCLUSIONS

The cefazolin dosing used in this study achieves plasma and tissue concentrations that should be effective against methicillin-sensitive Staphylococcus aureus but may not be effective against some gram-negative pathogens. The timing of the cefazolin administration prior to incision and a second dose given during cardiopulmonary bypass may be important factors for achieving goal tissue concentrations.

Toward a definition of "fresh" whole blood: an in vitro characterization of coagulation properties in refrigerated whole blood for transfusion

BACKGROUND

The hemostatic property of "fresh" whole blood (WB) has been observed in military application and cardiac surgery and is associated with reduced blood loss, transfusion requirements, and donor exposures. The time from donation to transfusion defining "fresh" has not been systematically studied. We undertook an in vitro study of coagulation properties of refrigerated WB stored for 31 days.

STUDY DESIGN AND METHODS

Twenty-one WB units were obtained from healthy volunteer donors and stored under standard AABB refrigerated conditions. Samples were obtained on the day after donation and again on Days 2, 4, 7, 11, 14, 17, 21, 24, and 31. Tests included complete blood count, pH, pO2, pCO2, glucose, lactate, thromboelastography (TEG), and platelet function by light transmission aggregometry (LTA).

RESULTS

There was progressive decline in pH, pO2, glucose, and sodium, but progressive increase in potassium, pCO2, and lactate. TEG variables in all units were normal through Day 11; abnormal values in some variables in some units began on Day 14. Final aggregation levels exhibited no change from Day 1 to Day 21 with adenosine diphosphate and epinephrine, but a decline with collagen (Day 7) and ristocetin (Day 17).

CONCLUSION

This in vitro study of coagulation properties demonstrates preservation of normal integrated coagulation function to a minimum of 11 days under standard conditions of refrigerated storage of WB for transfusion. These observations strongly suggest that the hemostatic quality of WB may extend beyond current transfusion practices. If confirmed clinically, this would increase availability and extend benefits of reduced donor exposure and transfusion requirements.

The internal suicide debate hypothesis: exploring the life versus death struggle

Researchers and theorists (e.g., Shneidman, Stengel, Kovacs, and Beck) hyothesized that suicidal people engage in an internal debate, or struggle, over whether to live or die, but few studies have tested its tenability. This study introduces direct assessment of a suicidal debate, revealing new aspects of suicidal ideation. Results, from an online survey (N = 1,016), showed nearly all suicide-risk respondents engaged in the debate. In addition, debate frequency accounted for 54% of the variance in suicidality scores, and showed significant associations with other indicators of suicide risk. Likely factors of the debate, reasons for living and dying, showed significant differences by suicidality, and most suicide-risk participants reported going online for such purposes, demonstrating a behavioral component of the debate.

Working with Suicidal Clients Using the Collaborative Assessment and Management of Suicidality (CAMS)

The Collaborative Assessment and Management of Suicidality (CAMS) was developed to modify clinician behaviors in how they initially identify, engage, assess, conceptualize, treatment plan, and manage suicidal outpatients. This approach integrates a range of theoretical orientations into a structured clinical format emphasizing the importance of the counselor and client working together to elucidate and understand the "functional" role of suicidal thoughts and behaviors from the client's perspective. Based on clinical research in various outpatient settings, CAMS provides mental health counselors with a novel clinical approach that is tailored to a suicidal client's idiosyncratic needs thereby insuring the effective clinical assessment, treatment, and tracking of high risk suicidal clients.

Activated clotting time (ACT) testing: analysis of reproducibility

Activated Clotting Time (ACT) has been the standard for monitoring heparin anticoagulation in cardiac surgery for three decades. Although a 10% coefficient of variation (CV) is the referenced standard for the test, no recent reports of precision are available. The precision of Hemochron FTCA510 (celite) and KACT (kaolin) ACT test tubes was evaluated using a retrospective analysis of results from both laboratory studies and routine clinical usage. Laboratory studies of reproducibility included analysis of the CV from repetitive testing using multiple lots of ACTs. Substrates used included 40 consecutive lots of control plasma and freshly heparinized donor blood. Across the lots of control plasma, the celite ACT yielded an average CV of 5.4% for the normal control level and 4.0% in the abnormal control level (range 3.6-9.7% and 2.7-6.3%, respectively). The KACT showed similar performance for the normal (mean = 4.5%, range 2.2-7.8%) and abnormal (mean = 3.8%, range 2.0-10.0%). These values, significantly less than 10%, reflect the combined variability of both the ACT tests and the lyophilized, single use vial, control material. Fresh whole blood samples exhibited improved ACT precision when compared to this artificial substrate. CVs for the celite ACT range from 0.6-6.0% at one unit heparin/ml blood to 2.4-11.6% at 5 units/ml where clotting times exceed 650 sec. The KACT showed even lower CVs at all heparin levels, with values of 2.4-7.0%. Clinical evaluations included samples (N = 56) collected from cardiac surgery patients with celite ACT values ranging to 744 sec. Duplicate values differed by an average of 7.5 sec or 1.8%. There was only one clinically significant difference in paired values; a 376 sec paired with a 406 sec, 400 sec being the clinical target time. This retrospective data analysis demonstrates that Hemochron ACT variability is significantly less than 10%.

Comparison of the hemostatic effects of fresh whole blood, stored whole blood, and components after open heart surgery in children

In a double-blind study, we compared the postoperative (post-op) blood loss in 161 children undergoing open heart surgery with cardiopulmonary bypass whose immediate post-op transfusion requirements were met with either very fresh whole blood (VFWB), 24- to 48-hour-old whole blood or reconstituted whole blood (packed red blood cells, fresh frozen plasma [FFP], and platelets). Assignment to treatment groups was not strictly random but dependent, in part, on the ability of families to provide directed donors for fresh blood. The three patient groups were comparable with respect to patient age, pre-op coagulation profiles (bleeding time, prothrombin time, activated partial thromboplastin time, platelet count, fibrin split products, fibrinogen, and platelet aggregation tests) difficulty of operative procedures and time spent on CPB. Mean 24-hour post-op blood loss in milliliters per kilogram was 50.9 +/- 9.3 in the VFWB group, 44.8 +/- 6.0 in the 24- to 48-hour-old group, and 74.2 +/- 8.9 in the reconstituted group (p = .03). When blood loss was compared in the 93 children less than 2 years of age, mean blood loss was 52.3 +/- 10.8 in the VFWB group, 51.7 +/- 7.4 in the 24- to 48-hour-old group, and 96.2 +/- 10.7 in the reconstituted group (P = .001). For subjects who had received reconstituted blood, 30-minute and 3-hour post-op platelet aggregation responses to adenosine diphosphate (10 mumol/L) and 30-minute aggregation response to epinephrine (2.5 mumol/L) were more depressed than in the VFWB and 24- to 48-hour groups (P less than .001, P = .005, and P = .02). Comparison of other post-op coagulation tests could not explain the increased blood loss in the reconstituted group. We conclude that the transfusion of less than 48 hours old whole blood is associated with significantly less post-op blood loss than the transfusion of packed red blood cells, FFP, and platelets in children under 2 years old who underwent complex cardiac surgery. The blood losses associated with the transfusion of VFWB and 24- to 48-hour-old blood are comparable and may be, in part, due to better functioning platelets.