Risk factors of suicide re-attempt: A two-year prospective study

BACKGROUND

History of suicide attempt (SA) is the strongest predictor of a new SA and suicide. It is primordial to identify additional risk factors of suicide re-attempt. The aim of this study was to identify risk factors of suicide re-attempt in patients with recent SA followed for 2 years.

METHODS

In this multicentric cohort of adult inpatients, the median of the index SA before inclusion was 10 days. Clinicians assessed a large panel of psychological dimensions using validated tools. Occurrence of a new SA or death by suicide during the follow-up was recorded. A cluster analysis was used to identify the dimensions that best characterized the population and a variable "number of personality traits" was created that included the three most representative traits: anxiety, anger, and anxious lability. Risk factors of re-attempt were assessed with adjusted Cox regression models.

RESULTS

Among the 379 patients included, 100 (26.4 %) re-attempted suicide and 6 (1.6 %) died by suicide. The two major risk factors of suicide re-attempt were no history of violent SA and presenting two or three personality traits among trait anxiety, anger and anxious lability.

LIMITATIONS

It was impossible to know if treatment change during follow-up occur before or after the re-attempt.

DISCUSSION

One of the most important predictors of re-attempt in suicide attempters with mood disorders, was the presence of three personality traits (anger, anxiety, and anxious lability). Clinicians should provide close monitoring to patients presenting these traits and proposed treatments specifically targeting these dimensions, especially anxiety.

Functioning and neurocognition in very early and early-life onset bipolar disorders: the moderating role of bipolar disorder type

Defining homogeneous subgroups of bipolar disorder (BD) is a major goal in personalized psychiatry and research. According to the neurodevelopmental theory, age at onset may be a key variable. As potential trait markers of neurodevelopment, cognitive and functional impairment should be greater in the early form of the disease, particularly type 1 BD (BD I). The age at onset was assessed in a multicenter, observational sample of 4190 outpatients with BD. We used a battery of neuropsychological tests to assess six domains of cognition. Functioning was measured using the Functioning Assessment Short Test (FAST). We studied the potential moderation of the type of BD on the associations between the age at onset and cognitive and functioning in a subsample of 2072 euthymic participants, controlling for potential clinical and socio-demographic covariates. Multivariable analyses showed cognition to not be impaired in individuals with early (21-30 years) and very early-life (before 14 years) onset of BD. Functioning was equivalent between individuals with early and midlife-onset of BD II and NOS but better for individuals with early onset of BD I. In contrast, functioning was not worse in individuals with very early-onset BD I but worse in those with very early-onset BD II and NOS. Early-life onset BDs were not characterized by poorer cognition and functioning. Our results do not support the neurodevelopmental view that a worse cognitive prognosis characterizes early-life onset BD. This study suggests that functional remediation may be prioritized for individuals with midlife-onset BD I and very early life onset BD 2 and NOS.

Incidence and predictors of metabolic syndrome onset in individuals with bipolar disorders: A longitudinal study from the FACE-BD cohort

INTRODUCTION

Metabolic syndrome (MetS) is a cluster of components including abdominal obesity, hyperglycemia, hypertension, and dyslipidemia. MetS is highly prevalent in individuals with bipolar disorders (BD) with an estimated global rate of 32.6%. Longitudinal data on incident MetS in BD are scarce and based on small sample size. The objectives of this study were to estimate the incidence of MetS in a large longitudinal cohort of 1521 individuals with BD and to identify clinical and biological predictors of incident MetS.

METHODS

Participants were recruited from the FondaMental Advanced Center of Expertise for Bipolar Disorder (FACE-BD) cohort and followed-up for 3 years. MetS was defined according to the International Diabetes Federation criteria. Individuals without MetS at baseline but with MetS during follow-up were considered as having incident MetS. A logistic regression model was performed to estimate the adjusted odds ratio and its corresponding 95% confidence interval (CI) for an association between each factor and incident MetS during follow-up. We applied inverse probability-of-censoring weighting method to minimize selection bias due to loss during follow-up.

RESULTS

Among individuals without MetS at baseline (n = 1521), 19.3% developed MetS during follow-up. Multivariable analyses showed that incident MetS during follow-up was significantly associated with male sex (OR = 2.2, 95% CI = 1.7-3.0, p < 0.0001), older age (OR = 2.14, 95% CI = 1.40-3.25, p = 0.0004), presence of a mood recurrence during follow-up (OR = 1.91, 95% CI = 1.22-3.00, p = 0.0049), prolonged exposure to second-generation antipsychotics (OR = 1.56, 95% CI = 0.99, 2.45, p = 0.0534), smoking status at baseline (OR = 1.30, 95% CI = 1.00-1.68), lifetime alcohol use disorders (OR = 1.33, 95% CI = 0.98-1.79), and baseline sleep disturbances (OR = 1.04, 95% CI = 1.00-1.08), independently of the associations observed for baseline MetS components.

CONCLUSION

We observed a high incidence of MetS during a 3 years follow-up (19.3%) in individuals with BD. Identification of predictive factors should help the development of early interventions to prevent or treat early MetS.

Biomarkers of Bipolar Disorder in Late Life: An Evidence-Based Systematic Review

PURPOSE OF REVIEW

Review the current evidence on biomarkers for bipolar disorder in the older adults. We conducted a systematic search of PubMed MEDLINE, PsycINFO, and Web of Science databases using the MeSH search terms "Biomarkers", "Bipolar Disorder", "Aged" and and "Aged, 80 and over". Studies were included if they met the following criteria: (1) the mean age of the study population was 50 years old or older, (2) the study included patients with bipolar disorder, and (3) the study examined one type of biomarkers or more including genetic, neuroimaging, and biochemical biomarkers. Reviews, case reports, studies not in English and studies for which no full text was available were excluded. A total of 26 papers were included in the final analysis.

RECENT FINDINGS

Genomic markers of bipolar disorder in older adults highlighted the implication of serotonin metabolism, while the expression of genes involved in angiogenesis was dysregulated. Peripheral blood markers were mainly related with low grade inflammation, axonal damage, endothelial dysfunction, and the dysregulation of the HPA axis. Neuroanatomical markers reflected a dysfunction of the frontal cortex, a loss of neurones in the anterior cingulate cortex and a reduction of the hippocampal volume (in patients older than 50 years old). While not necessarily limited to older adults, some of them may be useful for differential diagnosis (neurofilaments), disease staging (homocysteine, BDNF) and the monitoring of treatment outcomes (matrix metalloproteinases). Our review provides a comprehensive overview of the current evidence on biomarkers for bipolar disorder in the older adults. The identification of biomarkers may aid in the diagnosis, treatment selection, and monitoring of bipolar disorder in older adults, ultimately leading to improved outcomes for this population. Further research is needed to validate and further explore the potential clinical utility of biomarkers in this population.

Comparative analysis of anticholinergic burden scales to explain iatrogenic cognitive impairment and self-reported side effects in the euthymic phase of bipolar disorders: Results from the FACE-BD cohort

Bipolar disorders (BD) are characterized by cognitive impairment during the euthymic phase, to which treatments can contribute. The anticholinergic properties of medications, i.e., the ability of a treatment to inhibit cholinergic receptors, are associated with cognitive impairment in elderly patients and people with schizophrenia but this association has not been well characterized in individuals with remitted BD. Moreover, the validity of only one anticholinergic burden scale designed to assess the anticholinergic load of medications has been tested in BD. In a literature review, we identified 31 existing scales. We first measured the associations between 27 out of the 31 scales and objective cognitive impairment in bivariable regressions. We then adjusted the bivariable models with covariates: the scales significantly associated with cognitive impairment in bivariable and multiple logistic regressions were defined as having good concurrent validity to assess cognitive impairment. In a sample of 2,031 individuals with euthymic BD evaluated with a neuropsychological battery, two scales had good concurrent validity to assess cognitive impairment, whereas chlorpromazine equivalents, lorazepam equivalents, the number of antipsychotics, or the number of treatments had not. Finally, similar analyses with subjective anticholinergic side-effects as outcome variables reported 14 scales with good concurrent validity to assess self-reported peripheral anticholinergic side-effects and 13 to assess self-reported central anticholinergic side-effects. Thus, we identified valid scales to monitor the anticholinergic burden in BD, which may be useful in estimating iatrogenic cognitive impairment in studies investigating cognition in BD.

How to target disturbed identity in borderline patients? Self-identification program: A case study

Borderline personality disorder (BPD) is a severe and relatively prevalent psychiatric disorder, responsible for high rates of suicidal behaviors. Disturbed identity appears as at the very core of this disorder, being inter-related with all other BPD features. Notably, from a dimensional perspective on mental disorders, one should realize that it is from our usual self-representation that we live all our daily experiences. Then, if the understanding of self-concept (or identity) is impaired, all the interventions implemented to decrease the self's suffering will subsequently be impaired. The purpose of the present case study was to illustrate the nine identity diffusion categories described by Jørgensen & Bøye (2022) and how the level of identity function can be improved in a third-wave cognitive and behavioral therapy targeting progressive correct self-identification.

Childhood trauma increases vulnerability to attempt suicide in adulthood through avoidant attachment

BACKGROUND

Childhood trauma and affective disorders are known risk factors for adult suicidal behavior. Studies have shown a mediating effect of insecure attachment on the effect of childhood trauma and suicidal behavior but so far it is not clear whether this effect is related to an attachment dimension (anxiety, avoidance).

AIM

The present study sought to examine the mediating effect of attachment anxiety and avoidance on suicidal behavior.

METHODS

We analyzed data on childhood trauma, attachment style, depression severity, presence of prior suicide attempts and current suicide ideation from 96 patients diagnosed with an affective disorder. Two mediation analyses were conducted to assess the effect of childhood trauma on 1) prior suicide attempts and 2) current suicidal ideation through its effect on attachment.

RESULTS

We found that childhood trauma had a complete mediated effect on the presence of prior suicide attempts through its effect on avoidant attachment (a1b1 = 0.0120, 95%-CI [0.0031, 0.0276]). However, only emotional abuse had a direct influence on suicidal ideation (c' = 0.0273, p < 0.01) without any indirect effect of anxious or avoidant attachment.

LIMITATIONS

Variables were not assessed in a prospective way and sample size was small.

CONCLUSIONS

Our findings suggest that individuals with avoidant attachment and childhood trauma are likely to present a high suicide risk. Since avoidant attachment is associated with altered perceptions and eventual rejection of social support, we recommend to screen for attachment early and to engage patients in therapeutical approaches focusing on the client-therapist alliance.

Neutrophil-to-lymphocyte ratio (NLR) variations in relationship with childhood maltreatment in patients with anorexia nervosa: a retrospective cohort study

PURPOSE

Anorexia nervosa (AN) is a serious mental illness. It is frequently accompanied by a history of childhood maltreatment (CM) that may constitute a specific ecophenotype in patients with eating disorders necessitating special assessment and management. This retrospective study tested whether in patients with AN, CM-related chronic stress may manifest through low-grade inflammation reflected by an increase in white blood cell ratios (neutrophil-to-lymphocyte ratio, NLR, platelet-to-lymphocyte ratio, and monocyte-to-lymphocyte ratio).

METHODS

Participants (N = 206) were enrolled at an eating disorder daycare unit in Montpellier, France, from March 2013 and January 2020. CM was assessed using the childhood trauma questionnaire (CTQ). The Eating Disorder Examination Questionnaire (EDE-Q) and the MINI were used to assess AN severity and the other clinical characteristics, respectively.

RESULTS

NLR was higher in patients with AN and history of CM (p = 0.029) and in patients with AN and history of emotional abuse (p = 0.021), compared with patients with AN without history of CM. In multivariate analysis, emotional abuse (β = 0.17; p = 0.027) contributed significantly to NLR variability.

CONCLUSION

In patients with AN, NLR is a low-grade inflammation marker that is influenced by various sociodemographic, clinical and biological factors. It is more directly affected by some CM types, especially emotional abuse, than by the presence/absence of CM history. Future studies should focus on mediators between CM and increased inflammation, such as interoceptive awareness, emotional dysregulation, food addiction, and stress sensitization.

LEVEL OF EVIDENCE

III. Evidence obtained from well-designed cohort or case-control analytic studies.

Suicide Prevention in Patients with Severe Mental Disorders

Until 2016, only few interventions were supposed to work in suicide prevention: restriction of access to lethal means, school-based universal prevention, treatment of depression and ensuring chain of care. Then, despite the multiplication of the therapeutic strategies for psychiatric disorders during the last decades, the incidence of suicide has not substantially decreased. Among several hypotheses, we proposed that suicidal depression is a specific form of depression, less responsive to antidepressants, carrying a high suicide risk, which deserves specific interventions. During the last decade, few controlled studies have been performed in at risk patients with short term reduction of the risk of suicide as a main objective, and the interest for old drugs such as lithium and clozapine remains. Recent data allow to propose that a new era is coming with evidence-based strategies of suicide prevention that should lead to change the way we deal with suicidal patients. Importantly, most efforts to develop interventions have moved to a perspective that suicide- specific treatments are necessary in addition to interventions for primary psychiatric disorders. By formulating the hypothesis that suicidal patients present a dysregulated response to social adversity based on specific brain areas associated with psychological pain, relying to opioidergic, immune and glutamatergic systems. Last, due to the difficult management of suicidal patients, innovative psychosocial interventions should be implemented for patients in suicidal crises and including safety planning, coordination of care, brief contact using phone calls. We have probably more solutions than ever to prevent suicide.

How to Manage Suicidal Risk at Digital Distance

Suicide prevention remains very difficult to achieve for many reasons, notably because we do not have any indicator of risk prediction, short-term risk factors being little explored, and evaluations being retrospective they are biased. Furthermore, patients at risk are not followed up, because of their lack of confidence in care, stigma, shame. On the other hand, the gap observed during the covid19 pandemic between distress and less occurrence of suicides could be linked to more virtual contacts. Then, the smartphone might be a good tool to stay connected to a protective network. We will discuss the opportunity offered by the smartphone to monitor patients with ecological momentary assessment, allowing to better characterize their acute states and detect an increased risk in real time, and thanks to the ecological momentary intervention 24/7 availability, improve access to care and better coordinate resources, and encourage self-care. These tools while offering new solutions for an efficient real time suicide prevention, may also raise some ethical issues that should be addressed.

Social Cohesion, Connection and Prescription: Good ways for Preventing Suicide?

Despite the multiplication of the therapeutic strategies for psychiatric disorders during the last decades, the incidence of suicide has not decreased substantially. Specifically, the most commonly used strategy, which is the use of antidepressant treatments, is clearly nonsufficient to attain the goal of a substantial reduction of suicides. Then, we will discuss the hypothesis that people who are more sensitive to experiences of social disconnection may activate a pathophysiological process which lead to a greater risk of suicide, and by such its study may offer new avenues for assessing the suicide risk as well as in providing new therapeutic targets. It is well demonstrated that both the objective condition of being alone and loneliness are strongly associated with suicide. From a series of cognitive imaging studies, it appears that suicidal patients are more sensitive to social exclusion, relying on a neural network implicated in the pain matrix, and individuals experiencing more psychological pain in daily life would be less prone to activate orbitofrontal cortex in social contexts which would facilitate disadvantageous decision-making, leading to choose options (i.e. suicidal act) with short-term reward (i.e. relief from pain) in spite of the risks (i.e. death). As psychological pain predicts suicidal behaviour, suggesting the need in assessing it in clinical practice, in using alleviating drugs i.e. opiates or ketamine, and in implementing evidence-based psychosocial strategies, based on caring contacts and social prescription. In conclusion, there are many innovations available to help tackle social vulnerability, which should be a priority in suicide prevention.

Influence of childhood maltreatment on prevalence, onset and persistence of psychiatric comorbidities and suicide attempts in bipolar disorders

Background

Methods

Results

Conclusions

[Feasibility of a psychoeducation group for patients with anorexia nervosa: An open study]

INTRODUCTION

Management of anorexia nervosa is difficult and few treatments have shown their effectiveness, justifying the exploration of new therapeutic approaches. Available evidence suggests an interest of psychoeducational groups in a significant number of psychiatric disorders. In patients suffering from anorexia, to date there are few groups or interventions available. We aimed to assess the feasibility and acceptability of a psycho-educational program promoting information about the disease and presenting techniques that can help to cope with anorexia and the functional impact it causes. The exploratory secondary objectives were to evaluate if such a group is associated with clinical improvement.

METHOD

Twenty-seven patients suffering from anorexia nervosa, in three groups, received eight weekly interventions in addition to their usual care. The study was open-label and non-randomized. Patients were assessed three times (baseline, at the end of the group and three months later). The assessments were both qualitative (Eating Disorder Examination questionnaire, The Anorexia Nervosa Stage of Change Questionnaire, the Eating Disorders Quality of Life questionnaire, Work and Social Adjustment Scale) and qualitative.

RESULTS

Seventy-eight percent of participants attended more than 75 % of the sessions. Seventy percent of participants found the group useful, and 95 % said it helped them improve their knowledge of the disease and its consequences. The average BMI of participants changed significantly with an average increase of 2.5kg between baseline and the three month assessment. There was an improvement of the eating disorders features in EDE-Q for the total score and for all subscores. The improvement in the total score was significant at the end of the group sessions, while the improvement in the sub scores became significant at three months. There was also a significant mood improvement at the end of the group. Finally, there was a significant improvement in daily functioning with a decrease in Work and Social Adjustment Scale scores and an improvement in quality of life. On qualitative assessment, patients were satisfied with the care proposal. They were able to appreciate the support and sharing of experience provided by the group formula. Most of them reported changes in their daily lives, either in their relationship to care and illness, or in their relationships with their loved ones, their leisure/work, their mood or their eating behavior.

CONCLUSION

Both qualitative and quantitative results suggest that this group psychoeducation program is feasible and well accepted by patients in addition to usual management. Although the methodology does not allow any conclusions, the clinical improvements observed during the group are encouraging with regard to the safety of this type of intervention and its possible effectiveness and argue for a controlled study.

What is special about suicidal depression?

Objective

Bipolar disorder is one of the most frequent psychiatric disorders among suicidal patients. A large part of patients with bipolar disorder (30–50%) will attempt suicide. Suicidal ideation being a major risk factor of suicidal act, it is crucial to better characterize patients with suicidal bipolar depression (i.e. depression with current suicidal ideation). The aim of this study was to characterize suicidal bipolar depressed patients in comparison with non-suicidal depressed patients in terms of clinical characteristics, evolution of depression and suicidal ideation course over time, and risk of suicide attempt during follow-up.

Methods

Among patients with bipolar disorder recruited from the network of FondaMental expert centres for bipolar disorder between 2009 and 2017, we selected patients with at least mild depression and without current manic symptomatology at baseline (N = 938). Suicidal depression was defined by a baseline score ⩾2 for item 12 of the QIDS-SR (28.9%). A subsample of about 300 patients (w/ or w/o suicidal ideation at baseline) was followed up for 2 years.

Results

Baseline clinical features (e.g. depression severity, childhood trauma, global functioning) were more severe in patients with without suicidal depression. Suicidal patients tended to remain more suicidal throughout the followup (3.4-fold higher risk of persistent suicidal ideation at the 2-year visit despite an improvement in depressive symptomatology).

Conclusions

Depressed bipolar disorder patients reporting suicidal ideation had more severe clinical features and were more prone to report persistent suicidal ideation during the follow-up, independently of thymic state. Clinicians should closely monitor this subgroup of patients

Disclosure

No significant relationships.

Game changer in the diagnosis of bipolar disorder using RNA editing-based blood biomarkers

Introduction

In clinical practice, differentiating Bipolar Disorder (BD) from unipolar depression is challenging due to the depressive symptoms, which are the core presentations of both disorders. Patients with BD are often misdiagnosed during depressive episodes resulting in a delay in proper treatment and a poor management of their condition.

Objectives

The aim of the present study is to discriminate between unipolar depression and BD using a panel of RNA edited blood biomarkers.

Methods

Depressed patients were classified according to clinical scores in MADRS and IDSC-30 depression scales. After blood collection and RNA extraction, we used whole-transcriptome sequencing to identify differential A-to-I editing events, and Targeted Next Generation Sequencing to validate those biomarkers.

Results

We discovered 646 variants differentially edited between depressed patients and control in a discovery cohort of 57 participants. After using stringent criteria and biological pathway analysis, 6 biomarker candidates were singled out and tested in a validation cohort of 160 patients suffering from unipolar depression and 95 BD patients in a depressive episode, which allowed a differential diagnosis of BD with an AUC of 0.935 and high specificity (Sp=84.6%) and sensitivity (Se=90.9%).

Conclusions

We have shown that a combination of 6 blood RNA editing-related biomarkers allows to discriminate unipolar and bipolar depression This 6 BMKs panel may be crucial to improve BD diagnosis and orientate the treatment therefore addressing the needs of millions of patients suffering from misdiagnosis and incorrect treatment for their diseases. This will change the game for the management of patients.

Disclosure

No significant relationships.

The Anti-inflammatory Effect of the Tricyclic Antidepressant Clomipramine and Its High Penetration in the Brain Might Be Useful to Prevent the Psychiatric Consequences of SARS-CoV-2 Infection

At the time of writing (December 2020), coronavirus disease 2019 (COVID-19) has already caused more than one million deaths worldwide, and therefore, it is imperative to find effective treatments. The “cytokine storm” induced by Severe Acute Respiratory Syndrome-Coronavirus type 2 (SARS-CoV-2) is a good target to prevent disease worsening, as indicated by the results obtained with tocilizumab and dexamethasone. SARS-CoV-2 can also invade the brain and cause neuro-inflammation with dramatic neurological manifestations, such as viral encephalitis. This could lead to potentially incapacitating long-term consequences, such as the development of psychiatric disorders, as previously observed with SARS-CoV. Several pathways/mechanisms could explain the link between viral infection and development of psychiatric diseases, especially neuro-inflammation induced by SARS-CoV-2. Therefore, it is important to find molecules with anti-inflammatory properties that penetrate easily into the brain. For instance, some antidepressants have anti-inflammatory action and pass easily through the blood brain barrier. Among them, clomipramine has shown very strong anti-inflammatory properties in vitro, in vivo (animal models) and human studies, especially in the brain. The aim of this review is to discuss the potential application of clomipramine to prevent post-infectious mental complications. Repositioning and testing antidepressants for COVID-19 management could help to reduce peripheral and especially central inflammation and to prevent the acute and particularly the long-term consequences of SARS-CoV-2 infection.

Clinical predictors of recurrences in bipolar disorders type 1 and 2: A FACE-BD longitudinal study

OBJECTIVE

To examine which characteristics predict the time to a first mood recurrence at three years in Bipolar Disorder type I (BD-I) and type II (BD-II).

METHODS

Individuals with BD were followed up to 3 years. Turbull's extension of the Kaplan-Meier analysis for interval-censored data was used to estimate the cumulative probability of recurrence over time. Separate models were performed according to BD subtype to determine which baseline factors were predictive of recurrences and were adjusted for age, gender and educational level.

RESULTS

We included 630 individuals with BD-I and 505 with BD-II. The first recurrence of any polarity occurred earlier in BD-II (p = 0.03). The first depressive recurrence occurred earlier in BD-II (p < 0.0001), whereas the first (hypo)manic recurrence occurred earlier in BD-I (p = 0.0003). In BD-I, the clinical variables that were associated to the time to a first mood recurrence were depressive symptoms, lifetime rapid cycling, global activation and the number of psychotropic medications at baseline. In BD-II, the time to a first recurrence was associated with a younger age at onset of BD and a higher number of lifetime mood episodes. The Areas Under the Curve for both models were moderate.

CONCLUSION

Predictors of recurrences showed few specificities to BD-I or BD-II. The ability to predict recurrences in BD based on socio-demographic and clinical variables remained too moderate for a transfer in daily practice. This study highlights the need for further studies that would include other types of predictors, such as molecular, cognitive or neuro-imaging ones, to achieve an accurate level of prediction of recurrences in BD.

How Does COVID-19 Affect the Neurobiology of Suicide?

PURPOSE OF REVIEW

The aim of this review was to analyze COVID-19 effect on the biological features of suicidal vulnerability and its interaction with suicide-related biological pathways. We carried out a narrative review of international publications on the interactions of COVID-19 with the biological bases of suicide.

RECENT FINDINGS

We hypothesize that SARS-CoV-2 interacts with multiple biological processes that underlie suicidal behavior, such as the renin-angiotensin system, nicotinic receptors, and central and systemic inflammation. Social distancing measures may also worsen subjective or objective social disconnection, thus increasing the risk of suicide. Interestingly, the drugs used to prevent suicide could be promising options to counteract brain damage caused by this coronavirus. SARS-CoV-2 interacts with multiple biological pathways involved in suicide and opens a new window for understanding the suicidal process. The development of suicide prevention treatments in the context of a pandemic may benefit from knowledge on these interactions.

Non-alcoholic fatty liver disease in a sample of individuals with bipolar disorders: results from the FACE-BD cohort

OBJECTIVE

Non-Alcoholic fatty liver disease (NAFLD) is becoming the most common liver disease in Western populations. While obesity and metabolic abnormalities are highly frequent in bipolar disorders (BD), no studies have been performed to estimate the prevalence of NALFD in individuals with BD. The aim of our study is to estimate the prevalence of NAFLD and to identify the potential associated risk factors in a large sample of BD individuals.

METHODS

Between 2009 and 2019, 1969 BD individuals from the FACE-BD cohort were included. Individuals with liver diseases, Hepatitis B or C, and current alcohol use disorders were excluded from the analyses. A blood sample was drawn from participants. Screening of NAFLD was determined using fatty liver index (FLI). Individuals with FLI> 60 were considered as having NAFLD.

RESULTS

The prevalence of NAFDL in this sample was estimated at 28.4%. NAFLD was observed in 40% of men and 21% of women. NAFLD was independently associated with older age, male gender, sleep disturbances, and current use of atypical antipsychotics or anxiolytics. As expected, the prevalence of NALFD was also higher in individuals with overweight and in those with metabolic syndrome.

CONCLUSIONS

This study reinforces the view that individuals with BD are highly vulnerable to metabolic and cardiovascular diseases. The prevalence of NAFLD in individuals with BD was two times higher than the prevalence reported in the general population. The regular screening of the MetS in individuals with BD should be therefore complemented by the additional screening of NAFLD among these vulnerable individuals.

Evolution and characteristics of the use of valproate in women of childbearing age with bipolar disorder: Results from the FACE-BD cohort

BACKGROUND

Valproate is associated with teratogenic and neurodevelopmental effects. Several agencies have restricted the conditions of its prescription in bipolar disorders (BD). We aimed to assess the evolution of valproate prescription and the clinical profile of BD women of childbearing age receiving valproate.

METHODS

Based on a large national cohort, we included all BD women 16-50 years old. Sociodemographic, clinical and pharmacological data were recorded. Logistic regression analyses were used to describe variables associated with valproate prescription.

RESULTS

Of the 1018 included women 16-50 years old, 26.9% were treated with valproate with a mean daily dosage of 968 mg. The prevalence of BD women using valproate was 32.6% before May 2015 and 17.3% after May 2015 (p<0.001), the date of French regulatory publication of restriction of valproate prescription. The multivariate analysis revealed that the inclusion period after May 2015 (OR=0.54, CI 95% 0.37-0.78, p=0.001), the age lower than 40 years (OR=0.65, CI 95% 0.43-0.98, p=0.040) and the number of lifetime mood episodes (OR=0.98, CI 95% 0.95-0.99, p=0.040) were the variables negatively associated with the use of valproate.

LIMITATIONS

Study could be underpowered to determine a clinical profile associated with valproate prescription.

CONCLUSIONS

The regulatory change in BD women of childbearing age had a significant impact on valproate prescription, even if the prescription rate remains high. Important efforts are needed to help clinicians and patients to improve quality of care in BD women of childbearing age.

Compulsory admissions of patients with mental disorders: State of the art on ethical and legislative aspects in 40 European countries

Background.

Compulsory admission procedures of patients with mental disorders vary between countries in Europe. The Ethics Committee of the European Psychiatric Association (EPA) launched a survey on involuntary admission procedures of patients with mental disorders in 40 countries to gather information from all National Psychiatric Associations that are members of the EPA to develop recommendations for improving involuntary admission processes and promote voluntary care.

Methods.

The survey focused on legislation of involuntary admissions and key actors involved in the admission procedure as well as most common reasons for involuntary admissions.

Results.

We analyzed the survey categorical data in themes, which highlight that both medical and legal actors are involved in involuntary admission procedures.

Conclusions.

We conclude that legal reasons for compulsory admission should be reworded in order to remove stigmatization of the patient, that raising awareness about involuntary admission procedures and patient rights with both patients and family advocacy groups is paramount, that communication about procedures should be widely available in lay-language for the general population, and that training sessions and guidance should be available for legal and medical practitioners. Finally, people working in the field need to be constantly aware about the ethical challenges surrounding compulsory admissions.

Cognitive modelling to assess decision-making impairments in patients with current depression and with/without suicide history

It has been reported that decision making is impaired in suicide attempters. Decision making is a complex process and little is known about its different components. Yet, this information would help to understand the functioning of suicidal minds. In this study, the Prospect Valence-Learning (PVL) computational model was applied to the Iowa Gambling Task (IGT) to investigate and compare decision-making components in patients with affective disorder and with/without history of suicide attempts and in healthy controls. To this aim, 116 inpatients with current major depressive episode (among whom 62 suicide attempters) and 38 healthy controls were recruited. Decision-making performance was measured using the IGT. The Bayesian computational PVL model was applied to compare the feedback sensitivity, loss aversion, learning/memory, and choice consistency components of decision making in the different groups. Depressive symptomatology was assessed using the Beck Depression Inventory short form (BDI-SF). The total IGT net score and the loss aversion and learning/memory scores were lower in suicide attempters than in healthy controls. The choice consistency score was low in all patients (with/without suicide history) compared with healthy controls. Moreover, patients with high BDI score showed a positive relationship between the choice consistency score and suicide attempt. These findings suggest that decision-making impairment in depressed patients with and without suicidal history might be the result of underlying problems in feedback processing and task learning, which influence the building of long-term strategies. All these impairments should be targeted in therapeutic strategies for suicidal patients.

Suicidal ideation and affect lability in single and multiple suicidal attempters with Major Depressive Disorder: An exploratory network analysis

INTRODUCTION

A better understanding of the specific contribution of risk factors to suicidal behavior could arise from analyzing suicidal ideation (SI) in clinical samples, and comparing single versus multiple suicide attempters through contemporary methods allowing complex and dynamical analyses of multiple and simultaneously interacting suicide risk factors.

METHOD

We explored associations among suicidal ideation (SI), affect lability and other suicide risk factors in 323 suicidal attempters diagnosed with major depressive disorder (MDD). We analyzed the network structure and centrality of the total sample, and compared single versus multiple attempters and subjects with low and high suicidal ideation.

RESULTS

SI was connected with anxiety (trait) and hopelessness. Central nodes for global and specific groups were affect lability (from anxiety to depression), anxiety as a trait, and harm avoidance. We observed some specific differences between clinical profiles of repeaters and non-repeaters and significant network density between high and low SI.

LIMITATIONS

Because our cross-sectional design, we cannot establish casual relationships among variables. We only examined associations at group level but not at single subject level.

CONCLUSIONS

Affect lability (mainly the shifts from anxiety to depression) and trait anxiety were central in each estimated network. These symptoms might be suitable targets for early detecting and treating suicidal patients.

Actualité sur le risque suicidaire et les sels de lithium

Le traitement au long cours des troubles de l’humeur conduit à une diminution marquée de la mortalité, notamment par suicide, de ces patients dont le risque suicidaire est majeur. Les données s’accumulent depuis 40 ans pour proposer que le lithium bénéficie d’un effet suicide, lui conférant une place à part dans l’arsenal thérapeutique. En effet, le lithium présente un effet préventif des conduites suicidaires dans le trouble bipolaire comme dans le trouble unipolaire. Cet effet semble indépendant de son efficacité thymorégulatrice et supérieur à ce qui est observé avec les anticonvulsivants. Les mécanismes d’action du lithium continuent d’être étudiés tant ils sont complexes. Les pistes se multiplient pour envisager que le lithium agisse sur différents traits de vulnérabilité suicidaire ou qu’il puisse corriger des anomalies cérébrales associées au suicide. Les travaux scientifiques, de la molécule à l’épidémiologie, concourent à proposer le lithium en première ligne pour lutter contre le risque suicidaire des patients souffrant de troubles thymiques. Il est alors envisageable de recourir au lithium dans une perspective dimensionnelle, pour traiter le risque suicidaire, l’impulsivité et l’agressivité, et ce, indépendamment du traitement thymorégulateur choisi pour le patient.

Decision making and vulnerability to suicidal behaviour in elderly

Suicide is a major public health concern, especially for older adults, who have higher rates of completed suicide than any other age group in most countries of the world. However, understanding suicidal behaviour remains a challenging task particularly among the elders who have been poorly studied. Decision making has been recently found to be altered in suicide attempters under 65.To test wether decision making would be a neuropsychological trait of vulnerability to suicidal behaviours, the authors used the Iowa Gambling Task to investigate normothymic non demented elders with a history of suicidal behaviour (N = 35) and compared it to decision making in non suicide attempters with a past history of depression (N = 52) and comparison subjects (N = 43). The data also were compared to those of similar groups of younger normothymic subjects. Moreover, the old suicidal patients were assessed according to the age at the onset of suicidal behaviour (before or after 60).Old suicide attempters did not significantly differ from the other aged groups and according to the age of first suicidal behaviour. Old suicide attempters presented better performances than that of younger suicidal patients.Vulnerability to suicidal behaviour in older people may proceed from cognitive processes which are different from the ones involved in suicidal vulnerability of younger subjects. These results are preliminary and further studies are needed to explore vulnerability cognitive patterns to suicide among elders.

La sensibilité aux stress sociaux chez les suicidants. Observation écologique

La démonstration de l’efficacité des soins basés sur le recontact, comme l’observation qu’un geste suicidaire suit régulièrement un événement de vie stressant, notamment dans le domaine social, suggèrent que les stress sociaux conduisant à l’exclusion sociale occupent un rôle central dans la survenue des conduites suicidaires. Les nouvelles technologies de la communication, à l’aide de Smartphones, permettent l’évaluation in vivo des patients à risque suicidaire. Non seulement, l’évaluation répétée du risque suicidaire dans l’environnement naturel du sujet n’est pas délétère pour les sujets, mais en outre, ce type d’innovation apporte des informations de grand intérêt pour suivre les séquences environnementales conduisant à la génération des idées de suicide. Ainsi, nous avons observé dans une étude d’évaluation écologique instantanée que les stress sociaux et eux-seuls, prédisent la survenue ultérieure d’idées de suicide. Ainsi, les individus vulnérables au suicide pourraient être particulièrement sensibles au stress sociaux. À ce titre, les études d’imagerie cérébrale démontrent l’existence d’anomalies cérébrales chez les suicidants lors de paradigmes d’exclusion sociale. Par ailleurs, les études récentes avancent la possibilité d’une inflammation chronique modérée dans les conduites suicidaires. Ainsi, divers marqueurs de l’inflammation, dont la CRP plasmatique et les taux de cytokines centraux et périphériques ont été associés aux conduites suicidaires. Il se trouve que les stress sociaux sont des inducteurs particulièrement puissants de cytokines pro-inflammatoires, en faisant intervenir des régions cérébrales également impliquées dans la vulnérabilité suicidaire (insula antérieure, cortex cingulaire antérieur). Nous formulons l’hypothèse que les sujets vulnérables aux conduites suicidaires présenteraient une réponse inflammatoire et algique exagérée aux stress sociaux.

Sleep quality and emotional reactivity cluster in bipolar disorders and impact on functioning

Objective:

Bipolar disorders (BD) are characterized by sleep disturbances and emotional dysregulation both during acute episodes and remission periods. We hypothesized that sleep quality (SQ) and emotional reactivity (ER) defined clusters of patients with no or abnormal SQ and ER and we studied the association with functioning.

Method:

We performed a bi-dimensional cluster analysis using SQ and ER measures in a sample of 533 outpatients patients with BD (in remission or with subsyndromal mood symptoms). Clusters were compared for mood symptoms, sleep profile and functioning.

Results:

We identified three clusters of patients: C1 (normal ER and SQ, 54%), C2 (hypo-ER and low SQ, 22%) and C3 (hyper-ER and low SQ, 24%). C1 was characterized by minimal mood symptoms, better sleep profile and higher functioning than other clusters. Although highly different for ER, C2 and C3 had similar levels of subsyndromal mood symptoms as assessed using classical mood scales. When exploring sleep domains, C2 showed poor sleep efficiency and a trend for longer sleep latency as compared to C3. Interestingly, alterations in functioning were similar in C2 and C3, with no difference in any of the sub-domains.

Conclusion:

Abnormalities in ER and SQ delineated three clusters of patients with BD and significantly impacted on functioning.

Risk of Suicide Mortality Among Cancer Patients: A Meta-Analysis of Observational Studies

Introduction

Suicide rates among patients with cancer are higher than ones in the general population.

Objective

This meta-analysis aims to estimate the suicide risk in patients with cancer.

Methods

We searched Medline, PsycINFO, and the Cochrane library to identify articles published before July 1, 2016, examining the association between suicide [death (SD), attempt (SA), ideation (SI)] and any form of diagnosed cancer.

Results

We initially identified 4880 records and after unsuitable studies were removed, our search yielded 102 publications of which 14 were used in the meta-analyses. Patients with cancer had higher risk of SD (seven studies, 247.869 participants; odds ratio [OR] = 1.52, 95% CI = 1.22–1.89, P = 0.0002) compared with those without cancer (among case-control studies focused on SD versus living controls). Among studies focused on SD versus other deaths, patients with cancer had higher risk of SD (two studies, 23.839 participants; OR = 1.53, 95% CI = 1.03–2.27, P = 0.03). No difference has been detected for risk of SA (four studies, 8.147.762 participants) and for SI (two studies, 37.879 participants).

Since publication bias was detected, the “trim and fill” method was applied. The majority of the included studies have a high quality at the STROBE statement.

Conclusion

The assessment of suicide risk in this population is crucial.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Borderline personality disorder and childhood maltreatment: A genome-wide methylation analysis

Early life adversity plays a critical role in the emergence of borderline personality disorder (BPD) and this could occur through epigenetic programming. In this perspective, we aimed to determine whether childhood maltreatment could durably modify epigenetic processes by the means of a whole-genome methylation scan of BPD subjects. Using the Illumina Infinium® Human Methylation 450 Bead Chip, global methylation status of DNA extracted from peripheral blood leucocytes was correlated to the severity of childhood maltreatment in 96 BPD subjects suffering from a high level of child adversity and 93 subjects suffering from major depressive disorder (MDD) and reporting a low rate of child maltreatment. Several CpGs within or near the following genes (IL17RA, miR124-3, KCNQ2, EFNB1, OCA2, MFAP2, RPH3AL, WDR60, CST9L, EP400, A2ML1, NT5DC2, FAM163A and SPSB2) were found to be differently methylated, either in BPD compared with MDD or in relation to the severity of childhood maltreatment. A highly relevant biological result was observed for cg04927004 close to miR124-3 that was significantly associated with BPD and severity of childhood maltreatment. miR124-3 codes for a microRNA (miRNA) targeting several genes previously found to be associated with BPD such as NR3C1. Our results highlight the potentially important role played by miRNAs in the etiology of neuropsychiatric disorders such as BPD and the usefulness of using methylome-wide association studies to uncover such candidate genes. Moreover, they offer new understanding of the impact of maltreatments on biological processes leading to diseases and may ultimately result in the identification of relevant biomarkers.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Adherence to treatment guidelines in clinical practice for using electroconvulsive therapy in major depressive episode

BACKGROUND

ECT is the most effective treatment of major depressive episode (MDE) but remains a neglected treatment. The French Society for Biological Psychiatry and Neuropsychopharmacology aimed to determine whether prescribing practice of ECT followed guidelines recommendations.

METHODS

This multicenter, retrospective study included adult patients with major depressive disorder (MDD) or bipolar disorder (BD), who have been treated with ECT for MDE. Duration of MDE and number of lines of treatment received before ECT were collected. The reasons for using ECT, specifically first-line indications (suicidality, urgency, presence of catatonic and psychotic features, previous ECT response, patient preference) were recorded. Statistical comparisons between groups used standard statistical tests.

RESULTS

Seven hundred and forty-five individuals were included. The mean duration of MDE before ECT was 10.1 months and the mean number of lines of treatment before ECT was 3.4. It was significantly longer for MDD single episode than recurrent MDD and BD. The presence of first-line indications for using ECT was significantly associated to shorter duration of MDE (9.1 vs 13.1 months, p<0.001) and lower number of lines of treatment before ECT (3.3 vs 4.1, p<0.001).

LIMITATIONS

This is a retrospective study and not all facilities practicing ECT participated that could limit the extrapolation of the results.

CONCLUSION

Compared to guidelines, ECT was not used as first-line strategy in clinical practice. The presence of first-line indications seemed to reduce the delay before ECT initiation. The improvements of knowledge and access of ECT are needed to decrease the gap between guidelines and clinical practice.

Somatic assessment of one hundred inpatients in a psychiatric crisis unit: A retrospective observational study

OBJECTIVES

Compared to the general population, psychiatric patients are more exposed to physical illness but have reduced access to care.

METHODS

We conducted a descriptive study in Montpellier between November 2011, 2nd and December 2012, 21st. Every Wednesday and Friday, the last two inpatients admitted in the psychiatric post-emergency unit of the University Hospital of Montpellier were assessed by a general practitioner and included in the study. This unit takes care of suicidal patients suffering from mood and/or personality disorders. The general practitioner assessed lifetime somatic history, current somatic comorbidities and medical follow-up for non-psychiatric issues.

RESULTS

One hundred patients were included. The sample consisted of 81% women with a mean age of 43 years (18-79 years). The majority of patients had a lifetime history of somatic disease (96%) and was followed by a general practitioner (99%). Six patients had no met general practitioner for at least one year. Dyslipidemia was reported in 32 patients, among those only one patient was on lipid-lowering drug (96.88%). Among patients with impaired dental condition, 29 (55.77%) had not met a dentist for at least one year. Among those with impaired near visual acuity and/or impaired distance visual acuity, 19 (65.52%) had not met an ophthalmologist for at least one year.

CONCLUSION

Although detected, somatic comorbidities seem outsourced in psychiatric patients. Greater awareness among different health professionals about the medical care of such patients could improve healthcare management and life expectancy.

[Suicidal risk during the first psychotic episode]

Suicide is the most common cause of early mortality during the course of schizophrenia. The most recent data in the literature show that the risk of suicide is greater at the beginning of the course of schizophrenia. The risk of suicide during the first year is 12 times higher than that of the general population. Specifically, 2-5 % of people with first-episode psychosis will die by suicide in long-term follow-up studies. Regarding the presence of suicidal ideation that are a major factor of suicide in subjects suffering from psychotic disorders, their prevalence remains extremely worrying, since they are substantial and persistent. Consequently, suicide prevention should be a major and immediate objective in the management of the disease, as soon as the diagnosis has been made. Suicidal ideas are a potential precursor to the evolution towards acting out. Their evolution must be specifically assessed in each individual. Indeed, in the influential Danish OPUS study the authors reported heterogeneity in suicidal ideations in young patients with first episode of psychosis and identified three prototypical trajectories of suicidal ideations over the first 2 years in treatment. Particularly, nearly 40 % of patients with first-episode psychosis have persisting suicidal thoughts over the initial treatment period. Consequently, the authors recommend routine screening for suicidality when providing treatment for first-episode psychosis. The main risk factors for suicidal behavior in patients with a first episode are classical ones. Previous research has suggested that, in addition to young age and early course of illness, other important clinical predictors of suicide in individuals with schizophrenia include presence of depressive symptoms and misuse of substances, which are very common conditions in these patients. Lack of social support, loss, rejection, stigma, insight, fear of future losses, are all negative experiences experienced by patients starting a psychotic disorder. Negative connotations of the diagnosis of psychotic disorders, feelings of being trapped that can be directly related to feeling a burden can lead to suicidal crisis in these individuals. Then, the painful experience of the disease and its consequences associated with self-stigmatization and social rejection may induce hopelessness and suicidal thoughts in these young subjects. The quality of the insight and its evolution may worsen the depressive experience and suicidal risk and they therefore also require to be measured regularly. Thus, the clinical evaluation of patients entering psychosis should focus on those dimensions that are not directly related to the psychotic symptoms. At the precise evaluation of each patient must be associated personalized measures of prevention. It is now proposed that prevention strategies targeting suicidal behaviour in first-episode psychosis should not be universal. On a more general level, evidence-based data to support specific care programs are still lacking, and only few data are in favor of integrated care in patients presenting with first episode. It should also be kept in mind that the risk of suicide is extraordinarily high for all psychiatric patients during the first few months after discharge from hospital. This should encourage caregivers to offer intensive follow-up programs to their patients and to embrace recontact and follow-up initiatives using the tools of e-health. Last, programs for the early detection of schizophrenia seem to be beneficial for the prevention of suicide in these subjects.

Impact of bipolar disorder on eating disorders severity in real-life settings

BACKGROUND

Comorbidity of bipolar disorder (BD) and eating disorders (ED) is common and increases the course and severity of BD. However, the impact of comorbid BD on the clinical profile of ED patients remains unclear. Most studies have focused on patients primarily assessed for BD and data on patients with a primary diagnosis of ED are sparse. We investigated the association between a dual diagnosis and severity in terms of clinical, neuropsychological dimensions and daily functioning.

METHOD

Two hundred and sixty-one patients with ED were consecutively recruited. BD was screened with the MINI and further confirmed in the French expert centre network. The severity of ED symptoms was assessed with the EDE-Q and EDI-2, daily functioning with the FAST. The neurocognitive assessment targeted attention, set-shifting and decision-making.

RESULTS

Forty-nine patients screened positive for BD, but diagnosis was confirmed in only thirty patients (11.5% of the cohort). After multiple adjustments, comorbidity was associated with greater severity on the total score and three subscales of the EDE-Q and on four of the ten dimensions of the EDI-2. Comorbid BD was associated with lower daily functioning but not with lower neuropsychological performance.

LIMITATIONS

Sample referred to specialist clinics not large enough to authorize an analysis by subtype and cross-sectional evaluation.

CONCLUSION

The association between ED and BD increases ED severity for most of these core features. It negatively impacts daily functioning. The results also highlight issues about the validity of screening tools to detect BD in patients with ED.

Polymorphism A118G of opioid receptor mu 1 (OPRM1) is associated with emergence of suicidal ideation at antidepressant onset in a large naturalistic cohort of depressed outpatients

Antidepressants have been the object of an international controversy for about thirty years. Some patients are inclined to develop suicidal ideation (SI) at antidepressant onset; this phenomenon is known as Treatment Emergent Suicidal Ideation (TESI), and it has conducted regulatory bodies to prompt warnings on antidepressants. Since, few studies have explored the pharmacogenomics of TESI. Given the growing body of evidence connecting the opioidergic system with suicidal behavior (particularly mu opioid receptor (MOR)), we decided to examine the relationship between two genetic polymorphisms (SNPs) in the opioidergic system and TESI in a sample of 3566 adult depressed outpatients. General practitioners and psychiatrists throughout France followed participants for 6 weeks after an initial prescription of tianeptine, an antidepressant treatment with mu agonism. Suicidal ideation was assessed with the item 10 of the Montgomery-Asberg Depression Rating Scale (item dedicated to SI) at baseline, and after 2 weeks, 4 weeks and 6 weeks. We analysed rs1799971 from the OPRM1 gene and rs105660 from the OPRK1 gene. Within the sample, 112 patients reported TESI while 384 did not. We found a significant association between AA genotype of rs1799971 and TESI even after adjustment for potential cofounders (OR = 1.93, 95% CI = [1.07; 3.49]; p-value = 0.03). On the other hand there were no significant association between rs1799971 and rs105560 with worsening of suicidal ideation or lifetime suicide attempts. Nevertheless, our results suggest a possible involvement of opioidergic system in TESI.

Clinical guidelines for the management of depression with specific comorbid psychiatric conditions French recommendations from experts (the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental)

BACKGROUND

Recommendations for pharmacological treatments of major depression with specific comorbid psychiatric conditions are lacking.

METHOD

The French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental developed expert consensus guidelines for the management of depression based on the RAND/UCLA Appropriatneness Method. Recommendations for lines of treatment are provided by the scientific committee after data analysis and interpretation of the results of a survey of 36 psychiatrist experts in the field of major depression and its treatments.

RESULTS

The expert guidelines combine scientific evidence and expert clinician's opinion to produce recommendations for major depression with comorbid anxiety disorders, personality disorders or substance use disorders and in geriatric depression.

CONCLUSION

These guidelines provide direction addressing common clinical dilemmas that arise in the pharmacologic treatment of major depression with comorbid psychiatric conditions.

[Social pain at the core of suicidal behavior]

BACKGROUND

Intolerable pain is often reported in suicide notes. Moreover, the frequency of life events preceding a suicidal act is high, especially interpersonal difficulties. Such adversity is the source of psychological or social pain.

METHODS

We propose a narrative review to discuss the role of pain in the suicidal process while having a focus on social ties.

RESULTS

Using Ecological Momentary Assessment in suicide attempters it has been shown that being alone increased suicidal ideation while being with close others significantly reduced this risk. At a neuroanatomical level, suicidal vulnerability is associated with dysfunctional insula activation during social exclusion, a region involved in social and physical pain processing. Social pain elicited by social exclusion or devaluation shares common neurobiological patterns with physical pain. It is also an exemplar of psychological pain. Despite the complexity of its definition, higher psychological pain levels are associated with suicidal ideation and acts. Finally, intense physical pain or chronic pain are strong risk factors of suicidal ideation and act. Interestingly, suicide notes often report the existence of an intolerable pain. Presence of psychological pain and difficulties in communication predict the lethality and seriousness of suicide attempts. Moreover, presence of psychological pain is associated with more impulsive choices in suicidal patients, suggesting that a suicidal act is a means to escape intolerable suffering despite negative long-term consequences (i.e. death). Analgesics are usually used to get relief from pain but are also frequently involved in suicidal overdoses. It has been shown that opioid analgesics are associated with an increased risk of suicide. Higher consumption of opioid analgesics has been shown in suicidal patients in comparison to patients with history of depression but no suicidal act and healthy controls whereas non-suicidal patients were those reporting higher presence of pain in comparison to healthy controls. It may suggest that opioids are being used by suicidal patients to get relief from psychological/social pain rather than from physical pain. Involvement of opioidergic system in suicidal process opens new therapeutic strategies. Recently, the time-limited, short-term use of very low dosages of sublingual buprenorphine (vs. placebo) was associated with decreased suicidal ideation and mental pain in severely suicidal patients without substance abuse. In a randomized controlled trial comparing a 7-week acceptance and commitment therapy (ACT) versus relaxation group, as adjunct to treatment as usual for adult outpatients suffering from a current suicidal behavior disorder, ACT has shown its effectiveness in reducing suicidal ideation and psychological pain. Evidence indicates that maintaining contact either via letter, postcard or telephone with at-risk adults following discharge from care services after a suicide attempt can reduce reattempt risk. Based on these results, a preventive program of recontact for suicide attempters, VIGILANS, has been developed in France in usual care.

CONCLUSION

The approach of the suicidal issue by the angle of pain and social disconnection offers new advances to improve clinical assessment, to identify new biological pathways involved in suicidal risk, and to propose innovative therapeutic and preventive actions.

Examining relationships between psychotic experiences and suicidal ideation in adolescents using a network approach

BACKGROUND

Suicide is one of the leading causes of death in young individuals. Timely and adequate identification of individuals with suicidal ideation could prevent from suicidal behavior. Psychotic experiences (PE) have been shown to increase levels of suicidal ideation (SI) in the general population. Therefore, detailed investigation of the relationship of PE and SI is relevant. However, the exact nature of the relationship between these two phenomena remains unclear. Understanding psychopathology as a complex network of interacting symptoms could be helpful to elucidate specific associations existing between PE and SI.

METHOD

A specific type of network analysis, the Ising model, was used to examine connections between dichotomized questions on psychotic experiences and suicidal ideation in a cross-sectional study with 1685 adolescents from the general population aged 13-18 years.

RESULTS

SI was mostly connected to the PE domains perceptual anomalies (PA) and bizarre experiences (BE), which have higher strength values in the network. Central nodes within these domains, as indexed by higher centrality measures (strength and betweenness) were: auditory experiences (PA1: hearing voices when you are alone), persecutory ideation (BE1: feelings of being persecuted; BE2: conspiracy against you), and social anxiety (SANX) (SANX1: I cannot get close to people).

CONCLUSIONS

Suicidal ideation is differentially connected to specific psychotic experiences. Auditory PE, persecutory ideation, and social anxiety symptoms could play a central role in the interconnectedness of the two constructs.

Emotional hyper-reactivity and cardiometabolic risk in remitted bipolar patients: a machine learning approach

OBJECTIVE

Remitted bipolar disorder (BD) patients frequently present with chronic mood instability and emotional hyper-reactivity, associated with poor psychosocial functioning and low-grade inflammation. We investigated emotional hyper-reactivity as a dimension for characterization of remitted BD patients, and clinical and biological factors for identifying those with and without emotional hyper-reactivity.

METHOD

A total of 635 adult remitted BD patients, evaluated in the French Network of Bipolar Expert Centers from 2010-2015, were assessed for emotional reactivity using the Multidimensional Assessment of Thymic States. Machine learning algorithms were used on clinical and biological variables to enhance characterization of patients.

RESULTS

After adjustment, patients with emotional hyper-reactivity (n = 306) had significantly higher levels of systolic and diastolic blood pressure (P < 1.0 × 10^-8 ), high-sensitivity C-reactive protein (P < 1.0 × 10^-8 ), fasting glucose (P < 2.23 × 10^-6 ), glycated hemoglobin (P = 0.0008) and suicide attempts (P = 1.4 × 10^-8 ). Using models of combined clinical and biological factors for distinguishing BD patients with and without emotional hyper-reactivity, the strongest predictors were: systolic and diastolic blood pressure, fasting glucose, C-reactive protein and number of suicide attempts. This predictive model identified patients with emotional hyper-reactivity with 84.9% accuracy.

CONCLUSION

The assessment of emotional hyper-reactivity in remitted BD patients is clinically relevant, particularly for identifying those at higher risk of cardiometabolic dysfunction, chronic inflammation, and suicide.

[French Society for Biological Psychiatry and Neuropsychopharmacology and Fondation FondaMental task force: Formal Consensus for the management of treatment-resistant depression]

Major depression represents among the most frequent psychiatric disorders in the general population with an estimated lifetime prevalence of 16-17%. It is characterized by high levels of comorbidities with other psychiatric conditions or somatic diseases as well as a recurrent or chronic course in 50 to 80% of the cases leading to negative repercussions on the daily functioning, with an impaired quality of life, and to severe direct/indirect costs. Large cohort studies have supported that failure of a first-line antidepressant treatment is observed in more than 60% of patients. In this case, several treatment strategies have been proposed by classical evidence-based guidelines from internationally recognized scientific societies, referring primarily on: I) the switch to another antidepressant of the same or different class; II) the combination with another antidepressant of complementary pharmacological profile; III) the addition of a wide range of pharmacological agents intending to potentiate the therapeutic effects of the ongoing antidepressant medication; IV) the association with appropriate psychological therapies; and, V) the use of non-invasive brain stimulation techniques. However, although based on the most recently available data and rigorous methodology, standard guidelines have the significant disadvantage of not covering a large variety of clinical conditions, while currently observed in everyday clinical practice. From these considerations, formalized recommendations by a large panel of French experts in the management of depressed patients have been developed under the shared sponsorship of the French Association of Biological Psychiatry and Neuropsychopharmacology (AFPBN) and the Fondation FondaMental. These French recommendations are presented in this special issue in order to provide relevant information about the treatment choices to make, depending particularly on the clinical response to previous treatment lines or the complexity of clinical situations (clinical features, specific populations, psychiatric comorbidities, etc.). Thus, the present approach will be especially helpful for the clinicians enabling to substantially facilitate and guide their clinical decision when confronted to difficult-to-treat forms of major depression in the daily clinical practice. This will be expected to significantly improve the poor prognosis of the treatment-resistant depression thereby lowering the clinical, functional and costly impact owing directly to the disease.

Tianeptine is associated with lower risk of suicidal ideation worsening during the first weeks of treatment onset compared with other antidepressants: A naturalistic study

Worsening of suicidal ideation during the first weeks of antidepressant treatment is a poorly understood phenomenon that prompted regulatory bodies to issue specific warnings. To better understand the causes of this phenomenon, this study compared the risk of suicidal ideation worsening in patients taking different types of antidepressant medications. To this aim, 4017 depressed adult outpatients were followed by general practitioners and psychiatrists throughout France for 6 weeks after prescription of an antidepressant treatment. The main study outcomes were to monitor changes (worsening or improvement) in suicidal ideation between baseline (treatment onset) and the study end (week 6) and to determine the remission rates according to the treatment type. Depression severity was assessed with the patient-administered Hospital Anxiety and Depression Scale and suicidal ideation with the 9-item Montgomery-Asberg Depression Rating Scale and the Hopelessness Scale. Use of tianeptine, a mu-opioid receptor agonist was significantly associated with a lower risk of suicidal ideation worsening compared with other antidepressants in the first 6 weeks of treatment. Conversely, remission rates were not significantly affected by the treatment type. Our results highlight a potential interest of opioid agonists to reduce the risk of worsening of suicidal ideation at antidepressant initiation.

Childhood trauma, dimensions of psychopathology and the clinical expression of bipolar disorders: A pathway analysis

BACKGROUND

This study aims at testing for paths from childhood abuse to clinical indicators of complexity in bipolar disorder (BD), through dimensions of affective dysregulation, impulsivity and hostility.

METHOD

485 euthymic patients with BD from the FACE-BD cohort were included from 2009 to 2014. We collect clinical indicators of complexity/severity: age and polarity at onset, suicide attempt, rapid cycling and substance misuse. Patients completed questionnaires to assess childhood emotional, sexual and physical abuses, affective lability, affect intensity, impulsivity, motor and attitudinal hostility.

RESULTS

The path-analysis demonstrated significant associations between emotional abuse and all the affective/impulsive dimensions (p < 0.001). Sexual abuse was moderately associated with emotion-related dimensions but not with impulsivity nor motor hostility. In turn, affect intensity and attitudinal hostility were associated with high risk for lifetime presence of suicide attempts (p < 0.001), whereas impulsivity was associated with a higher risk of lifetime presence of substance misuse (p < 0.001). No major additional paths were identified when including Emotional and Physical Neglect in the model.

CONCLUSIONS

This study provides refinement of the links between early adversity, dimensions of psychopathology and the complexity/severity of BD. Mainly, dimensions of affective dysregulation, impulsivity/hostility partially mediate the links between childhood emotional to suicide attempts and substance misuse in BD.