Interplay of combat deployment harassment, testosterone concentrations and post-deployment suicide risk in male veterans

OBJECTIVE

Many combat veterans exhibit suicidal ideation and behaviour, but the relationships among experiences occurring during combat deployment and suicidality are still not fully understood. In this study, we tested the hypothesis that harassment during a combat deployment is associated with post-deployment suicidality and testosterone function.

METHODS

Male combat veterans who made post-deployment suicide attempts and demographically matched veterans without a history of suicide attempts were enrolled in the study. Demographic and clinical parameters of study participants were assessed and recorded. Study participants were interviewed by a trained clinician using the Mini-International Neuropsychiatric Interview (MINI), the Deployment Risk and Resilience Inventory (DRRI) – Relationships within unit scale, the Scale for Suicidal Ideation (SSI), and the Brown–Goodwin Aggression Scale. Free testosterone levels were assessed in morning blood samples.

RESULTS

DRRI harassment scores were higher and free testosterone levels were lower among suicide attempters in comparison with non-attempters. In the whole sample, DRRI harassment scores positively correlated with SSI scores and negatively correlated with free testosterone levels. Free testosterone levels negatively correlated with SSI scores. Aggression scale scores positively correlated with DRRI harassment scores among non-attempters but not among attempters.

CONCLUSION

Our observations that harassment scores are associated with suicidality and testosterone levels, and suicidality is associated with testosterone levels may indicate that there is a link between deployment harassment, testosterone function and suicidality.

Antisuicidal effect of lithum in bipolar disorder: is there an age-specific effect?

OBJECTIVE

Our group reported previously a comparable overall antisuicidal effect of lithium and valproate in bipolar patients. We investigated factors associated with higher antisuicidal efficacy of lithium in older individuals.

METHODS

The age-related antisuicidal effect of lithium and valproate was compared in ninety-four (n = 94) high-risk bipolar suicide attempters who participated in a 2.5-year randomized, double-blind trial.

RESULTS

Age significantly moderated the effect of lithium vs. valproate on the risk of suicide event during the study (z = -1.98, p = 0.049). We found that those who were 42 years or older (above the 75th percentile), and on lithium had significantly lower risk of suicidal behavior than older patients on valproate (>42y) or younger (<42 y) patients on either medication (interaction HR = 0.09, 95%CI: 0.01-0.89, z = -2.07, p = 0.039). This difference in risk differences was not explained away by age-related differences in the proportion of participants with bipolar II disorder (Fisher's test p = 0.020) or higher lethality of past suicide attempts in younger participants (Wilcoxon test p = 0.024); neither was there any correlation with age in the longitudinally measured blood lithium levels (t = 1.04, df = 36, p = 0.307) or valproate levels (t = -0.50, df = 41, p = 0.621).

LIMITATIONS

Besides the fact that this is a secondary analysis, a limitation is that the study is not powered to detect suicide deaths or suicide attempts.

CONCLUSION

Bipolar patients randomized to lithium and older than 42 years had less suicidal behavior compared to same aged patients on valproate or younger patients (<42 y) on either medication. This effect was independent of clinical and sociodemographic characteristics.

The uncounted casualties of war: suicide in combat veterans

Military conflicts are ubiquitous. There are a lot of combat veterans around the world. Suicidality in combat veterans is a large and important issue. In this article, the author discusses some aspects of this issue. The combat environment is characterized by violence, physical strains, separation from loved ones, and other hardships. Combat deployment may lead to multiple emotional, cognitive, psychosomatic symptoms, suicidal ideation and behavior. Pre-deployment, deployment and post-deployment adversities may increase suicide risk in combat veterans. The act of killing in combat is a stressor which may raise suicide risk. Combat-related injuries are associated with increased suicide risk. Post-deployment difficulties of reintegrating into civilian life may lead to depression and suicidality. Studies suggest that suicidal behavior in combat veterans may have a neurobiological basis. Prevention of suicide among combat veterans should include pre-deployment screening to exclude individuals with psychiatric disorders; psychological support and prevention of harassment and/or abuse during deployment; psychosocial support after deployment; diagnosing and treating psychiatric and medical disorders including neurological disorders; frequent suicide screening; education of mental and non-mental health clinicians, war veterans, their families and friends regarding signs/symptoms of suicidality; and restriction of access to lethal means. We need to study the specific psychobiology of combat veterans to understand how to develop effective suicide prevention interventions for this population.

Clinical features of individuals with schizotypal personality disorder with and without suicidal ideation

This study compared demographic and clinical features in a sample of 384 participants: healthy controls (HC; n = 166) and individuals with schizotypal personality disorder (SPD) with (n = 50) and without (n = 168) suicidal ideation (SI) to examine specific risk factors for suicidality in SPD. Compared to the non-SI group, the SI group showed significantly greater severity of depression, aggression, impulsivity, affective lability, schizotypal features, poorer social adjustment, and had fewer social contacts. Individuals in the SI group were also more likely to have a history of a suicide attempt and comorbid borderline personality disorder in comparison to the non-SI group. Logistic regression analysis indicated that severity of depression and the number of social contacts drove the difference between the SI and non-SI groups. Compared with both SPD subgroups, the HC group was significantly less depressed, aggressive, impulsive, affectively labile, had fewer schizotypal features, was better socially adjusted, and had more social contacts. This study indicates that overall, the SI group is a more severely impaired group of individuals with SPD compared to the non-SI group. Better educating medical professionals about the diagnosis and management of SPD and its associations with suicidality is warranted.

Testosterone and Suicidal Behavior in Bipolar Disorder

Bipolar disorder is associated with suicidal behavior. The risk of suicide for individuals with bipolar disorder is up to 20-30 times larger than that of the general population. Considerable evidence suggests that testosterone may play a role in the pathophysiology of suicidal behavior in both men and women with bipolar disorder and other psychiatric conditions. Testosterone has complex effects on psychological traits. It affects mood and behavior, including interactions with other people. Testosterone regulates pro-active and re-active aspects of aggression. Probably, both high and low levels of testosterone may contribute to the neurobiology of suicide in various patient populations. The effects of endogenous and exogenous testosterone on suicidality in patients with bipolar disorder need further investigation. The aim of this commentary article is to provide a commentary on the author's work on the topic, summarize the literature on testosterone, bipolar disorder, and suicide, and encourage future research on this poorly studied topic.

Suicide: An Overview for Clinicians

Most suicides have a diagnosable psychiatric disorder, most frequently, a mood disorder. Psychosocial issues and neurobiological abnormalities such as dysregulation in stress response systems contribute to suicidal behavior. All psychiatric patients need to be screened for the presence of suicidal ideation. Clinicians are expected to gather information about patient's clinical features and to formulate decisions about patient's dangerousness to self and the treatment plan. As psychiatric disorders are a major risk factor for suicide their pharmacologic and psychological treatment is of utmost importance to prevent suicide. Restriction of access to lethal means is important for suicide prevention.

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

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

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

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

Prevention of suicidal behavior in diabetes: the role of primary care

Studies in different countries suggest that the rates of suicide ideation, attempts and death are increased in patients with diabetes in comparison to the general population. Suicidal behavior in patients with diabetes is a significant but underappreciated problem. Elevated suicide risk in individuals with diabetes may be related to comorbid psychiatric disorders, particularly depression. Considerable evidence suggests a bidirectional relationship between diabetes and depression: individuals with diabetes are at elevated risk of developing depression and patients with depression are more likely to develop diabetes. Frequent comorbidity of diabetes and depression may be related to psychosocial and neurobiological factors. Other comorbid psychiatric conditions including anxiety and alcohol use disorders may also increase suicide risk in diabetes. Primary care physicians are likely the key to suicide prevention efforts in individuals with diabetes since they see almost half of individuals who die by suicide within 1 month of their suicide. The management of potentially suicidal patients with diabetes in primary care comprises six major components: management of diabetes and its complications, especially conditions associated with pain; diagnosis and treatment of comorbid psychiatric disorders; frequent assessment of suicide risk; restricting access to the means of suicide; specific treatments to reduce the predisposition to attempt suicide; and referral to psychiatric care. Suicide prevention in individuals with diabetes and other medical disorders is a difficult but critically important task.

Identifying and Managing Suicidality in Children and Adolescents with Chronic Pain: Evidence-Based Treatment Strategies

Children and adolescents with chronic pain are at an increased risk of suicidality. This narrative review article aims to inform clinical practice in the assessment and management of suicidality in youth with chronic pain. The article begins with a survey of the background and prevalence of youth with chronic pain. A review of the current evidence behind the increased risk of suicidality in youth with chronic pain follows. Contextualization of this data with general tenets of child and adolescent suicide risk and risk assessment is provided. Suicidology theory including the interpersonal theory of suicide is overviewed to help clinicians to conceptualize the reviewed data. Guiding parameters for the suicide risk assessment and management planning is presented. Concluding recommendations are made to guide clinical practice in the assessment and management of suicidality in youth with chronic pain.

Brain-derived neurotrophic factor in war veterans with or without a history of suicide attempt

BACKGROUND

Brain-derived neurotrophic factor (BDNF) plays a central role in brain development and plasticity and has been demonstrated to be altered in neuropsychiatric diseases and suicidal behavior. We examined whether there is a difference with regard to plasma BDNF levels between veterans who made or did not make a suicide attempt post-deployment.

METHODS

Combat veterans who made or did not make post-deployment suicide attempts were interviewed using Mini-International Neuropsychiatric Interview, the Montgomery-Åsberg Depression Rating Scale, the Barratt Impulsivity Scale (BIS) and the Scale for Suicidal Ideation (SSI). Reaction to the most recent suicide attempt was evaluated using item 16 of the Suicide Intent Scale. Plasma BDNF levels were determined by the BDNF ELISA kit.

RESULTS

Controlling for age and body-mass index (BMI), BDNF levels were higher among suicide attempters than non-attempters. We observed a positive correlation between BDNF levels and SSI scores among non-attempters but not among attempters. BDNF levels positively correlated with BIS scores among suicide attempters but not among non-attempters. Suicide attempters who regretted that they made a suicide attempt had significantly higher BDNF levels in comparison to attempters who did not regret their attempts, controlling or not controlling for age and BMI.

LIMITATIONS

A modest sample size is a shortcoming of our study.

CONCLUSIONS

Our study demonstrates that BDNF may be involved in the pathophysiology of suicidal behavior in combat veterans. Given the relative ease of measuring plasma BDNF levels, it may be appropriate to consider adding such assessments to studies of suicidal behavior.

Association between lithium levels in drinking water and suicide rates: Role of affective disorders

OBJECTIVE

The study aimed to assess the association between lithium levels in drinking water from public supplies and suicide rates in different municipalities of Lithuania in relation with incidence of affective disorders.

METHODS

53 drinking water samples were analysed from the main public drinking water systems of the country's municipalities. Lithium levels were determined using the ion chromatography method. Information on all registered affective disorders across all age groups and gender within the 5-year period was obtained from the Department of Statistics, and was averaged across the investigation time period. For the statistical analysis, lithium levels were averaged per municipality and plotted against suicide standardized mortality rates per 100,000 populations, within the 5-year period.

RESULTS

We found that lithium levels in drinking water are positively associated with the incidence of affective disorders. Our findings suggest higher incidence rates of affective disorders in the municipalities with a lithium level in drinking water above median compared to those in the municipalities with a lithium level below median and with the same socio-demographic and psychiatric characteristics. Suicide mortality rates are inversely associated with lithium levels in drinking water only in municipalities with higher lithium levels (above median) and with a high rate of affective disorders.

CONCLUSION

Based on our study results and insights we generate the following hypothesis for the further research, that lithium level in drinking water might have an important protective effect against suicide rates in the population with affective disorders.

Smoking enhances suicide risk-a significant role in the COVID-19 pandemic?

The COVID-19 outbreak has severely affected the whole world. Considerable evidence suggests that tobacco smoking is associated with increased severity of COVID-19 and death in COVID-19 patients. Tobacco smoking cessation is necessary to decrease COVID-19-related hospitalizations and deaths. In this commentary, I suggest that tobacco smoking cessation is also needed to reduce suicidal behavior during and after the COVID-19 pandemic. Significant evidence suggests that the COVID-19 pandemic leads to increased tobacco consumption as smokers use more tobacco to cope with pandemic-related stress, anxiety, depression and loneliness. Multiple studies have demonstrated that tobacco smoking is associated with suicidal ideation, suicide attempts, suicide death and a contributing factor in the pathophysiology of suicide. Smoking may increase the probability of development of post-COVID syndrome because it increases severity of COVID-19. Suicide risk may be increased in individuals with post-COVID syndrome. Smoking prevention and cessation should be a target of suicide prevention interventions during and after the COVID-19 pandemic. The COVID-19 pandemic enhances the need to act to integrate tobacco smoking cessation in the health care as a standard of patient care.

The effect of oral dexamethasone administration on testosterone levels in combat veterans with or without a history of suicide attempt

Combat exposure has been linked to increased risk of suicidal ideation, suicide attempts, and death by suicide, and suicidality has been linked with altered testosterone levels. In this study, we examined morning baseline free and total testosterone levels and the effect of dexamethasone administration on testosterone levels in male combat veterans with or without a history of suicide attempt. Demographic and clinical parameters of the study participants were assessed and recorded. Blood samples were collected between 8:00 and 8:30 a.m. on the day prior to and following dexamethasone (0.5 mg) ingestion. Suicide attempters had higher schedule for suicidal ideation (SSI) scores in comparison to non-attempters. Baseline free and total testosterone levels were lower in suicide attempters compared to non-attempters. In the whole sample, both baseline free and total testosterone levels negatively correlated with SSI scores. Free testosterone levels decreased after dexamethasone administration among non-attempters but not among attempters. Free testosterone post-dexamethasone levels positively correlated with aggression scores among non-attempters but not among suicide attempters. Our findings indicate that there are substantial differences in the testosterone regulation between combat veterans with or without a history of suicide attempt. Studies of the relation between the testosterone function and suicidal behavior among combat veterans may lead to improvement in detection of suicidality and finding new pharmacological targets for prevention of suicide among veterans.

Clinical features and psychiatric comorbidities in military veterans with schizophrenia with or without suicidality

Suicide is currently among the leading causes of death among individuals with schizophrenia. Reducing mortality from suicide remains a major clinical challenge in the care of veterans with schizophrenia. There is a need to increase our understanding of what elevates suicide risk in veterans with schizophrenia as a first step towards the future development of suicide prevention interventions. This study compared demographic and clinical features of military veterans with schizophrenia with vs. without suicidality to determine specific risk factors for suicidality. The sample consisted of two groups of veterans with schizophrenia: suicide ideators and/or attempters (SIA) and individuals without a history of suicidal ideation or attempts (no-SIA). Participants were interviewed using the Structured Clinical Interview for DSM-5 Axis I disorders (SCID-I), Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Hamilton Depression Rating Scale (HDRS), and Schizotypal Personality Questionnaire (SPQ). In bivariate analyses, the PANSS-Positive Symptom scores, PANSS-General Psychopathology scores, HDRS total score, HDRS-Paranoid symptoms item score, and SPQ total scores were higher among SIA compared with no-SIA patients. In this unique clinical sample of veterans with schizophrenia, SIA patients were more likely to have mood disorders, post-traumatic stress disorder (PTSD), and/or alcohol use disorder in comparison to the no-SIA group. Logistic regression analysis indicated that the HDRS total score and presence/absence of comorbid mood disorder drive the difference between the groups. These results indicate that suicide risk assessment in veterans with schizophrenia should include identifying individuals with comorbid mood disorders/symptoms, PTSD, alcohol use disorder, marked positive symptoms, and schizotypal features.

Post-COVID syndrome and suicide risk

A significant number of coronavirus disease SARS-CoV-2 (COVID-19) patients continue to have symptoms related to COVID-19 after the acute phase of illness. This post-COVID condition is sometimes called 'post-COVID syndrome', 'long COVID' or 'post-acute COVID-19'. Persistent psychiatric symptoms among COVID-19 survivors such as depression, anxiety, post-traumatic symptoms and cognitive impairment may be related to psychological factors and neurobiological injury. COVID-19 related neurological symptoms including anosmia, ageusia, dizziness, headache and seizures may persist for a long time after the acute COVID-19 illness. Many COVID-19 survivors experience persistent physical symptoms such as cough, fatigue, dyspnea and pain after recovering from their initial illness. There is a high probability that symptoms of psychiatric, neurological and physical illnesses, as well as inflammatory damage to the brain in individuals with post-COVID syndrome increase suicidal ideation and behavior in this patient population. COVID-19 survivors without post-COVID syndrome may also be at elevated suicide risk. Studies of suicidality in COVID-19 survivors are urgently needed and will be a new area of suicide research. An appropriate management of psychiatric, neurological and medical conditions may reduce suicide risk among COVID-19 survivors with or without post-COVID syndrome.

Psychopathological consequences related to COVID-19 infection: The most relevant reactions of the general population

Introduction

As a result of the emergence of coronavirus disease 2019 (COVID-19) outbreak caused by acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the Chinese city of Wuhan, a situation of socio-economic crisis and profound psychological distress rapidly occurred worldwide.

Objectives

This work aimed to comprehensively review the current literature about the impact of COVID-19 infection on the mental health in the general population.

Methods

A detailed review has been conducted in order to identify the main psychopatological consequences related to Covid-19 infection in the general population.

Results

Various psychological problems and important consequences in terms of mental health including stress, anxiety, depression, frustration, uncertainty during COVID-19 outbreak emerged progressively. The psychological impact of quarantine related to COVID-19 infection has been additionally documented together with the most relevant psychological reactions in the general population related to COVID-19 outbreak.

Conclusions

The role of risk and protective factors against the potential to develop psychiatric disorders in vulnerable individuals with Covid-19 infection need to be carefully addressed in the clinical practice.

Relationship between Lithium Levels in Drinking Water and Suicide Rates: A Nationwide Study in Lithuania

To investigate an association of lithium levels in the drinking water with suicide mortality rates in Lithuania. Methods: Samples from public drinking water systems were taken in all districts of Lithuania. Lithium levels were determined using the ion chromatography method. For the statistical calculations, lithium levels were averaged per district municipality and plotted against suicide standardized mortality rates (SMR) per 100,000 populations, within the 5-year period from 2012 to 2016. Results: We found that lithium concentrations in drinking water were significantly negatively associated with total suicide rates in a nonlinear way. Conclusion: Lithium intake with drinking water may affect suicide rates in some geographical areas.

The impact of the COVID-19 pandemic on suicide rates

Multiple lines of evidence indicate that the coronavirus disease 2019 (COVID-19) pandemic has profound psychological and social effects. The psychological sequelae of the pandemic will probably persist for months and years to come. Studies indicate that the COVID-19 pandemic is associated with distress, anxiety, fear of contagion, depression and insomnia in the general population and among healthcare professionals. Social isolation, anxiety, fear of contagion, uncertainty, chronic stress and economic difficulties may lead to the development or exacerbation of depressive, anxiety, substance use and other psychiatric disorders in vulnerable populations including individuals with pre-existing psychiatric disorders and people who reside in high COVID-19 prevalence areas. Stress-related psychiatric conditions including mood and substance use disorders are associated with suicidal behavior. COVID-19 survivors may also be at elevated suicide risk. The COVID-19 crisis may increase suicide rates during and after the pandemic. Mental health consequences of the COVID-19 crisis including suicidal behavior are likely to be present for a long time and peak later than the actual pandemic. To reduce suicides during the COVID-19 crisis, it is imperative to decrease stress, anxiety, fears and loneliness in the general population. There should be traditional and social media campaigns to promote mental health and reduce distress. Active outreach is necessary, especially for people with a history of psychiatric disorders, COVID-19 survivors and older adults. Research studies are needed of how mental health consequences can be mitigated during and after the COVID-19 pandemic.

The psychological impact of COVID-19 on the mental health in the general population

As a result of the emergence of coronavirus disease 2019 (COVID-19) outbreak caused by acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the Chinese city of Wuhan, a situation of socio-economic crisis and profound psychological distress rapidly occurred worldwide. Various psychological problems and important consequences in terms of mental health including stress, anxiety, depression, frustration, uncertainty during COVID-19 outbreak emerged progressively. This work aimed to comprehensively review the current literature about the impact of COVID-19 infection on the mental health in the general population. The psychological impact of quarantine related to COVID-19 infection has been additionally documented together with the most relevant psychological reactions in the general population related to COVID-19 outbreak. The role of risk and protective factors against the potential to develop psychiatric disorders in vulnerable individuals has been addressed as well. The main implications of the present findings have been discussed.

Endogenous cannabinoid levels and suicidality in combat veterans

Combat veterans are at elevated suicide risk. The goal of this study was to test the hypothesis that combat veterans who have made a suicide attempt post-deployment can be distinguished from combat veterans who have never made a suicide attempt based on differences in psychological and biological variables. For the latter, we focused on endogenous cannabinoids, neuroendocrine markers that are associated with stress. Demographic and clinical parameters of suicide attempters and non-attempters were assessed. Blood samples were assayed for anandamide (AEA), 2-arachidonoylglycerol (2-AG), and cortisol. Suicide attempters had higher Scale for Suicidal Ideation (SSI) scores in comparison to non-attempters. Controlling for gender, 2-AG levels were higher among suicide attempters in comparison to non-attempters. Cortisol levels positively correlated with 2-AG levels and negatively correlated with SSI scores among non-attempters but not among attempters. AEA levels negatively correlated with SSI scores among attempters but not among non-attempters. Our results indicate that there are psychological and biological differences between combat veterans with or without a history of suicidal attempt. Our findings also suggest that clinically observed differences between the groups may have a neurobiological basis.