Suicide mortality in Spain during the COVID-19 pandemic: Longitudinal analysis of sociodemographic factors

The COVID-19 pandemic has compromised public health response across the globe. Several countries reported increasing number of suicides during the pandemic. This study aimed to analyze the suicide mortality series in Spain (2000-2021), with a particular interest in depicting longitudinal trends during the COVID-19 pandemic. Moreover, it intended to identify sociodemographic groups with a higher increase in suicide victims during the pandemic. To do so, suicide cases from the National death index data were used. Weighted annual mortality rate was compared between pre-pandemic and pandemic years. Poisson time series models were used to analyze the trend in suicide mortality, considering sociodemographic variables (sex, age, migration status, marital status, and urbanicity). As a result, weighted mortality rate for 2020 was 8.92 (CI95 = [8.29, 9.57]) and 9.21 for 2021 (CI95 = [8.56, 9.88]). Annual mortality from the pandemic years was significantly higher than mortality from the prepandemic ones (p < .01). Poisson regression revealed a significant increase of cases during the pandemic months, RR = 1.05 (CI95 = [1.02, 1.08]); being significant for both sexes, and migration groups (RR > 1.02, across series). A significantly increased number of suicides was also observed for mid-age adults, large urban areas, and single people (RR > 1.05, across series). To sum up, our study supports an increasing number of suicide victims in Spain during the pandemic. We show that the COVID-19 influence on suicide risk factors (e.g., lack of social support networks) plays a critical role in the increasing trend of specific sociodemographic groups.

Risk factors for suicide reattempt: a systematic review and meta-analysis

BACKGROUND

Suicide is one of the main external causes of death worldwide. People who have already attempted suicide are at high risk of new suicidal behavior. However, there is a lack of information on the risk factors that facilitate the appearance of reattempts. The aim of this study was to calculate the risk of suicide reattempt in the presence of suicidal history and psychosocial risk factors and to estimate the effect of each individual risk factor.

METHODS

This systematic review and meta-analysis were conducted following the PRISMA-2020 guidelines. Studies on suicide reattempt that measured risk factors were searched from inception to 2022. The risk factors studied were those directly related to suicide history: history of suicide prior to the index attempt, and those that mediate the transition from suicidal ideation to attempt (alcohol or drug misuse, impulsivity, trauma, and non-suicidal self-injury).

RESULTS

The initial search resulted in 11 905 articles. Of these, 34 articles were selected for this meta-analysis, jointly presenting 52 different effect sizes. The pooled effect size across the risk factors was significant (OR 2.16). Reattempt risk may be increased in presence of any of the following risk factors: previous history, active suicidal ideation, trauma, alcohol misuse, and drug misuse. However, impulsivity, and non-suicidal self-injury did not show a significant effect on reattempt.

CONCLUSION

Most of the risk factors traditionally associated with suicide are also relevant when talking about suicide reattempts. Knowing the traits that define reattempters can help develop better preventive and intervention plans.

Suicide mortality in Spain in 2020: The impact of the COVID-19 pandemic

INTRODUCTION

Suicide constitutes a major concern with evident contribution to global mortality worldwide. Evidence on suicide trends is mixed in the COVID-19 pandemic era. Spain may be an at-risk country for increased suicide risk in the time of COVID-19 pandemic due to prolonged restrictions and lockdown, elevated COVID-19 wave recurrence and related mental health impact. This brief report aims to provide some insight into the suicide mortality trends in the first COVID-19 pandemic year in Spain, using national data.

MATERIAL AND METHODS

Data from the National Death Index were used. Annual mortality rate was calculated at a province level under random-effects models for the 2019 and 2020 years. Poisson timeseries regression was used to study the relationship between monthly suicide mortality and COVID-19 pandemic outbreak and lockdown, and second COVID-19 wave peak covariates.

RESULTS

3671 people died by suicide in 2019 in Spain and 3941 people died by suicide in 2020. The random-effects mortality rate in 2019 was 8.3 (CI95=7.6, 9.0) per 100,000 inhabitants, and mortality rate in 2020 was 8.9 (CI95=8.3, 9.6). No significant differences between mortality rates were found (p=.18). The Poisson regression showed a significant relationship between the COVID-19 outbreak and suicide mortality trend, with OR=1.07 (CI95=1.02, 1.12).

CONCLUSIONS

Although annual mortality rates were not significantly different, an increased suicide risk was found from May, 2020 onwards. Our results claim for action to tackle suicide in the post-pandemic era taking into account the discouraging upcoming scenario.

Prospective cohort study of early biosignatures of response to lithium in bipolar-I-disorders: overview of the H2020-funded R-LiNK initiative

Background

Lithium is recommended as a first line treatment for bipolar disorders. However, only 30% of patients show an optimal outcome and variability in lithium response and tolerability is poorly understood. It remains difficult for clinicians to reliably predict which patients will benefit without recourse to a lengthy treatment trial. Greater precision in the early identification of individuals who are likely to respond to lithium is a significant unmet clinical need.

Structure

The H2020-funded Response to Lithium Network (R-LiNK; http://www.r-link.eu.com/) will undertake a prospective cohort study of over 300 individuals with bipolar-I-disorder who have agreed to commence a trial of lithium treatment following a recommendation by their treating clinician. The study aims to examine the early prediction of lithium response, non-response and tolerability by combining systematic clinical syndrome subtyping with examination of multi-modal biomarkers (or biosignatures), including omics, neuroimaging, and actigraphy, etc. Individuals will be followed up for 24 months and an independent panel will assess and classify each participants’ response to lithium according to predefined criteria that consider evidence of relapse, recurrence, remission, changes in illness activity or treatment failure (e.g. stopping lithium; new prescriptions of other mood stabilizers) and exposure to lithium. Novel elements of this study include the recruitment of a large, multinational, clinically representative sample specifically for the purpose of studying candidate biomarkers and biosignatures; the application of lithium-7 magnetic resonance imaging to explore the distribution of lithium in the brain; development of a digital phenotype (using actigraphy and ecological momentary assessment) to monitor daily variability in symptoms; and economic modelling of the cost-effectiveness of introducing biomarker tests for the customisation of lithium treatment into clinical practice. Also, study participants with sub-optimal medication adherence will be offered brief interventions (which can be delivered via a clinician or smartphone app) to enhance treatment engagement and to minimize confounding of lithium non-response with non-adherence.

Conclusions

The paper outlines the rationale, design and methodology of the first study being undertaken by the newly established R-LiNK collaboration and describes how the project may help to refine the clinical response phenotype and could translate into the personalization of lithium treatment.

Electronic supplementary material

The online version of this article (10.1186/s40345-019-0156-x) contains supplementary material, which is available to authorized users.

Neuropsychiatric Symptoms as Predictors of Clinical Course in Neurodegeneration. A Longitudinal Study

Background: To study the extent to which neuropsychiatric symptoms (NPS) influence the cognitive and functional decline in frontotemporal degeneration (FTD) and Alzheimer’s disease (AD).

Methods: We assessed the progression of NPS and their influence on cognitive and functional progression in a group of FTD (n = 36) and AD patients (n = 47) at two different stages of the disease (2.5 years). A standardized scale was used to assess NPS—the Columbia University Scale for Psychopathology in Alzheimer’s Disease (CUSPAD)—which tracks different symptoms including depression, psychotic symptoms, as well as sleep and conduct problems. In addition, in a subsample of patients (AD n = 14 and FTD n = 14), we analyzed another group of NPS by using the Neuropsychiatric Inventory (NPI). Cognitive declines were tracked by using the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE), while functionality was tracked by using the Lawton scale and the Barthel Index.

Results: The presence of NPS impacts cognitive and functional decline in both groups of patients 2.5 years after disease onset. However, we observed a dissociable profile of the affectation of NPS in each group. In the AD group, results indicate that the progression of depressive symptoms and sleep problems predict cognitive and functional decline. In contrast, the progression of a mixed group of NPS, including conduct problems and delusions, predicts cognitive and functional decline in FTD.

Conclusion: The presence of NPS has a critical impact on the prediction of cognitive decline in FTD and AD patients after 2.5 years of disease progression. Our results demonstrate the importance of assessing different types of NPS in neurodegenerative disorders which, in turn, predict disease progression. Future studies should assess the role of NPS in predicting different neurocognitive pathways and in neurodegeneration.

Prefrontal cortical thickness related to negative symptoms in antipsychotic-naive, first-episode psychotic patients

Introduction

A significant cortical thinning has been repeatedly observed in adult-onset first-episode schizophrenia patients compared to healthy controls, mostly in medial and inferior prefrontal cortices. However, it is yet unclear whether all these replicated alterations are related to any particular clinical feature.

Objectives

This study aimed to investigate differences of cortical thickness in a sample of first-episode, drug-naive psychotic patients and age- and gender-matched healthy controls and explore clinical correlates of these parameters regarding negative symptoms.

Methods

High-resolution T1-weighted images were acquired from 23 antipsychotic-naive, first-episode psychotic patients and 26 age-matched healthy comparison subjects. Clinical features were measured with the negative subscale of the Positive and Negative Syndrome Scale (PANSS) at baseline and after a 2-month follow-up period.

Results

No differences were found regarding age or gender when comparing patients and controls. We found a significant cortical thinning in the left medial orbitofrontal cortex and in the right lateral orbitofrontal cortex in patients compared to healthy age- and gender-matched controls. Regarding clinical performance, no correlation was found at baseline between left medial orbitofrontal nor right lateral ortitofrontal cortical thickness and scores of the negative subscale of the PANSS. However, at the 2-month evaluation clinical performances were significantly associated to the left medial orbitofrontal cortical thickness values.

Conclusions

Cortical thickness alterations in prefontal cortex appear to be present at disease onset and these alterations may relate to clinical outcome. However, our findings must be considered just as exploratory. Larger longitudinal studies may help characterize, replicate and consolidate these findings.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Different levels of lack of improvement at 4 weeks of escitalopram treatment as predictors of poor 8-week outcome in MDD

BACKGROUND

Several post-hoc studies have shown that lack of early improvement reduces the chance of later response or remission. This post-hoc analysis evaluates different cut-off points of non-improvement at 4 weeks of escitalopram treatment to predict 8-week non-response and non-remission.

METHOD

This study consisted of MDD patients with an absence of improvement (<30% reduction in baseline score of the HAMD-17) at Week 4 of escitalopram treatment (10mg/day) that continued escitalopram treatment (10-20mg/day) for a further 4-week period (n=251). Predictive, sensitivity and specificity values for the several definitions of non-improvement (≤ 25%, ≤ 20% and ≤ 15% reduction in the HAMD-17 baseline total score) at 4 weeks were calculated.

RESULTS

Overall, 70.1% (176/251) of patients did not achieve response at Week 8 and 84.5% (212/251) did not achieve remission. The predictive value for non-response was high (71.4-74.3%) for all cut-off points of non-improvement tested. The respective values for non-remission were placed between 85.0% and 87.2%.

LIMITATIONS

This was a post-hoc subgroup analysis. The only drug assessed was escitalopram.

CONCLUSIONS

Our data indicate that an absence of improvement, <30% reduction in the HAMD-17, after 4 weeks of escitalopram treatment should prompt clinicians to consider a change in treatment strategy. Similar findings were previously reported for other antidepressants.

Methylphenidate in mania project (MEMAP): study protocol of an international randomised double-blind placebo-controlled study on the initial treatment of acute mania with methylphenidate

BACKGROUND

Treatment of patients with acute mania remains a considerable medical challenge since onset of action of antimanic medication is delayed for several days. Psychostimulants could have an earlier onset of action. This assumption is based on the 'vigilance regulation model of mania' which postulates that vigilance is unstable in manic patients. Accordingly, vigilance-stabilising psychostimulants could be more useful than conventional treatment in acute mania. We present here the study protocol of a trial intended to study the efficacy and safety of methylphenidate in the initial treatment of acute mania.

METHODS/DESIGN

A multi-centre, randomised, double-blind, placebo-controlled clinical trial will be conducted in 88 bipolar inpatients with acute mania. Male and female patients older than 18 years will be randomised to treatment with either methylphenidate (20 to 40 mg/day) or placebo for 2.5 days, given once or twice daily. The main outcome measure is the reduction in the Young Mania Rating Scale (YMRS) after 2.5 days of treatment. Other outcome measures include the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) the Clinical Global Impression-Bipolar Scale (CGI-BP), the Screen for Cognitive Impairment in Psychiatry (SCIP), actigraphy and the EEG-'Vigilance Algorithm Leipzig' (VIGALL).

DISCUSSION

A positive study outcome of the proposed study could substantially impact our understanding of the etiopathogenesis of mania and open new treatment perspectives.

Fluoxetine in the prevention of depressive recurrences: a double-blind study

Optimal outcomes from depression treatment are long-term recovery and, in the case of recurrent depression, prevention of new episodes. However, few data are available concerning the long-term efficacy of antidepressants in prophylactic treatment to prevent recurrences of depression. The efficacy and safety of fluoxetine 20 mg/day was evaluated in reducing the number of depressive episodes and in extending the time free of symptoms in patients with recurrent unipolar major depression. Patients with recurrent unipolar major depression according to DSM-III-R criteria and who responded to 32 weeks of open-label fluoxetine were randomly assigned to receive fluoxetine 20 mg/day (N = 70) or placebo (N = 70) for 48 weeks of double-blind maintenance treatment. Outcome measures were the percentage of recurrences and time to recurrence. Safety assessments included treatment-emergent adverse events, reasons for discontinuation, vital signs, and laboratory measures. Fluoxetine was associated with a statistically significantly smaller percentage of patients who had a recurrence compared with placebo (20% vs. 40%; chi2 analysis, p = 0.010). The symptom-free period was significantly longer for patients treated with fluoxetine versus placebo (295 vs. 192 days; Kaplan-Meier estimates, log-rank test, p = 0.002). Treatments were well tolerated during maintenance treatment. The only statistically significant difference in adverse events between treatment groups was anxiety, which was more frequent in the placebo group (fluoxetine, 12.9% vs. placebo, 30%; chi2 analysis, p = 0.013). Two placebo-treated patients and no fluoxetine-treated patients were withdrawn because of adverse events. In conclusion, fluoxetine at 20 mg/day was effective and well tolerated for the prophylactic treatment of recurrent unipolar major depression.