The management of adolescents at risk of suicide by Australian general practitioners: issues in practice and confidence

This study involved an anonymous survey of 41Victorian GPs regarding their diagnostic and treatment practices with adolescent patients with depression and/or suicide ideation. The results indicated that the majority of respondents correctly diagnosed the level of depression and the risk of suicide in a case scenario. Although they commonly asked some of the questions related to an assessment of suicide risk, they rarely conducted a comprehensive risk assessment and the level of referral to telephone and internet crisis services was poor. Most GPs indicated a lack of confidence in their ability to detect and manage depression and suicide in this population and strongly emphasized a need for more training.

Dancing with death : the grey area between suicide related behavior, indifference and risk behaviors of heroin users

Suicide-related behavior (SRB) among heroin users is a complex and multifaceted continuum, including such fringe areas as indifference and "risky" behavior. The article investigates the nuances and intersections of SRB, using qualitative semi-structured interviews with 60 regular heroin users recruited primarily from syringe programs in Geelong, Australia. Twenty-eight percent of interviewees reported a previous suicide attempt and 45% reported serious consideration of it. Types of SRB reported included: Suicide attempts, instrumental suicide-related behaviors, suicidal ideation, indifference and risk-taking thoughts and behaviors. Heroin users engage in much behavior which inhabits a grey area of SRB. The use of a nomenclature which addresses the elements of lethality and intent improves the ability of research to properly define and categorize SRB in drug-using populations. But the categories should not be overinclusive; indifferent attitudes towards death and risk-taking behaviors can sometimes be a functional response to the risk environment of heroin users.

The impact of age at onset of bipolar I disorder on functioning and clinical presentation

Objectives: Recent studies have proposed the existence of three distinct subgroups of bipolar 1 disorder based on age at onset (AAO). The present study aims to investigate potential clinical and functional differences between these subgroups in an Australian sample.

Methods: Participants (n = 239) were enrolled in the Bipolar Comprehensive Outcomes Study (BCOS), a 2-year longitudinal, observational, cross-sectional study. Assessment measures included the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HAMD21), Clinical Global Impressions Scale (CGI-BP), SF-36, SLICE/Life Scale, and the EuroQol (EQ-5D). Participants were also asked about their age at the first major affective episode.

Results: Three AAO groups were compared: early (AAO < 20, mean = 15.5 ± 2.72; 44.4% of the participants); intermediate (AAO 20–39, mean = 26.1 ± 4.8; 48.14% of the participants) and late (AAO > 40, mean = 50.6 ± 9.04; 7.4% of the participants). Higher rates of depression, suicidal ideation and binge drinking were reported by the early AAO group. This group also reported poorer quality of life in a number of areas. The early AAO group had a predominant depressive initial polarity and the intermediate group had a manic predominance.

Conclusion: Early AAO is associated with an adverse outcome.

Antidepressants and suicidal thought

The association of antidepressants with suicidal thought in people aged up to 25 year is a thorny issue. Balancing risk with benefit must always be at the core of any decision to treat and when the risk is an increased risk of suicide then a balanced decision can be difficult to make. Some clinicians who have been successfully treating patients using antidepressants have felt skepticism with these studies, finding them to be not reflective of their personal clinical experience. It may be wondered by some whether highlighting the link between suicidal thoughts and antidepressants may paradoxically lead to an increase in suicide by reducing the number of cases treated, however there is no evidence that this has occurred.

The association between antidepressants and suicidal thought may be unpalatable, but as with all new research the only way it can be judged is by the evidence to support it. The weight of evidence to demonstrate the association between antidepressants and suicidal thought in young people is convincing although the risk is low, estimated at one case of emerging suicidal ideation or suicide attempt for every 143 pediatric patients treated [1]. This risk is too low to displace antidepressants as the first line of treatment for depression but is too high a risk to be ignored. The risk is also too low to be recognized based on clinical experience alone as it is low enough to be imperceptible amongst suicides which occur due to depressive illness independent of antidepressant treatment. Only large studies are sufficiently powered to detect suicidal thought associated with antidepressant treatment. Clearly further studies would be helpful, especially if they can help characterize those at greatest risk. This is why the study by Lucy Goldsmith and Joanna Moncrieff in this issue of Current Drug Safety is an important step towards improving our understanding of antidepressant safety. These researchers find a link between increased suicidal impulses and emotional blunting and emotional instability.

Treating clinicians are urged to monitor for risk of suicide after initiation of antidepressant treatment, typically more frequently for the first four weeks of treatment and as indicated thereafter. However, if there is no history of suicidal thought or attempt and the patient does not admit to suicidal thought, suicidality may be missed by the treating clinician, ending in tragedy. Studies that provide new insights into this serious problem may lead to improvements in the effectiveness of monitoring patients for suicide risk, ultimately leading to better outcomes for patients.

Living with suicidal thoughts

The dominant understandings of suicide have privileged the professional observations of health professionals and sociologists over the lived experiences of persons who have reported feeling suicidal. The current study explores what it is like to feel suicidal by examining comments posted voluntarily in an online forum. Adopting an inductive thematic analysis, a number of themes were uncovered which shed light on the following questions: Who has suicidal thoughts? What triggers suicidal thoughts? What is it like to feel suicidal? Also drawn from the data, was information relating to the types of treatments that people received, as well as ongoing survival strategies that people have relied on. The fi ndings indicated people with suicidal thoughts form a heterogeneous group with mixed opinions about the causes of suicidal thoughts. The findings also highlighted a variety of experiences, descriptions and means for survival highlighting the depth of insight that those with fi rst-hand experience have about suicidal thoughts, highlighting also the deep gap in knowledge and understanding in the existing literature about suicide and suicidal ideation. The recommendations for future direction in practice and research include, listening to, and valuing more, the voices and perspectives of suicidal people themselves.

The relationship between suicide and violence in schizophrenia: analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) dataset

Background

Suicide and violence often co-occur in the general population as well as in mentally ill individuals. Few studies, however, have assessed whether these suicidal behaviors are predictive of violence risk in mental illness.

Aims

The aim of this study is to investigate whether suicidal behaviors, including suicidal ideation, threats, and attempts, are significantly associated with increased violence risk in individuals with schizophrenia.

Method

Data for these analyses were obtained from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) trial, a randomized controlled trial of antipsychotic medication in 1460 adults with schizophrenia. Univariate Cox regression analyses were used to calculate hazard ratios (HRs) for suicidal ideation, threats, and attempts. Multivariate analyses were conducted to adjust for common confounding factors, including: age, alcohol or drug misuse, major depression, antisocial personality disorder, depression, hostility, positive symptom, and poor impulse control scores. Tests of discrimination, calibration, and reclassification assessed the incremental predictive validity of suicidal behaviors for the prediction of violence risk.

Results

Suicidal threats and attempts were significantly associated with violence in both males and females with schizophrenia with little change following adjustment for common confounders. Only suicidal threats, however, were associated with a significant increase in incremental validity beyond age, diagnosis with a comorbid substance use disorder, and recent violent behavior.

Conclusions

Suicidal threats are independently associated with violence risk in both males and females with schizophrenia, and may improve violence risk prediction.

Ideações e tentativas de suicídio em adolescentes com práticas sexuais hetero e homoeróticas

Esta pesquisa, que teve como população-alvo adolescentes com idade entre 12 e 20 anos, residentes em três municípios do interior Paulista, buscou conhecer as associações entre orientação sexual e ideações e tentativas de suicídio. Corroborando com as pesquisas internacionais, evidenciou-se que os não heterossexuais têm mais chances de pensarem e tentarem suicídio, comparativamente aos heterossexuais. Todavia, encontrou-se que, dentre o grupo de adolescentes que se assumiram não heterossexuais, os que estão mais vulneráveis são aqueles que se autodefiniram bissexuais e outros, os quais constituem o grupo de pessoas menos assumidas, dentre os não heterossexuais. do mesmo modo, constatou-se que os respondentes apresentam diversas opiniões e valores homofóbicos, sexistas e heterocentrados, o que revela ser o espaço escolar, onde se encontram esses jovens não heterossexuais, bastante carregado de posicionamentos discursivos discriminatórios. Conclui-se que a questão do suicídio é uma problemática de saúde pública e que a população de jovens não heterossexuais necessita de abordagens específicas para a prevenção e de atenção relativas a essa conduta.

Suicidality in Obsessive-Compulsive Disorder: Prevalence and Relation to Symptom Dimensions and Comorbid Conditions

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

An exploratory dimensional approach to premenstrual manifestation of obsessive-compulsive disorder symptoms: A multicentre study

Objective: In women with obsessive-compulsive disorder (OCD), symptom severity appears to fluctuate over the course of the menstrual cycle. The objective of this paper was to compare female OCD patients with and without premenstrual worsening of obsessive-compulsive symptoms (OCS), in terms of the clinical characteristics of OCD. Methods: This was a cross-sectional study involving 455 women with OCD, of whom 226 (49.7%) had experienced premenstrual OCS worsening and 229 (50.3%) had not (PMOCS-worse and PMOCS-same groups, respectively). Data were collected with the original and dimensional versions of the Yale-Brown Obsessive-Compulsive Scale, as well as with the Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI). Results: We found significant differences between the PMOCS-same and PMOCS-worse groups, the latter showing a higher frequency of suicidal ideation (P<.001), suicide attempts (P=.027), current use of selective serotonin reuptake inhibitors (P=.022), lifetime use of mood stabilisers (P=.015), and sexual/religious obsessions (P<.001; OR. =1.90), as well as higher scores on the BDI (P<.001) and BAI (P<.001). Conclusion: Underscoring the fact that OCD is a heterogeneous disorder, there appears to be a subgroup of female OCD patients in whom the premenstrual period is associated with a higher frequency of sexual/religious obsessions, depression, anxiety, and suicidality. This might be attributable to hormonal fluctuations. Further studies are warranted in order to investigate this hypothesis by evaluating such patients at different phases of the menstrual cycle, as well as measuring hormonal levels. © 2012 Elsevier Inc.

Dilemas do planejamento e da gestão municipal na Amazônia ribeirinha: uma análise do caso de Cametá à luz do ideário da reforma urbana e do Estatuto da Cidade

Trata a presente pesquisa de um estudo que discute os instrumentos de reforma urbana concebidos no Estatuto da Cidade relacionados às especificidades sócio-espaciais de um município ribeirinho amazônico. Busca-se identificar e analisar o ideário de reforma urbana proposto pelo Movimento Nacional pela Reforma Urbana (MNRU) e concebido no Estatuto da Cidade atentando para as especificidades sócio-espaciais do Município de Cametá, Estado do Pará. Para a realização da pesquisa recorreu-se a uma abordagem histórico-dialética sobre a problemática enfocada e se utilizou, como procedimentos de pesquisa o levantamento e a análise bibliográfica e documental (Estatuto da Cidade e Plano diretor de Cametá); aplicação de entrevistas semi-estruturadas junto à equipe elaboradora do plano diretor municipal, junto aos integrantes de movimentos sociais urbanos e rurais e junto ao poder público. Por meio da análise, concluiu-se que municípios ribeirinhos como Cametá, em virtude de apresentarem especificidades sócio-espaciais no contexto amazônico e brasileiro, enfrentam dilemas relacionados ao planejamento e à gestão urbana e municipal, distanciando-se, algumas vezes, das diretrizes e princípios estabelecidos genericamente para o território nacional. Tal questão revela a importância de pensar a diversidade sócio-espacial brasileira e amazônica, bem como a necessidade de viabilizar adequações de instrumentos e preceitos que buscam nortear as diversas práticas de planejamento e de gestão em nível local, não obstante os avanços relacionados a essas mesmas práticas nos últimos anos no Brasil.

Suicide attempts are associated with worse quality of life in patients with bipolar disorder type I

Background: The association between suicidal behavior and quality of life (QoL) in bipolar disorder (BD) is poorly understood. Worse QoL has been associated with suicide attempts and suicidal ideation in schizophrenic patients, but this relationship has not been investigated in BD. This study tested whether a history of suicide attempts was associated with poor QoL in a well-characterized sample of patients with BD, as has been observed in other psychiatric disorders and in the general population. Methods: One hundred eight patients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BD type I (44 with previous suicide attempts, 64 without previous suicide attempts) were studied. Quality of life was assessed using the World Health Organization's Quality of Life Instrument Short Version. Depressive and manic symptoms were assessed using the Hamilton Depression Rating Scale-17 items and the Young Mania Rating Scale. Results: Patients with BD and previous suicide attempts had significantly lower scores in all the 4 domains of the World Health Organization's Quality of Life Instrument Short Version scale than did patients with BD but no previous suicide attempts (physical domain P=.001; psychological domain P <.0001; social domain P=.001, and environmental domain P=.039). In the euthymic subgroup (n=70), patients with previous suicide attempts had significantly lower scores only in the psychological and social domains (P=.020 and P=.004). Limitations: This was a cross-sectional study, and no causal associations can be assumed. Conclusions: Patients with BD and a history of previous suicide attempts seem to have a worse QoL than did patients who never attempted suicide. Poorer QoL might be a marker of poor copying skills and inadequate social support and be a risk factor for suicidal behavior in BD. Alternatively, poorer QoL and suicidal behavior might be different expressions of more severe BD. (C) 2012 Elsevier Inc. All rights reserved.

Perception of causality in schizophrenia spectrum disorder

Patients with schizophrenia spectrum disorders often maintain deviating views on cause-effect relationships, especially when positive and disorganization symptoms are manifest. Altered perceived causality is prominent in delusional ideation, in ideas of reference, and in the mentalizing ability (theory of mind [ToM]) of patients. Perceiving causal relationships may be understood either as higher order cognitive reasoning or as low-level information processing. In the present study, perception of causality was investigated as a low-level, preattentional capability similar to gestalt-like perceptual organization. Thirty-one patients (24 men and 7 women with mean age 27.7 years) and the same number of healthy control subjects matched to patients with respect to age and sex were tested. A visual paradigm was used in which 2 identical discs move, from opposite sides of a monitor, steadily toward and then past one another. Their coincidence generates an ambiguous, bistable percept (discs either "stream through" or "bounce off" one another). The bouncing perception, ie, perceived causality, is enhanced when auditory stimuli are presented at the time of coincidence. Psychopathology was measured using the Positive and Negative Syndrome Scale. It was found that positive symptoms were strongly associated with increased perceived causality and disorganization with attenuated perceived causality. Patients in general were not significantly different from controls, but symptom subgroups showed specifically altered perceived causality. Perceived causality as a basic preattentional process may contribute to higher order cognitive alterations and ToM deficiencies. It is suggested that cognitive remediation therapy should address both increased and reduced perception of causality.

Links between body mass index, total body fat, cholesterol, high-density lipoprotein, and insulin sensitivity in patients with obesity related to depression, anger, and anxiety

OBJECTIVE: Define links between psychosocial parameters and metabolic variables in obese females before and after a low-calorie diet. METHOD: Nine female obese patients (age 36.1 +/- 7.1 years, body mass index [BMI] > 30 kg/m2) were investigated before and after a 6-week low-calorie diet accompanied by behavior therapy. Blood lipids, insulin sensitivity (Bergman protocol), fat distribution (by dual-energy X-ray absorptiometry [DEXA]), as well as psychological parameters such as depression, anger, anxiety, symptom load, and well-being, were assessed before and after the dieting period. RESULTS: The females lost 9.6 +/- 2.8 kg (p < .0001) of body weight, their BMI was reduced by 3.5 +/- 0.3 kg/m2 (p < .0001), and insulin sensitivity increased from 3.0 +/- 1.8 to 4.3 +/- 1.5 mg/kg (p = .05). Their abdominal fat content decreased from 22.3 +/- 5.5 to 18.9 +/- 4.5 kg (p < .0001). In parallel, psychological parameters such as irritability (p < .05) and cognitive control (p < .0001) increased, whereas feelings of hunger (p < .05), externality (p < .05), interpersonal sensitivity (p < .01), paranoid ideation (p < .05), psychoticism (p < .01), and global severity index (p < .01) decreased. Prospectively, differences in body fat (percent) were correlated to nervousness (p < .05). Waist-to-hip ratio (WHR) differences were significantly correlated to sociability (p < .05) and inversely to emotional instability (p < .05), whereas emotional instability was inversely correlated to differences in insulin sensitivity (p < .01). DISCUSSION: Weight reduction may lead to better somatic risk factor control. Women with more nervousness and better sociability at the beginning of a diet period may lose more weight than others.

Brain electric correlates of strong belief in paranormal phenomena: intracerebral EEG source and regional Omega complexity analyses

The neurocognitive processes underlying the formation and maintenance of paranormal beliefs are important for understanding schizotypal ideation. Behavioral studies indicated that both schizotypal and paranormal ideation are based on an overreliance on the right hemisphere, whose coarse rather than focussed semantic processing may favor the emergence of 'loose' and 'uncommon' associations. To elucidate the electrophysiological basis of these behavioral observations, 35-channel resting EEG was recorded in pre-screened female strong believers and disbelievers during resting baseline. EEG data were subjected to FFT-Dipole-Approximation analysis, a reference-free frequency-domain dipole source modeling, and Regional (hemispheric) Omega Complexity analysis, a linear approach estimating the complexity of the trajectories of momentary EEG map series in state space. Compared to disbelievers, believers showed: more right-located sources of the beta2 band (18.5-21 Hz, excitatory activity); reduced interhemispheric differences in Omega complexity values; higher scores on the Magical Ideation scale; more general negative affect; and more hypnagogic-like reveries after a 4-min eyes-closed resting period. Thus, subjects differing in their declared paranormal belief displayed different active, cerebral neural populations during resting, task-free conditions. As hypothesized, believers showed relatively higher right hemispheric activation and reduced hemispheric asymmetry of functional complexity. These markers may constitute the neurophysiological basis for paranormal and schizotypal ideation.

The structure of psychopathological symptoms and the associations with DSM-diagnoses in treatment seeking individuals

BACKGROUND: Research on comorbidity of psychiatric disorders identifies broad superordinate dimensions as underlying structure of psychopathology. While a syndrome-level approach informs diagnostic systems, a symptom-level approach is more likely to represent the dimensional components within existing diagnostic categories. It may capture general emotional, cognitive or physiological processes as underlying liabilities of different disorders and thus further develop dimensional-spectrum models of psychopathology. METHODS: Exploratory and confirmatory factor analyses were used to examine the structure of psychopathological symptoms assessed with the Brief Symptom Inventory in two outpatient samples (n=3171), including several correlated-factors and bifactor models. The preferred models were correlated with DSM-diagnoses. RESULTS: A model containing eight correlated factors for depressed mood, phobic fear, aggression, suicidal ideation, nervous tension, somatic symptoms, information processing deficits, and interpersonal insecurity, as well a bifactor model fit the data best. Distinct patterns of correlations with DSM-diagnoses identified a) distress-related disorders, i.e., mood disorders, PTSD, and personality disorders, which were associated with all correlated factors as well as the underlying general distress factor; b) anxiety disorders with more specific patterns of correlations; and c) disorders defined by behavioural or somatic dysfunctions, which were characterised by non-significant or negative correlations with most factors. CONCLUSIONS: This study identified emotional, somatic, cognitive, and interpersonal components of psychopathology as transdiagnostic psychopathological liabilities. These components can contribute to a more accurate description and taxonomy of psychopathology, may serve as phenotypic constructs for further aetiological research, and can inform the development of tailored general and specific interventions to treat mental disorders.