Suicide prevention in childhood and adolescence: a narrative review of current knowledge on risk and protective factors and effectiveness of interventions.

INTRODUCTION: Suicide is a global mental health problem for people of all ages. While rates of suicide in children and adolescents are reported as lower than those in older populations worldwide, they represent the third leading cause of death in 15-19-year-olds. The rates are higher among boys than girls worldwide, though the death rates for girls exceed those for boys in Bangladesh, China, India, and Nepal. There has been a general decrease in adolescent suicide rates over recent decades. However, increases are reported in South East Asia as well as South America over the same time period. METHODS: A narrative review method has been used to summarize current knowledge about risk and protective factors for suicide among children and adolescents and to discuss evidence-based strategy for suicide prevention in this age group. RESULTS: Identified suicide risk and protective factors for children and adolescents largely overlap with those for adults. Nevertheless, developmental characteristics may strengthen the impact of some factors, such as decision-making style, coping strategies, family and peer relationships, and victimization. The implementation of evidence-based suicide preventive strategies is needed. Restricting access to lethal means, school-based awareness and skill training programs, and interventions delivered in clinical and community settings have been proven effective. The effectiveness of gatekeeper training and screening programs in reducing suicidal ideation and behavior is unproven but widely examined in selected settings. DISCUSSION: Since most studies have been conducted in western countries, future research should assess the effectiveness of these promising strategies in different cultural contexts. The use of more rigorous study designs, the use of both short- and long-term follow-up evaluations, the larger inclusion of individuals belonging to vulnerable groups, the evaluation of online intervention, and the analysis of programs' cost-effectiveness are also required.

Suicide prevention in psychiatric patients.

An increased risk of suicide has been reported for psychiatric patients. In several world regions, an underlying psychiatric disorder is reported in up to 90% of people who die from suicide, though this rate seems to be considerably lower in low- and middle-income countries. Major psychiatric conditions associated with suicidality are mood disorders, alcohol and substance use disorders, borderline personality disorder, and schizophrenia. Comorbidity between different disorders is frequently associated with a higher suicide risk. A history of suicide attempts, feelings of hopelessness, impulsivity and aggression, adverse childhood experiences, severe psychopathology, and somatic disorders are common risk factors for suicide among psychiatric patients. Stressful life events and interpersonal problems, including interpersonal violence, are often triggers. A comprehensive and repeated suicide risk assessment represents the first step for effective suicide prevention. Particular attention should be paid during and after hospitalization, with the first days and weeks after discharge representing the most critical period. Pharmacological treatment of mood disorders and schizophrenia has been shown to have an anti-suicidal effect. A significant reduction of suicidal thoughts and behavior has been reported for cognitive behavioral therapy and dialectical behavior therapy. Brief interventions, including psychoeducation and follow-ups, are associated with a decrease in suicide deaths. Further development of suicide prevention in psychiatric patients will require a better understanding of additional risk and protective factors, such as the role of a person's decision-making capacity and social support, the role of spiritual and religious interventions, and the reduction of the treatment gap in mental health care.

A Naturalistic, European Multi-Center Clinical Study of Electrodermal Reactivity and Suicide Risk Among Patients With Depression.

Background: Electrodermal hyporeactivity has been proposed as a marker of suicidal risk. The EUDOR-A study investigated the prevalence of electrodermal hyporeactivity among patients with depression and its association with attempted and completed suicide. Methods: Between August 2014 and March 2016, 1,573 in- and outpatients with a primary diagnosis of depression (active or remission phase) were recruited at 15 European psychiatric centers. Each patient was followed-up for 1 year. Electrodermal activity was assessed at baseline with the ElectroDermal Orienting Reactivity Test. Data on the sociodemographic characteristics, clinical diagnoses, and treatment of the subjects were also collected. The severity of the depressive symptoms was assessed through the Montgomery-Asberg Depression Rating Scale. Information regarding number, time, and method of suicide attempts was gathered at baseline and at the end of the 1-year follow-up. The same data were collected in case of completed suicide. Results: Hyporeactive patients were shown to be significantly more at risk of suicide attempt compared to reactive patients, both at baseline and follow-up. A sensitivity of 29.86% and a positive predictive value (PPV) of 46.77% were found for attempted suicide at baseline, while a sensitivity of 35.36% and a PPV of 8.92% were found for attempted suicide at follow-up. The sensitivity and PPV for completed suicide were 25.00 and 0.61%, respectively. However, when controlled for suicide attempt at baseline, the association between hyporeactivity and follow-up suicide attempt was no longer significant. The low number of completed suicides did not allow any analysis.

Adaptation of evidence-based suicide prevention strategies during and after the COVID-19 pandemic.

Suicide is preventable. Nevertheless, each year 800,000 people die of suicide in the world. While there is evidence indicating that suicide rates de-crease during times of crises, they are expected to increase once the immediate crisis has passed. The COVID-19 pandemic affects risk and pro-tective factors for suicide at each level of the socio-ecological model. Economic downturn, augmented barriers to accessing health care, increased access to suicidal means, inappropriate media reporting at the societal level; deprioritization of mental health and preventive activities at the community level; interpersonal conflicts, neglect and violence at the relationship level; unemployment, poverty, loneliness and hopelessness at the individual level: all these variables contribute to an increase of depression, anxiety, post-traumatic stress disorder, harmful use of alcohol, substance abuse, and ultimately suicide risk. Suicide should be prevented by strengthening universal strategies directed to the entire population, including mitigation of unemployment, poverty and inequalities; prioritization of access to mental health care; responsible media reporting, with information about available support; prevention of increased alcohol intake; and restriction of access to lethal means of suicide. Selective interventions should continue to target known vulnerable groups who are socio-economically disadvantaged, but also new ones such as first responders and health care staff, and the bereaved by COVID-19 who have been deprived of the final contact with loved ones and funerals. Indicated preventive strategies targeting individuals who display suicidal behaviour should focus on available pharmacological and psychological treatments of mental disorders, ensuring proper follow-up and chain of care by increased use of telemedicine and other digital means. The scientific community, health care professionals, politicians and decision-makers will find in this paper a systematic description of the effects of the pandemic on suicide risk at the society, community, family and individual levels, and an overview of how evidence-based suicide preventive interventions should be adapted. Research is needed to investigate which adaptations are effective and in which con-texts.

5-HTTLPR-brain-derived neurotrophic factor (BDNF) gene interactions and early adverse life events effect on impulsivity in suicide attempters.

OBJECTIVES: An expanding body of research suggests that childhood adverse experiences can lead to different negative health outcomes, including attempted suicide. Serotonergic genes such as the promoter region of the serotonin transporter gene (5-HTTLPR) have been associated both with impulsivity in suicide attempts and reactivity to environmental stress exposure. BDNF gene may play an epigenetic role. METHODS: We studied the influence of childhood stressful events and 5-HTTLPR genotype on impulsivity measured by Barratt Impulsivity Scale (BIS-10) in a multicentre sample of 1,655 suicide attempters (69.4% women, 30.6% men; mean age 40.13 years). A co-dominant additive genetic model was used for the statistical analyses. Interaction between 5-HTTLPR genotype and early trauma exposure was tested using moderated and multiple regression techniques. Interaction plots were used to explore BDNF genotype modulation. RESULTS: Mildly higher impulsivity scores were found in men with SS compared with SL or LL genotypes, and men with childhood emotional and physical abuse. Interaction analyses showed that combination of 5-HTTLPR-SS genotype and early trauma exposure increase impulsivity scores independently. Impulsivity scores were not affected by the modulation of BDNF genes. CONCLUSIONS: Childhood trauma and 5-HTTLPR genotype seem to be independently involved in suicide attempts, sharing a common pathway of increasing impulsivity.

Psychopathology is associated with reproductive health risk in European adolescents.

BACKGROUND: Reproductive and mental health are key domains of adolescent wellbeing but possible interrelationships are poorly understood. This cross-sectional study evaluated the association between psychopathology and reproductive health risk among European adolescents. METHODS: A structured self-report questionnaire was delivered to 12,395 pupils of 179 randomly selected schools in 11 European countries within the EU funded "Saving and Empowering Young Lives in Europe" (SEYLE) project. The questionnaire included items about sexual initiation and reproductive health risk factors, such as number of sexual partners, frequency of condom use, and pregnancy involvement. Psychopathology was evaluated with validated instruments and/or ad-hoc questions. RESULTS: Of 11,406 respondents (median age 15; interquartile range [IQR] 14-15; 57% females), 18.8% reported sexual initiation. Sixty percent of them also reported at least one reproductive risk factor. Sexual initiation was significantly more common among pupils older than 15 years (38% versus 13.2% younger pupils) and males (21.3% versus 16.9% females). It was also more common among pupils with depression (age/sex-adjusted odds ratio [aOR] 1.871), anxiety (aOR 2.190), severe suicidal ideation (aOR 2.259), self-injurious behaviour (aOR 2.892), and suicide attempts (aOR 3.091). These associations were particularly strong among pupils ≤15 years old and, for overt psychopathology, among pupils with low non-sexual risk behaviour profile and females. Depression (aOR 1.937), anxiety (aOR 2.282), severe suicidal ideation (aOR 2.354), self-injurious behaviour (aOR 3.022), and suicide attempts (aOR 3.284) were associated with higher reproductive health risk, defined by an increasing number of coexisting reproductive risk factors. CONCLUSIONS: These findings suggest an alignment between mental and reproductive health risk and support the value of cross-domain collaboration in adolescent health. The association between psychopathology and reproductive health risk, as well as its variations with age, sex, and associated risk behaviours, should be considered when designing health-promoting or disease-preventing interventions for adolescents.

Interactions between youth and mental health professionals: The Youth Aware of Mental health (YAM) program experience.

THE YOUTH AWARE OF MENTAL HEALTH (YAM) EXPERIENCE: Youth stand at the core of much mental health promotion, yet little is written about their experiences of such efforts. We aimed to take this on by interviewing youth after they participated in Youth Aware of Mental Health (YAM), a universal mental health promotion program. YAM has a non-anticipatory methodology that provides youth with a safe space for reflection, role-play, and discussion. Addressing everyday mental health, YAM invites the experiences and issues relevant to the youth present to influence the program in a slightly different direction every time. The YAM instructor guides the participants but does not present the youth with given formulas on how to solve their problems. Like any mental health promotion, YAM appeals to some more than others in its intended audience and individuals engage with the program in many different ways. We set out to learn more about these experiences. CONVERSATIONS ABOUT MENTAL HEALTH: Thirty-two semi-structured interviews were conducted with 15-17 year olds in Estonia, Italy, Romania and Spain. In these interviews, the researchers made an effort to discuss mental health in terms relevant to youth. Still, wide-ranging levels of motivation, ease with engaging in dialogue with mental health professionals, and comfort with the format and content of YAM were detected. The youth were clustered in five different groups relating to their positioning vis-à-vis the researcher during the interview. The following evocative labels were used: "interested", "foot in the door", "respect for authority", "careful", and "not my topic". Corresponding labels were devised for their YAM experience: "engaged", "initially hesitant", "cautious", "eager to please", or "disengaged". We also observed that the researchers brought their own expectations and employed a variety of approaches that led to anticipating answers, stating the obvious, or getting along better with some of the youth. These modes of interaction were categorized under: "favoritism", "familiarity", "frustration", "out of sync", and "insecurity". Similar power dynamics likely transpire in other encounters between youth and researchers, including interventions such as YAM. YOUTH AND MENTAL HEALTH PROFESSIONALS: NOTICING THE DYNAMICS AT PLAY: As mental health professionals, we need to be aware of the professional habits and biases that sometimes obstruct us in understanding the experiences of youth. By initiating dialogue and listening closely to youth we can find a way to those experiences. Qualitative research can help bring the underlying interplay between mental health professionals and youth to the surface while also orienting the conversation towards topics that matter to youth. Some youth are more interested or feel more at ease in speaking openly with mental health professionals, while others find such exchanges less appealing or almost intolerable. Future mental health promotion initiatives would benefit from involving youth in the design of interventions to create an inclusive atmosphere and engage with topics that appeal to youth with diverse experiences of mental health.

The association between electrodermal activity (EDA), depression and suicidal behaviour: A systematic review and narrative synthesis.

BACKGROUND: Electrodermal activity (EDA) and other peripheral autonomic electrical parameters have been used as indicators of emotional states, including depressive states and suicidal state. We aimed to review EDA research systematically, focusing on EDA's usefulness as a biomarker for depression and suicidal behaviour. METHODS: We searched MEDLINE, Scopus, Cochrane Library, and Web of Science databases, following PRISMA guidelines. The initial screening of articles was based on titles and abstracts; then the full text was reviewed. A preliminary synthesis of findings was developed using tables, thematic analysis and quality ratings. RESULTS: 1287 articles were screened and 77 relevant studies were identified and included in the systematic review. The studies were fairly consistent in maintaining that hypoactive electrodermal response is an established feature of patients affected by depression. There is also preliminary evidence that monitoring EDA may help to differentiate the phases of mood disorders. A few studies provided evidence that EDA can be used to differentiate acutely suicidal subjects from depressed patients who are not severely suicidal. Although EDA has been shown to be a valid, sensitive marker of suicidal ideation, suicide attempts and violent suicidal behaviour, it also seems to be influenced to some extent by antidepressant treatment. CONCLUSIONS: Most of the studies summarised in this review are quite outdated and employed a variety of designs and methods to evaluate EDA. This limits the generalisability of the results and makes it difficult to draw clear conclusions about the role of EDA in real-world settings. Electrodermal hypoactivity seems to be a reliable feature of depression and a valid marker of suicidal risk. Nevertheless, the potential utility of EDA in diagnosis, prevention, and treatment planning for depression and suicidal behaviour, should be thoroughly studied.

EUDOR-A multi-centre research program: A naturalistic, European Multi-centre Clinical study of EDOR Test in adult patients with primary depression.

BACKGROUND: Electrodermal reactivity has been successfully used as indicator of interest, curiosity as well as depressive states. The measured reactivity depends on the quantity of sweat secreted by those eccrine sweat glands that are located in the hypodermis of palmar and plantar regions. Electrodermal hyporeactive individuals are those who show an unusual rapid habituation to identical non-significant stimuli. Previous findings suggested that electrodermal hyporeactivity has a high sensitivity and a high specificity for suicide. The aims of the present study are to test the effectiveness and the usefulness of the EDOR (ElectroDermal Orienting Reactivity) Test as a support in the suicide risk assessment of depressed patients and to assess the predictive value of electrodermal hyporeactivity, measured through the EDOR Test, for suicide and suicide attempt in adult patients with a primary diagnosis of depression. METHODS AND DESIGN: 1573 patients with a primary diagnosis of depression, whether currently depressed or in remission, have been recruited at 15 centres in 9 different European countries. Depressive symptomatology was evaluated through the Montgomery-Asberg Depression Scale. Previous suicide attempts were registered and the suicide intent of the worst attempt was rated according to the first eight items of the Beck Suicide Intent Scale. The suicide risk was also assessed according to rules and traditions at the centre. The EDOR Test was finally performed. During the EDOR Test, two fingers are put on gold electrodes and direct current of 0.5 V is passed through the epidermis of the fingers according to standards. A moderately strong tone is presented through headphones now and then during the test. The electrodermal responses to the stimuli represent an increase in the conductance due to the increased number of filled sweat ducts that act as conductors through the electrically highly resistant epidermis. Each patient is followed up for one year in order to assess the occurrence of intentional self-harm. DISCUSSION: Based on previous studies, expected results would be that patients realizing a suicide attempt with a strong intent or committing suicide should be electrodermally hyporeactive in most cases and non-hyporeactive patients should show only few indications of death intent or suicides. TRIAL REGISTRATION: The German Clinical Trials Register, DRKS00010082 . Registered May 31st, 2016. Retrospectively registered.

Physical activity in European adolescents and associations with anxiety, depression and well-being.

In this cross-sectional study, physical activity, sport participation and associations with well-being, anxiety and depressive symptoms were examined in a large representative sample of European adolescents. A school-based survey was completed by 11,110 adolescents from ten European countries who took part in the SEYLE (Saving and Empowering Young Lives in Europe) study. The questionnaire included items assessing physical activity, sport participation and validated instruments assessing well-being (WHO-5), depressive symptoms (BDI-II) and anxiety (SAS). Multi-level mixed effects linear regression was used to examine associations between physical activity/sport participation and mental health measures. A minority of the sample (17.9 % of boys and 10.7 % of girls; p < 0.0005) reported sufficient activity based on WHO guidelines (60 min + daily). The mean number of days of at least 60 min of moderate-to-vigorous activity in the past 2 weeks was 7.5 ± 4.4 among boys and 5.9 days ± 4.3 among girls. Frequency of activity was positively correlated with well-being and negatively correlated with both anxiety and depressive symptoms, up to a threshold of moderate frequency of activity. In a multi-level mixed effects model more frequent physical activity and participation in sport were both found to independently contribute to greater well-being and lower levels of anxiety and depressive symptoms in both sexes. Increasing activity levels and sports participation among the least active young people should be a target of community and school-based interventions to promote well-being. There does not appear to be an additional benefit to mental health associated with meeting the WHO-recommended levels of activity.