Autopsy rates and the misclassification of suicide and accident deaths.

Mortality statistics are critical to determine the burden of disease. Certain causes of death are prone to being misclassified on cause of death certificates. This poses a serious risk for public health and safety, as accurate death certificates form the basis for mortality statistics, which in turn are crucial for research, funding allocation and health interventions. This study uses generalised estimating equations and regression modelling to investigate for which cause of death categories suicide and accident deaths are misclassified as. National mortality statistics and autopsy rates from North America and Europe covering the past forty years were analysed to determine the associations between the different causes of death in cross-sectional and longitudinal models. We find that suicides and deaths by accidents are frequently mutually misclassified. We also find that suicides are frequently misclassified as drug use disorder deaths, in contrast to accident deaths, which are not misclassified as drug use disorder deaths. Furthermore, suicides do not seem to be misclassified as undetermined deaths or ill-defined deaths. The frequency of misclassification shows that the quality of death certificates should be improved, and autopsies may be used systematically to control the quality of death certificates.

E-learning as a tool of suicide prevention training: A meta-analysis and systematic review.

Suicide is a global health challenge. One prevention strategy is teaching individuals how to detect and respond to suicidality. These training have increasingly been delivered online. We searched WoS, Scopus, and PubMed from inception until the 20 September 2023 to evaluate e-learning efficacy as standardized mean changes and standardized mean differences. We synthesized main results using multilevel meta-analyses and subgroups using random-effects meta-analyses. Robins-I, RoB-II and trim-and-fill were used to assess the risk of bias. Of the 6516 initially screened articles, 26 were included. Overall, e-learning increased suicide prevention skills. Subgroups reported differing results: e-learning affected knowledge and self-efficacy more than behavior and attitudes. Efficacy, short duration, and low-cost suggest that e-learning may be feasible in teaching basic suicide prevention skills to lay people. However, current evidence suggests that health care professionals should not rely on e-learning as a training modality, except when no other form of training is available. Preregisteration: CRD42020218978.

The fearlessness about death scale's efficacy for differentiating suicide attempts from non-suicidal self-injury, a meta-analysis.

We used multivariate meta-analysis modeling variances and covariances of suicidal ideation, suicide attempts, and non-suicidal self-injury to investigate if the Fearlessness About Death scale differentiated between suicide attempts and non-suicidal self-injury. The systematic search yielded 27 studies that fulfilled the inclusion criteria. The association of suicidal ideation with suicide attempts was comparable to the association of suicidal ideation with non-suicidal self-injury. The Fearlessness About Death scale weakened both associations to a comparative degree. These results cast doubt on the clinical utility of the Fearlessness About Death scale, as well as the self-assessment of suicidal ideation, suicide attempts and non-suicidal self-injury.

Oxytocin receptor gene methylation as a molecular marker for severity of depressive symptoms in affective disorder patients.

BACKGROUND: Oxytocin (OXT) is a neuropeptide and hormone involved in emotional functioning and also seems to play a role in moderating the stress response. Both preclinical and clinical studies point to an increased methylation status of the Oxytocin receptor (OXTR) promoter region with concomitant deficits in social, cognitive and emotional functioning. We hypothesize that methylation levels (%) of the oxytocin receptor promoter region correlate with the severity of depression symptoms and/or with the severity of childhood trauma within this present sample of affective disorder patients. METHODOLOGY: Eight hundred forty six (846) affective disorder patients of Central European origin were recruited at the Department of Psychiatry and Psychotherapy of the Medical University Vienna, the Karl Landsteiner University for Health and Science and Zentren für seelische Gesundheit, BBRZ-Med Leopoldau. Psychiatric assessment included a semi-structured diagnostic interview (Schedules for Clinical Assessment in Neuropsychiatry), the Hamilton Depression Scale and the Childhood Trauma Questionnaire. Concomitantly DNA samples of peripheral blood cells were collected for Multiplexed and Sensitive DNA Methylation Testing. RESULTS: Our data suggests a positive but not significant association between OXTR promoter Exons 1-3 methylation levels and severity of depression symptoms as well as severity of emotional neglect in affective disorder patients and no association with childhood trauma. CONCLUSIONS: Our findings contribute to elucidate the role of OXTR in affective disorders, but further longitudinal studies in particular are necessary to broaden the current state of knowledge.

Coparenting Intervention for Expectant Parents Affects Relationship Quality: A Pilot Study.

Research has shown that the transition to parenthood is a particularly challenging period of life which is often associated with a decline in relationship quality and an increase in mental health problems. Emerging parents often experience difficulties in coping with new tasks and challenges in the relationship, resulting in inadequate mutual support, stress, conflicts and even depressive symptoms. To support expectant parents in establishing an effective and strong coparenting alliance, we have employed an educational coparenting intervention to teach important coparenting skills. The intervention was a non-randomized case-control study with 126 expectant parents. The intervention group participated in a five-session intervention, whereas the control group received an information booklet and had an optional meeting postpartum. The purpose of this study was to ease the transition to parenthood in order to prevent postpartum conflict and depression. Parents in the intervention group (n = 34 couples) showed significantly fewer conflicts postpartum than before (Z = -3.28, p = 0.00), and scored better in postnatal delegated dyadic coping (ß = 0.25, p = 0.00, R2 = 0.32), a form of mutual support. Neither the intervention group (Z = -0.83, p = 0.40) nor the control group (Z = -0.86, p = 0.38) showed a significant increase in depression scores after childbirth. Although conflicts during the transition to parenthood declined and postnatal delegated dyadic coping strengthened, the study design does not allow to draw conclusion on group effects. Nevertheless, the promising results of this pilot intervention are a base for future studies.

Clinical Components of Borderline Personality Disorder and Personality Functioning.

BACKGROUND: Impairment in personality functioning (PF) represents a salient criterion of the DSM-5 alternative diagnostic model for personality disorders (AMPD). The main goal of this study is to analyze the relationship of the borderline personality disorder (BPD) clinical components derived from the DSM-5 categorical diagnostic model (affective dysregulation, behavioral dysregulation, and disturbed relatedness) with personality organization (PO), i.e., PF, assessed by the Structured Interview of Personality Organization (STIPO). METHODS: STIPO and the Structured Clinical Interviews for DSM-IV (SCID-I and -II) were administered to 206 BPD patients. The relationship between PO and BPD components were studied using Spearman correlations and independent linear regression analyses. RESULTS: Significant positive correlations were observed between STIPO scores and several DSM-5 BPD criteria and comorbid psychiatric disorders. STIPO dimensions mainly correlated with disturbed relatedness and, to a lesser extent, affective dysregulation components. Each BPD clinical component was associated with specific STIPO dimensions. CONCLUSIONS: Both diagnostic models, DSM-5 BPD criteria and PO, are not only related but complementary concepts. The results of this study particularly recommend STIPO for the assessment of relational functioning, which is a major domain of the Personality Functioning Scale Levels of the DSM-5 AMPD.

[Psychometric Properties of the German Version of the Suicide Behaviors Questionnaire Revised (SBQ-R)]. / Psychometrische Eigenschaften der deutschen Version des Suicide Behaviors Questionnaire Revised (SBQ-R).

OBJECTIVES: The Suicide Behaviors Questionnaire-Revised (SBQ-R) was developed by Osman et al. (2001) to economically assess different aspects of suicidality. It consists of 4 items. There are several critical points concerning item construction: (1) temporal frame (e. g. retrospective vs. prospective) and (2) response labels of item 1 and 3 (e. g. 2 alternatives with the same scoring). Information about psychometric properties of the German version of the SBQ-R were not available until now. The SBQ-R is assumed to be a unidimensional measure and is evaluated using a total score, although its dimensionality has never been tested. METHODS: The SBQ-R and several measures for convergent validity were assessed in a representative sample of the German general population (N=2497). Convergent validity was tested against symptoms of depression and anxiety (PHQ-4), as well as the core constructs of the Interpersonal Theory of Suicidal Behavior (IPTS) (INQ, ACSS-FAD). Unidimensionality of the SBQ-R was tested using confirmatory factor analysis and intercorrelations with the convergent measures were calculated. RESULTS: The initial model fit of the unidimensional solution was unsatisfactory. After inclusion of a correlated error term of item 2 and item 4 based on modification indices, the model fit was very good. Moreover the SBQ-R showed satisfactory internal consistency (Cronbach's α=0.72). With the exception of the ACSS-FAD, all correlations with convergent measures were according to the theoretically proposed expectations. CONCLUSION: In principle the findings on the psychometric properties justify the use of the SBQ-R, although several critical points concerning item scoring remain unresolved. Moreover, sufficient unidimensional model fit was not possible without including correlated errors. Since suicidality is a frequently assessed construct in suicide research and as an exclusion criterion in clinical studies, it would be desirable to develop an economic, psychometrically sound and compelling instrument for the assessment of the different aspects of suicidality in future.

On hate crime victimization: Rates, types, and links with suicide risk among sexual orientation minority special interest group members.

Hate crimes remain pressing traumatic events for sexual orientation minority adults. Previous literature documents patterns in which hate crime victimization is associated with elevated risk for poor mental health. The present paper held 2 aims to advance literature. First, we investigated the rates and types of hate crime victimization among sexual orientation minority adults. Second, adopting a mental health amplification risk model, we evaluated whether symptoms of depression, impulsivity, or post-traumatic stress exacerbated the hate crime victimization-suicide risk link. Participants were 521 adult sexual orientation minority-identifying members of the National Coalition for Sexual Freedom (i.e., a bondage and discipline, and sadomasochism-identifying sexuality special interest group). Participants completed demographic and mental health inventories via online administration. Results showed: (1) low rates of total lifetime hate crime victimization and (2) higher rates of interpersonal violence compared to property crime victimization within the sample. Regression results showed: (1) independent positive main effects of all 3 mental health symptom categories with suicide risk; (2) an interaction pattern in which impulsivity was positively associated with suicide risk for non-victims; and (3) an interaction pattern in which post-traumatic stress was positively associated with suicide risk for hate crime victims and non-victims. Results are discussed concerning implications for trauma-informed mental healthcare, mental health amplification models, and hate crime and suicide prevention policies.

Triggers for attempted suicide in Istanbul youth, with special reference to their socio-demographic background.

OBJECTIVE: Suicidal behavior of young people is a topic of utmost importance because suicide is irreversible, and should be prevented. Knowing about the psychosocial background and the triggering events could help in preventing suicidal behavior. We therefore aimed at identifying psychosocial factors that may trigger suicidal behavior in youth. METHODS: We analyzed retrospectively the standardized records of 2232 youths aged ≤25 years, who were treated after a suicide attempt at emergency units of public hospitals in Istanbul, Turkey during a period of 1 year. We describe this population according to sex and socio-economic conditions, like educational, occupational, relationship status and link them with their reported reasons for suicide attempts. RESULTS: The majority of patients were female (81.6%, N = 1822 females, 18.4%, N = 410 males). Independent of their educational and occupational background, patients indicated most frequently intra-familial problems (females 45.8%, males 30.5%), intrapersonal problems (females 19.9%, males 18.5%), and relationship problems (females 11.3%, males 23.9%) as triggering reasons. CONCLUSIONS: Because intra-familial problems were the most frequently reported triggers of suicide attempts, preventive measures should focus on handling intra-familial conflicts. As sex differences were observed for the second-most common trigger-reasons, prevention should also focus on differentially handling intrapersonal and relationship conflicts better.

[Transitional and Adolescent Psychiatry in Austria: A Pilot Study on the Attitudes of Experts]. / Transitions- und Adoleszenzpsychiatrie in Österreich: Eine Pilotuntersuchung zur Sicht von Expert(innen).

Transitional and Adolescent Psychiatry in Austria: A Pilot Study on the Attitudes of Experts Abstract. OBJECTIVE: This pilot study establishes baseline data on the current situation of transitional processes in Austrian psychiatry. We sought to gather information on the specific problems and needs occurring during the transition of mentally ill adolescents from child and adolescent to adult psychiatry. METHOD: Professionals (psychiatrists, psychologists, psychotherapists) working in child and adolescent psychiatry and adult psychiatry (N = 86) were assessed by means of an online survey concerning their experience with the transition of young adults. RESULTS: Almost all of the subjects queried (98.8 %) considered the current system inappropriate, and the majority (70.9 %) thought that patients would not tolerate transition from youth to adult psychiatric institutions very well. Only 16.3 % reported having a structured transition protocol at their workplace. Further 83.7 % expressed the need to improve collaboration between adolescent and adult psychiatry. CONCLUSIONS: This sample of Austrian healthcare professionals describes large deficits regarding transitional issues in psychiatry. There is an urgent need to establish structured protocols for transition, especially since experiences occurring during this vulnerable period are crucial to the mental health of young people later in life.

The effect of seasonal changes and climatic factors on suicide attempts of young people.

BACKGROUND: Seasonal changes and climatic factors like ambient temperature, sunlight duration and rainfall can influence suicidal behavior. METHODS: This study analyses the relationship between seasonal changes and climatic variations and suicide attempts in 2131 young patients in Istanbul, Turkey. RESULTS: In our study sample, there was an association between suicide attempts in youths and seasonal changes, as suicide attempts occurred most frequently during summer in females as well as in males. Furthermore, there was a positive correlation between the mean temperature over the past 10 days and temperature at the index day and suicide attempts in females. After seasonality effects were mathematically removed, the mean temperature 10 days before a suicide attempt remained significant in males only, indicating a possible short-term influence of temperature on suicide attempts. CONCLUSIONS: This study shows an association between suicide attempts of young people and climatic changes, in particular temperature changes as well as seasonal changes. Therefore, the influence of seasonal changes and climatic factors on young suicide attempters should get more attention in research to understand the biopsychosocial mechanisms playing a role in suicide attempts of young people. As suicide attempts most frequently occur in young people, further research is of considerable clinical importance.

[Assessment and therapy of suicidality in adolescence: the most important recommendations of the current guideline]. / Diagnostik und Therapie von Suizidalität im Jugendalter: Das Wichtigste in Kürze aus den aktuellen Leitlinien.

Due to the clinical relevance of suicidal risks, suicide attempts, and suicides in adolescence consensus-based guidelines with clinical recommendations were updated and summarized in this article. It should be considered that each indication has to be taken serious. Suicidality is an essential component of the psychopathological report and should be explored for the short- and long term risk. The clinical assessment of the acute suicidality results from a trustful anamnestic conversation, assessment of risk factors, mental disorders, and the use of alcohol and drugs. Acute suicidality is an indication for an inpatient treatment that for the protection of the patient has to be implemented also against his will. An adequate documentation is inevitable. After a suicide attempt, in addition to the initial medical treatment it has to be paid attention that the patient cannot harm himself any further and a rapid consultation in the responsible clinic takes place. First therapeutic goal is the reduction of suicidality and if necessary the re-achievement of the ability to negotiate a non-suicide agreement. For recurrent suicide thoughts an emergency plan has to be created. In addition to offer conversations, for a further relief a temporary sedated psychopharmacology can be necessary. In case of a suicide in a clinic, recommendations should be present that regulates responsibilities and procedures. Effective prevention methods are multiplier training, public education, restricted access to methods, and complying with media guidelines.

[Nonsuicidal self-injury in adolescence: a clinical guideline for diagnostics and therapy]. / Nicht-suizidales selbstverletzendes Verhalten (NSSV) im Jugendalter: Klinische Leitlinie zur Diagnostik und Therapie.

Objective: Nonsuicidal self-injury (NSSI) is a frequent, clinically relevant phenomenon occurring in adolescence, which can be observed parallel to various mental disorders. Within Europe, Germany has one of the highest prevalence rates in youths, with the lifetime prevalence ranging between 25­35 %. To date a guideline on the treatment of self-injury and stereotypic motoric disorders has been available, the last having been updated in 2006 and expired in 2011. Methods: The guideline development group consisted of members of 11 medical, psychological, or psychotherapeutic professional associations and two members from patient and prevention groups. The guideline was developed in two meetings followed up by consecutive literature searches; it was adopted in a final consensus conference. The algorithm on the treatment of NSSI was approved in three rounds of a Delphi process. Results: Although there is solid evidence of NSSI from the fields of epidemiology and diagnostics, few studies report data on the longitudinal course as well as on the psychotherapeutic and adjuvant psychopharmacological treatment of NSSI in adolescence. The stepped care regimens in cases demanding somatic treatment were addressed interdisciplinarily. Conclusions: In accordance with the heterogeneous evidence, important points for the treatment of NSSI in adolescence were determined in a consensus conference. There is still a lack of knowledge on prevention as well as clinical interventions, both of which need to be addressed by further research.

The prevalence of Nonsuicidal Self-Injury (NSSI) in a representative sample of the German population.

BACKGROUND: Non-suicidal self-injury (NSSI) is a proposed new "condition for further study" in the DSM-5. To date no prevalence data has been available on this diagnostic entity from a representative sample of the general population. METHODS: A representative sample of the German population (N = 2509, mean age = 48.8 years, SD = 18.1, female 55.4 %) completed the NSSI section of the German version of the Self-Injurious Thoughts and Behaviors Interview (SITBI-G). RESULTS: A history of NSSI at least once during lifetime was reported by 3.1 % of all participants, with higher lifetime prevalence rates in younger age groups. DSM-5 NSSI disorder criteria were met by 0.3 %. The most common function of NSSI was automatic negative reinforcement (e.g. to alleviate negative feelings). CONCLUSIONS: To the best of our knowledge, this is the first study reporting rates for the proposed NSSI category in DSM-5 from a representative sample of the general population. In comparison to findings from community samples of adolescents, adults seem to have lower lifetime prevalence rates of NSSI, thus making it necessary to emphasize prevention and treatment efforts in younger age groups.

Lithium in drinking water and suicide mortality: interplay with lithium prescriptions.

BACKGROUND: Little is known about the effects of lithium intake through drinking water on suicide. This intake originates either from natural rock and soil elution and/or accumulation of lithium-based pharmaceuticals in ground water. AIMS: To examine the interplay between natural lithium in drinking water, prescribed lithium-based pharmaceuticals and suicide in Austria. METHOD: Spatial Bayesian regressions for males, females and pooled suicide mortality rates were estimated. RESULTS: Although the expected inverse association between lithium levels in drinking water and suicide mortality was confirmed for males and for total suicide rates, the relationship for females was not significant. The models do not indicate that lithium from prescriptions, assumed to accumulate in drinking water, is related to suicide risk patterns either as an individual effect or as a moderator of lithium levels in drinking water. Gender-specific differences in risk factors and local risk hot spots are confirmed. CONCLUSIONS: The findings do not support the hypotheses that lithium prescriptions have measureable protective effects on suicide or that they interact with lithium in drinking water.

Confronting death from drug self-intoxication (DDSI): prevention through a better definition.

Suicide and other self-directed violence deaths are likely grossly underestimated, reflecting inappropriate classification of many drug intoxication deaths as accidents or unintentional and heterogeneous ascertainment and coding practices across states. As the tide of prescription and illicit drug-poisoning deaths is rising, public health and research needs would be better satisfied by considering most of these deaths a result of self-intoxication. Epidemiologists and prevention scientists could design better intervention strategies by focusing on premorbid behavior. We propose incorporating deaths from drug self-intoxication and investigations of all poisoning deaths into the National Violent Death Reporting System, which contains misclassified homicides and undetermined intent deaths, to facilitate efforts to comprehend and reverse the surging rate of drug intoxication fatalities.

[Non-Suicidal Self-Injury (NSSI) and Suicidal Behavior Disorder in the DSM-5]. / Nicht-suizidales selbstverletzendes Verhalten (NSSV) und Suizidale Verhaltensstörung (SVS) im DSM-5.

Non-Suicidal Self-Injury (NSSI) and Suicidal Behavior Disorder (SBD) were included as diagnostic categories in Section 3 of the 5th edition of the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association (APA). Thus, these diagnostic entities were not recognized as formal clinical diagnoses, but rather for the first time clearly defined in a classificatory system to standardize further research in this field. This paper introduces both concepts and addresses the discussion about NSSI and suicidal behavior disorder based on a selective review of the literature. First studies using the new definitions are introduced. In Germany the prevalence of NSSI is estimated to lie at about 4 %, of SBD at about 9 %. It can be expected that in the future the new definitions will lead to a better comparability of study outcomes with regards to NSSI and suicidal behavior disorder.

Mentalizing in female inpatients with major depressive disorder.

Depression is associated with profound impairments in social and interpersonal functioning. However, little research has addressed deficits in mentalizing capacity that may underlie these impairments. The aim of this study was, therefore, to investigate the capacity for mentalization in female inpatients with depression in comparison with healthy controls. We assessed 46 inpatients with major depressive disorder with regard to psychiatric diagnoses, severity of depression, cognitive impairment, and verbal intelligence. In addition, 20 healthy controls matched for sex, age, and education were included. Mentalization was scored on the Adult Attachment Interview using the Reflective Functioning Scale. The female inpatients with depression showed a significantly lower capacity for mentalization compared with the healthy controls. Mentalization deficits were not restricted to depression-specific topics. Moreover, deficits in mentalizing capacity were related to illness duration, number of admissions, and cognitive impairment. The results indicate severe impairment in the ability of the female inpatients with depression to identify and interpret mental states of the self and others. Correlations with illness duration and number of admissions suggest that a chronic course of depression results in further mentalizing impairments. The investigation of mentalization may be of particular importance for the development of targeted psychotherapeutic interventions for depression.

Psychological reactions related to fetal magnetic resonance imaging: a follow-up study.

AIMS: To assess the women's retrospective perception of fetal magnetic resonance imaging (MRI). METHODS: Thirty-six women were investigated 1 year after fetal MRI. Data was acquired by telephone interviews and standardised rating scales (i.e., Postscan Imaging Distress Questionnaire, mood and anxiety scales). RESULTS: In retrospect, most women felt that fetal MRI was associated with marked psychological distress, notably with significant greater distress than at the time of the actual investigation. In total, 55.6% of the women rated at least one aspect of fetal MRI as "not tolerable" at follow-up. These findings were irrespective of the affective status and of the outcome of the pregnancy. Yet, MRI was rated as "the most important" investigation during the prenatal period by 69.4% of subjects, and 80.6% felt that they had sufficiently been informed about the MRI findings. CONCLUSIONS: The acceptance of fetal MRI was found to be very high; however, fetal MRI is linked with marked psychological distress, which was still present - and in many cases even stronger - 1 year after the investigation. These data highlight the importance of sufficient information about fetal MRI and the necessity of adequate emotional support in this emotional vulnerable patient sample.

Videoconferencing psychotherapy from a psychodynamic point of view. A qualitative analysis.

There is a growing interest in delivering videoconferencing psychotherapy (VCP) due to the enormous impact of the COVID-19 pandemic on our lives since the beginning of severe restrictions worldwide in March 2020. Scientific literature has provided interesting results about the transition to remote sessions and its implications, considering different psychotherapy orientations. Less is known about whether and how VCP affects psychodynamic psychotherapeutic approaches and reports on remote work with severe and complex mental health problems such as severe personality disorders are still scarce. The aim of the study was to examine the experiences of psychodynamic psychotherapists, mainly delivering Transference-Focused Psychotherapy (TFP), with the transition and delivery of VCP during the first wave of the COVID-19 pandemic. Four hundred seventy-nine licensed psychotherapists completed an online survey during the peak of the pandemic. Survey data were analyzed using qualitative analysis. Results are presented and discussed concerning advantages and disadvantages regarding the access to psychotherapy, the specificity of the online video setting, bodily aspects, the quality of the therapeutic relationship, the therapeutic process including technical aspects and therapist's experience. Furthermore, we analyzed and discussed the statements concerning transference and countertransference reactions differentiating between high-level borderline and neurotic patients and low-level borderline patients. Our results support the importance to identify patients who potentially benefit from VCP. Further research including more prospective randomized controlled trials are needed to investigate the therapeutic implications of the findings.