Psychosocial and psychiatric factors preceding death by suicide: A case-control psychological autopsy study involving multiple data sources.

BACKGROUND: A range of factors including mental disorders and adverse life events can increase the risk of suicide. The objectives of this study were to examine psychosocial and psychiatric factors and service engagement among suicide decedents compared with living controls. METHODS: A case-control study using multiple sources was conducted. Information on 132 consecutive cases of suicide was drawn from coronial files, and interviews were carried out with 35 family informants and 53 living controls. GPs completed questionnaires for 60 suicide cases and 27 controls. RESULTS: The majority (83.3%) of suicide decedents had contacted a GP in the year prior to death, while 23.3% had 10 or more consultations during the year prior to death. Half of suicide decedents had a history of self-harm. Suicide cases were significantly more likely than controls to have a psychiatric diagnosis (60% vs. 18.5%) and a depressive illness (36.7% vs. 14.8%). Over one-quarter of suicide decedents had been treated as a psychiatric inpatient. DISCUSSION: Primary care providers should be supported to deliver multidisciplinary interventions to engage, assess, and treat patients at risk of suicide, targeting those who present very frequently, those with a history of self-harm or substance misuse, and those with psychological presentations.

Sleeve Gastrectomy in Obese Zucker Rats Restores Cardiac Function and Geometry Toward a Lean Phenotype Independent of Weight Loss.

OBJECTIVE: Bariatric surgery, including sleeve gastrectomy (SG), significantly improves cardiac geometry and function in patients with heart failure. In this study, we used the obese Zucker rat as an animal model of heart failure with preserved ejection fraction (HFpEF) to test the hypothesis that a SG will improve cardiac function independent of weight loss. METHODS AND RESULTS: Obese, male Zucker rats underwent SG, pair-fed sham, or ad-lib sham surgery. Lean Zucker rats also underwent ad-lib sham surgery. Echocardiograms were performed preoperatively and at 6 weeks postoperatively. Obese SG and obese pair-fed sham rats had similar body weights postoperatively. Obese SG and lean, ad-lib, sham rats had a significant increase in postoperative stroke volume, and left ventricular internal diameter in diastole and systole. SG preserved systolic function and significantly improved isovolumetric relaxation time (13.9 ± 2.4 to 11.1 ± 2.1 ms, P = .02) independent of weight loss. DISCUSSION: SG has a beneficial impact on both systolic and diastolic cardiac function in obese Zucker rats toward a lean phenotype independent of weight loss and caloric restriction. These findings may represent a weight-loss independent mechanism generated from the gastrointestinal tract that has the potential to improve diastolic dysfunction independent of obesity status and translate to patients with HFpEF.

Early Weight Loss Independent Effects of Sleeve Gastrectomy on Diet-Induced Cardiac Dysfunction in Obese, Wistar Rats.

INTRODUCTION: Several reports suggest that bariatric surgery significantly improves cardiac function in patients with obesity cardiomyopathy. The mechanism is unknown but may be due to weight-loss independent factors. We predict that the changes in gastrointestinal anatomy after a rodent model of sleeve gastrectomy (SG) will have weight-loss independent effects on cardiac dysfunction. METHODOLOGY: Cardiac dysfunction was induced by feeding a 60% kcal from fat diet to male Wistar rats for 10 weeks. Rats underwent either a SG (n = 12) or pair-fed, PF (n = 8) sham surgery. Echocardiograms were performed pre- and post-operatively at 6 and 13 weeks. Blood samples were obtained at 10 weeks post-operatively for assessment of insulin sensitivity and heart failure. RESULTS: Forty-four percent of SG rats had a normal ejection fraction (EF) at 13 weeks ("responders") compared to five SG rats who did not recover EF ("non-responders"). Zero percent of the PF rats normalized EF (p = 0.03). SG responders had a smaller left ventricular internal diameter in systole and end systolic volume with improved systolic function compared to SG non-responders (EF 90.7 ± 1.7 vs. 75.4 ± 3.6%, p = <0.001). At 10 weeks post-operatively, plasma glucose and B-type natriuretic peptide levels were significantly lower in SG rats compared to PF rats. CONCLUSIONS: A SG significantly improved systolic function in 44% of rats with diet-induced obesity and cardiac dysfunction. This improvement is related to weight-loss independent effects of the surgery on the entero-cardiac axis. These results offer a novel weight-loss independent, metabolic role for bariatric surgery as a potential treatment modality for obesity-associated cardiac dysfunction.

Schizophrenia and bipolar disorder: no recovery without suicide prevention.

Suicide prevention for people with schizophrenia or bipolar disorder warrants an evidence-based approach to service design as well as clinical practice. The issue of personal responsibility (diminished when mental capacity is impaired) contributing to reduction of suicide risk has, arguably, been neglected.

European Training and Research in Peritoneal Dialysis: scientific objectives, training, implementation and impact of the programme.

BACKGROUND: Peritoneal dialysis (PD) offers many advantages over hospital-based haemodialysis, including better quality of life. Despite this, there is a general under-utilisation of PD in Europe, which, to some extent, can be attributed to a lack of knowledge and education amongst renal clinicians and nurses. OBJECTIVES: The specific aim of the European Training and Research in Peritoneal Dialysis (EuTRiPD) programme is to address this lack of knowledge, to develop a minimum of five biomarkers that allow the prediction of outcome in PD and three therapeutic treatments to improve outcome in PD. APPROACH: EuTRiPD is a EU-wide consortium with clinical, academic and commercial partners set up to address this knowledge gap. By training through research and close collaboration between academic and commercial entities we hope to improve the outcome and uptake of PD. It is the goal of EuTRiPD to improve the currently hampered diagnostic therapeutic developments in renal replacement therapy (RRT) and structure existing high-quality PD-related research across Europe. CONCLUSION: It is hoped that EuTRiPD can and will have a significant impact on socio-economic and scientific aspects of PD. It is the aim for EuTRiPD to boost the uptake of PD throughout Europe by making PD the obvious choice for patients.

Suicide prevention as a prerequisite for recovery from severe mental illness.

For a significant number of people suffering from severe mental illness (SMI) prevention of suicide is a prerequisite for their recovery. This review summarises and interprets risk/protective factors for suicide in the context of schizophrenia and bipolar disorder, thereby enabling evidence-based suicide risk assessment and management. A history of self-harm greatly increases suicide risk among people with schizophrenia or bipolar disorder. Suicide prevention for patients with SMI necessitates constant vigilance by (mental) health and social care professionals in contact with them, particularly those with a history of self-harm, males, young people, those near illness onset, people with a family history of suicidal behaviour (especially suicide), victims of childhood abuse, those challenged by recent adverse life events (notably interpersonal conflict), people with aggressive/impulsive personality features, and those who have expressed hopelessness. Research suggests that suicide risk associated with SMI should be reduced by early intervention, restricting access to lethal means, improvement of treatment adherence, treating more patients with clozapine and lithium, assertive outreach, treating psychiatric comorbidity (depression, alcohol/drug misuse, etc.), 24-hour crisis care, timely (compulsory) hospitalization (sufficient bed provision imperative), improving psychiatric inpatient ward safety, lowering the risk of absconding from wards, appropriate use of electroconvulsive therapy, intensive follow-up postdischarge, and improving access to psychological/psychosocial interventions, notably cognitive behavioural therapy. The clinical interview is the optimum method of suicide risk assessment and locally developed risk assessment tools should not be used. Evidence-based suicide risk assessment/management within primary care and secondary mental health services warrants recurrent, mandatory training.

Risk and protective genetic variants in suicidal behaviour: association with SLC1A2, SLC1A3, 5-HTR1B &NTRK2 polymorphisms.

BACKGROUND: Suicidal behaviour is known to aggregate in families. Patients with psychiatric disorders are at higher risk for suicide attempts (SA), however protective and risk genetic variants for suicide appear to be independent of underlying psychiatric disorders. Here we investigate genetic variants in genes important for neurobiological pathways linked to suicidal behaviour and/or associated endophenotypes, for association with SA among patients with co-existing psychiatric illness. Selected gene-gene and gene-environment interactions were also tested. METHODS: DNA was obtained from bloods of 159 patients (76 suicide attempters and 83 non-attempters), who were profiled for DSM-IV Axis I psychiatric diagnosis. Twenty-eight single nucleotide polymorphisms (SNPs) from 18 candidate genes (COMT, 5-HT2A, 5-HT1A, 5-HTR1B, TPH1, MAO-A, TPH2, DBH, CNR1, BDNF, ABCG1, GABRA5, GABRG2, GABRB2, SLC1A2, SLC1A3, NTRK2, CRHR1) were genotyped. Genotyping was performed by KBioscience. Tests of association between genetic variants and SA were conducted using Chi squared and Armitage Trend tests. Binary logistical regression analyses were performed to evaluate the contribution of individual genetic variants to the prediction of SA, and to examine SNPs for potential gene-gene and gene-environment interactions. RESULTS: Our analysis identified 4 SNPs (rs4755404, rs2269272, rs6296 and rs1659400), which showed evidence of association with SA compared to a non-attempter control group. We provide evidence of a 3-locus gene-gene interaction, and a putative gene-environment interaction, whereby genetic variation at the NTRK2 locus may moderate the risk associated with history of childhood abuse. CONCLUSION: Preliminary findings suggest that allelic variability in SLC1A2/3, 5-HTR1B and NTRK2 may be relevant to the underlying diathesis for suicidal acts.

Adverse life events proximal to adult suicide: a synthesis of findings from psychological autopsy studies.

The objective of this review was to summarize and interpret data about adverse life events proximal to adult suicide from major psychological autopsy studies. A PubMed search was conducted. Nearly all suicides have experienced at least 1 (usually more) adverse life event within 1 year of death (concentrated in last few months). Controlled studies have revealed specific life events, notably interpersonal conflict, as risk factors for suicide with some evidence of a dose-response effect. Some of the risk is independent of mental disorder. The suicidogenic impact of adverse life events, especially interpersonal conflict, necessitates specific objectives in suicide prevention strategies. Cultural influences on relative contributions of adversity and mental disorder to suicide warrant further research. Limitations of psychological autopsy studies suggest the need for complementary research into life events prior to serious suicide attempts.

Naive and activated T cells display differential responsiveness to TL1A that affects Th17 generation, maintenance, and proliferation.

Tumor necrosis factor (TNF)-like cytokine (TL1A) is a T-cell costimulator that bolsters cytokine-induced activation through death receptor 3 (DR3). To explore the relationship between T-cell activation and TL1A responsiveness, flow cytometry profiled DR3 expression in resting and activated T cells. In human CD4(+) T cells, DR3 was induced rapidly following activation and expressed prominently by interleukin (IL)-17-secreting T cells (Th17). Splenic T cells from wild-type and DR3-deficient mice showed that TL1A activation of DR3 inhibits Th17 generation (81 ± 2.6% at 100 ng/ml TL1A) from naive T cells. This response was not associated with suppression of T-cell proliferation. Using neutralizing antibodies or T cells derived from genetically modified mice, TL1A inhibition of Th17 development was found to be independent of IL-2, IL-27, γIFN, IFNAR1, and STAT1. Under suboptimal TCR activation, TL1A continued to block IL-17A secretion, however, the reduced threshold of TCR engagement was now linked with an increase in TL1A-driven proliferation. In contrast, fully committed Th17 cells displayed an altered TL1A responsiveness and in the absence of TCR costimulation supported the maintenance of T cell IL-17A expression. Consequently, TL1A orchestrates unique outcomes in naive and effector T-helper cells, which may affect the proliferation, differentiation and maintenance of Th17 cells in peripheral compartments and inflamed tissues.

Read all about it: guided bibliotherapy for depression in adults.

Early intervention in depression is important for many reasons including expeditious alleviation of suffering, assisting parenthood, suicide prevention and helping the economy. The fact that people with depression frequently employ maladaptive coping strategies, notably alcohol misuse, suggests the need for evidence-based self-help for sufferers. Self-help can be viewed as a philosophy of patient empowerment and as "a health technology solution to volume and demand". Bibliotherapy (self-help using written materials) provides information and encourages the reader to make changes leading to improved self-management. Enthusiasm for the use of bibliotherapy in depression should be tempered by pursuit of a sound evidence base.

The therapeutic relationship: dead or merely impeded by technology?

The ways in which current nurse education is delivered, combined with rapid increases in technological advances in health care, are having a major impact on the delivery of care to patients. This article focuses on one aspect of that care: the establishment, development and maintenance of the therapeutic relationship. The authors argue that the changes in education delivery and the rapid introduction of technologies are contributing to the possible demise of the contemporary nurse-patient relationship and, therefore, the loss of that essence of nursing which is essential to the patients' well-being and the nurses' professional satisfaction. The article explores the requisite knowledge and skills competences essential for the formation of the therapeutic relationship and asks whether these are being impeded by simulated educational activities and the advent of ubiquitous computing. The authors acknowledge the difficulties associated with the assessment of an effective therapeutic relationship and suggest a possible framework in which a performance of understanding of the formation of a therapeutic relationship can be established.

Doctor Foster 'went' to Gloucester: the origin and aims of The Royal College of Psychiatrists.

In 1841 Dr Samuel Hitch organised a meeting at Gloucester Lunatic Asylum during which a decision was taken to establish the Association of Medical Officers of Asylums and Hospitals for the Insane with a view to "improvement in the management of such institutions and the treatment of the insane, and the acquirement of a more extensive and more correct knowledge of insanity". From the six medical officers present at this historic meeting the membership of The Royal College of Psychiatrists has grown to more than 11,000, of whom over 1,500 practise overseas. Dr Mike Shooter (President) believes that the College's most important, and painful, transformation has been from a largely educational to a political organisation.

Suicide note themes and suicide prevention.

OBJECTIVE: The aim was to determine if suicide note themes might inform suicide prevention strategies. METHOD: The themes of 42 suicide notes from the Northern Ireland Suicide Study (major psychological autopsy study) were examined. RESULTS: The commonest themes were "apology/shame" (74%), "love for those left behind" (60%), "life too much to bear" (48%), "instructions regarding practical affairs post-mortem" (36%), "hopelessness/nothing to live for" (21%) and "advice for those left behind" (21%). Notes of suicides with major unipolar depression were more likely than notes of suicides without major unipolar depression to contain the themes "instructions regarding practical affairs post-mortem" (67% versus 19%, p = 0.005) and "hopelessness/nothing to live for" (40% versus 11%, p = 0.049). Notes of suicides with a previous history of deliberate self-harm were less likely than notes of suicides without a history of deliberate self-harm to contain the theme "apology/shame" (58% versus 87%, p = 0.04). Notes of elderly suicides were more likely than non-elderly notes to contain the theme "burden to others" (40% versus 3%, p = 0.03). CONCLUSIONS: The fact that three quarters of suicide notes contained the theme "apology/shame" suggests that the deceased may have welcomed alternative solutions for their predicaments. Scrutiny of suicide note themes in the light of previous research findings suggests that cognitive therapy techniques, especially problem solving, may have an important role to play in suicide prevention and that potential major unipolar depressive (possibly less impulsive) suicides, in particular, may provide fertile ground for therapeutic intervention (physical and psychological). Ideally all primary care doctors and mental health professionals working with (potentially) suicidal people should be familiar with basic cognitive therapy techniques, especially problem solving skills training.