Effects of a Serious Game for Adolescent Mental Health on Cognitive Vulnerability: Pilot Usability Study.

Background: Adolescent mental health is of utmost importance. E-mental health interventions, and serious games in particular, are appealing to adolescents and can have beneficial effects on their mental health. A serious game aimed at improving cognitive vulnerability (ie, beliefs or attitudes), which can predispose an individual to mental health problems, can contribute to the prevention of these problems in adolescents. Objective: This study aimed to assess the feasibility of the prototype of a serious game called "Silver." Methods: The prototype of the serious game was developed using a user-centered participatory design. The prototype of Silver focused on 1 aspect of a serious game for improving cognitive vulnerability in adolescents, that is, the recognition and identification of cognitive distortions. Through the game, players were required to identify and classify the character's thoughts as helpful or unhelpful. Upon successful advancement to the next level, the task becomes more challenging, as players must also identify specific types of cognitive distortions. A pre- and posttest uncontrolled design was used to evaluate the game, with a 1-week intervention phase in which participants were asked to play the game. Participants aged 12-16 years were recruited in schools. The outcomes of interest were the recognition of cognitive distortions and presence of participants' cognitive distortions. The game was also evaluated on its effects, content, and usefulness. Results: A total of 630 adolescents played Silver and completed the assessments. Adolescents were significantly better at recognizing cognitive distortions at the pretest (mean 13.09, SD 4.08) compared to the posttest (mean 13.82, SD 5.09; t629=-4.00, P<.001). Furthermore, their cognitive distortions decreased significantly at the posttest (mean 38.73, SD 12.79) compared to the pretest (mean 41.43, SD 10.90; t629=7.98, P<.001). Participants also indicated that the game helped them recognize cognitive distortions. Many participants considered the game appealing (294/610, 48.2%) but boring (317/610, 52%) and preferred a more comprehensive game (299/610, 49%). Conclusions: Findings from this study suggest that a serious game may be an effective tool for improving cognitive vulnerability in adolescents. The development of such a serious game, based on the prototype, is recommended. It may be an important and innovative tool for the universal prevention of mental health problems in adolescents. Future research on the effects of the game is warranted.

Evaluation of an online suicide prevention campaign targeting men.

BACKGROUND: Men are at elevated risk of suicide compared to women. Adherence to traditional norms of masculinity can interfere with potential protective factors such as openness to talk and seeking social support, which can contribute to the increased suicide risk. An online public health campaign was developed to improve mental health among men and tackle the stigma surrounding it. This study aimed at examining whether the online suicide prevention campaign targeting men increased openness to talk about emotions and help-seeking behavior and decreased hopelessness and adherence to traditional gender norms concerning self-reliance. METHOD: 250 men (18+) from Flanders (Belgium) were recruited online and given access to the campaign website for a period of 3 days. Before and after viewing the campaign website, participants were asked to complete an online survey. RESULTS: Viewing the campaign was associated with a small increase in help-seeking intention when experiencing suicidal thoughts. Among men who reported mental health problems, a small increase in openness to communicating and expressing emotions was found after viewing the campaign. In general, participants evaluated the campaign positively. CONCLUSION: This study demonstrated the potential beneficial impact of an online prevention campaign specifically targeting men on health behaviors that may protect against suicidal behavior.

Mindfulness-Based Cognitive Therapy for Individuals Who Are Suicidal: A Randomized Controlled Trial.

There is a need for well-described treatments targeting individuals at risk for suicidal behaviors. The present study aims to investigate the effectiveness of MBCT adapted to individuals who are suicidal (MBCT-S) in a randomized controlled trial, comparing an intervention group receiving MBCT-S and treatment as usual (TAU) with a control group receiving TAU only. Participants who were 18 years or older and experienced suicidal ideation were included. Assessments on suicidal ideation and symptoms associated with suicidal behavior were carried out at baseline, post-treatment, and 12 weeks after the end of the training. When comparing the intervention group with the control group, a significant reduction was found at follow-up in suicidal ideation and depressive symptoms. When focusing on the intervention group only, a significant reduction was found in suicidal ideation, depressive symptoms, hopelessness, worrying, defeat, and entrapment, and a significant increase in mindfulness both at post-treatment and at follow-up. The findings suggest that MBCT-S is a promising suicide-specific intervention as it may have the potential to reduce suicidal ideation and suicide-related components.

Future-Oriented Group Training for suicidal individuals: A randomized controlled trial.

INTRODUCTION: Suicide is a serious public health concern worldwide. Current psychological interventions targeting suicidal ideation and behavior are, however, limited and often lack convincing empirical support. Future-Oriented Group Training (FOGT) targets crucial aspects of the suicidal process, thus possibly offering a promising intervention for suicidal ideation. This study aimed at investigating the short-term and long-term effects of FOGT on suicidal thoughts and related variables. METHODS: A randomized controlled trial was conducted, comparing the intervention group (FOGT + treatment as usual (TAU)) to a control group (TAU) at pre and posttreatment and at a 12-week follow-up. Suicidal ideation was the primary outcome, while depressive symptoms, hopelessness, defeat, entrapment, worrying, and the ability for future-oriented thinking were secondary outcomes. RESULTS: When compared to the control group, the intervention group showed significant decreases in worrying at posttreatment and significant increases in future-oriented thinking at follow-up. Pre-post analyses within the intervention group showed significant small-to-medium effects for primary as well as most secondary outcomes. Changes in suicidal ideation, depression, hopelessness, and future-oriented thinking remained significant at follow-up. CONCLUSION: This study provides promising empirical evidence for the use of FOGT for individuals with suicidal ideation.

Suicide Prevention in the European Region.

Although the majority of the world's suicides occur in Asia, suicide and self-harm are major concerns in Europe as well. Suicide accounts for 1.4% of the total number of deaths in Europe, with rates highest among those aged over 70 and also high among those aged 45-59 years. Europe accounts for six of the top ten countries with the highest suicide rates internationally. Although rates of suicide attempts and self-harm are not consistently recorded, evidence from hospital-based studies and school-based surveys highlight their extent and scale. Numerous countries in Europe have developed national suicide prevention strategies and action plans. Some of the suicide prevention activities in Belgium, Estonia, Finland, Scotland, France, Germany, Romania, Russia, Sweden, Ukraine, and Italy are summarized. In the chapter we also highlight novel suicide prevention projects funded by the EU which have advanced our understanding of suicide risk and have developed the evidence base for what works to prevent suicide. Examples include the European Alliance Against Depression (EAAD), Saving and Empowering Young Lives in Europe (SEYLE), Suicide Prevention Through Internet and Media Based Mental Health Promotion (SUPREME), and Reduction of Suicides and Trespasses on Railway Property (RESTRAIL). Future challenges and opportunities for suicide prevention in Europe are also discussed.

Psychosocial Interventions for People Who Self-Harm: Methodological Issues Involved in Trials to Evaluate Effectiveness.

We have assessed the methodological quality of randomized controlled trials (RCTs) of interventions to prevent self-harm repetition and suicide. Trials were identified in two systematic reviews of RCTs of psychosocial treatments following a recent (within six months) episode of self-harm indexed in any of five electronic databases (CCDANCTR-Studies and References, CENTRAL, Medline, Embase, and PsycINFO) between 1 January, 1998 and 29 April, 2015. A total of 66 trials were included, 55 in adults and 11 in children and adolescents. While evidence for efficacy of some approaches has grown, there were few trials from low-to-middle income countries, little information on interventions for males, information on the control condition was often limited, data on suicides were often not reported, and, while trials have increased in size in recent years, most have included too few participants to detect clinically significant results. There are major limitations in many trials of interventions for individuals who self-harm. Improved methodology, especially with regard to study size, provision of details of control therapy, and evaluation of key outcomes, would enhance the evidence base for clinicians and service users.

Electroencephalogram Resting State Frequency Power Characteristics of Suicidal Behavior in Female Patients With Major Depressive Disorder.

BACKGROUND: Difficulties in predicting suicidal behavior hamper effective suicide prevention. Therefore, there is a great need for reliable biomarkers, and neuroimaging may help to identify such markers. METHODS: Electroencephalography (EEG) was used to investigate resting state spatial-frequency power characteristics of female patients with major depressive disorder (MDD); 19 were recent suicide attempters (within the previous 30 days), 36 were suicide ideators, and 23 were nonsuicidal. Patients were enrolled at neuroCare Clinic Nijmegen (Nijmegen, the Netherlands) between May 2007 and November 2016, and the primary diagnosis of nonpsychotic MDD was confirmed using the Mini-International Neuropsychiatric Interview, DSM-IV criteria, and a score of ≥ 14 on the 21-item Beck Depression Inventory. Nonparametric, cluster-based permutation tests were applied to detect robust power differences between the study groups on the EEG broadband signal (2-100 Hz). Furthermore, a nonadaptive distributed source imaging method (eLORETA) was utilized to examine if these suicide-based frequency characteristics are localized in brain areas previously reported in the neuroimaging literature. RESULTS: When compared to nonsuicidal depressed patients, attempters and ideators displayed both decreased beta and low gamma activity in the frontal regions. Moreover, ideators had increased alpha activity over the posterior regions and increased high beta, low gamma activity over the left occipital region when compared to psychiatric controls. Attempters had reduced beta and low gamma activity over the right temporal region when compared to ideators. In addition, eLORETA localized attempter and ideator reduced frontal activity within the orbito-, medial-, middle-, superior-, and inferior-frontal areas and the anterior cingulate cortex. In attempters, reduced right temporal activity was localized within the right inferior-, middle-, and superior-temporal cortices and the fusiform gyrus. CONCLUSIONS: Frequency power characteristics of attempters and ideators are consistent with findings from the neuroimaging literature concerning suicide, implying EEG resting state assessment could become a potential biomarker to predict suicide risk.

The online treatment of suicidal ideation: A randomised controlled trial of an unguided web-based intervention.

Suicide is a major public health issue, and treatment of suicidal thoughts may contribute to its prevention. Provision of online treatment of suicidal ideation may reduce barriers that suicidal individuals experience in face-to-face treatment. We therefore aimed at evaluating the effectiveness of a web-based intervention targeting a reduction of suicidal ideation. We carried out a two-arm, parallel-design, randomised controlled trial in the general population in Flanders (Belgium) (registered as NCT03209544). Participants who were 18 years or older and experienced suicidal ideation were included. The intervention group (n = 365) received access to the unguided web-based intervention, and the control group (n = 359) was placed on a waitlist. Assessments were carried out at baseline and at 6 and 12 weeks. Participants reported high levels of suicidal ideation, depression, hopelessness, worrying, and anxiety at baseline. Compared to the control group, participants in the intervention group experienced a significant decline in suicidal ideation, depression, hopelessness, worrying, and anxiety both at post-test and at follow-up. An important limitation of the study was a high dropout rate, in particular in the intervention group. Our findings suggest that the online self-help intervention was more effective in reducing suicidal ideation and suicide-related symptoms than a waitlist control in a severely affected population. It can help in filling the gap between crisis help and face-to-face treatment.

Medication used in intentional drug overdose in Flanders 2008-2013.

BACKGROUND: Intentional drug overdose is the most common method of self-harm. As psychiatric disorders are very common in self-harm patients, the medication used to treat these disorders can become the means for the self-harm act. The present study aimed at investigating an association between the use of prescribed medication (analgesics and antipyretics, anti-epileptics, antipsychotics, antidepressants and psychostimulants) as a method of self-harm and prescription rates of this medication in Flanders. We investigated the possible effect of gender, alcohol use during the self-harm act and a history of self-harm. METHODS: Data from the multicenter study of self-harm in Flanders between 2008 and 2013 were used. The significance of differences in percentages was calculated by GEE and the strength by odds ratios (OR). RESULTS: There was an increase in the odds of using antidepressants (0.8%) and antipsychotics (2%) among females when the rate of prescription increases. Analgesics and antipyretics (39.3/1,000) and antidepressants (124.9/1,000) were the most commonly prescribed drugs among females. Antidepressants (63.9/1,000) and antipsychotics (26.5/1,000) were the most commonly prescribed drugs among males. Antidepressants and analgesics and antipyretics were the most frequently used medications for self-harm. Analgesics and antipyretics during the self-harm act were more common among first-timers, while repeaters more commonly overdosed using antipsychotics and antidepressants. CONCLUSION: These findings suggest that the availability of medication via prescriptions plays an important role in the choice of the medication ingested during the self-harm act. Precautions are necessary when prescribing medication, including restrictions on the number of prescriptions and the return of unused medication to pharmacies after cessation of treatment. These issues should be a focus of attention in the education and training of physicians and pharmacists.

Placebo aiTBS attenuates suicidal ideation and frontopolar cortical perfusion in major depression.

The application of repetitive transcranial magnetic stimulation has been shown to rapidly decrease suicidal ideation in major depressive disorder (MDD). However, the neural working mechanisms behind this prompt attenuation of suicidal thoughts remains to be determined. Here, we examined how placebo-accelerated intermittent theta burst stimulation (aiTBS) may influence brain perfusion and suicidal thoughts using arterial spin labeling (ASL). In a randomized double-blind sham-controlled crossover trial, 45 MDD patients received aiTBS applied to the left dorsolateral prefrontal cortex (Trial registration: http://clinicaltrials.gov/show/NCT01832805 ). With each ASL scan measurement, suicidal ideation was assessed with the Beck Scale for Suicidal Ideation (BSI) and depression severity with the Beck Depression Inventory (BDI). Compared with active stimulation, the attenuation of suicidal ideation after 4 days of placebo aiTBS was related to significant frontopolar prefrontal perfusion decreases. These findings were unrelated to changes in depression severity scores. Although both active and sham aiTBS resulted in prompt decreases in suicidal ideation, specifically sham aiTBS significantly attenuated frontopolar perfusion in relation to reductions in BSI scores. Our findings show that in accelerated neurostimulation paradigms, placebo responses are related to perfusion decreases in brain areas associated with higher cognitive processes, resulting in suicidal ideation attenuation.

The association between motives, perceived problems and current thoughts of self-harm following an episode of self-harm. A network analysis.

BACKGROUND: A history of self-harm is a major risk factor for suicide. Some patients are more likely than others to repeat suicidal behaviour after an episode of self-harm. Insight in the relation between current thoughts of self-harm, motives for the self-harm episode and perceived problems may improve prevention strategies. Network analysis allows to investigate the co-occurence of these factors and their association with each other. METHODS: Ising model based networks are estimated on data collected between 2007-2015 within the Multicentre Study of Self-harm in Flanders. Patients were interviewed within 24 hours after hospitalization by a trained professional on their motives for the episode of self-harm and their perceived problems. Additionally, they were asked whether they had current thoughts of self-harm. Network analyses are used to determine which motives and problems are uniquely related to current thoughts of self-harm, and which are most central in the network. RESULTS: Data were used of 6068 patients (2279 males and 3789 females). Four internal motives (wish to die, lost control, escape from situation, situation was unbearable), one external motive (show somebody how hopeless I was) and four perceived problems (psychiatric, loneliness, trauma, rejection) are directly related to current thoughts of self-harm. Of all motives and problems, the motive a wish to die is most strongly related to current thoughts of self-harm. However, external motives are more central in the network when compared to internal motives and perceived problems. LIMITATIONS: Data most probably refer to a selected group of self-harm patients as many individuals who self-harm do not come to the attention of hospital services. Patients might be reluctant to tell professionals they had current thoughts of self-harm. CONCLUSIONS: Many internal motives and problems are directly related to current thoughts of self-harm, but external motives are more central in the network. The clinically most important motive (wish to die) does not play a central role in the network.

Treatment as usual (TAU) as a control condition in trials of cognitive behavioural-based psychotherapy for self-harm: Impact of content and quality on outcomes in a systematic review.

BACKGROUND: Randomized controlled trials (RCTs) are the mainstay of evaluations of the efficacy of psychosocial interventions. In a recent Cochrane systematic review we analysed the efficacy of cognitive behavioural-based psychotherapies compared to treatment as usual (TAU) in adults who self-harm. In this study we examine the content and reporting quality of TAU in these trials and their relationship to outcomes. METHODS: Five electronic databases (CCDANCTR-Studies and References, CENTRAL, MEDLINE, EMBASE, and PsycINFO) were searched for RCTs, indexed between 1 January 1998 and 30 April 2015, of cognitive-behavioural interventions compared to TAU for adults following a recent (within six months) episode of self-harm. Comparisons were made between outcomes for trials which included different categories of TAU, which were grouped as: multidisciplinary treatment, psychotherapy only, pharmacotherapy only, treatment by primary care physician, minimal contact, or unclear. RESULTS: 18 trials involving 2433 participants were included. The content and reporting quality of TAU varied considerably between trials. The apparent effectiveness of cognitive behavioural psychotherapy varied according to TAU reporting quality and content. Specifically, effects in favour of cognitive-behavioural psychotherapy were strongest in trials in which TAU content was not clearly described (Odds Ratio: 0.29, 95% Confidence Interval 0.15-0.62; three trials) compared to those in which TAU comprised multidisciplinary treatment (Odds Ratio: 0.79, 95% CI 0.63 to 0.97; 12 trials). LIMITATIONS: The included trials had high risk of bias with respect to participant and clinical personnel blinding, and unclear risk of bias for selective outcome reporting. CONCLUSIONS: TAU content and quality represents an important source of heterogeneity between trials of psychotherapeutic interventions for prevention of self-harm. Before clinical trials begin, researchers should plan to carefully describe both aspects of TAU to improve the overall quality of investigations.

BackUp: Development and evaluation of a smart-phone application for coping with suicidal crises.

BACKGROUND: Suicide is a major public health issue and has large impact on the lives of many people. Innovative technologies such as smartphones could create new possibilities for suicide prevention, such as helping to overcome the barriers and stigma on help seeking in case of suicidal ideation. Due to their omnipresence, smartphone apps can offer suicide prevention tools very fast, they are easily-accessible, low-threshold and can help overcome some of the help-seeking barriers suicidal people experience. This article describes the development, testing and implementation of a mobile application for coping with suicidal crisis: BackUp. METHODS: Based on the analysis of literature and existing suicide prevention apps several tools were identified as relevant to include in a suicide prevention app. The selected tools (a safety planning tool, a hope box, a coping cards module, and a module to reach out) are evidence based in a face to face context, and could be easily transferred into a mobile app. The testing of existing apps and the literature also revealed important guidelines for the technical development of the application. RESULTS: BackUp was developed and tested by an expert panel (n = 9) and a panel of end users (n = 21). Both groups rated BackUp as valuable for suicide prevention. Suicidal ideation of the end user group was measured using the Beck Scale for Suicidal Ideation before and after testing BackUp, and showed a small but non-significant decrease. The majority of the testers used BackUp several times. All tools were evaluated as rather or very useable in times of suicidal crisis. CONCLUSION: BackUp was positively evaluated and indicates that self-help tools can have a positive impact on suicidal ideation. Apps in particular create opportunities in approaching people that are not reached by traditional interventions; on the other hand they can contribute to suicide prevention in addition to regular care. However, more research is needed on the impact and effect of suicide prevention apps.

Knowledge, Self-Confidence and Attitudes towards Suicidal Patients at Emergency and Psychiatric Departments: A Randomised Controlled Trial of the Effects of an Educational Poster Campaign.

Educational posters are used to enhance knowledge, attitudes and self-confidence of patients. Little is known on their effectiveness for educating health care professionals. As these professionals may play an important role in suicide prevention, the effects of a poster and accompanying evaluation and triage guide on knowledge, self-confidence and attitudes regarding suicidal thoughts and behaviours, were studied in a multicentre cluster randomised controlled trial, involving staff from 39 emergency and 38 psychiatric departments throughout Flanders (n = 1171). Structured self-report questionnaires assessed the knowledge, confidence and beliefs regarding suicidal behaviour management, and attitudes. Data were analysed through a Solomon four-group design, with random assignment to the different conditions. Baseline scores for knowledge and provider confidence were high. The poster and accompanying evaluation and triage guide did not have an effect on knowledge about suicide and self-confidence in suicidal behaviour management. However, the poster campaign appeared to be beneficial for attitudes towards suicidal patients, but only among staff from mental health departments that were assigned to the un-pretested condition. Given the limited effects of the poster campaign in the studied population with a relatively high baseline knowledge, the evaluation of this poster as part of a multimodal educational programme in a more heterogeneous sample of health care professionals is recommended.

Subgenual Anterior Cingulate-Medial Orbitofrontal Functional Connectivity in Medication-Resistant Major Depression: A Neurobiological Marker for Accelerated Intermittent Theta Burst Stimulation Treatment?

BACKGROUND: Accelerated repetitive transcranial magnetic stimulation paradigms have been shown to result in fast decreases in depressive symptoms and suicidal ideation. Although the subgenual anterior cingulate cortex (sgACC) region has been put forward as a possible biological marker, so far, no studies evaluated the clinical effects of accelerated intermittent theta burst stimulation (aiTBS) on sgACC functional connectivity (FC). METHODS: Fifty patients with treatment-resistant depression were enrolled in this registered randomized double-blind sham-controlled crossover aiTBS treatment study. All received 20 iTBS sessions applied to the left dorsolateral prefrontal cortex (5 daily sessions spread over 4 days). Forty-four complete resting-state functional magnetic resonance imaging scans were collected. Baseline resting-state functional magnetic resonance imaging scans were compared with a matched healthy control group. Besides depression severity, all patients were also assessed with the Scale for Suicide Ideation and the Beck Hopelessness Scale. RESULTS: Our main resting-state functional magnetic resonance imaging findings indicate that a positive sgACC FC correlation with the medial orbitofrontal cortex could distinguish aiTBS responders from nonresponders at baseline. Beneficial aiTBS treatment strengthened sgACC-medial orbitofrontal cortex FC patterns. Moreover, this increased FC pattern was associated with a decrease in feelings of hopelessness. CONCLUSIONS: Clinical response to aiTBS treatment is not only characterized by stronger FC patterns between the sgACC and the medial orbitofrontal cortex, but it is also associated with decreases in hopelessness. Our observations provide a possible neurobiological explanation why accelerated repetitive transcranial magnetic stimulation paradigms may result in prompt attenuation of negative thinking in depressed patients.

Are neurocognitive factors associated with repetition of self-harm? A systematic review.

BACKGROUND: Prediction of self-harm is limited clinically. Early identification of individuals likely to repeat self-harm could improve outcomes and reduce suicide risk. Various neurocognitive deficits have been found in people who self-harm, but the ability of these to predict repetition has yet to be established AIMS: Identify neurocognitive factors that may predict repetition of self-harm. METHODS: Systematic narrative review of English language publications assessing neurocognitive functioning and self-harm repetition, searching multiple databases from inception to March 2015. Quality of studies was appraised. A narrative synthesis was performed. RESULTS: 7026 unique records were identified, and 169 full-texts assessed. 15 unique studies provided data. No imaging studies could be included. Most studies assessed cognitive control or problem solving, but neither factor was consistently associated with repetition. However, specific tasks may show promise. Two studies in adolescents suggest that value-based decision-making impairments could be predictive of repetition. There were too few results for memory to draw specific conclusions. CONCLUSIONS: Selected studies suggest promise for particular neurocognitive factors and specific cognitive tasks in terms of repetition of self-harm.

Decreased resting state metabolic activity in frontopolar and parietal brain regions is associated with suicide plans in depressed individuals.

Suicide plans are a major risk factor for suicide, which is a devastating outcome of depression. While structural and functional brain changes have been demonstrated in relation to suicidal thoughts and behaviour, brain mechanisms underlying suicide plans have not yet been studied. Here, we studied changes in regional cerebral metabolic activity in association with suicide plans in depressed individuals. Using 18FDG-PET, a comparative study of regional cerebral glucose metabolism (rCMRglu) was carried out in depressed individuals with suicidal thoughts and suicide plans, depressed individuals with only suicidal thoughts, depressed individuals without suicide thoughts and plans, and healthy controls. When compared to the other groups, depressed individuals with suicide plans showed relative hypometabolism in the right middle frontal gyrus and the right inferior parietal lobe (Brodmann areas 10 and 39). Suicide plans in depressed individuals appear to be associated with reduced activity in brain areas that are involved in decision-making and choice, more particularly in exploratory behaviour.

Accelerated Intermittent Theta Burst Stimulation for Suicide Risk in Therapy-Resistant Depressed Patients: A Randomized, Sham-Controlled Trial.

Objectives: We aimed to examine the effects and safety of accelerated intermittent Theta Burst Stimulation (iTBS) on suicide risk in a group of treatment-resistant unipolar depressed patients, using an extensive suicide assessment scale. Methods: In 50 therapy-resistant, antidepressant-free depressed patients, an intensive protocol of accelerated iTBS was applied over the left dorsolateral prefrontal cortex (DLPFC) in a randomized, sham-controlled crossover design. Patients received 20 iTBS sessions over 4 days. Suicide risk was assessed using the Beck Scale of Suicide ideation (BSI). Results: The iTBS protocol was safe and well tolerated. We observed a significant decrease of the BSI score over time, unrelated to active or sham stimulation and unrelated to depression-response. No worsening of suicidal ideation was observed. The effects of accelerated iTBS on mood and depression severity are reported in Duprat et al. (2016). The decrease in suicide risk lasted up to 1 month after baseline, even in depression non-responders. Conclusions: This accelerated iTBS protocol was safe. The observed significant decrease in suicide risk was unrelated to active or sham stimulation and unrelated to depression response. Further sham-controlled research in suicidal depressed patients is necessary. (Clinicaltrials.gov identifier: NCT01832805).