Sleep influences daily suicidal ideation through affective reactivity to interpersonal events among high-risk adolescents and young adults.

BACKGROUND: Identifying proximal risk factors for suicidal ideation that are modifiable and relevant for adolescents and young adults is critical for suicide prevention. This study used an intensive monitoring approach to examine whether objectively- and subjectively- measured sleep characteristics predict next-day suicidal ideation occurrence and intensity through affective reactivity to interpersonal events in young people at high risk for suicide. METHODS: Participants included 59 (13-23 years; 76% White; 75% female) adolescents and young adults undergoing intensive outpatient program treatment for depression and suicidality. Participants completed daily ratings of suicidal ideation, sleep quality, and affective reactivity to positive and negative interpersonal events for up to 3 months (M = 56 days, SD = 24.13). Actigraphy captured behavioral sleep duration and timing. Multilevel modeling was used to evaluate within-person fluctuations in sleep and affective reactivity as predictors of suicidal ideation, and multilevel mediation tested the indirect effects of sleep on suicidal ideation via affective reactivity to interpersonal events. RESULTS: Results indicate significant indirect effects of objectively measured sleep duration and subjective sleep quality on next-day suicidal ideation via affective reactivity to negative and positive interpersonal events, respectively. Shorter-than-usual sleep predicted the presence and intensity of next-day suicidal ideation via heightened affective reactivity to negative interpersonal events. Worse sleep quality than usual predicted next-day suicidal ideation via reduced affective reactivity to positive interpersonal events. CONCLUSIONS: Affectivity reactivity is a proximal mechanism through which sleep indices may influence risk for suicidal thinking on a daily basis. Findings highlight the utility of targeting sleep and emotion regulation in suicide prevention among adolescents and young adults at high-risk for suicide.

Examining the Supports and Advice That Women With Intimate Partner Violence Experience Received in Online Health Communities: Text Mining Approach.

BACKGROUND: Intimate partner violence (IPV) is an underreported public health crisis primarily affecting women associated with severe health conditions and can lead to a high rate of homicide. Owing to the COVID-19 pandemic, more women with IPV experiences visited online health communities (OHCs) to seek help because of anonymity. However, little is known regarding whether their help requests were answered and whether the information provided was delivered in an appropriate manner. To understand the help-seeking information sought and given in OHCs, extraction of postings and linguistic features could be helpful to develop automated models to improve future help-seeking experiences. OBJECTIVE: The objective of this study was to examine the types and patterns (ie, communication styles) of the advice offered by OHC members and whether the information received from women matched their expressed needs in their initial postings. METHODS: We examined data from Reddit using data from subreddit community r/domesticviolence posts from November 14, 2020, through November 14, 2021, during the COVID-19 pandemic. We included posts from women aged ≥18 years who self-identified or described experiencing IPV and requested advice or help in this subreddit community. Posts from nonabused women and women aged <18 years, non-English posts, good news announcements, gratitude posts without any advice seeking, and posts related to advertisements were excluded. We developed a codebook and annotated the postings in an iterative manner. Initial posts were also quantified using Linguistic Inquiry and Word Count to categorize linguistic and posting features. Postings were then classified into 2 categories (ie, matched needs and unmatched needs) according to the types of help sought and received in OHCs to capture the help-seeking result. Nonparametric statistical analysis (ie, 2-tailed t test or Mann-Whitney U test) was used to compare the linguistic and posting features between matched and unmatched needs. RESULTS: Overall, 250 postings were included, and 200 (80%) posting response comments matched with the type of help requested in initial postings, with legal advice and IPV knowledge achieving the highest matching rate. Overall, 17 linguistic or posting features were found to be significantly different between the 2 groups (ie, matched help and unmatched help). Positive title sentiment and linguistic features in postings containing health and wellness wordings were associated with unmatched needs postings, whereas the other 14 features were associated with postings with matched needs. CONCLUSIONS: OHCs can extract the linguistic and posting features to understand the help-seeking result among women with IPV experiences. Features identified in this corpus reflected the differences found between the 2 groups. This is the first study that leveraged Linguistic Inquiry and Word Count to shed light on generating predictive features from unstructured text in OHCs, which could guide future algorithm development to detect help-seeking results within OHCs effectively.

Childhood maltreatment, neuropsychological function and suicidal behavior.

BACKGROUND: Suicide is the second leading cause of death in young people. Childhood maltreatment, neuropsychological dysfunction and psychopathology have each been shown to increase risk for suicidal behavior. However, few studies have examined their interactions and the effects of those interactions on suicidal behavior. METHODS: Across two sites, a total of 382 offspring of depressed parents underwent neuropsychological assessments. This high-risk sample included nearly equal numbers of males and females. Average age at the time of neuropsychological assessment was 18.5 years. The most prevalent lifetime psychiatric disorders were mood (43%), anxiety (37%) and alcohol and substance use disorders (21%). Childhood maltreatment was reported by 44% of offspring. Participants underwent extensive neuropsychological testing assessing the following domains: attention, memory, executive function, working memory, language fluency, and impulse control. Logistic regression was used to examine the association of reported childhood maltreatment, neuropsychological functioning, psychopathology and their interactions with suicidal behavior. Bonferroni correction was used to adjust for multiple comparisons. RESULTS: Maltreatment was associated with increased risk of suicidal behavior with odds ratios ranging between 2.40 and 4.43. Moderation analyses found that adaptive neuropsychological functioning was not protective against childhood maltreatment's effect on suicidal risk. While lifetime history of mood disorder was strongly associated with suicidal behavior, higher scores in working memory (OR = 0.21; 95% CI = 0.09, 0.45; p < .001) and executive function (OR = 0.15; 95% CI = 0.05, 0.43; p < .001) were protective against suicidal behavior even in the presence of a lifetime history of mood disorder. CONCLUSIONS: Further research is needed to determine how neuropsychological capacity protects depressed patients against the risk of suicidal behavior.

Suicidal Ideation and Behaviors Among LGBTQ+ Adolescents and Young Adults Who Have Experienced Sexual Violence: A Scoping Review of the Literature.

INTRODUCTION: The relationship between sexual violence (SV) experiences and suicidal ideation (SI) is known. However, when applied to lesbian, gay, bisexual, transgender, queer, and more (LGBTQ+) populations, the impact that experiences with SV have on the severity and magnitude of SI continues to be explored. A scoping review of the literature was conducted to summarize the current literature related to SI experienced by LGBTQ+ adolescents and young adults (AYAs) who have experienced SV. METHODS: Studies were found by searching electronic databases. To be included in the review, the study must have (a) been written in the English language, (b) been conducted in the United States, (c) presented empirical data, (d) been exclusively focused on LGBTQ+ AYAs, (e) focused on experiences with SV or have analyses separate from other types of violence, and (f) investigated suicidality as an outcome. All relevant studies published to date were included. Forty-one articles were retrieved for full-text review, of which five were determined to meet eligibility. RESULTS: LGBTQ+ AYAs were significantly associated with increased rates of SI compared with their cisgender heterosexual peers. LGBTQ+ AYAs were also associated with higher rates of SV victimization, ranging from intimate partner violence to previous child sexual abuse. Higher rates of depression were also associated with the population studied in each included article. CONCLUSION: The relationship between SV and SI in this population is not well studied, as highlighted through this completed review. Targeting this knowledge gap through future research can lead to intervention development for this population niche.

Bridging Gaps in Care Following Hospitalization for Suicidal Adolescents: As Safe As Possible (ASAP) and BRITE App.

OBJECTIVE: We present results from a 2-site, randomized clinical trial to assess the efficacy of a brief intervention (As Safe As Possible [ASAP]), a safety plan phone application (BRITE), and their combination on suicide attempts, suicidal ideation, non-suicidal self-injury, re-hospitalizations. and suicidal events among adolescents. METHOD: Adolescents (n= 240; 12-17 years of age) who were hospitalized for suicidal ideation with plan and/or intent, and/or suicide attempt, were assigned to 1 of 4 treatment conditions in a 2 by 2 design: ASAP+BRITE app+treatment as usual (TAU); (2) BRITE+TAU; (3) ASAP+TAU; and (4) TAU alone. Independent evaluators assessed suicidal ideation and behavior at 4, 12, and 24 weeks using the Columbia-Suicide Severity Rating Scale (C-SSRS) and re-hospitalization using the Child and Adolescent Services Assessment (CASA). RESULTS: No group differences were found on primary outcomes, except that ASAP participants were less likely to be re-hospitalized over 6 months (15.6%, vs 26.5%, p = .046). Participants hospitalized for an attempt and assigned to BRITE had a lower rate of subsequent attempts (odds ratio [OR] = 0.16, p = .01) and a greater time to attempt (hazard ratio [HR] = 0.20, p = .02). ASAP+BRITE, albeit not statistically significant, was most consistently associated with a reduction (60% reduction) in suicide attempts. CONCLUSION: ASAP, BRITE, and their combination are equally effective at decreasing risk for suicidal events 6 months post hospital discharge among suicidal adolescents; the ASAP intervention (with or without BRITE) was associated with lower rates of re-hospitalization. The BRITE app in youth hospitalized for suicide attempt had promising outcomes in regard to future attempts. DIVERSITY & INCLUSION STATEMENT: We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. The research was performed with permission from the University of Pittsburgh Institutional Review Board and the University of Texas Institutional Review Board. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. One or more of the authors of this paper received support from a program designed to increase minority representation in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. CLINICAL TRIALS REGISTRATION INFORMATION: Establishing Efficacy of an Inpatient Intervention and Phone App to Reduce Suicidal Risk (ASAP+BRITE); https://clinicaltrials.gov/study/; NCT03825588.

Familial transmission of parental mood disorders: unipolar and bipolar disorders in offspring.

OBJECTIVES: Offspring of depressed parents are at increased risk for psychiatric disorders. Although bipolar disorder (BD) and major depressive disorder (MDD) are both found in the same families, it is not clear whether transmission to offspring of BD or MDD tends to occur from parents with the same mood disorder subtype. Our primary hypothesis was that the offspring of parents with BD would be at increased risk for BD and other comorbid disorders common to BD, such as anxiety and substance use, relative to the offspring of parents with MDD. The offspring of parents with BD versus those with MDD were also hypothesized to be at greater risk for externalizing disorders (i.e., conduct disorder, attention-deficit hyperactivity disorder, or antisocial personality disorder). METHODS: Parents (n = 320) with mood disorders and their offspring (n = 679) were studied. Adult offspring were administered the Structured Clinical Interview for DSM-IV Axis I Disorders to establish the presence of psychopathology. Offspring aged 10-18 years were assessed using the School Aged Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version, and parents of children under the age of ten completed the Child Behavioral Checklist. Data were examined using Cox proportional hazard regression. RESULTS: There was no difference in hazard of mood disorders in the offspring of parents with BD as compared to the offspring of parents with MDD. However, a number of other parent and offspring characteristics increased the risk of mood, anxiety, externalizing, and substance use disorders in the offspring, including self-reported childhood abuse in the parent or offspring, offspring impulsive aggression, and the age at onset of parental mood disorder. CONCLUSIONS: Mood disorders are highly familial, a finding that appears independent of whether the parent's condition is unipolar or bipolar, suggesting considerable overlap in the heritability of MDD and BD. Although parental characteristics had a limited influence on the risk of offspring psychopathology, reported childhood adversity, be it in the parent or child, is a harbinger of negative outcomes. These risk factors extend previous findings, and are consistent with diathesis-stress conceptualizations.

Risk for Suicidal Behavior After Psychiatric Hospitalization Among Sexual and Gender Minority Patients.

Importance: The months following inpatient psychiatric hospitalization are a period of high risk for suicidal behavior. Sexual and gender minority (SGM) individuals have elevated risk for suicidal behavior, but no prior research has examined whether SGM inpatients have disproportionate risk for suicidal behavior following discharge from psychiatric hospitalization. Objectives: To evaluate whether SGM patients have elevated risk for suicidal behavior following discharge from psychiatric hospitalization compared with heterosexual and cisgender patients and to examine whether differences in risk across groups were accounted for by demographic characteristics and clinical factors known to be associated with suicidal behavior. Design, Setting, and Participants: This prospective cohort study was conducted from August 2017 to July 2021 among inpatients aged 18 to 30 years who were voluntarily enrolled during psychiatric hospitalization. The study was conducted at an inpatient psychiatric hospital, with prospective data collected via follow-up visits and electronic health records. Main Outcomes and Measures: Onset and/or recurrence of suicidal behavior following discharge from psychiatric hospitalization, assessed at follow-up visits and through electronic health records. Results: A total of 160 patients were included, with 56 sexual minority (SM) and 15 gender minority (GM) patients. The median (IQR) age of the patients was 23.5 (20.4-27.6) years, 77 (48%) reported male sex assigned at birth, and 114 (71%) identified their race as White. During the follow-up period, 33 suicidal behavior events occurred (among 21% of patients). SM (hazard ratio [HR], 2.02; 95% CI, CI, 1.02-4.00; log-rank P = .04) and GM (HR, 4.27; 95% CI, 1.75-10.40; log-rank P < .001) patients had significantly higher risk for suicidal behavior compared with their heterosexual and cisgender counterparts, respectively, in bivariable analyses. Risk between SM and heterosexual patients was not different after controlling for demographic characteristics and clinical factors associated with suicidal behavior. GM patients exhibited elevated risk during the 100 days following discharge even after controlling for demographic and clinical characteristics (HR, 3.80; 95% CI, 1.18-11.19; P = .03). Conclusions and Relevance: Within this cohort study of psychiatric patients, SGM patients had higher risk for suicidal behavior than non-SGM patients following discharge. While SM patients' risk was accounted for by clinical characteristics, GM patients' risk for suicidal behavior was not accounted for by their acute psychiatric state on admission. Future studies with larger subsamples of GM individuals are needed, and inpatient clinicians must attend to the unique needs of SGM individuals to ensure they receive affirming services.

Intensive Longitudinal Assessment of Adolescents to Predict Suicidal Thoughts and Behaviors.

OBJECTIVE: Suicide is a leading cause of death among adolescents. However, there are no clinical tools to detect proximal risk for suicide. METHOD: Participants included 13- to 18-year-old adolescents (N = 103) reporting a current depressive, anxiety, and/or substance use disorder who owned a smartphone; 62% reported current suicidal ideation, with 25% indicating a past-year attempt. At baseline, participants were administered clinical interviews to assess lifetime disorders and suicidal thoughts and behaviors (STBs). Self-reports assessing symptoms and suicide risk factors also were obtained. In addition, the Effortless Assessment of Risk States (EARS) app was installed on adolescent smartphones to acquire daily mood and weekly suicidal ideation severity during the 6-month follow-up period. Adolescents completed STB and psychiatric service use interviews at the 1-, 3-, and 6-month follow-up assessments. RESULTS: K-means clustering based on aggregates of weekly suicidal ideation scores resulted in a 3-group solution reflecting high-risk (n = 26), medium-risk (n = 47), and low-risk (n = 30) groups. Of the high-risk group, 58% reported suicidal events (ie, suicide attempts, psychiatric hospitalizations, emergency department visits, ideation severity requiring an intervention) during the 6-month follow-up period. For participants in the high-risk and medium-risk groups (n = 73), mood disturbances in the preceding 7 days predicted clinically significant ideation, with a 1-SD decrease in mood doubling participants' likelihood of reporting clinically significant ideation on a given week. CONCLUSION: Intensive longitudinal assessment through use of personal smartphones offers a feasible method to assess variability in adolescents' emotional experiences and suicide risk. Translating these tools into clinical practice may help to reduce the needless loss of life among adolescents.

Development of An Ecological Momentary Assessment of the Impact of Social Media Use Among Suicidal Adolescents.

OBJECTIVE: We aimed to develop an ecological momentary assessment (EMA) measure and sampling protocol to assess the near-term impact of experiences with social media use (SMU) that are associated with risk and protective factors for adolescent suicide. METHODS: To develop the EMA measure, we consulted literature reviews and conducted focus groups with the target population, adolescents at risk for suicide. Subsequently, we refined the measure through interviews with experts and cognitive interviews with adolescents, through which we explored adolescents' thought processes as they considered questions and response options. Data were recorded, transcribed, and analyzed using thematic analysis. RESULTS: The initial measure had 37 items assessing a range of harmful and beneficial aspects of SMU. Through expert and cognitive interviews, we refined the measure to 4 pathways assessing positive and negative experiences with SMU as well as positive and negative in-person interactions. Each pathway included a maximum of 11 items, as well as 2 items pertaining to SMU at nighttime to be assessed once daily. Acceptable targets the EMA measure's sampling protocol included a 10-day data collection window with text message-based prompts to complete the measure triggered 2-4 times daily. CONCLUSIONS: By assessing a range of risk and protective factors for youth suicide, while using methods to reduce participant burden, we established content validity for the EMA measure and acceptability for the sampling protocol among youth at high risk of suicide.HIGHLIGHTSDevelopment of an ecological momentary assessment measure and sampling protocolExploring brief momentary assessment of social media's impact on adolescent suicidal riskMulti-phase approach to establishing content validity and an acceptable sampling protocol.

Opioid use as a proximal risk factor for suicidal behavior in young adults.

INTRODUCTION: There is a concomitant rise in suicide rates with the prevalence of opioids involved in overdose deaths, especially among adolescents and young adults. However, there are limited studies on whether opioid use prospectively predicts suicidal behavior in youth. METHODS: Our sample included 183 psychiatric patients (18-30 years) admitted for a suicide attempt (SA), have current suicidal ideation (SI), and psychiatric controls without ideation or attempt (PC). Suicidal behavior was assessed using the Columbia Suicide Severity Rating Scale. We also recruited a healthy control group (HC; n = 40). Patients and controls were followed over a year. ANOVA, regression, and cox regression were used. RESULTS: Suicide attempt (ß = 0.87, CI [0.1-1.6], p = 0.02) and SI [(ß = 0.75, CI [0.03-1.5], p = 0.04) were significantly more likely than HCs to have used opioids in the past year at baseline. Opioid use was associated with increased anxiety symptoms (ß = 0.75, CI [0.001-1.5], p = 0.05), PTSD symptoms (ß = 3.90, CI [1.1-6.7], p = 0.01), and aggression (ß = 0.02, CI [0.01-0.04], p = 0.02). Opioid use in the month prior to hospitalization predicted SA at 6 months (OR = 1.87, CI [1.06-3.31], p = 0.032). CONCLUSIONS: Opioid use is a proximal predictor for SA. These findings may help clinicians better identify patients at risk for suicidal behavior, allowing for more personalized treatment approaches.

Molecular genomic research designs.

Genetic and genomic research approaches have the capability to expand our understanding of the complex pathophysiology of disease susceptibility, susceptibility to complications related to disease, trajectory of recovery from acquired injuries and infections, patient response to interventions and therapeutics, as well as informing diagnoses and prognoses. Nurse scientists are actively involved in all of these fields of inquiry, and the goal of this chapter is to assist with incorporation of genetic and genomic trajectories into their research and facilitate the design and execution of these studies. New studies that are going to embark on recruitment, phenotyping, and sample collection will benefit from forethought about research design to ensure that it addresses the research questions or hypotheses being tested. Studies that will use existing data or samples will also benefit from forethought about research design for the same reason but will also address the fact that some designs may not be feasible with the available data or samples. This chapter discusses candidate gene association, genome-wide association, candidate gene expression, global gene expression, and epigenetic/epigenomic study designs. Information provided includes rationale for selecting an appropriate study design, important methodology considerations for each design, key technologies available to accomplish each type of study, and online resources available to assist in executing each type of study design.

Automated Monitoring of Suicidal Adolescents' Digital Media Use: Qualitative Study Exploring Acceptability Within Clinical Care.

BACKGROUND: Monitoring linguistic cues from adolescents' digital media use (DMU; ie, digital content transmitted on the web, such as through text messages or social media) that could denote suicidal risk offers a unique opportunity to protect adolescents vulnerable to suicide, the second leading cause of death among youth. Adolescents communicate through digital media in high volumes and frequently express emotionality. In fact, web-based disclosures of suicidality are more common than in-person disclosures. The use of automated methods of digital media monitoring triggered by a natural language processing algorithm offers the potential to detect suicidal risk from subtle linguistic units (eg, negatively valanced words, phrases, or emoticons known to be associated with suicidality) present within adolescents' digital media content and to use this information to respond to alerts of suicidal risk. Critical to the implementation of such an approach is the consideration of its acceptability in the clinical care of adolescents at high risk of suicide. OBJECTIVE: Through data collection among recently suicidal adolescents, parents, and clinicians, this study examines the current context of digital media monitoring for suicidal adolescents seeking clinical care to inform the need for automated monitoring and the factors that influence the acceptance of automated monitoring of suicidal adolescents' DMU within clinical care. METHODS: A total of 15 recently suicidal adolescents (aged 13-17 years), 12 parents, and 10 clinicians participated in focus groups, qualitative interviews, and a group discussion, respectively. Data were recorded, transcribed, and analyzed using thematic analysis. RESULTS: Participants described important challenges to the current strategies for monitoring the DMU of suicidal youth. They felt that automated monitoring would have advantages over current monitoring approaches, namely, by protecting web-based environments and aiding adolescent disclosure and support seeking about web-based suicidal risk communication, which may otherwise go unnoticed. However, they identified barriers that could impede implementation within clinical care, namely, adolescents' and parents' concerns about unintended consequences of automated monitoring, that is, the potential for loss of privacy or false alerts, and clinicians' concerns about liability to respond to alerts of suicidal risk. On the basis of the needs and preferences of adolescents, parents, and clinicians, a model for automated digital media monitoring is presented that aims to optimize acceptability within clinical care for suicidal youth. CONCLUSIONS: Automated digital media monitoring offers a promising means to augment detection and response to suicidal risk within the clinical care of suicidal youth when strategies that address the preferences of adolescents, parents, and clinicians are in place.

Risk factors for pre-adolescent onset suicidal behavior in a high-risk sample of youth.

OBJECTIVE: To identify risk factors for preadolescent onset suicidal behavior compared with adolescent/young adult onset suicidal behavior in a longitudinal sample of youth with parental history of mood disorders. METHODS: The sample includes 545 youth who were age 21 years or less at the time of their baseline assessment. Participants underwent baseline and yearly study assessments. Observations were censored at the time point closest to the first episode of suicidal behavior for youth with suicidal behavior and at the time of last observation for youth without suicidal behavior. Youth were categorized into 3 groups: first onset of suicidal behavior before the age of 13 (n = 32), first onset of suicidal behavior between the ages of 13-21 (n = 51) and those without suicide related behaviors (n = 462). ANOVA, Chi-square, Fisher's exact test and multinomial regression were used to test the hypotheses. RESULTS: Significant predictors of preadolescent onset suicidal behavior were diagnosis of depressive disorder (RRR = 11.41, p<.001) and diagnosis of ADHD (RRR = 2.86, p = .02). Adolescent onset was predicted by diagnosis of depressive disorder (RRR = 4.12, p = .008), female sex (RRR = 2.68, p = .02) and self-reported suicidal ideation (RRR = 1.48, p = .004). LIMITATIONS: These results are most applicable to offspring of parents with significant mood disorders. CONCLUSIONS: The strongest predictor of suicidal behavior in both groups was a diagnosis of depressive disorder, and the risk was nearly 3 times higher in preadolescents. ADHD was a significant predictor only for preadolescents, while female sex and self-reported suicidal ideation predicted suicidal behavior in adolescents.

Depression Severity Assessment for Adolescents at High Risk of Mental Disorders.

Recent progress in artificial intelligence has led to the development of automatic behavioral marker recognition, such as facial and vocal expressions. Those automatic tools have enormous potential to support mental health assessment, clinical decision making, and treatment planning. In this paper, we investigate nonverbal behavioral markers of depression severity assessed during semi-structured medical interviews of adolescent patients. The main goal of our research is two-fold: studying a unique population of adolescents at high risk of mental disorders and differentiating mild depression from moderate or severe depression. We aim to explore computationally inferred facial and vocal behavioral responses elicited by three segments of the semi-structured medical interviews: Distress Assessment Questions, Ubiquitous Questions, and Concept Questions. Our experimental methodology reflects best practise used for analyzing small sample size and unbalanced datasets of unique patients. Our results show a very interesting trend with strongly discriminative behavioral markers from both acoustic and visual modalities. These promising results are likely due to the unique classification task (mild depression vs. moderate and severe depression) and three types of probing questions.

Cortisol response to stress as a predictor for suicidal ideation in youth.

OBJECTIVE: To examine the association between cortisol response to stress and suicidal ideation (SI) cross-sectionally and longitudinally in our sample of bereaved and non-bereaved youth. METHODS: The sample included 114 youth bereaved by sudden parental death and 109 non-bereaved controls, mean age of 12.3 (SD = 3.6), evaluated at four time-points over an average follow-up period of 7 years. The Trier Social Stress Test (TSST) was conducted on average 6 years after bereavement. We used latent class analyses to examine the trajectories of SI over follow-up and up to the time of the TSST and compare them on cortisol measures. We examined whether cortisol measures predicted future SI at 18.5 months on average after the TSST. RESULTS: Bereavement was associated with higher cortisol reactivity after controlling for covariates [ß = 0.96, 95% CI (0.28, 1.65), p < 0.01, d = 0.41]. Cortisol reactivity to stress was higher in those belonging to the high SI trajectory [ß = 1.23, 95% CI (0.41, 2.06), p = 0.004, d = 0.23] compared to the low SI trajectory. Higher baseline cortisol showed small to medium effect size in predicting future SI [ß = 2.34, 95% CI (0.17, 4.51), p = 0.03, d = 0.38]. CONCLUSION: The persistence of SI is associated with higher cortisol reactivity to stress, and higher baseline cortisol may predict future SI. These results emphasize the importance of HPA-axis activity in youth exposed to major stressors, and those with SI. More research is needed to further clarify biological mechanisms linking SI and behavior, bereavement, and HPA axis response to stress, to better identify at-risk subjects for targeted prevention and intervention efforts.

Severity and Variability of Depression Symptoms Predicting Suicide Attempt in High-Risk Individuals.

Importance: Predicting suicidal behavior continues to be among the most challenging tasks in psychiatry. Objectives: To examine the trajectories of clinical predictors of suicide attempt (specifically, depression symptoms, hopelessness, impulsivity, aggression, impulsive aggression, and irritability) for their ability to predict suicide attempt and to compute a risk score for suicide attempts. Design, Setting, and Participants: This is a longitudinal study of the offspring of parents (or probands) with mood disorders who were recruited from inpatient units at Western Psychiatric Institute and Clinic (Pittsburgh) and New York State Psychiatric Institute. Participants were recruited from July 15, 1997, to September 6, 2005, and were followed up through January 21, 2014. Probands and offspring (n = 663) were interviewed at baseline and at yearly follow-ups for 12 years. Lifetime and current psychiatric disorders were assessed, and self-reported questionnaires were administered. Model evaluation used 10-fold cross-validation, which split the entire data set into 10 equal parts, fit the model to 90% of the data (training set), and assessed it on the remaining 10% (test set) and repeated that process 10 times. Preliminary analyses were performed from July 20, 2015, to October 5, 2016. Additional analyses were conducted from July 26, 2017, to July 24, 2018. Main Outcomes and Measures: The broad definition of suicide attempt included actual, interrupted, and aborted attempts as well as suicidal ideation that prompted emergency referrals during the study. The narrow definition referred to actual attempt only. Results: The sample of offspring (n = 663) was almost equally distributed by sex (316 female [47.7%]) and had a mean (SD) age of 23.8 (8.5) years at the time of censored observations. Among the 663 offspring, 71 (10.7%) had suicide attempts over the course of the study. The trajectory of depression symptoms with the highest mean scores and variability over time was the only trajectory to predict suicide attempt (odds ratio [OR], 4.72; 95% CI, 1.47-15.21; P = .01). In addition, we identified the following predictors: younger age (OR, 0.82; 95% CI, 0.74-0.90; P < .001), lifetime history of unipolar disorder (OR, 4.71; 95% CI, 1.63-13.58; P = .004), lifetime history of bipolar disorder (OR, 3.4; 95% CI, 0.96-12.04; P = .06), history of childhood abuse (OR, 2.98; 95% CI, 1.40-6.38; P = .01), and proband actual attempt (OR, 2.24; 95% CI, 1.06-4.75; P = .04). Endorsing a score of 3 or higher on the risk score tool resulted in high sensitivity (87.3%) and moderate specificity (63%; area under the curve = 0.80). Conclusions and Relevance: The specific predictors of suicide attempt identified are those that clinicians already assess during routine psychiatric evaluations; monitoring and treating depression symptoms to reduce their severity and fluctuation may attenuate the risk for suicidal behavior.

Quantification of 5-HT1A and 5-HT2A receptor Binding in Depressed Suicide Attempters and Non-Attempters.

OBJECTIVE: To determine serotonin system abnormalities related to major depression or previous suicidal behavior. METHODS: [11C]WAY100635, [18F]altanserin and positron emission tomography were used to compare 5-HT1A and 5-HT2A binding in MDD patients divided into eight past suicide attempters (>4yrs prior to scanning) and eight lifetime non-attempters, and both groups were compared to eight healthy volunteers. RESULTS: The two receptor types differed in binding pattern across brain regions from each other, but there were no differences in binding between healthy volunteers and the two depressed groups or between depressed suicide attempters and non-attempters. No effects of depression severity or lifetime aggression were observed for either receptor. CONCLUSION: Limitations of this study include small sample size and absence of high lethality suicide attempts in the depressed attempter group. No trait-like binding correlations with past suicide attempt or current depression were observed. Given the heterogeneity of nonfatal suicidal behavior, a larger sample study emphasizing higher lethality suicide attempts may find the serotonin biological phenotype seen in suicide decedents.

Correction.

This corrects the article DOI: 10.4088/JCP.09m05885blu.​​.

Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial.

CONTEXT: Only about 60% of adolescents with depression will show an adequate clinical response to an initial treatment trial with a selective serotonin reuptake inhibitor (SSRI). There are no data to guide clinicians on subsequent treatment strategy. OBJECTIVE: To evaluate the relative efficacy of 4 treatment strategies in adolescents who continued to have depression despite adequate initial treatment with an SSRI. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial of a clinical sample of 334 patients aged 12 to 18 years with a primary diagnosis of major depressive disorder that had not responded to a 2-month initial treatment with an SSRI, conducted at 6 US academic and community clinics from 2000-2006. INTERVENTIONS: Twelve weeks of: (1) switch to a second, different SSRI (paroxetine, citalopram, or fluoxetine, 20-40 mg); (2) switch to a different SSRI plus cognitive behavioral therapy; (3) switch to venlafaxine (150-225 mg); or (4) switch to venlafaxine plus cognitive behavioral therapy. MAIN OUTCOME MEASURES: Clinical Global Impressions-Improvement score of 2 or less (much or very much improved) and a decrease of at least 50% in the Children's Depression Rating Scale-Revised (CDRS-R); and change in CDRS-R over time. RESULTS: Cognitive behavioral therapy plus a switch to either medication regimen showed a higher response rate (54.8%; 95% confidence interval [CI], 47%-62%) than a medication switch alone (40.5%; 95% CI, 33%-48%; P = .009), but there was no difference in response rate between venlafaxine and a second SSRI (48.2%; 95% CI, 41%-56% vs 47.0%; 95% CI, 40%-55%; P = .83). There were no differential treatment effects on change in the CDRS-R, self-rated depressive symptoms, suicidal ideation, or on the rate of harm-related or any other adverse events. There was a greater increase in diastolic blood pressure and pulse and more frequent occurrence of skin problems during venlafaxine than SSRI treatment. CONCLUSIONS: For adolescents with depression not responding to an adequate initial treatment with an SSRI, the combination of cognitive behavioral therapy and a switch to another antidepressant resulted in a higher rate of clinical response than did a medication switch alone. However, a switch to another SSRI was just as efficacious as a switch to venlafaxine and resulted in fewer adverse effects. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00018902.

As Safe as Possible (ASAP): A Brief App-Supported Inpatient Intervention to Prevent Postdischarge Suicidal Behavior in Hospitalized, Suicidal Adolescents.

OBJECTIVE: The authors report on a pilot study of an inpatient intervention for suicidal adolescents, As Safe as Possible (ASAP), supported by a smartphone app (BRITE) to reduce suicide attempts following hospital discharge. METHOD: Across two sites, 66 adolescents hospitalized for suicidal ideation (N=26) or a recent suicide attempt (N=40) were randomly assigned to the ASAP intervention program plus treatment as usual or to treatment as usual alone. ASAP, which focuses on emotion regulation and safety planning, is a 3-hour intervention delivered on the inpatient unit. The BRITE app prompted participants to rate their level of emotional distress on a daily basis and provided personalized strategies for emotion regulation and safety planning. A blind, independent evaluator assessed suicide attempts following hospital discharge and suicidal ideation at 4, 12, and 24 weeks after discharge. RESULTS: The ASAP intervention did not have a statistically significant effect on suicide attempt, although findings were in the hypothesized direction for occurrence of an attempt (16% compared with 31%; χ2=1.86, df=1, g=-0.36) and time to an attempt (hazard ratio=0.49, 95% CI=0.16, 1.47). Past history of a suicide attempt was a significant moderator of treatment outcome, with a stronger, albeit nonsignificant, effect of the ASAP intervention among participants with a history of suicide attempt (hazard ratio=0.23, 95% CI=0.05, 1.09). There were no treatment effects on suicidal ideation. The majority of participants (70%) used the BRITE app (median usage, 19 times). Participants reported high satisfaction with both the intervention and the app. CONCLUSIONS: The ASAP intervention program shows promise in reducing the incidence of postdischarge suicide attempts among adolescents hospitalized for suicidality and merits further study.