The communication of suicidal intentions: a meta-analysis.

BACKGROUND: Among the myths that are often cited about suicide is that 'people who talk about killing themselves rarely die by suicide', but the evidence seems to contradict this statement. The aim of this study was to conduct a meta-analysis of studies reporting a prevalence of suicide communication (SC), and to examine the diagnostic accuracy of SC towards suicide in case-control reports. METHOD: Eligible studies had to examine data relative to completed suicides and report the prevalence of SC. Data relative to sample characteristics, study definition, modality and recipient of the SC were coded. RESULTS: We included 36 studies, conducted on a total of 14 601 completed suicides. The overall proportion of SC was 44.5% [95% confidence interval (CI) 35.4-53.8], with large heterogeneity (I 2 = 98.8%) and significant publication bias. The prevalence of SC was negatively associated with the detection of verbal communication as the sole means of SC and, positively, with study methodological quality. Based on seven case-control studies, SC was associated with an odds ratio of 4.66 for suicide (95% CI 3.00-7.25) and was characterized by sufficient diagnostic accuracy only if studies on adolescents were removed. CONCLUSION: Available data suggest that SC occurs in nearly half of subjects who go on to die by suicide, but this figure is likely to be an underestimate given the operational definitions of SC. At present, SC seems associated with overall insufficient accuracy towards subsequent suicide, although further rigorous studies are warranted to draw definite conclusions on this issue.

Insomnia as a predictor of high-lethality suicide attempts.

INTRODUCTION: Research has demonstrated that patients with insomnia are at an increased risk of experiencing suicidal ideation and/or making a suicide attempt. OBJECTIVES: To evaluate the relation between insomnia and suicidal behaviour. AIMS: To examine factors associated with a diagnosis of insomnia in patients admitted to an Emergency Department (ED) and assessed by the psychiatrist in charge. METHODS: Participants were 843 patients consecutively admitted to the ED of Sant'Andrea Hospital in Rome, between January 2010 and December 2011. All patients admitted were referred to a psychiatrist. A clinical interview based on the Mini International Neuropsychiatric Interview (MINI) and a semi-structured interview was conducted. Patients were asked about 'ongoing' suicidal ideation or plans for suicide. RESULTS: Forty-eight percent of patients received a diagnosis of bipolar disorder (BD), major depressive disorder (MDD) or an anxiety disorder; whereas, 17.1% were diagnosed with Schizophrenia or other non-affective psychosis. Patients with insomnia (compared to patients without insomnia) more frequently had a diagnosis of BD (23.9% vs. 12.4%) or MDD (13.3% vs. 9.5%; p < 0.001). Moreover, patients with insomnia less frequently had attempted suicide in the past 24 h (5.3% vs. 9.5%; p < 0.05) as compared with other patients, but those patients with insomnia who attempted suicide more frequently used a violent method (64.3% vs. 23.6%; p < 0.01) compared to other suicide attempters. CONCLUSIONS: Our results do not support an association between insomnia and suicidal behaviour. However, suicide attempters with insomnia more frequently used violent methods, and this phenomenon should be taken into serious consideration by clinicians.

Gene variants with suicidal risk in a sample of subjects with chronic migraine and affective temperamental dysregulation.

BACKGROUND: Risk factors for suicide are at least partially heritable and functional polymorphisms of targeted genes have been suggested to be implicated in the pathogenesis of this phenomenon. However, other studies examining the association between specific gene variants and suicide revealed inconsistent findings. We aims to evaluate the possible association between MAO-A3, CYP1A2*1F and GNB3 gene variants, hopelessness and suicidal risk in a sample of subjects with chronic migraine and affective temperamental dysregulation. METHODS: 56 women were genotyped for MAO-A3, CYP1A2*1F and GNB3 gene variants. Participants were also assessed using Beck Hopelessness Scale (BHS), the Temperament Evaluation of the Memphis, Pisa, Paris and San Diego-Autoquestionnaire (TEMPS-A), and the Suicidal History Self-Rating Screening Scale (SHSS). RESULTS: Patients with higher total scores on affective dysregulated temperaments are more likely to have higher BHS (11.27+/=5.54 vs. 5.73+/=3.81; t19.20 = -3.57; p < 0.01) and higher SHSS total scores (4.79+/=3.31 vs. 1.05±2.31; t17.74 = -3.90; p < 0.001) than those with lower total scores. 67% of patients in the dysregulated group has BHS total scores >= 9 indicating high levels of hopelessness. No association was found between MAO-A3, CYP1A2*1F and GNB3 gene variants and suicidal risk as assessed by BHS and SHSS. CONCLUSIONS: This study did not sustain the association between MAO-A3, CYP1A2*1F and GNB3 gene variants and increased suicidal risk in patients with chronic migraine and affective temperamental dysregulation. Further studies investigating the gene-environment interaction or focusing on other genetic risk factors involved in suicidal behaviour are needed.  

Affective temperaments are associated with higher hopelessness and perceived disability in patients with open-angle glaucoma.

AIM: The aims of the study were to study: (i) affective temperaments in open-angle glaucoma (OAG) patients with some degree of functional visual impairment; (ii) psychological well-being and perceived disability, and their associations with affective temperaments; and (iii) associations between visual impairment, affective temperaments and psychological well-being. METHOD: Participants were 91 outpatients (39 women, and 52 men) with open-angle glaucoma (OAG) who were assessed for Visual Field Index, Mean Defect and Pattern Standard Deviation. Patients were also administered the Beck Hopelessness Scale, the TEMPS-A (Rome), the Gotland Male Depression Scale, the Emotional Well-being Scale, the Perceived Disability Questionnaire and the Suicidal History Self-Rating Screening Scale. RESULTS: Open-angle glaucoma patients (compared with a non-clinical sample of university students) had higher scores on the TEMP-A dysthimic and hyperthimic traits and lower scores on cyclothimic, irritability and anxiety traits. Such temperament variability was not linked to differences in severity of glaucoma. We did not find strong evidence supporting the fact that measures of visual impairment were linked to emotional well-being and depression. However, logistic regression analysis revealed that patients may have different patterns related to their illness according to specific temperaments. CONCLUSION: Patients with OAG may have different temperament profiles than non-clinical individuals. Such categorisation may be useful for predicting how they face the illness, for providing better care as well as for early recognition of mood disorders symptoms.

Prospective, open study of long-acting injected risperidone versus oral antipsychotics in 88 chronically psychotic patients.

INTRODUCTION: A long-acting, injected, carbohydrate-microsphere preparation of risperidone (RLAI; Risperdal Consta ((R))) is reported to be safe and effective in chronic psychotic illnesses but, as its long-term and comparative efficacy remain unclear, this study compared clinical status during oral antipsychotic treatment versus conversion to RLAI. METHODS: Psychotic patients (n=88; initial BPRS=93+/-5) were treated for 6 months with clinically chosen oral medication and then converted to biweekly RLAI for the first 6 months (6-6 months matched mirror comparison) and then for another 18 months. Clinical status in the two treatment periods and in the 18 months of follow-up was compared with measures including BPRS improvement (primary outcome), CGI variants and SF-36 ratings. RESULTS: RLAI (at a mean dose of 47 mg/2 weeks at six and up to 23.1+/-3.3 months) was associated with major improvements in all outcome measures (p<0.001). Initial BPRS scores fell by an average of 50% within six months; hospitalizations declined from 19.8% to 0%, and rates of adverse events were reduced by 2.5- to 7.4-fold. Such benefits were sustained during 18 months of follow-up with RLAI-treatment. CONCLUSIONS: The findings are limited by the lack of a parallel control treatment, such as with oral risperidone or another antipsychotic, lack of blinded assessments, and a moderate number of subjects. Nevertheless, the findings add to indications that RLAI can be an effective and well-tolerated treatment-option for chronically psychotic patients.

[Predicting risk of suicide in bipolar and unipolar depression: correlation between temperament and personality]. / Prädiktion des Suizidrisikos bei bipolar und unipolar depressiven Patienten: Wechselwirkung von Temperament und Persönlichkeit.

OBJECTIVE: The aim of this study was to evaluate the roles of personality and affective temperament traits in the prediction of suicide risk in mood disorders. METHODS: The participants were 147 psychiatric inpatients with bipolar disorders I and II and major depressive disorder. Patients undertook the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego self-rating questionnaire, the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), and the Beck Hopelessness Scale. RESULTS: Sixty-four subjects were diagnosed with increased suicidal risk based on the Mini International Neuropsychiatric Interview (MINI). Logistic regression analysis resulted in two models predictive of MINI-based suicidal risk: irritable temperament and the MMPI-2 scale. Multiple regression analysis further indicated that higher hyperthymic values are protective against hopelessness, while MINI-based suicidal intent is a predictor of hopelessness. CONCLUSIONS: Personality and affective temperament traits may have a role in the prediction of suicide.

Psychiatric comorbidity in the frail patient.

The psychopathological syndromes associated with the organic disease in the frail patient are put in the focus of our studies. In the frail patient, mood disorders show a multifacet appearance often associated to the invalidating pathologies or determined by the interaction between the diseases and the individual personality traits. A psychotic break can worsen the evolution of the clinical status. In the clinical practice with the frail elderly, the diagnostic and therapeutic phases change to some extent. The psychiatric diagnosis based upon the DSM-IV-TR shall include a multiaxial approach, with the general medical conditions coded on axis III. The therapeutic planning must be based on rules taken from the field of sciences of complexity; in the field of complexity, the evolution of the clinical status is not expectable and the points of discontinuity are the rule. The difficulties to reach a "secure base" makes the therapeutic dynamics be attracted from areas of stability in the mid of chaos, named "chaotic attractors".

[Affective temperaments and psychopathological dimensions of personality in Bipolar Disorder]. / Temperamenti affettivi e dimensioni psicopatologiche di personalità nel Disturbo Bipolare.

OBJECTIVES: The first objective of our study is the evaluation of correlation between affective temperaments and psychopathological dimensions in a clinical sample of patients with Bipolar Disorder and the individualization of possible differences within the three diagnostic subtypes (bipolar I, II and cyclothymia). The second one is to observe whether any specific temperament may influence the number of hospitalizations or the age of the bipolar depression onset. MATERIALS AND METHODS: At the Bipolar Disorder Unit of Policlinico Gemelli (Rome, Italy) a group of 60 patients with Bipolar Disorder (BD) has been enrolled. All patients have been submitted to the TEMPS-A for the evaluation of affective temperament and TCI-R for the evaluation of psychopathological dimensions of personality. RESULTS: BD I group showed 5 significant correlations from moderate (r=0.40) to high degree (r=0.60). SD dimension of TCI shows 3 significant correlations with TEMPS-A dimensions: it is inversely correlated with Cyclothymia (r= -0.57; p<0.01), Irritability (r=0.60; p<0.01) and Anxiety (r=-.45; p<0.05). BDII group showed 5 significant correlations. Irritability dimension of TEMPS-A presented the highest number of correlations with TCI dimensions: it was inversely correlated to SD (r= -.65; p<0.01) and directly correlated with HA (r=0.48; p<0.05) and ST (r=-0.49; p<0.05). In the comparison of diagnostic groups with regards to temperamental dimensions, only Hyperthymia and Irritability dimensions were significative. CONCLUSIONS: Many works have evaluated temperament through the use of these two tools (TEMPS-A and TCI-R) but few have analysed correlation between them and none has focused attention on patients with bipolar disorder diagnosis only.

Burnout, hopelessness and suicide risk in medical doctors.

OBJECTIVES: The aim of the present study was to investigate the association between burnout and hopelessness in medical doctors. MATERIALS AND METHODS: We conducted an investigation of 133 medical doctors working either in a hospital setting or in general practice to explore the relationship between the level of burnout and hopelessness, a psychometric marker for suicide risk. The participants were administered the Oldenburg Burnout Inventory (OBI) and Beck's Hopelessness Scale (BHS). RESULTS: Burnout is an important issue in mediating the level of hopelessness. Doctors with high hopelessness had higher scores on the disengagement factor (2.61±0.47 vs 2.14±0.41; t131=-4.37; p<0.001; Cohen D=1.07), and on the exhaustion factor (2.68±0.65 vs 2.19±0.54; t131=-3.39; p<0.001; Cohen D=0.82) than doctors with low hopelessness. A multivariate regression analysis confirmed that disengagement and exhaustion are significant predictors of the BHS scores. CONCLUSIONS: People in charge of workers' health should pay particular attention to the level of burnout in doctors, intervene with changes in the work environment and evaluate the impact of such procedures.

White matter hyperintensities, suicide risk and late-onset affective disorders: an overview of the current literature.

White matter hyperintensities (WMHs) refer to areas of hyperintense signal on T2- or proton density-weighted brain magnetic resonance imaging. Although WMHs are a common finding in patients with bipolar disorder (BD), particularly with a later disease onset, some studies report a higher frequency of WMHs only in unipolar affective disorders. We reviewed the literature examining examining both the severity and presence of WMHs in late life and particularly in individuals with late-onset BD (LOBD). Studies investigating white matter lesions in LOBD were systematically retrieved and the reference lists of these studies were scanned for additional relevant studies of neuroimaging in LOBD. The majority of neuroimaging studies reported an association between older age and LOBD and the presence of WMHs in LOBD. Also, we found in a small sample of patients preliminary evidence of a significant relationship between older age with late-onset BD and WMHs having a higher prevalence of cardiovascular and cerebrovascular risk factors. In conclusion over 60 years older individuals with LOBD and WMHs might have a type of illness characterized by more neuropathological changes and biologically different compared to non LOBD. This is consistent with the hypothesis of vascular mania. WMHs could be a reliable biological risk marker for late onset mood disorders.

Duloxetine versus venlafaxine in the treatment of unipolar and bipolar depression.

OBJECTIVES: Both duloxetine and venlafaxine are efficacious in treating patients with Major Depressive Disorder (MDD), even though the advantages in treatment patients with bipolar disorder is unclear. This study aimed to evaluate the efficacy of duloxetine vs venlafaxine in the acute treatment of unipolar and bipolar depression. MATERIALS AND METHODS: The study was a non randomized controlled trial. The participants were 62 consecutive outpatients (41 men; 21 women) affected by unipolar and bipolar depression treated either with duloxetine and venlafaxine. RESULTS: More patients treated with duloxetine had a positive response to treatment and remission both for depression (HAMD17 response: 90.3% vs 0.0%; p < .001; HAM-D17 remission: 48.4% vs 0.0%; p < .001), and anxiety (HAM-A response: 90.3% vs 6.5%; p < .001; HAM-A remission: 71.0% vs 6.5%; p < .001) than controls. Patients treated with duloxetine were also more likely to show a decrease in HAM-D17 suicidality (100% vs 45.2%; p less than .001) and an increase in the quality of life (SF-36 percentage of improvement: 6.35 [SD=9.66 vs -2.58 [9.98]; p less than .001) than controls. CONCLUSIONS: Duloxetine is more effective in reducing anxiety and suicidal ideation. Both treatments were safe and tolerated, and both may be successfully used in unipolar and bipolar depression.

Suicide prevention among youths. Systematic review of available evidence-based interventions and implications for Italy.

Suicide completion is a leading cause of death for children, adolescents, and young adults. There is evidence that the suicide rate for those aged 15 to 24 years has tripled since 1950, and suicide is now the second or third leading cause of death in this age group. Recent studies indicate that the incidence of suicide attempts among adolescents may exceed 10% annually. The role of caregivers and schools (as well as colleges and universities) is important in the assessment, management, and prevention of suicidal behaviour in children and youth. Recognition of risk factors for suicide is of paramount importance for prevention. Furthermore, a number of educational programs have demonstrated possible key roles in implementing suicide prevention strategies. As suicide is a problem of concern among Italian youths, this paper overviews current official statistical evidence of the phenomenon and suggests a national suicide prevention strategy based on a number of tools already involved in this field, especially in the USA.