Psychiatric comorbidity in individuals with bipolar disorder: relation with clinical outcomes and functioning.

The aim was to assess the lifetime prevalence of psychiatric comorbidity (PC) in Brazilian euthymic individuals with bipolar disorder type I, and investigate its effects on clinical outcomes and functioning. A group of 179 outpatients with BD-I in the recuperation phase were assessed, of whom 75 (41.9%) had PC and 104 (58.1%) had not. Both groups were compared using sociodemographic/clinical questionnaire, Structured Clinical Interview for DSM-IV axis I and II, Sheehan Disability and Barratt Impulsiveness Scales. Patients with PC presented less religious affiliation, more history of lifetime psychotic symptoms, rapid cycling, suicide attempts, worse scores of functioning, and higher prevalence of personality disorders. Ordinal logistic regression indicated that PC was associated with increased odds of worse levels of disability. Therefore, it could be observed that patients with BD evaluated only in euthymia presented a high mental disorders comorbidity. Considering their burdensome impact, appropriate management is a challenging reality and a crucial factor in reducing morbidity and mortality associated with BD. Further longitudinal studies on their relationship may broaden interventions to reduce patient's suffering.

Social support among individuals with bipolar disorder during euthymic phase: A systematic review.

INTRODUCTION: In spite of the recent increase in scientific publications showing an expressive interest in studies about social support, there are still scarce publications regarding this thematic and bipolar disorder, mostly when evaluating the individuals in the state of euthymia. Euthymia referred a state that a bipolar patient does not have signs/symptoms of (hipo)mania or depression, thus assessing individuals in this state may reduce response bias. OBJECTIVE: The objective of this study is to identify the impact of social support on bipolar disorder in patients in the euthymic phase. METHODS: A systematic search of observational studies on PubMed/Medline, PsycINFO, EMBASE, Scopus and Web of Science databases was performed from February 2021 to August 2022. RESULTS: In total, seven studies fulfilled the eligibility criteria. According to three studies, bipolar disorder patients had lower social support than healthy controls. Contrastingly, one study showed bipolar patients did not have different social support compared to healthy controls. CONCLUSIONS: Even though few papers with low or middle risk of bias were included in this review, we found that not only does social support could act as a protective factor for bipolar patients but also that clinical manifestations of the disorder seem to affect social support. This systematic review suggests the narrowed evidence field with different measures and type of evaluation from studies on social support and bipolar disorder, which highlights the need for further investigations on this theme.

Social support in patients with bipolar disorder and differing ages at onset.

OBJECTIVE: The main purpose of this study was to evaluate the association between age at onset and social support in outpatients with bipolar disorder who were in the recovery phase. We also investigated the association between age at onset and disability. METHODS: A total of 180 bipolar disorder I outpatients, of whom 50 had early onset with age at onset ≤18 years old, 108 had middle onset with age at onset between 19 and 39 years old, and 22 had late onset with age at onset ≥40 years old, were assessed with the Medical Outcomes Study Social Support Scale and Sheehan Disability Scale. RESULTS: The early onset group had lower tangible social support, longer length of illness, more childless participants, lower income and more suicide attempters than the late onset group. CONCLUSIONS: Early onset seems to have inferior outcomes in tangible social support than late onset, but this trend should be considered as a starting point for future studies.

History of suicide attempts in patients with bipolar disorder type I: socio-demographic and clinical factors, quality of life and functioning.

INTRODUCTION: This study aims to evaluate sociodemographic and clinical factors, quality of life (QoL) and functioning associated with history of suicide attempts (SA) in a sample of bipolar disorder (BD) type I patients. METHODS: A total of 417 BD type I patients, with and without history of SA were recruited from two Brazilian specialized Mood Disorder Centers. They were assessed with a sociodemographic and clinical questionnaire, the Young Mania Rating Scale, the Hamilton Depression Rating Scale, the Structured Clinical Interviews for DSM-IV Axis I Disorders, the World Health Organization Quality of Life-BREF, and the Sheehan Disability Scale. RESULTS: One hundred and seventy-nine (42.9%) patients had a history of SA. There were no statistically significant sociodemographic differences between BD patients with and without a history of SA. Logistic regression found that lifetime hospitalization, comorbid anxiety disorders, depressive polarity in the first episode, current intensity of depressive symptoms, history of rapid cycling, family history of suicide and age at onset were significantly associated with SA in BD. Multiple linear regression showed that SA had no effect on QoL and functioning, which were affected mainly by comorbid anxiety disorders and current intensity of depressive symptoms, even in patients considered euthymic. CONCLUSION: Suicidal behavior in patients with BD is a complex phenomenon and reflects a more severe course of illness. Patients with history of SA may have worse QoL and functional impairment not because of its direct effect, but because of the greater association with clinical factors related to poor prognosis.

Functioning in euthymic patients with bipolar disorder: A systematic review and meta-analysis using the Functioning Assessment Short Test.

OBJECTIVES: Systematically review the prevalence of functional impairment (FI) in euthymic patients with bipolar disorder (BD), as assessed only with the Functioning Assessment Short Test (FAST), explore the prevalence of this impairment among all the domains, identify the most compromised of them and the clinical variables associated with low functioning in this population. METHODS: Meta-analyses were performed, searching for relevant papers published from 2007 to 2019 in Medline, Embase, Cochrane, PsycINFO databases and via hand-searching, without language restrictions. 1128 studies were initially identified, 13 of which were ultimately chosen based on the eligibility criteria. A two-step meta-analysis was performed using the mean difference with a 95% confidence interval for continuous variables and proportion estimation with a fixed-effects model for categorical variables. RESULTS: In the first step, all FAST domains showed worse FI in patients than in healthy controls, with significant differences between groups. In the second step, the prevalence of FI domains were as follows: global, 58.6%; occupational, 65.6%; cognitive, 49.2%; autonomy, 42.6%; interpersonal relationships, 42.1%; leisure, 29.2%; and financial issues, 28.8%. Residual depressive symptoms were the most frequently cited variable associated with FI. CONCLUSIONS: This study reinforces the relevant functional impact of BD in this population and suggests that the occupational domain may be the most impaired. Greater efforts should be directed toward targeting functioning in patient care, as it constitutes the most meaningful endpoint of response to treatment, especially with occupational and cognitive rehabilitation, thus allowing patients to overcome the course of illness and carry fulfilling lives.

Neurocognitive Impairment in Bipolar Disorder and Associated Factors: Using Population-based Norms and a Strict Criterion for Impairment Definition.

BACKGROUND: Cognitive impairment is often identified in individuals with bipolar disorder and is associated with their functional impairment. However, there is controversy surrounding potential classification methods for impairment in cognitive measures. OBJECTIVE: To examine the proportion of cognitive measures indicating impairment of attention, processing speed, memory, visuoconstructional abilities, and executive functions in individuals with bipolar disorder type I (euthymic) and healthy controls, using a strict criterion for defining impairment. METHODS: We gave 43 individuals with bipolar disorder type I and 17 healthy controls a comprehensive clinical and neuropsychological assessment. All scores were standardized using means and standard deviations according to age. Impaired performance in all cognitive measures was determined using a distribution-based threshold of z=±1645. The effects of the sociodemographic and clinical variables on cognitive performance were examined using multiple stepwise backward regression analyses. RESULTS: Clinically significant cognitive impairment was observed more frequently in the bipolar disorder group, compared to controls, on all measures. From participant factors, we found that level of education and number of manic episodes predicted variation in more cognitive measure scores. DISCUSSION: The use of population-based norms to standardize cognitive measures, and a strict criterion to define cognitive impairment, in individuals with bipolar disorder type 1 and healthy controls resulted in a prevalence of impairment in cognitive domains' frequencies of deficits that fell within the ranges previously reported in meta-analyses. CONCLUSIONS: Clinically introducing population norms and a stringent cognitive impairment criterion can facilitate more accurate measures of cognitive impairment in individuals with bipolar disorder.

Psychiatric disorders in individuals diagnosed with gender dysphoria: A systematic review.

AIM: Although there has been an increase in the social acceptance of the gender dysphoria (GD) population, these individuals still suffer a high degree of emotional stress, which highlights the importance of knowing their mental illness diagnosis. METHODS: A systematic review was conducted to identify the frequency of lifetime Axis I mental disorders in this population, using the MEDLINE/PubMed, SciELO, Cochrane, EMBASE, and PsychINFO databases and manual searching, examining articles published after 1980. The search used the key words: ('transgender' OR 'gender identity disorder' OR 'gender dysphoria' OR 'transsexualism' OR 'gender dysphoric patients' OR 'gender incongruence') AND ('mental disorder' OR 'axis I' OR 'psychiatric disorders') AND ('comorbidity' OR 'comorbid' OR 'prevalence'). RESULTS: From 233 papers found, five were included. The total sample comprised 577 individuals diagnosed with GD, of whom 307 (53.2%) had presented with at least one mental disorder in their lifetime. Among this high frequency of Axis I disorders, mood disorders were the most frequent (found in 243 individuals [42.1%]), followed by anxiety disorders (155 [26.8%]), and substance use/abuse disorders (85 [14.7%]). CONCLUSION: This study offers important data to researchers and clinicians so they can recognize and contribute to the development of public policy on the mental health of the population diagnosed with GD. The mental health of these individuals requires special attention as it contributes to their functional impairment.

Bipolar disorder and tobacco smoking: Categorical and dimensional clinical correlates in subjects from the Brazilian bipolar research network.

BACKGROUND: People with bipolar disorder (BD) have high rates of smoking. However, the scientific literature examining the association between clinical outcomes in BD and tobacco smoking is still limited and there are conflicting results. The objective of the current study was to comprehensively investigate associations between BD and tobacco smoking in a large Brazilian sample. METHODS: This study evaluated 336 outpatients from the Brazilian Bipolar Research Network, which is a collaboration between three large academic centers in Brazil. MAIN FINDINGS: Regarding the categorical analysis (i.e. current smokers versus non-smokers), tobacco smokers showed: 1) a higher percentage of individuals identifying as Non-Caucasians; 2) a longer duration of illness; 3) a longer duration of untreated illness; 4) more severe manic symptoms; 4) a stronger family history of mood disorder; and 6) a higher current prevalence of alcohol/substance use disorder. The dimensional analysis in smokers (i.e. number of cigarettes per day versus clinical variables) found a positive correlation between number of cigarettes per day and a) age, b) age at onset of BD, c) duration of illness, and d) current diagnosis of panic disorder. CONCLUSION: This study found important clinical correlates of tobacco smoking in BD subjects. We observed that the variables associated with current smoker status (categorical approach) are not necessarily correlated with number of cigarettes per day (dimensional approach). Duration of illness appears to be a particularly relevant clinical variable in the association between BD and tobacco smoking.

Case series of diagnostic shift from bipolar disorder to schizoaffective disorder.

OBJECTIVE: To describe three cases of diagnostic shift from bipolar I disorder (BD) to schizoaffective disorder (SAD). METHODS: BD patients were clinically assessed and followed up in a mood disorder program. A questionnaire was applied to assess clinical and socio-demographic characteristics, and a Structured Clinical Interview (SCID-I) was conducted. RESULTS: We identified three patients with diagnosis conversion to SAD from 2005 to 2016. The mean time between BD diagnosis and the diagnostic shift to SAD was 9 years. CONCLUSIONS: Psychotic symptoms may become persistent, chronic and unrelated to the presence of mood episodes many years after the beginning of BD. Psychiatrists should be aware of this and reassess the diagnosis during the longitudinal course of BD, especially in those patients who present psychotic symptoms.

Suicide attempts in Brazil, 1998-2014: an ecological study.

BACKGROUND: Attempted suicide is the main predictor of suicide constituting a major public health issue worldwide. It is estimated that for every completed suicide, 10 to 20 suicide attempts occur. Important part of the occurrences of suicide attempts in Brazil are registered in the hospital information system for coverage of more than 70 % allows to evaluate the extent of this problem in the country. The scope of this article is to analyse hospitalizations resulting from suicide attempts at public hospitals or services contracted out by the public health system (SUS) in Brazil from 1998 to 2014. METHODS: This is an ecological study of secondary morbidity data obtained from the Hospital Information System. The overall rate of suicide attempts per 100 000 (10(5)) individuals and rates stratified by age group and sex were calculated. To measure trends, simple linear regression coefficients were calculated. The hospital mortality rate was calculated per 100 individuals. RESULTS: The overall rate of hospitalization decreased from 1998 to 2014. The young and adult age groups had the highest hospitalization rates. Men were admitted more and the elderly had higher hospital mortality rates. The main cause of hospitalization was poisoning, accounting for 70.4 % of hospitalizations. Among the people who used poisoning by non-medical drugs as the method of attempted suicide, 58 178 (69.6 %) were men and 49 585 people who are poisoned by medical drugs (60.1 %) were women. CONCLUSIONS: Although hospitalization rates for attempted suicide have declined in Brazil, it remains a serious public health problem. Because a suicide attempt is the main predictor of suicide, studies to identify those most vulnerable to attempted suicide will help in the development of prevention strategies for mental health.

The fatigue impact scale for daily use in patients with hepatitis B virus and hepatitis C virus chronic infections.

INTRODUCTION: Fatigue is an important clinical finding in the hepatitis virus chronic infection. However, the absence of scales to measure fatigue, translated and validated for Brazilian Portuguese, prevents access to information essential in clarifying specific clinical conditions in this population. AIM: The aim of this study was to determine the psychometric properties of the fatigue impact scale for daily use (D-FIS), in Brazilian Portuguese, for patients with the hepatitis C virus (HCV) and hepatitis B virus (HBV) chronic infection. MATERIAL AND METHODS: In this cross-sectional study, the authors evaluated the D-FIS in 101 outpatients, followed at the reference hospital. The Mini International Neuropsychiatric Interview Brazilian (MINI PLUS) was used to identify psychiatric disorders, and the Short Form Health Survey 36-item (SF-36) to evaluate the self-reported quality of life. We also examined the impact of fatigue on the quality of life of this group of patients. RESULTS: Relevant psychometric D-FIS results were: floor effect proved to be 1%; skewness was 0.46; item homogeneity was 0.59 and SEM (SD = 8.51) was 2.4. The Cronbach's alpha was 0.920 and item total correlation yielded coefficients ranging from 0.65 (item 1) to 0.85 (item 3). In a linear regression model, fatigue and depression influenced the self-reported quality of life. CONCLUSION: This study presents that the fatigue scale for daily use in Brazilian Portuguese can be considered a useful tool to verify the presence of fatigue in patients with the hepatitis viruses B and C.

Religiosity and Impulsivity in Mental Health: Is There a Relationship?

Our aim is to evaluate the relationship between religiosity and impulsivity in patients with mental illness who had attempted suicide and in healthy individuals. This is a cross-sectional study that included 61 healthy individuals and 93 patients. The instruments used were a sociodemographic data questionnaire, the Mini International Neuropsychiatric Interview, the Barratt Impulsiveness Scale, and the Duke University Religion Index. The healthy individuals presented higher scores in the religiosity domains (organizational, p = 0.028; non-organizational, p = 0.000; intrinsic, p = 0.000). The patients presented higher scores in the impulsivity dimensions (attentional, p = 0.000; motor, p = 0.000; absence of planning, p = 0.000). In the patient group, intrinsic religiosity had a significant inverse relationship with total impulsivity (p = 0.023), attentional (p = 0.010), and absence of planning (p = 0.007), even after controlling for sociodemographic variables. Healthy individuals were more religious and less impulsive than patients. The relationship between religiosity, impulsiveness, and mental illness could be bidirectional; that is, just as mental illness might impair religious involvement, religiosity could diminish the expression of mental illness and impulsive behaviors.

Normal Metabolic Levels in Prefrontal Cortex in Euthymic Bipolar I Patients with and without Suicide Attempts.

Introduction/Objective. Evidence suggests that the prefrontal cortex has been implicated in the pathophysiology of bipolar disorder (BD), but few neurochemical studies have evaluated this region in bipolar patients and there is no information from BD suicide attempters using Proton Magnetic Resonance Spectroscopy (H(+)MRS). The objective was to evaluate the metabolic function of the medial orbital frontal cortex in euthymic BD type I suicide and nonsuicide attempters compared to healthy subjects by H(+)MRS. Methods. 40 euthymic bipolar I outpatients, 19 without and 21 with history of suicide attempt, and 22 healthy subjects were interviewed using the Structured Clinical Interview with the DSM-IV axis I, the Hamilton Depression Rating Scale, the Young Mania Rating Scale, and the Barratt Impulsiveness Scale-11 and underwent H(+)MRS. Results. We did not find any metabolic abnormality in medial orbital frontal regions of suicide and nonsuicide BD patients and BD patients as a group compared to healthy subjects. Conclusions. The combined chronic use of psychotropic drugs with neuroprotective or neurotrophic effects leading to a euthymic state for longer periods of time may improve neurometabolic function, at least measured by H(+)MRS, even in suicide attempters. Besides, these results may implicate mood dependent alterations in brain metabolic activity. However, more studies with larger sample sizes of this heterogeneous disorder are warranted to clarify these data.

Prevalence and clinical correlates of alcohol use disorders among bipolar disorder patients: results from the Brazilian Bipolar Research Network.

OBJECTIVES: To investigate prevalence rates and clinical correlates of alcohol use disorders (AUD) among bipolar disorder (BD) patients in a large sample from the Brazilian Bipolar Research Network. METHODS: Four hundred and eighty-three DSM-IV BD patients, divided according to the presence or absence of a lifetime AUD diagnosis (BD-AUD vs. BD-nonAUD), were included. Demographic and clinical characteristics of these two groups were compared. Logistic regression was performed to identify which characteristics were most strongly associated with a lifetime AUD diagnosis. RESULTS: Nearly 23% presented a lifetime AUD diagnosis. BD-AUD patients were more likely to be male, to present rapid cycling, post-traumatic stress disorder (PTSD), anorexia, other substance use disorders (SUD), family history of SUD, any substance misuse during the first mood episode, history of psychosis, suicide attempts, and younger age at onset of illness than BD-nonAUD patients. Logistic regression showed that the variables most strongly associated with a lifetime AUD diagnosis were SUD (non-alcohol), any substance misuse during the first mood episode, PTSD, male gender, suicide attempt, family history of SUD, and younger age at onset of BD. CONCLUSIONS: BD-AUD patients begin their mood disorder earlier and present more suicidal behaviors than BD-nonAUD patients. Personal and family history of SUD may be good predictors of comorbid AUD among BD patients. These variables are easily assessed in the clinical setting and may help to identify a particularly severe subgroup of BD patients.

Lifetime prevalence of psychiatric comorbidities in patients with bipolar disorder: A systematic review and meta-analysis.

BACKGROUND: Bipolar disorder (BD) is a severe psychiatric disease and part of its burden is related to the high rates of lifetime psychiatric comorbidity (PC), with diagnostic, therapeutic, and prognostic implications. METHODS: Registered in PROSPERO (CRD42021282356). Meta-analyses were performed, searching for relevant papers published from 1993 to 2022 in Medline/PubMed (including E-Pub Ahead of Print), Embase, Cochrane Library (Central), PsycINFO, Scopus, Web of Science and via hand-searching, without language restrictions. 12.698 studies were initially identified, 114 of which were ultimately chosen based on the eligibility criteria. We performed two meta-analyses (prevalence and risk ratio) of mental health conditions among subjects with BD and then conducted a comprehensive examination of moderator effects using multivariable meta-regression models for moderators identified as significant in the univariable analysis. FINDINGS: Overall PC prevalence of at least one disorder was 38.91 % (95 % CI 35.24-42.70) and the most frequent disorders were: anxiety (40.4 % [34.97-46.06]), SUD (30.7 % [23.73-38.73]), ADHD (18.6 % [10.66-30.33]) and Disruptive, impulse-control and conduct disorder (15 % [6.21-31.84). The moderators with higher association with individual prevalences were UN's Human Development Index (HDI), female gender, age, suicide attempt, and age at onset (AAO). INTERPRETATION: It becomes evident that the prevalence of PC among individuals with BD is notably high, surpassing rates observed in the general population. This heightened prevalence persists despite significant heterogeneity across studies. Consequently, it is imperative to redirect clinical focus towards comprehensive mental health assessments, emphasizing personalized and routine screening. Additionally, there is a pressing need for the enhancement of public policies to create a supportive environment for individuals with BD, ensuring better therapeutic conditions and sustained assistance. By addressing these aspects, we can collectively strive towards fostering improved mental health outcomes for individuals with BD.

Systemic lupus, folie a trois and homicide.

Folie a trois is a syndrome characterized by the transfer of delusional ideas from one person to two other persons. This condition rarely ends in the murder of any involved and we are unaware of where the primary case had the diagnosis of acute psychosis in systemic lupus erythematosus (SLE). We present a case report of folie a trois resulting in murder, secondary to acute psychosis in SLE.

Psychopathological symptoms in parents and siblings of people on the autism spectrum: A systematic review and meta-analysis.

Parents and siblings of children on the autism spectrum experience significant distress, and for this reason, it is essential to understand the most prevalent psychopathological symptoms among this population. This work aims to establish the prevalence of psychopathological symptoms in parents and siblings of individuals on the autism spectrum, following the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols (PRISMA-P) criteria. Searches were carried out using the PubMed/Medline, Embase, PsycINFO, SciELO, and Biblioteca Virtual em Saúde (BVS) databases. Twenty-three articles were included in this review. Depressive symptoms were the most frequently reported conditions, with a higher prevalence in mothers of children on the autism spectrum. In the meta-analysis, mothers of children on the autism spectrum scored higher by 0.42 standard deviations on the symptom scales (SMD 0.42; CI 0.25-0.59), with low statistical heterogeneity (I2 0%, p = 0.5) when compared with mothers of children with atypical development. The psychopathological symptoms of relatives should be investigated as part of the follow-up procedures for the child on the autism spectrum to facilitate their treatment.

Arketamine for bipolar depression: Open-label, dose-escalation, pilot study.

There are significantly fewer options for the treatment of bipolar depression than major depressive disorder, with an urgent need for alternative therapies. In this pilot study, we treated six subjects with bipolar disorder types I and II (according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria) who had been in a current depressive episode for at least four weeks. Four subjects were female (66.66%), and the mean age was 45.33 (±12.32). Subjects received adjunct treatment with two arketamine intravenous infusions one week apart-0.5 mg/kg first and then 1 mg/kg. The mean baseline Montgomery-Åsberg Depression Rating Scale (MADRS) total score was 36.66, which decreased to 27.83 24h after the first infusion of 0.5 mg/kg of arketamine (p = 0.036). In respect of the 1 mg/kg dose, the mean MADRS total score before the second infusion was 32.0, which dropped to 17.66 after 24h (p < 0.001). Arketamine appears to have rapid-acting antidepressant properties, consistent with previous animal studies on major depression. All individuals tolerated both doses, exhibiting nearly absent dissociation, and no manic symptoms. To the best of our knowledge, this pilot trial is the first to test the feasibility and safety of the (R)-enantiomer of ketamine (arketamine) for bipolar depression.

Impact of comorbid migraine on the clinical course of bipolar disorder.

BACKGROUND: Recent evidence suggests an association between migraine and bipolar disorder (BD), although the impact of this association in the clinical course of BD is relatively unknown. OBJECTIVE: This study aimed to compare 2 groups of individuals with BD (with vs without comorbid migraine) and evaluate differences in severity of clinical course. METHODS: Three hundred thirty-nine adults with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-defined bipolar I or II disorder were enrolled and divided into 2 groups: with and without comorbid migraine. Demographic and clinical data were obtained using standardized interviews. RESULTS: Patients with comorbid migraines had more mood episodes, especially those with depressive polarity. In addition, comorbid migraine was associated with a higher prevalence of psychiatric and general medical comorbidities. Differences between the 2 groups in number of lifetime hospitalizations for depression/mania, rates of rapid cycling, and history of suicide attempts were not observed after Bonferroni correction. CONCLUSIONS: Comorbid migraine seems to be associated with poor outcomes in BD. Additional studies should be conducted to investigate shared vulnerabilities and pathophysiologic mechanisms as well as treatment optimization of both illnesses.

Religiosity as a protective factor in suicidal behavior: a case-control study.

The impact of religiosity in suicidal behavior was evaluated in Brazil through a case-control study in which 110 subjects who had attempted suicide through the use of toxic substances were compared with 114 control subjects with no history of suicide attempts. Religiosity was measured in three aspects: organizational religious activities (ORAs), nonorganizational religious activities (NORAs), and intrinsic religiosity (IR). Multivariate logistic regression was used to evaluate the impact of religiosity on suicide attempts, controlling for sociodemographic variables, impulsivity, and mental illness. Religiosity, in its three dimensions, was shown to be an important protective factor against suicide attempts, even after controlling for relevant risk factors associated with suicidal behavior: ORA: odds ratio (OR), 0.63 (95% confidence interval [CI], 0.45-0.89); NORA: OR, 0.56 (95% CI, 0.42-0.75); and IR: OR, 0.59 (95% CI, 0.49-0.70). These data have important implications for understanding religiosity factors that might protect against suicide.