Induced erotomania by online romance fraud - a novel form of de Clérambault's syndrome.

BACKGROUND: Although the impact of internet usage on mental health is extensively documented, there is a notable scarcity of reports in the literature concerning internet-induced erotomania. Erotomania is a rare and likely underdiagnosed delusional disorder. It is characterized by an irrational belief held by the affected persons that someone of higher socioeconomic status harbor romantic feelings toward them. Here, we describe the psychopathology of erotomanic delusion induced by online romantic fraud in a female patient. Employing this case as a focal point, we illuminate novel aspects of erotomania that warrant attention and examination. CASE PRESENTATION: We present a compelling case involving a 70-year-old married Caucasian woman diagnosed with medically controlled persistent depressive disorder for several years. The intricacies of her condition became evident as she became deeply engrossed in online profiles featuring the image of a renowned musician, inadvertently falling victim to an online romantic fraud. Subsequently, this distressing experience triggered the emergence of erotomanic delusions and a suicide attempt. The patient's history reveals an array of medical conditions and stressful life events, contributing to her vulnerability. The diagnosis of erotomanic delusional disorder, dysthymia, and mild cognitive impairment with cerebral vascular background was established. Treatment involved her previous antidepressant with low-dose risperidone, alongside supportive individual and group therapy. Her delusion showed remission four weeks later, prompting her discharge for outpatient follow-up. Although she retained some false beliefs, the intensity of the symptoms had notably diminished and her functionality improved. CONCLUSION: This case underscores the complex interplay between mental health, online activities, and the consequences of delusions, including suicidal thoughts, shedding light on the need for a comprehensive approach in addressing such challenging psychiatric scenarios.

Investigation of peripheral inflammatory biomarkers in association with suicide risk in major depressive disorder.

Suicide is the most severe complication of major depressive disorder (MDD). Novel research assumes the role of immunological dysregulation in the background - several studies have reported alterations in the number of inflammatory cells related to both MDD and suicidality. There are currently no objective, routinely measured parameters to indicate suicidal vulnerability. However, altered inflammatory cell numbers and ratios have been proposed as potential biomarkers of suicide risk (SR). The present research aims to examine changes of these values related to increased SR in MDD as an assumed inflammatory state. We investigated laboratory parameters of psychiatric in-patients diagnosed with MDD (n = 101) retrospectively. Individuals with recent suicide attempt (SA) (n = 22) and with past SA (n = 19) represented the high SR group. MDD patients with no history of SA (n = 60) composed the intermediate SR group. We compared the number of neutrophil granulocytes, monocytes, lymphocytes, platelets, white blood cell count (WBC), neutrophil-to-lymphocyte (NLR), monocyte-to-lymphocyte (MLR), platelet-to-lymphocyte ratio (PLR), mean platelet volume (MPV), red blood cell distribution width (RDW) and erythrocyte sedimentation rate (ESR). Furthermore, we evaluated alterations of these parameters related to antidepressant (AD) and antipsychotic (AP) treatment, which have been proved to have anti-inflammatory effects. We found a significant increase in neutrophil granulocyte count, NLR, monocyte count, MLR, WBC and ESR in patients with recent SA compared to patients with no history of SA. Moreover, there was a significant elevation in monocyte count, MLR, ESR and RDW in patients with high SR compared to patients with intermediate SR. AD treatment resulted in a significant decrease in neutrophil granulocyte count and NLR, however, it did not affect monocyte count and MLR. Assuming immunological mechanisms in the background of MDD and suicidality, our findings support the role of NLR as a biomarker of acute SR, though its alterations may be masked by possible anti-inflammatory effects of AD treatment in the long term. However, MLR, a marker exhibiting changes which are not attenuated by pharmacotherapy, may be a possible indicator of both acute and long-term suicidal vulnerability.

Recovering from the first shock? Changes in suicidality during the first two years of the COVID-19 pandemic in a country with traditionally high levels of completed suicides.

BACKGROUND: Hungary was among the few countries where suicidality increased in the first year of the COVID pandemic. In this study, we sought to investigate whether that elevated suicide mortality had changed by 2021, when the number of fatalities due to COVID-19 was much higher than in 2020. METHODS: We used an interrupted time-series analysis with (quasi-) Poisson regression, controlling for linear trend and seasonal effects, to estimate the effect of the pandemic on the suicide rates of various subpopulations. For both pandemic years the changes in risk of suicide were compared to the period between 2015 and 2019. RESULTS: Although the pandemic had a significant adverse effect on suicidality in 2020 in the Hungarian total population and in males, by 2021 this effect had vanished. In the total population, those aged 25 years and older had elevated suicidality in 2020 but neither age group in the total population had elevated suicidality in 2021. In the total population, increased risks of suicide death could be observed among residents of the capital city (in 2020 and 2021), villages (in 2020), and - in terms of regions - "Central Hungary" (in 2020 and 2021). Only the risk of violent suicides was significantly higher for both the total and male populations (and only in 2020). LIMITATIONS: We used non-individual level data. CONCLUSIONS: The increased suicidality in 2020 had abated by 2021. In the paper, we discuss the possible explanations for our findings.

Efficacy of repetitive transcranial magnetic stimulation (rTMS) adjunctive therapy for major depressive disorder (MDD) after two antidepressant treatment failures: meta-analysis of randomized sham-controlled trials.

BACKGROUND: Several meta-analyses demonstrated the efficacy of unilateral High-Frequency Left-sided (HFL) repetitive Transcranial Magnetic Stimulation (rTMS) for individuals with Major Depressive Disorder (MDD); however, results are contradictory due to heterogeneity of the included studies. METHODS: A systematic literature review (SLR) of English language articles published since 2000 was performed in March 2022 on PubMed and Scopus databases. Empirical evidence on the relative efficacy of rTMS treatment compared with standard pharmacotherapy in Treatment-Resistant Depression (TRD) were extracted. Random effects models were used to assess the effects of rTMS on response and remission rates. RESULTS: 19 randomized double-blinded sham-controlled studies were included for quantitative analysis for response (n = 854 patients) and 9 studies for remission (n = 551 patients). The risk ratio (RR) for response and remission are 2.25 and 2.78, respectively for patients after two treatment failures using rTMS as add-on treatment compared to standard pharmacotherapy. Cochrane's Q test showed no significant heterogeneity. No publication bias was detected. CONCLUSIONS: rTMS is significantly more effective than sham rTMS in TRD in response and remission outcomes and may be beneficial as an adjunctive treatment in patients with MDD after two treatment failures. This finding is consistent with previous meta-analyses; however, the effect size was smaller than in the formerly published literature.

Paclitaxel Protects against Isoproterenol-Induced Damage in Rat Myocardium: Its Heme-Oxygenase Mediated Role in Cardiovascular Research.

(1) Background: In cardiovascular applications, paclitaxel inhibits smooth muscle cell proliferation and migration and significantly reduces the occurrence of restenosis and target lesion revascularization. However, the cellular effects of paclitaxel in the myocardium are not well understood; (2) Methods: Wistar rats were divided into four groups: control (CTRL), isoproterenol (ISO) treated (1 mg/kg) and two groups treated with paclitaxel (PAC), which was administrated (10 mg/kg/day) for 5 days by gavage/per os alone or in combination (ISO + PAC) 3 weeks after ISO treatment. Ventricular tissue was harvested 24 h later for measurements of heme oxygenase (HO-1), reduced glutathione (GSH), oxidized glutathione (GSSG), superoxide dismutase (SOD), NF-κB, TNF-α and myeloperoxidase (MPO); (3) Results: HO-1 protein concentration, HO-1 activity, SOD protein concentration and total glutathione significantly decreased in response to ISO treatment. When PAC was administered in conjunction with ISO, HO-1, SOD concentration and total glutathione were not different from control levels. MPO activity, NF-κB concentration and TNF-α protein concentration were significantly increased in the ISO-only group, while the levels of these molecules were restored when PAC was co-administered; (4) Conclusions: Oral administration of PAC can maintain the expression of important antioxidants, anti-inflammatory molecules, HO-1, SOD and GSH, and suppress the production of TNF-α, MPO and NF-κB, which are involved in myocardial damage. The principal component of this cellular defense seems to be the expression of HO-1.

DNA methylation clock DNAmFitAge shows regular exercise is associated with slower aging and systemic adaptation.

DNAmPhenoAge, DNAmGrimAge, and the newly developed DNAmFitAge are DNA methylation (DNAm)-based biomarkers that reflect the individual aging process. Here, we examine the relationship between physical fitness and DNAm-based biomarkers in adults aged 33-88 with a wide range of physical fitness (including athletes with long-term training history). Higher levels of VO2max (ρ = 0.2, p = 6.4E - 4, r = 0.19, p = 1.2E - 3), Jumpmax (p = 0.11, p = 5.5E - 2, r = 0.13, p = 2.8E - 2), Gripmax (ρ = 0.17, p = 3.5E - 3, r = 0.16, p = 5.6E - 3), and HDL levels (ρ = 0.18, p = 1.95E - 3, r = 0.19, p = 1.1E - 3) are associated with better verbal short-term memory. In addition, verbal short-term memory is associated with decelerated aging assessed with the new DNAm biomarker FitAgeAcceleration (ρ: - 0.18, p = 0.0017). DNAmFitAge can distinguish high-fitness individuals from low/medium-fitness individuals better than existing DNAm biomarkers and estimates a younger biological age in the high-fit males and females (1.5 and 2.0 years younger, respectively). Our research shows that regular physical exercise contributes to observable physiological and methylation differences which are beneficial to the aging process. DNAmFitAge has now emerged as a new biological marker of quality of life.

[Recent approaches in suicide research. The psychology and neurobiology of the pre-suicidal state].

From the point of view of the prevention of suicidal behaviour, the recognition of acute suicidal risk is of particular importance, therefore one of the most important goals of recent suicidal research is the more precise detection of the psychological symptoms leading to a suicidal act. Classic risk factors can often be discovered in the background of suicidal thoughts, but they are not suitable for screening out those who will turn their thoughts into action. Since many people have suicidal thoughts, why, how and when suicidal thoughts are followed by a self-destructive act is a particularly important question. In order to answer this question, in my paper I review the symptom-focused models of the pre-suicidal state based on the recent suicidality literature, emphasizing the importance of "ideation to action" models. I summarize the psychological, interpersonal and neurobiological characteristics of the pre-suicidal state, highlighting the factors of the suicide capability. The new models of the pre-suicidal status represent a major step forward in the detection of the characteristics of the suicidal crisis and - in addition to the classic risk factors - in the more accurate assessment of the suicidal risk, in the more effective prediction of suicidal behaviour and thus in providing more effective treatment. Research on the characteristics leading to suicide can enrich our knowledge of the physical, neurobiological, and psychological processes underlying suicidal behaviour with important information. This is of great importance in terms of the screening and adequate treatment of our patients at risk of suicide.

Suicide in Hungary during the first year of the COVID-19 pandemic: Subgroup investigations.

BACKGROUND: COVID-19 may unfavourably affect the mental health of individuals in various ways. Accordingly, the concern has been raised that national suicide rates will increase in the wake of the outbreak of the pandemic. METHODS: In the current study, we tested this conjecture in three age groups (<25; 25-64; ≥65) of the Hungarian total population and the male and female populations. In addition, we assessed whether the pandemic had different effects on counts of suicides committed by violent or non-violent methods. Finally, by comparing the monthly suicide rates in 2020 and the corresponding monthly rates in 2019, we also investigated the "pulling together" hypothesis that postulates that a temporary decrease in suicides may occur after large-scale catastrophic events. RESULTS: With regard to the total population only the suicide counts of individuals aged 25-64 rose significantly (p < 0.05) during the COVID months of 2020. Similar patterns, but at lower levels of significance (0.05 < p < 0.1), were found in those members of the total population aged 65 or older and among males aged between 25 and 64. Furthermore, we found that the number of violent suicides increased significantly (p < 0.05) during the COVID months. Finally, our results have not confirmed the existence of a "pulling together" phenomenon in association with the COVID-19 pandemic in Hungary. LIMITATIONS: We used non-individual level data and were therefore unable to control suicide risk factors at the level of individuals. DISCUSSION: The number of suicides rose significantly in some subgroups of the Hungarian population during the COVID months of 2020.

[Suicide mortality in Hungary during the COVID-19 pandemic.] / Öngyilkossági halálozás Magyarországon a COVID­19-pandémia idején.

INTRODUCTION: While suicide rates did not change (or decreased) in the first pandemic year (i.e., 2020) in the majority of countries, in Hungary the number of completed suicides rose significantly. OBJECTIVE: In our study, we investigated whether the unfavourable trend reversal of the Hungarian suicide rate following the outbreak of COVID-19 pandemic persisted in the second pandemic year. METHOD: We used an interrupted time-series analysis with Prais-Winsten regression, controlling for time and seasonal effects as well as autoregressive effects, to estimate the effect of the pandemic on the suicide rates of the Hungarian male, female and total populations in 2020 and 2021. RESULTS: In the first pandemic year, we observed a significant increase in suicide rates in males and the total population. Although the case numbers for males and the total population in 2021 exceeded the case numbers of the pre-pandemic year, regression estimates suggest that the increase in rates did not differ significantly from the pre-pandemic years in males and it was only found to be significant at the 10% level in the total population. DISCUSSION AND CONCLUSION: Based on the examination of data from the first two pandemic years, we may conclude that by 2021 the adverse effect of the pandemic on suicidality reduced in the total population and disappeared in males. The question remains open whether this favourable development will continue. Orv Hetil. 2022; 163(48): 1895-1901.

High prevalence of suicide-related internet use among patients with depressive disorders - a cross-sectional study with psychiatric in-patients.

The association between Internet use and suicidal behavior is a subject of intense research. Internet use patterns of patients with depressive disorders were assessed to determine the prevalence and aim of browsing for suicide-related contents and its impact on help-seeking. Self-administered questionnaire among psychiatric in-patients treated for depression was used to assess suicidal behavior, characteristics of Internet use and help-seeking preferences. 113 psychiatric in-patients with depressive disorders participated in the study. One-third had a history of life-time suicide attempt and the majority had already encountered suicide-related contents while browsing the Internet. 27.4% reported intentional and specific search for suicidal contents. This suicide-related Internet user (SRIU) group was characterized by younger age, single status, more frequent suicidal ideations, and they more likely considered that they would attempt suicide in the future. Among patients with depressive disorders, a sub-group was identified with a potential higher suicide risk. The frequent use of the Internet and online help-seeking preference may provide an opportunity to prevent suicidal behavior in this high-risk sub-group. Further research is needed into the possibilities of using the Internet more effectively for suicide prevention.

Suicide risk management in clinical practice. Current challenges and future perspectives / Az öngyilkossági rizikó becslése a klinikai gyakorlatban. A jelen kihívásai és a jövo perspektívái

There is still little reliable information about the psychological processes underlying suicidal behaviour, and suicide risk assessment scales also have only limited predictive value. However, the recently described suicide-specific syndromes such as acute suicidal affective disorder (ASAD) and suicide crisis syndrome (SCS) open up new possibilities for a complex interpretation and prediction of suicidal behaviour. We briefly summarize modern theoretical approaches explaining the development of suicidal behaviour, the possibilities of predicting suicide risk, and contemporary methods of assessing pre-suicidal psychopathological symptoms, highlighting the suicide-specific syndromes and their screening tools. The results of the systematic review of the suicide-specific syndrome literature indicate that both the ASAD construct and the SCS may be helpful in predicting suicidal behaviour and they correlate with other similar questionnaires. Suicide-specific syndromes and the measurement tools are proven to be effective in theoretical research as well as in the field of clinical applicability in the prediction of suicidal behaviour, so their adaptation and application in Hungary may be recommended.

Repetitive transcranial magnetic stimulation may be a cost-effective alternative to antidepressant therapy after two treatment failures in patients with major depressive disorder.

BACKGROUND: The cost-effectiveness of treatment strategies for patients with Major Depressive Disorder (MDD) who have not responded to two adequate treatments with antidepressants (TRD) are still unclear. The aim of this analysis was to evaluate the cost-effectiveness of add-on repetitive Transcranial Magnetic Stimulation (rTMS) compared with standard treatment. METHODS: A Markov-model simulated clinical events over one year from the perspective of healthcare payer. Third- and fourth-line treatment pathways (augmentation, antidepressant switch or combination, and Electro-Convulsive Therapy (ECT)) were defined based on medical practice guidelines. Transition probabilities were derived from a recent meta-analysis and scientific publications. Resource utilization and cost estimates were based on the patient-level database of a large university hospital. RESULTS: Incremental Quality-Adjusted Life Years (QALYs) and costs were 0.053 and 785 €, respectively, corresponding to an Incremental Cost-Effectiveness Ratio (ICER) of 14,670 € per QALY. The difference in cost between standard treatment and rTMS is explained by the rTMS sessions used in acute (€660) and maintenance (€57/month) treatments, partly offset by lower hospital costs due to higher remission rates in the rTMS arm. Key parameters driving the ICER were incremental utility of remission, unit cost of rTMS treatment and remission rate. At a threshold of €22,243 add-on rTMS is a cost-effective alternative to pharmacotherapy. Evidence on long-term effectiveness is not yet available, so results are estimated for a one-year period. CONCLUSION: Not only does rTMS treatment have beneficial clinical effects compared with drug therapy in TRD, but it also appears to offer good value-for-money, especially in centres with larger numbers of patients where unit costs can be kept low.

[Text and behavior - analysis of farewell notes - pilot study].

Studying suicide notes, - last personal documents before a suicide act - as well as investigation of media and internet texts on self-destruction (including contents, "messages") can have a great significance. Individual and cultural valuations appear in the way farewell notes, media letters and other personal documents present self-destruction. These "messages", ideas about life, death and suicide are deeply embedded within the public context of culture too. In the present content analysis formal, syntactic and grammatical characteristic features, as well as speech patterns and verbal expressions of selected notes, samples have been investigated. Suicidal - fatal (n=49) and nonfatal group (n=31) of farewell letters were compared with the sample of a control group (n=33). Results have been discussed, interpreted and concluded. These appear to be useful and important not only in understanding of suicidal phenomenon and its psychodynamic background in clinical work or in suicide hotlines, but also in prevention, social-, and clinical intervention of self-destruction. The investigation of these new data may provide a much broader perspective in understanding suicidal process.

[Comments].

No abstract available.

Andrological Aspects of Exercise: Moderate Swimming Protects against Isoproterenol Induced Testis and Semen Abnormalities in Rats.

The development and progression of male infertility are closely linked to a sedentary lifestyle; however, its underlying mechanisms are not fully elucidated. Our aim was to assess the protective effects of moderate swimming exercise on the male reproductive system in isoproterenol-treated rats. Male Wistar rats were divided into five groups as follows: (1) non-interventional controls (CTRL), (2) isoproterenol-treated (ISO), (3) pre-treatment swimming training + ISO (PRE + ISO), (4) ISO + post-treatment swimming training (ISO+POST), (5) pre-treatment swimming training + ISO + post-treatment swimming training (PRE + ISO + POST) groups. Testicular oxidative stress was induced by ISO injection (1.0 mg/kg). Rats in the pre- or post-training groups were trained five days a week. At the end of the experimental period, serum testosterone levels, sperms' hyaluronan binding, and total glutathione (GSH) content, as well as myeloperoxidase activity (MPO), TNF alpha and IL6 concentrations in the testis and semen, were measured. Serum testosterone levels, sperms' hyaluronan binding, and GSH content were found to be significantly reduced, while MPO, TNF alpha and IL6 concentrations in the testis and semen were elevated after the ISO treatment compared to the CTRL group. Moderate-intensity swimming exercise effectively alleviated the negative effects of high oxidative stress. Our findings provide the first evidence that moderate-intensity swimming exercise confers sustained protection from isoproterenol-induced adverse effects on testicular inflammation.

[Memories and thoughts on the 100-year-old Pécs Psychiatric Clinic].

No abstract available.

Changes in suicide mortality of Hungary during the first year of the COVID-19 pandemic / A magyarországi öngyilkossági halálozás változásai a COVID-19-járvány elso évében.

Összefoglaló. Bevezetés: Az öngyilkosság fo rizikófaktorának a pszichiátriai zavarokat tekintjük. A COVID-19 többek között neuropszichiátriai kórképek kialakulásához is vezethet. Ezen túl a pandémia egyéb velejárói, mint például az izoláció vagy a munkahelyvesztés, a társadalom egészséges tagjaiban is stresszhez, végül pszichiátriai zavarokhoz vezethetnek. Célkituzés: Vizsgálatunk célja annak a teóriának a tesztelése volt, hogy a fenti tényezok miatt együtt járt-e a járvány a hazai suicid halálozás csökkeno trendjének irányváltásával. Módszer: Vizsgálatunkban a megszakított idosorok elemzésének módszerét használtuk, a becslésekhez kvázi-Poisson-regressziót alkalmazva, hogy összehasonlítsuk a 2010 és 2020 közötti idoszak havi bontású adataiból kirajzolódó trendek alapján a járvány idoszakában (2020. március-december) "elvárt" öngyilkossági esetszámokat a ténylegesen bekövetkezett esetek számával. Eredmények: A COVID-19-hónapok alatt a férfiak által elkövetett öngyilkosságok száma szignifikánsan, 18%-kal nott, ahhoz a trendhez képest, amely a COVID-19 hiányában állt volna elo. A teljes populációban szintén szignifikáns, 16%-os emelkedést lehetett megfigyelni, míg a nok által elkövetett öngyilkosságok száma nem tért el szignifikánsan a pre-COVID-19-idoszak trendje alapján elvárt értéktol. Megbeszélés és következtetés: A járvány kitörése utáni idoszakban a magyar férfiak szignifikánsan gyakrabban követtek el öngyilkosságot, míg a noknél az adatok nem tükröztek lényegi változást. A más országokban kivitelezett vizsgálatok eredményei érdekes módon inkább csökkenést vagy nem szignifikáns változást jeleztek, amikor a COVID-19-éra suicid számait az azt megelozo idoszakok számaival hasonlították össze. A hazai és a nemzetközi eredmények közti eltérések magyarázata egyelore még nem ismert, így a téma mindenképpen további vizsgálatokat igényel. Orv Hetil. 2021; 162(41): 1631-1636. INTRODUCTION: Psychiatric disorders are the main risk factors for suicide. COVID-19 may result in the appearance of neuropsychiatric syndromes. Moreover, other corollaries of the pandemic (e.g., isolation, job loss) may lead to increasing stress and, ultimately, psychiatric disorders even among the non-infected population. OBJECTIVE: We aimed to test the theory of whether the pandemic, due to the aforementioned factors, was associated with the reversal of the declining suicide rate trend in Hungary. METHOD: To compare the observed number of suicides during the COVID-19 months (March-December 2020) with the expected numbers, we used an interrupted time series model and, for the estimations, quasi-Poisson regression. Expected numbers were calculated based on trends derived from monthly data between 2010 and 2020. RESULTS: During the months of the pandemic, the number of suicides among males rose significantly by 18% compared to the hypothetical trend that would have occurred in the absence of COVID-19. A significant increase (16%) was also observed in the total population. By contrast, the number of female suicides did not differ significantly from the number expected based on the pre-COVID-19 trend. DISCUSSION AND CONCLUSION: After the outbreak of the epidemic, Hungarian males committed significantly more suicides, while no relevant changes were observed among females. Interestingly, studies from other countries found either no change or decrease when comparing suicide numbers from the COVID-19 period with the corresponding numbers from the pre-COVID-19 period. The explanation for this discrepancy is still lacking, so further investigations are needed. Orv Hetil. 2021; 162(41): 1631-1636.

Crisis Concept Re-loaded?-The Recently Described Suicide-Specific Syndromes May Help to Better Understand Suicidal Behavior and Assess Imminent Suicide Risk More Effectively.

Background: Despite of the decreasing suicide rates in many countries, suicide is still a major public health concern worldwide. Traditional suicide risk factors have limited clinical predictive value, as they provide little reliable information on the acute psychological processes leading to suicide. Aims: The aim of this analysis is to describe and compare the recently introduced two suicide-specific syndromes [Acute Suicidal Affective Disturbance (ASAD) and Suicidal Crisis Syndrome (SCS)] with the classic psychological features of pre-suicidal crisis and also to assess the clinical utility of the new suicide prediction scales in contrast to classical risk factors. Method: Conceptual analysis. Results: Suicide-specific syndromes are not novel in terms of symptomatology or dynamics of symptom onset, but in their use of well-defined diagnostic criteria. In addition to symptomatic classification, they also provide an opportunity to objectively measure the current pre-suicidal emotional and mental state by validated tools. Limitations: Future studies need to be completed to prove the reliability and predictive validity of suicide-specific diagnostic categories and the related suicide risk assessment tools. Conclusion: Clinical use of suicide-specific syndromes is suggested. This transdiagnostic approach not only enables a more accurate and objective assessment of imminent suicide risk, but also facilitates research in neuroscience, which represent a major step forward in managing and complex understanding of suicidal behavior.