Interplay of combat deployment harassment, testosterone concentrations and post-deployment suicide risk in male veterans.

OBJECTIVE: Many combat veterans exhibit suicidal ideation and behaviour, but the relationships among experiences occurring during combat deployment and suicidality are still not fully understood. In this study, we tested the hypothesis that harassment during a combat deployment is associated with post-deployment suicidality and testosterone function. METHODS: Male combat veterans who made post-deployment suicide attempts and demographically matched veterans without a history of suicide attempts were enrolled in the study. Demographic and clinical parameters of study participants were assessed and recorded. Study participants were interviewed by a trained clinician using the Mini-International Neuropsychiatric Interview (MINI), the Deployment Risk and Resilience Inventory (DRRI) ­ Relationships within unit scale, the Scale for Suicidal Ideation (SSI), and the Brown­Goodwin Aggression Scale. Free testosterone levels were assessed in morning blood samples. RESULTS: DRRI harassment scores were higher and free testosterone levels were lower among suicide attempters in comparison with non-attempters. In the whole sample, DRRI harassment scores positively correlated with SSI scores and negatively correlated with free testosterone levels. Free testosterone levels negatively correlated with SSI scores. Aggression scale scores positively correlated with DRRI harassment scores among non-attempters but not among attempters. CONCLUSION: Our observations that harassment scores are associated with suicidality and testosterone levels, and suicidality is associated with testosterone levels may indicate that there is a link between deployment harassment, testosterone function and suicidality.

The uncounted casualties of war: suicide in combat veterans.

Military conflicts are ubiquitous. There are a lot of combat veterans around the world. Suicidality in combat veterans is a large and important issue. In this article, the author discusses some aspects of this issue. The combat environment is characterized by violence, physical strains, separation from loved ones and other hardships. Combat deployment may lead to multiple emotional, cognitive, psychosomatic symptoms, suicidal ideation and behavior. Pre-deployment, deployment and post-deployment adversities may increase suicide risk in combat veterans. The act of killing in combat is a stressor which may raise suicide risk. Combat-related injuries are associated with increased suicide risk. Post-deployment difficulties of reintegrating into civilian life may lead to depression and suicidality. Studies suggest that suicidal behavior in combat veterans may have a neurobiological basis. Prevention of suicide among combat veterans should include pre-deployment screening to exclude individuals with psychiatric disorders; psychological support and prevention of harassment and/or abuse during deployment; psychosocial support after deployment; diagnosing and treating psychiatric and medical disorders including neurological disorders; frequent suicide screening; education of mental and non-mental health clinicians, war veterans, their families and friends regarding signs/symptoms of suicidality; and restriction of access to lethal means. We need to study the specific psychobiology of combat veterans to understand how to develop effective suicide prevention interventions for this population.

Suicide in individuals with no psychiatric disorders-what makes you vulnerable?

Globally, hundreds of thousands of people die by suicide every year. Suicides are usually associated with psychiatric illness. However, considerable evidence suggests that a significant number of individuals who die by suicide do not have diagnosable psychiatric disorders. The goal of this article is to attract attention to an overlooked issue of suicide in persons with no psychiatric disorders and to discuss some aspects of this issue. Research on identification and prevention of suicidal behavior in people with no psychiatric disorders is very limited. The available data indicates that suicides in individuals without psychiatric disorders are related to life stressors, lack of social support, and certain personality traits such as impulsivity. Suicide risk may be increased in military veterans with no psychiatric disorders. Many physical disorders, especially conditions associated with pain increase suicide risk in individuals with no diagnosable psychiatric disorders. Developmental, genetic, and physical factors may play a role in the psychobiology of suicide in people with no psychiatric conditions. Promoting resilience may reduce suicide risk in the general population. Clinicians who work with medical or surgical patients need to have sufficient training in suicide prevention. Possibly, shifting some suicide prevention resources from individuals who are regarded as high-risk suicide patients to the general population may reduce suicide rates. Public education and better awareness about suicide may reduce suicide deaths among people with no psychiatric disorders.

Antisuicidal effect of lithum in bipolar disorder: is there an age-specific effect?

OBJECTIVE: Our group reported previously a comparable overall antisuicidal effect of lithium and valproate in bipolar patients. We investigated factors associated with higher antisuicidal efficacy of lithium in older individuals. METHODS: The age-related antisuicidal effect of lithium and valproate was compared in ninety-four (n = 94) high-risk bipolar suicide attempters who participated in a 2.5-year randomized, double-blind trial. RESULTS: Age significantly moderated the effect of lithium vs. valproate on the risk of suicide event during the study (z = -1.98, p = 0.049). We found that those who were 42 years or older (above the 75th percentile), and on lithium had significantly lower risk of suicidal behavior than older patients on valproate (>42y) or younger (<42 y) patients on either medication (interaction HR = 0.09, 95%CI: 0.01-0.89, z = -2.07, p = 0.039). This difference in risk differences was not explained away by age-related differences in the proportion of participants with bipolar II disorder (Fisher's test p = 0.020) or higher lethality of past suicide attempts in younger participants (Wilcoxon test p = 0.024); neither was there any correlation with age in the longitudinally measured blood lithium levels (t = 1.04, df = 36, p = 0.307) or valproate levels (t = -0.50, df = 41, p = 0.621). LIMITATIONS: Besides the fact that this is a secondary analysis, a limitation is that the study is not powered to detect suicide deaths or suicide attempts. CONCLUSION: Bipolar patients randomized to lithium and older than 42 years had less suicidal behavior compared to same aged patients on valproate or younger patients (<42 y) on either medication. This effect was independent of clinical and sociodemographic characteristics.

Testosterone and Suicidal Behavior in Bipolar Disorder.

Bipolar disorder is associated with suicidal behavior. The risk of suicide for individuals with bipolar disorder is up to 20-30 times larger than that of the general population. Considerable evidence suggests that testosterone may play a role in the pathophysiology of suicidal behavior in both men and women with bipolar disorder and other psychiatric conditions. Testosterone has complex effects on psychological traits. It affects mood and behavior, including interactions with other people. Testosterone regulates pro-active and re-active aspects of aggression. Probably, both high and low levels of testosterone may contribute to the neurobiology of suicide in various patient populations. The effects of endogenous and exogenous testosterone on suicidality in patients with bipolar disorder need further investigation. The aim of this commentary article is to provide a commentary on the author's work on the topic, summarize the literature on testosterone, bipolar disorder, and suicide, and encourage future research on this poorly studied topic.

Clinical features of individuals with schizotypal personality disorder with and without suicidal ideation.

This study compared demographic and clinical features in a sample of 384 participants: healthy controls (HC; n = 166) and individuals with schizotypal personality disorder (SPD) with (n = 50) and without (n = 168) suicidal ideation (SI) to examine specific risk factors for suicidality in SPD. Compared to the non-SI group, the SI group showed significantly greater severity of depression, aggression, impulsivity, affective lability, schizotypal features, poorer social adjustment, and had fewer social contacts. Individuals in the SI group were also more likely to have a history of a suicide attempt and comorbid borderline personality disorder in comparison to the non-SI group. Logistic regression analysis indicated that severity of depression and the number of social contacts drove the difference between the SI and non-SI groups. Compared with both SPD subgroups, the HC group was significantly less depressed, aggressive, impulsive, affectively labile, had fewer schizotypal features, was better socially adjusted, and had more social contacts. This study indicates that overall, the SI group is a more severely impaired group of individuals with SPD compared to the non-SI group. Better educating medical professionals about the diagnosis and management of SPD and its associations with suicidality is warranted.

The Role of Inflammation in the Pathophysiology of Depression and Suicidal Behavior: Implications for Treatment.

Depression and suicidal behavior are 2 complex psychiatric conditions of significant public health concerns due to their debilitating nature. The need to enhance contemporary treatments and preventative approaches for these illnesses not only calls for distillation of current views on their pathogenesis but also provides an impetus for further elucidation of their novel etiological determinants. In this regard, inflammation has recently been recognized as a potentially important contributor to the development of depression and suicidal behavior. This review highlights key evidence that supports the presence of dysregulated neurometabolic and immunologic signaling and abnormal interaction with microbial species as putative etiological hallmarks of inflammation in depression as well as their contribution to the development of suicidal behavior. Furthermore, therapeutic insights addressing candidate mechanisms of pathological inflammation in these disorders are proposed.

Suicide: An Overview for Clinicians.

Most suicides have a diagnosable psychiatric disorder, most frequently, a mood disorder. Psychosocial issues and neurobiological abnormalities such as dysregulation in stress response systems contribute to suicidal behavior. All psychiatric patients need to be screened for the presence of suicidal ideation. Clinicians are expected to gather information about patient's clinical features and to formulate decisions about patient's dangerousness to self and the treatment plan. As psychiatric disorders are a major risk factor for suicide their pharmacologic and psychological treatment is of utmost importance to prevent suicide. Restriction of access to lethal means is important for suicide prevention.

Overall goal of Cognitive-Behavioral Therapy in Major Psychiatric Disorders and Suicidality: A Narrative Review.

Cognitive-behavioral therapy (CBT) is a form of psychological treatment that is based on the underlying assumption that mental disorders and psychological distress are maintained by cognitive factors, that is, that general beliefs about the world, the self, and the future contribute to the maintenance of emotional distress and behavioral problems. The overall goal of CBT is to replace dysfunctional constructs with more flexible and adaptive cognitions. The most relevant cognitive-behavioral techniques in clinical practice are: i. Cognitive Restructuring (also known as the ABCDE method) is indicated to support patients dealing with negative beliefs or thoughts. The different steps in the cognitive restructuring process are summarized by the letters in the ABCDE acronym that describe the different stages of this coaching model: Activating event or situation associated with the negative thoughts, Beliefs and belief structures held by the individual that explain how they perceive the world which can facilitate negative thoughts, Consequences or feelings related to the activating event, Disputation of beliefs to allow individuals to challenge their belief system, and Effective new approach or effort to deal with the problem by facilitating individuals to replace unhelpful beliefs with more helpful ones. ii. Problem-Solving (also known as SOLVE) to raise awareness for specific triggers, and evaluate and choose more effective options. Each letter of the SOLVE acronym identifies different steps of the problem-solving process: Select a problem, generate Options, rate the Likely outcome of each option, choose the Very best option, and Evaluate how well each option worked. For example, a suicide attempt is reconceptualized as a failure in problem-solving. This treatment approach attempts to provide patients with a better sense of control over future emerging problems. iii. Re-attribution is a technique that enables patients to replace negative self-statements (eg, "it is all my fault") with different statements where responsibility is attributed more appropriately. Furthermore, decatastrophizing may help subjects, especially adolescents decide whether they may be overestimating the catastrophic nature of the precipitating event, and by allowing them to scale the event severity they learn to evaluate situations along a continuum rather than seeing them in black and white. iv. Affect Regulation techniques are often used with suicidal adolescents to teach them how to recognize stimuli that provoke negative emotions and how to mitigate the resulting emotional arousal through self-talk and relaxation.

Identifying and Managing Suicidality in Children and Adolescents with Chronic Pain: Evidence-Based Treatment Strategies.

Children and adolescents with chronic pain are at an increased risk of suicidality. This narrative review article aims to inform clinical practice in the assessment and management of suicidality in youth with chronic pain. The article begins with a survey of the background and prevalence of youth with chronic pain. A review of the current evidence behind the increased risk of suicidality in youth with chronic pain follows. Contextualization of this data with general tenets of child and adolescent suicide risk and risk assessment is provided. Suicidology theory including the interpersonal theory of suicide is overviewed to help clinicians to conceptualize the reviewed data. Guiding parameters for the suicide risk assessment and management planning is presented. Concluding recommendations are made to guide clinical practice in the assessment and management of suicidality in youth with chronic pain.