Predictive value of psychological characteristics and suicide history on medical lethality of suicide attempts: A follow-up study of hospitalized patients.

BACKGROUND: This study examined the role of mental pain, communication difficulties, and suicide history in predicting the medical severity of follow-up suicide attempts. METHODS: The cohort included 153 consecutive psychiatric in-patients who participated in earlier studies 1-9 years previously. Fifty-three had a history of a medically serious suicide attempt (MSSA), 64 had a history of a medically non-serious suicide attempt (MNSSA), and 36 had no history of suicide. A MSSA was defined as a suicide attempt that warranted hospitalization for at least 24h and extensive medical treatment. Participants completed a battery of instruments measuring mental pain and communication difficulties. Findings were analyzed in relation to follow-up suicide attempts and their severity. RESULTS: Fifty-three patients (35.5%) had attempted suicide: 15 (9.9%) a MSSA (including 5 fatalities) and 38 (25%) a MNSSA. The medical severity of the index attempt and level of hopelessness at the index attempt were significantly correlated with medical severity of the follow-up attempt. In younger patients, high levels of depression and self-disclosure predicted the medical severity of the follow-up attempt. In patients with relatively low hopelessness, the medical severity of the attempt increased with the level of self-disclosure. LIMITATIONS: (i) Possibly incomplete patient information, as some of the patients who participated in the index studies could not be located. (ii) Relatively small group of patients with an index MSSA. CONCLUSIONS: Patients who have made a suicide attempt should be assessed for medical severity of the attempt, hopelessness, and communication difficulties, which are important factors in follow-up attempts.

Mental pain, communication difficulties, and medically serious suicide attempts: a case-control study.

Medical severe suicide attempts (MSSA) are epidemiologically very similar to individuals who complete suicide. Thus the investigation of individuals who have made MSSAs may add to our understanding of the risk factors for completed suicide. The aim of this study was to assess the role of mental pain and communication difficulties in MSSA. A total of 336 subjects were divided into 4 groups: 78 meeting criteria for MSSA compared with116 subjects who made a medically non-serious suicide attempt (MNSSA), 47 psychiatric controls with no history of suicidal behavior, and 95 healthy controls. Mental pain variants (e.g., hopelessness), facets of communication difficulties (e.g., self-disclosure), as well as socio-demographic and clinical characteristics were assessed. The MSSA had significantly higher communication difficulties than the other 3 groups. Moreover, the interaction between mental pain and communication difficulties explained some of the variance in suicide lethality, above and beyond the contribution of each component alone. This report underlines the importance of mental pain for suicide attempts in general while difficulties in communication abilities play a critical role in differentiating MSSA from MNSSA. The co-existence of unbearable mental pain with difficulties in communication significantly enhances the risk for more lethal forms of suicidal behavior.

Aggression-impulsivity, mental pain, and communication difficulties in medically serious and medically non-serious suicide attempters.

BACKGROUND: Unbearable mental pain, depression, and hopelessness have been associated with suicidal behavior in general, while difficulties with social communication and loneliness have been associated with highly lethal suicide attempts in particular. The literature also links aggression and impulsivity with suicidal behavior but raises questions about their influence on the lethality and outcome of the suicide attempt. OBJECTIVES: To evaluate the relative effects of aggression and impulsivity on the lethality of suicide attempts we hypothesized that impulsivity and aggression differentiate between suicide attempters and non-attempters and between medically serious and medically non-serious suicide attempters. METHOD: The study group included 196 participants divided into four groups: 43 medically serious suicide attempters; 49 medically non-serious suicide attempters, 47 psychiatric patients who had never attempted suicide; and 57 healthy control subjects. Data on sociodemographic parameters, clinical history, and details of the suicide attempts were collected. Participants completed a battery of instruments for assessment of aggression-impulsivity, mental pain, and communication difficulties. RESULTS: The medically serious and medically non-serious suicide attempters scored significantly higher than both control groups on mental pain, depression, and hopelessness (p<.001 for all) and on anger-in, anger-out, violence, and impulsivity (p<.05 for all), with no significant difference between the two suicide attempter groups. Medically serious suicide attempters had significantly lower self-disclosure (p<.05) and more schizoid tendencies (p<.001) than the other three groups and significantly more feelings of loneliness than the medically non-serious suicide attempters and nonsuicidal psychiatric patients (p<.05). Analysis of aggression-impulsivity, mental pain, and communication variables with suicide lethality yielded significant correlations for self-disclosure, schizoid tendency, and loneliness. The interaction between mental pain and schizoid traits explained some of the variance in suicide lethality, over and above the contribution of each component alone. CONCLUSIONS: Aggression-impulsivity and mental pain are risk factors for suicide attempts. However, only difficulties in communication differentiate medically serious from medically non-serious suicide attempters. The combination of unbearable mental pain and difficulties in communication has a magnifying effect on the risk of lethal suicidal behavior.

A double-blind, randomized study of minocycline for the treatment of negative and cognitive symptoms in early-phase schizophrenia.

BACKGROUND: Current antipsychotics have only a limited effect on 2 core aspects of schizophrenia: negative symptoms and cognitive deficits. Minocycline is a second-generation tetracycline that has a beneficial effect in various neurologic disorders. Recent findings in animal models and human case reports suggest its potential for the treatment of schizophrenia. These findings may be linked to the effect of minocycline on the glutamatergic system, through inhibition of nitric oxide synthase and blocking of nitric oxide-induced neurotoxicity. Other proposed mechanisms of action include effects of minocycline on the dopaminergic system and its inhibition of microglial activation. OBJECTIVE: To examine the efficacy of minocycline as an add-on treatment for alleviating negative and cognitive symptoms in early-phase schizophrenia. METHOD: A longitudinal double-blind, randomized, placebo-controlled design was used, and patients were followed for 6 months from August 2003 to March 2007. Seventy early-phase schizophrenia patients (according to DSM-IV) were recruited and 54 were randomly allocated in a 2:1 ratio to minocycline 200 mg/d. All patients had been initiated on treatment with an atypical antipsychotic < or = 14 days prior to study entry (risperidone, olanzapine, quetiapine, or clozapine; 200-600 mg/d chlorpromazine-equivalent doses). Clinical, cognitive, and functional assessments were conducted, with the Scale for the Assessment of Negative Symptoms (SANS) as the primary outcome measure. RESULTS: Minocycline was well tolerated, with few adverse events. It showed a beneficial effect on negative symptoms and general outcome (evident in SANS, Clinical Global Impressions scale). A similar pattern was found for cognitive functioning, mainly in executive functions (working memory, cognitive shifting, and cognitive planning). CONCLUSIONS: Minocycline treatment was associated with improvement in negative symptoms and executive functioning, both related to frontal-lobe activity. Overall, the findings support the beneficial effect of minocycline add-on therapy in early-phase schizophrenia. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00733057.

"Whose groups are these anyway?" on staff and patients' needs and their impact on the milieu.

The psychiatric ward is a complex organization. It contains two main groups: the patients and the staff. The different needs of each group influence the encounters between patients, the consumers, and staff, the suppliers. We shall discuss those needs and analyze the ways they interfere with or complement the therapeutic group work. For example: staff members need specific therapeutic group work for their professional development, and the patients need the group in order to maintain some form of interpersonal contact and to keep themselves active. The staff holds therapeutic groups in order to monitor the activity on the ward, while the patients seek a space where they can express their concerns about their treatment. Some vignettes will be presented which demonstrate these different needs, of staff and patients, and the way they were explored in the staff's group supervision meetings.

Mental pain and its communication in medically serious suicide attempts: an "impossible situation".

BACKGROUND: The study of near-fatal suicide attempters may provide insight into the minds of suicidal subjects. Our aim is to test the hypothesis that mental pain is a general risk factor for suicidal behavior and communication difficulties are a particular risk factor for medically serious suicidal behavior. METHODS: Thirty five subjects who made medically serious suicide attempts were compared with 67 medically not serious suicide attempters and 71 healthy controls. All were interviewed with the SCID-I and completed questionnaires covering mental pain, communication difficulties and seriousness of suicide attempt. RESULT: Variables from the mental pain domain (e.g. depression) predicted the presence of suicidal behavior, and variables from the communication difficulties domain (e.g., self-disclosure) predicted the lethality and seriousness of the suicide attempts. LIMITATIONS: Relatively small number of patients with medically serious suicide attempt and the relatively large number of questionnaires which may to some extent have diminished informant reliability. CONCLUSIONS: Problems with sharing of feelings with others are an important risk factor for near-lethal suicide, over and above the contribution of psychiatric illness and mental pain, including depression and hopelessness.

Ethical dilemmas in psychotherapy: comparison between patients, therapists and laypersons.

BACKGROUND: The attitudes of patients towards ethical dilemmas in psychotherapy have been reported in only a few studies. AIMS OF THE STUDY: We investigated whether the attitudes of patients undergoing psychotherapy to confidentiality and boundaries are different from those of therapists and laypersons. METHODS: Clinical vignettes describing ethical dilemmas of confidentiality and boundaries were presented to 103 patients undergoing psychotherapy (patient group), 93 psychotherapists of different professional backgrounds (professional group), and 55 staff and students from the fields of law and the humanities (lay group). Patients were asked how they think therapists should act in the situations presented and therapists were asked how they should behave in such situations. RESULTS: In general, the patient group showed a greater tendency to view their therapists as breaching confidentiality than the professional and lay groups. Regarding boundaries, the majority of psychotherapists were against initiating any sexual relationship with current patients, former patients, students or supervisees, whereas both patients and laypersons showed a less stringent attitude; these differences were statistically significant. The vast majority of therapists (96.7%) disapproved of accepting money in advance compared to only 31.1% in the patients group and 54.4% of the lay group. Analysis of the patients group by gender did not reveal any significant relationships. CONCLUSIONS: (1) Patients have different ethical codes from therapists and laypersons regarding the issues of confidentiality. (2) Patients and lay persons are less strict than therapists regarding issues of boundaries.

Are psychotherapists consistent in their ethical attitude to patient confidentiality?

BACKGROUND: The issue of confidentiality often causes an ethical dilemma for the psychotherapist. AIMS OF THE STUDY: We investigated if therapists are consistent in their attitude to confidentiality or judge each case on its own merit. METHODS: A questionnaire consisting of a series of clinical vignettes representing different ethical dilemmas in confidentiality in psychotherapy was completed by 93 therapists of different professional backgrounds and by a control group of 55 students from the fields of law and the humanities. RESULTS: Subjects in both groups were inconsistent in their attitude to confidentiality in two-thirds of cases, and most of the participants based their decisions on the particular history and circumstances of each case. CONCLUSION: The rules guiding psychotherapists for the disclosure of confidential information are unclear. These findings failed to pinpoint a common denominator to explain the manner in which professionals handle information that may demand a break of confidentiality.

Effect of L-tryptophan on memory in patients with schizophrenia.

SUMMARY: ABSTRACT It has been well established that patients with schizophrenia have impaired cognitive abilities on neuropsychological tasks related to memory. Previous studies also suggest a central role for serotonin in memory. This double-blind crossover study aimed to explore the effect of l-tryptophan, a serotonin precursor, on a variety of memory tasks in schizophrenic patients. Antipsychotic-treated schizophrenic patients in remission (N = 21) were randomly treated with l-tryptophan or placebo and then evaluated at three consecutive points on clinical measures (including Positive and Negative Syndrome Scale for Schizophrenia, Clinical Global Impression, and Extrapyramidal Symptoms Rating Scale) and by neuropsychological tests (including Digit-Span, Paired Association, Rey-Osterich Complex Figure Test, Digit Symbol, Number Facility Test, and the Rivermead Behavioral Memory Tests. Compared with placebo, l-tryptophan had a beneficial effect on memory functions but not on the patients' psychotic state or on the side effects of medications. These preliminary results suggest the possibility of using serotonin precursor to enhance memory function in schizophrenia.

Everyday memory and laboratory memory tests: general function predictors in schizophrenia and remitted depression.

This study was designed to compare neuropsychological memory measures ("laboratory memory tests") and an everyday memory measure in patients with schizophrenia, patients with major depression, and normal controls. Patients with schizophrenia ( N= 68) treated with typical (N = 33) or atypical ( N= 35) neuroleptics, patients with major depression (N = 30), and a control group (N = 36) were evaluated with clinical measures (Positive and Negative Syndrome Scale and Hamilton Depression Rating Scale), laboratory memory tests (Digit-Span, Paired-Associates, Rey Complex Figure Test, and Digit-Symbol), everyday memory test (RMBT), and the Global Assessment of Functioning (GAF). The schizophrenia group had a significantly lower level of performance in everyday memory and general function but not in laboratory memory tests. Verbal and everyday memory measures were correlated with general function. The diagnosis rather than current symptoms (in remission) contributed to test variance and was correlated with performance on everyday memory and general function tests. Everyday memory and verbal memory were good predictors of general function in schizophrenic and depressive patients in the remitted phase. However, the advantages of these tests over laboratory memory tests need to be further investigated in larger and more representative samples.

Hamilton Depression Scale in dementia.

INTRODUCTION: Wide variations in frequency of depression in primary degenerative dementia (PDD) and in vascular dementia (VD) have been reported. This may perhaps be due to inadequacy of common diagnostic tools in detecting depression in the face of cognitive decline. We evaluated here the Hamilton Depression Rating Scale (HDRS) in demented patients with PDD and VD. METHODS: We examined 50 consecutive patients with PDD and 50 consecutive patients with VD. All patients underwent neurological examination and their depression was evaluated using DSM-III-R criteria and the HDRS. The data obtained were analysed for distribution of depression and pattern of responses obtained in the HDRS. Sensitivity, specificity and Youden's J-indices for different cut-off scores of the HDRS in its ability to detect depression in this population were calculated. RESULTS: Dementia was associated with depression in 38% of the patients (DSM-III-R criteria). HDRS scores were higher in depressed patients (z= -5.7, P < 0.0001) with an HDRS cut-off score of 10 being indicative of depression in demented patients. Symptoms related to 'affective' components of the HDRS (such as depressive mood and anxiety) were strongly associated with the diagnosis of depression (Mann-Whitney tests, P < 0.0001). CONCLUSION: Depression is frequent in demented patients. The HDRS has good criterion validity in the evaluation of depression in demented patients. (Int J Psych Clin Pract 2002; 6: 91-94).