Identifying long-term and imminent suicide predictors in a general population and a clinical sample with machine learning.

BACKGROUND: Machine learning (ML) is increasingly used to predict suicide deaths but their value for suicide prevention has not been established. Our first objective was to identify risk and protective factors in a general population. Our second objective was to identify factors indicating imminent suicide risk. METHODS: We used survival and ML models to identify lifetime predictors using the Cohort of Norway (n=173,275) and hospital diagnoses in a Saskatoon clinical sample (n=12,614). The mean follow-up times were 17 years and 3 years for the Cohort of Norway and Saskatoon respectively. People in the clinical sample had a longitudinal record of hospital visits grouped in six-month intervals. We developed models in a training set and these models predicted survival probabilities in held-out test data. RESULTS: In the general population, we found that a higher proportion of low-income residents in a county, mood symptoms, and daily smoking increased the risk of dying from suicide in both genders. In the clinical sample, the only predictors identified were male gender and older age. CONCLUSION: Suicide prevention probably requires individual actions with governmental incentives. The prediction of imminent suicide remains highly challenging, but machine learning can identify early prevention targets.

Instability of Suicidal Ideation in Patients Hospitalized for Depression: An Exploratory Study Using Smartphone Ecological Momentary Assessment.

This study used ecological momentary assessment (EMA) to explore the correlates of suicidal ideation (SI) instability in patients hospitalized for depression and SI. Thirty-nine adult inpatients were given smartphones with visual analogue scales to rate current depressed mood, anger/irritability, feeling socially connected, and SI three times a day throughout hospitalization. Affective Lability Scales (ALS) were also completed at baseline. SI instability was correlated with SI intensity, depressed mood instability, and social connection instability. Social connection instability was not associated with SI instability after controlling for depressed mood instability. ALS scores were not associated with EMA-derived SI instability. Participants with multiple past suicide attempts experienced greater SI instability. More research examining the clinical significance of SI instability is warranted.

Exploring the Impact of Religion and Spirituality on Mental Health and Coping in a Group of Canadian Psychiatric Outpatients.

Research has shown that religious/spiritual (R/S) beliefs can impact mental health. In addition, individual attachment impacts R/S views and mental health. Still, clinical studies are lacking. This study explores the presence of R/S beliefs and attachment insecurity in psychiatric outpatients and the implication for mental health. Ninety psychiatric outpatients reported their R/S beliefs and were categorized into two groups: religious/spiritual (+R/S) or nonreligious/spiritual (-R/S). The groups were compared on attachment, psychiatric symptoms, religious coping, and life satisfaction. Multivariate linear regression was also performed. The +R/S group had significantly higher religious coping and lower attachment insecurity, depression severity, and social anxiety. Attachment insecurity was associated with negative religious coping. Higher attachment avoidance was associated with lower life satisfaction and higher social anxiety. Many patients in psychiatric care hold R/S views and use religious coping. Their R/S beliefs and attachment characteristics might influence each other and impact their mental illness.

Examining the role of borderline personality traits in the relationship between major depression and nonsuicidal self-injury.

BACKGROUND: Depression and borderline personality disorder (BPD) are highly comorbid conditions that are both associated with nonsuicidal self-injury (NSSI). AIMS: The purpose of this study was to determine if depression is associated with NSSI after controlling for BPD traits. A distinction was made between NSSI for emotional regulation and NSSI for interpersonal motives. METHOD: Logistic regression analyses were conducted on cross-sectional data from a general population sample of 7370 adults who completed the 2007 Adult Psychiatric Morbidity Survey. Depressive symptoms were assessed with the revised Clinical Interview Schedule. NSSI and motives for NSSI were also assessed during clinical interviews. BPD traits were assessed with the participant-completed Structured Clinical Interview for DSM-IV Axis II Personality Disorders. RESULTS: Participants in a major depressive episode were more likely to have engaged in emotional-regulation NSSI and interpersonal NSSI than participants without depression. After controlling for BPD traits depression remained associated with emotional-regulation NSSI, whereas the association with interpersonal NSSI became nonsignificant. There were statistically significant relationships between depression and both types of NSSI occurring indirectly through BPD traits. CONCLUSIONS: BPD traits account for a significant portion of the cross-sectional relationship between depression and past NSSI that varies in size depending on the motive for NSSI. People with depression are more likely to have engaged in NSSI for emotional regulation even in the absence of prominent BPD traits. In contrast, BPD traits may be more prominent in people with depression who have engaged in interpersonal NSSI.

The effect of socio-demographic factors on mental health and addiction high-cost use: a retrospective, population-based study in Saskatchewan.

OBJECTIVE: A small proportion of the population accounts for the majority of healthcare costs. Mental health and addiction (MHA) patients are consistently high-cost. We aimed to delineate factors amenable to public health action that may reduce high-cost use among a cohort of MHA clients in Saskatoon, Saskatchewan. METHODS: We conducted a population-based retrospective cohort study. Administrative health data from fiscal years (FY) 2009-2015, linked at the individual level, were analyzed (n = 129,932). The outcome of interest was ≥ 90th percentile of costs for each year under study ('persistent high-cost use'). Descriptive analyses were followed by logistic regression modelling; the latter excluded long-term care residents. RESULTS: The average healthcare cost among study cohort members in FY 2009 was ~ $2300; for high-cost users it was ~ $19,000. Individuals with unstable housing and hospitalization(s) had increased risk of persistent high-cost use; both of these effects were more pronounced as comorbidities increased. Patients with schizophrenia, particularly those under 50 years old, had increased probability of persistent high-cost use. The probability of persistent high-cost use decreased with good connection to a primary care provider; this effect was more pronounced as the number of mental health conditions increased. CONCLUSION: Despite constituting only 5% of the study cohort, persistent high-cost MHA clients (n = 6455) accounted for ~ 35% of total costs. Efforts to reduce high-cost use should focus on reduction of multimorbidity, connection to a primary care provider (particularly for those with more than one MHA), young patients with schizophrenia, and adequately addressing housing stability.

Neuroticism and suicide in a general population cohort: results from the UK Biobank Project.

BACKGROUND: Neuroticism has often been linked to suicidal thoughts and behaviour. AIMS: To examine whether neuroticism is associated with suicide deaths after adjusting for known risks. METHOD: UK Biobank participants (n = 389 365) were assessed for neuroticism as well as social, demographic and health-related variables at study entry and followed for up to 10 years. Suicide risk was modelled using Cox regression stratified by gender. RESULTS: Neuroticism increased the risk of suicide in both men (hazard ratio (HR) = 1.15, 95% CI 1.09-1.22) and women (HR = 1.16, 95% CI 1.06-1.27). In a subsample who were assessed for mood disorders, neuroticism remained a significant predictor for women (HR 1.25, 95% CI 1.03-1.51) but not for men. CONCLUSIONS: Screening and therapeutic interventions for neuroticism may be important for early suicide prevention. DECLARATION OF INTEREST: None.

Suicidality in People With Obsessive-Compulsive Symptoms or Personality Traits.

Objective: Obsessive-Compulsive Disorder (OCD) and Obsessive-Compulsive Personality Disorder (OCPD) have been reported to be associated with mood instability (MI), depression and suicide-related outcomes. We examined whether obsessive-compulsive symptoms and personality traits as well as obsessional thoughts of death, are associated with suicidal thoughts, non-suicidal self-injury and attempted suicide. Methods: We used data from 7,839 people from the 2000 British Adult Psychiatric Morbidity Survey that elicited symptoms of OCD with a computerized version of the Clinical Interview Schedule-Revised (CIS-R) and traits of OCPD with a self-completed version of the SCID-II. We created a series of logistic regression models, first entering only OCD symptoms and OCPD traits in separate models, to which depression and mood instability (MI) were added. We also examined the relation of obsessional thoughts about death with self-harm in a network analysis model that included the main symptoms of mood instability and depression. Results: OCD symptoms were associated with suicidal thoughts (OR: 1.23, 95% CI: 1.14-1.32), and suicide attempts (OR: 1.13, 95% CI: 1.04-1.24) in the fully-adjusted model. OCPD traits were associated with suicidal thoughts (OR: 1.14, 95% CI: 1.10-1.19), non-suicidal self-injury (OR: 1.14 95% CI: 1.03-1.26), and suicide attempts (OR: 1.09; 1.01-1.17). Depression and MI were both associated with all three suicide-related outcomes. In the network analysis, MI was the most prominent correlate of suicide-related outcomes, being associated with suicidal ideas (partial r = 0.15) and non-suicidal self-injury (partial r = 0.07). Limitation: This was a cross-sectional study that used a single-item measure for mood instability. Conclusions: Obsessive-compulsive symptoms and personality traits are related to suicide-related outcomes independently of depressive symptoms and mood instability. This relationship is not accounted for by obsessional thoughts of death alone.

Moods in Clinical Depression Are More Unstable than Severe Normal Sadness.

OBJECTIVE: Current descriptions in psychiatry and psychology suggest that depressed mood in clinical depression is similar to mild sadness experienced in everyday life, but more intense and persistent. We evaluated this concept using measures of average mood and mood instability (MI). METHOD: We prospectively measured low and high moods using separate visual analog scales twice a day for seven consecutive days in 137 participants from four published studies. Participants were divided into a non-depressed group with a Beck Depression Inventory score of ≤10 (n = 59) and a depressed group with a Beck Depression Inventory score of ≥18 (n = 78). MI was determined by the mean square successive difference statistic. RESULTS: Mean low and high moods were not correlated in the non-depressed group but were strongly positively correlated in the depressed group. This difference between correlations was significant. Low MI and high MI were weakly positively correlated in the non-depressed group and strongly positively correlated in the depressed group. This difference in correlations was also significant. CONCLUSION: The results show that low and high moods, and low and high MI, are highly correlated in people with depression compared with those who are not depressed. Current psychiatric practice does not assess or treat MI or brief high mood episodes in patients with depression. New models of mood that also focus on MI will need to be developed to address the pattern of mood disturbance in people with depression.

Disordered lives: Life circumstances and clinical characteristics of very frequent users of emergency departments for primary mental health complaints.

This study explored the life circumstances and clinical characteristics of very frequent users of emergency departments (EDs) presenting with a primary mental health complaint. Patients with 10 or more EDs visits in 2012 with a primary psychiatric diagnosis in a Canadian regional health authority were identified from electronic administrative files. The hospital charts for these patients were thoroughly reviewed for a three-year period, from 2011 to 2013. A retrospective thematic analysis was undertaken. Very frequent users of EDs were generally young to early middle aged, unemployed, living in transient accommodations, having substance abuse diagnoses, and self-referred to EDs for a variety of psychiatric and health symptoms and/or unmet needs. Four themes were identified: 1) substance abuse and associated health and social problems; 2) common mental disorders, which may include suicidality; 3) social and personal stressors with additional common mental disorders and somatic complaints; 4) cognitive impairment with concurrent psychiatric disorders. Traditional mental health services are ineffective in dealing with patients with complex psychiatric and social problems/needs. Efforts should focus on early detection, intervention, reducing mental and behavior problems, and developing appropriate case management and treatment options. Personalized care models are needed to meet their diverse needs.

The influence of a learning to forgive programme on negative affect among mentally disordered offenders.

BACKGROUND: Clinical trials and meta-analyses provide some evidence for effectiveness of forgiveness therapy delivered individually or in groups. To date, however, forgiveness therapy has not been evaluated with mentally disordered offenders. Given the high prevalence of experienced and perpetrated trauma among such people, this population may particularly benefit from such an intervention. AIM: The aim of this study is to test the feasibility and impact of a 'learn to forgive' group programme among mentally disordered offenders on a specialist secure hospital setting. METHODS: We conducted a non-randomised trial with 36 offenders with mental disorders and 29 comparison patients. The intervention group engaged in a six-week manual-based 'learn to forgive' treatment programme, while the comparison group watched a 90-minute video on forgiveness. Both groups completed measures of anger, depression, stress, forgiveness and satisfaction with life at baseline and then 6 and 18 weeks later. A repeated measures mixed-effects model was used to investigate the association between affective outcomes and type of intervention received, after adjusting for baseline characteristics. RESULTS: The group completion rate was over 90%. The treatment and comparison groups were similar on baseline demographic and criminological measures, but the treatment group had higher baseline anger and depression scores. While both groups showed improved capacity to forgive and reduced negative affect over time, those in the 'learn to forgive' programme showed significantly more improvement in forgiveness and on anger measures. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Forgiveness training can be delivered effectively to offenders with mental disorders in clinical settings. Its range of benefits, including reduction I in anger as well as improved capacity to forgive, suggest that it may have longer term implications for personal safety and reintegration into mainstream societal settings. Copyright © 2016 John Wiley & Sons, Ltd.

Mood Instability Is a Precursor of Relationship and Marital Difficulties: Results from Prospective Data from the British Health and Lifestyle Surveys.

The DSM system implies that affective instability is caused by reactivity to interpersonal events. We used the British Health and Lifestyle Survey that surveyed community residents in 1984 and again in 1991 to study competing hypotheses: that mood instability (MI) leads to interpersonal difficulties or vice versa. We analyzed data from 5,352 persons who participated in both waves of the survey. Factor analysis of the Eysenck Personality Inventory neuroticism scale was used to derive a 4-item scale for MI. We used depression measures that were previously derived by factor analyzing the General Health Questionnaire. We tested the competing hypotheses by regressing variables at follow-up against baseline variables. The results showed that MI in 1984 clearly predicted the development of interpersonal problems in 1991. After adjusting for depression, depression becomes the main predictor of spousal difficulties, but MI remains a predictor of interpersonal difficulties with family and friends. Attempts to investigate the reverse hypothesis were ambiguous. The clinical implication is that when MI and interpersonal problems are reported, the MI should be treated first, or at least concurrently.

Affective instability and impulsivity predict nonsuicidal self-injury in the general population: a longitudinal analysis.

BACKGROUND: Impulsivity and affective instability are related traits known to be associated with nonsuicidal self-injury, although few longitudinal studies have examined this relationship. The purpose of this study was to determine if impulsivity and affective instability predict future nonsuicidal self-injury in the general population while accounting for the overlap between these traits. METHODS: Logistic regression analyses were conducted on data from 2344 participants who completed an 18-month follow-up of the 2000 British National Psychiatric Morbidity Survey. Affective instability and impulsivity were assessed at baseline with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders. Nonsuicidal self-injury was assessed at baseline and follow-up during semi-structured interviews. RESULTS: Affective instability and impulsivity predicted the onset of nonsuicidal self-injury during the follow-up period. Affective instability, but not impulsivity, predicted the continuation of nonsuicidal self-injury during the follow-up period. Affective instability accounted for part of the relationship between impulsivity and nonsuicidal self-injury. CONCLUSIONS: Affective instability and impulsivity are important predictors of nonsuicidal self-injury in the general population. It may be more useful to target affective instability over impulsivity for the treatment of nonsuicidal self-injury.

Mood Instability and Irritability as Core Symptoms of Major Depression: An Exploration Using Rasch Analysis.

BACKGROUND: Mood instability (MI) and irritability are related to depression but are not considered core symptoms. Instruments typically code clusters of symptoms that are used to define syndromic depression, but the place of MI and irritability has been under-investigated. Whether they are core symptoms can be examined using Rasch analysis. METHOD: We used the UK Psychiatric Morbidity Survey 2000 data (n = 8,338) to determine whether the nine ICD/DSM symptoms, plus MI and irritability, constitute a valid depression scale. Rasch analysis was used, a method concerned with ensuring that items constitute a robust scale and tests whether the count of symptoms reflects an underlying interval-level measure. Two random samples of 500 were drawn, serving as calibration and validation samples. As part of the analysis, we examined whether the candidate symptoms were unidimensional, followed a Guttman pattern, were locally independent, invariant with respect to age and sex, and reliably distinguished different levels of depression severity. RESULTS: A subset of five symptoms (sad, no interest, sleep, cognition, suicidal ideas) together with mood instability and irritability satisfactorily fits the Rasch model. However, these seven symptoms do not separate clinically depressed persons from the rest of the population with adequate reliability (Cronbach α = 0.58; Person Separation Index = 0.35), but could serve as a basis for scale development. Likewise, the original nine DSM depression symptoms failed to achieve satisfactory reliability (Cronbach α = 0.67; Person Separation Index = 0.51). LIMITATIONS: The time frame over which symptoms were experienced varied, and some required recall over the last year. Symptoms other than those examined here might also be core depression symptoms. CONCLUSION: Mood instability and irritability are candidate core symptoms of the depressive syndrome and should be part of its clinical assessment.

Mood instability and impulsivity as trait predictors of suicidal thoughts.

OBJECTIVES: Impulsivity, the tendency to act quickly without adequate planning or concern for consequences, is a commonly cited risk factor for suicidal thoughts and behaviour. There are many definitions of impulsivity and how it relates to suicidality is not well understood. Mood instability, which describes frequent fluctuations of mood over time, is a concept related to impulsivity that may help explain this relationship. The purpose of this study was to determine whether impulsivity could predict suicidal thoughts after controlling for mood instability. METHODS: This study utilized longitudinal data from the 2000 Adult Psychiatric Morbidity Survey (N = 2,406). There was a time interval of 18 months between the two waves of the study. Trait impulsivity and mood instability were measured with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders. Logistic regression analyses were used to evaluate baseline impulsivity and mood instability as predictors of future suicidal thoughts. RESULTS: Impulsivity significantly predicted the presence of suicidal thoughts, but this effect became non-significant with mood instability included in the same model. CONCLUSIONS: Impulsivity may be a redundant concept when predicting future suicidal thoughts if mood instability is considered. The significance is that research and therapy focusing on mood instability along with impulsivity may be useful in treating the suicidal patient. PRACTITIONER POINTS: Mood instability and impulsivity both predict future suicidal thoughts. Impulsivity does not predict suicidal thoughts after controlling for mood instability. Assessing and treating mood instability could be important aspects of suicide prevention and risk management.

Mood instability underlies the relationship between impulsivity and internalizing psychopathology.

Impulsivity, the tendency to act without adequate forethought, has been associated with various internalizing disorders. Mood instability, the tendency to experience rapid and intense mood swings, relates to both internalizing disorders and impulsivity. We hypothesized that the association between mood instability and impulsivity accounts for the relationship between impulsivity and internalizing psychopathology. We conducted two studies to test our hypothesis. In Study 1 we used data from the 2007 Adult Psychiatric Morbidity Survey to examine mood instability in the relationship between depression and impulsivity. Mood instability and impulsivity were assessed with the Structured Clinical Interview for DSM-IV Axis-II Personality Disorders and depression was assessed with the revised Clinical Interview Schedule. In Study 2 we used data from the 1984 and 1991 British Health and Lifestyle Surveys to examine mood instability in the longitudinal relationship between impulsivity and internalizing symptoms. Mood instability and impulsivity were measured with the Eysenck Personality Inventory and internalizing symptoms were assessed with the General Health Questionnaire. In both studies we used a sequential regression analysis to test our hypothesis. Results from Study 1 showed that participants with depression were more likely to report impulsivity, but this effect became nonsignificant when mood instability was included in the same regression model. In Study 2 impulsivity predicted internalizing symptoms seven years in the future, but this effect became nonsignificant after mood instability was included in the same regression model. We conclude that impulsivity relates to internalizing psychopathology largely by being associated with mood instability. Research and therapy for internalizing conditions might be more productively directed at mood instability rather than impulsivity.

The dimensional structure of cycling mood disorders.

This study examines whether mood disorders differ fundamentally in terms of phase duration. Most clinically significant mood disorders are recurrent and cyclical. The phase duration of these cycles is part of the diagnostic criteria. Specifically, we determined whether a dimensional or taxonic latent structure better captures cycling mood disorders. 319 patients recruited from 5 psychiatrists and a psychoeducational program completed three questionnaires assessing aspects of mood cycling. These were the Affective Lability Scale-Short Form (ALS-SF), Mood Disorders Questionnaire (MDQ), and the Eysenck Neuroticism scale. Patient scores on these instruments were submitted to three taxometric procedures (MAMBAC, MAXEIG, and L-Mode). Comparison curve fit indices (CCFIs) were calculated to distinguish taxonic versus dimensional latent structure. In addition, graphs were produced for each procedure and compared with those of categorical or dimensional prototypes. The CCFIs of the three procedures ranged from 0.25 to 0.27, consistent with dimensional structure. The graphs closely resembled dimensional prototypes. Mood instability and other types of cycling moods probably conform to a dimensional latent structure. Patients with disorders featuring mood cycling might benefit from common treatments.

The Relationship between Mood Instability and Suicidal Thoughts.

The objective of this study was to determine whether affective instability predicts suicidal thoughts. Data from a Dutch panel study (N = 1686) was used. Affective instability was assessed with 7 items representing suddenly shifting moods. Suicidal thoughts were assessed by the occurrence of suicidal thoughts in the past week. Negative affect was indexed by anxious, depressed and angry moods extracted by factor analysis. Odds ratios using logistic regression modeling were calculated, adjusting for clinical and demographic variables. The study found that both males (OR: 1.14; 95% CI: 1.02-1.28) and females (OR: 1.11; 95% CI: 1.00-1.23) were more likely to experience suicidal thinking with higher affective instability. Affective instability and negative affect independently predict suicidal thoughts. Affective instability requires more attention in the assessment of suicide risk.

Religious attendance after elevated depressive symptoms: is selection bias at work?

In an attempt to determine if selection bias could be a reason that religious attendance and depression are related, the predictive value of elevated depressive symptoms for a decrease in future attendance at religious services was examined in a longitudinal panel of 1,673 Dutch adults. Religious attendance was assessed yearly over five years using the single question, "how often do you attend religious gatherings nowadays?" Depressive symptoms were assessed four times within the first year using the Depression subscale of the Brief Symptom Inventory. Logistic regression models of change in attendance were created, stratifying by baseline attendance status. Attenders who developed elevated symptoms were less likely to subsequently decrease their attendance (relative risk ratio: 0.55, 95% CI [0.38-0.79]) relative to baseline as compared to those without elevated symptoms. This inverse association remained significant after controlling for health and demographic covariates, and when using multiply imputed data to account for attrition. Non-attenders were unlikely to start attending after elevated depressive symptoms. This study provides counter evidence against previous findings that church attenders are a self-selected healthier group.