Characteristics of deaths by suicide in postmortem studies in Brazil: A systematic review and meta-analysis.

INTRODUCTION: Suicide is one of the leading causes of death, with a trend for its increase in Brazil in past decades. This study aimed to review the characteristics of suicides in Brazilian postmortem studies. METHODS: Studies investigating suicide deaths in Brazil, and based on autopsy or psychological autopsy were included. Proportions were pooled across studies with the use of random and fixed effects models. RESULTS: 6777 references were retrieved from six databases (searches up to January, 2023), and 45 studies included. In autopsy studies (k = 37, n = 16,231), substance use at toxicological analysis was found in 36.42% of cases (95% CI: 30.05-43.32), previous suicide attempts in 23.92% (95% CI: 6.73-57.78). In psychological autopsy studies (k = 8, n = 139), previous suicide attempts were reported in 28.09% (95% CI: 19.74-38.28), psychiatric conditions/symptoms in 90.67% (95% CI: 67.79-97.82), family history of suicidality in 21.33% (95% CI: 13.5-32.03). Most suicide deaths were reported in males and took place at the victim's home, hanging was the most frequent suicide method. Included studies presented significant limitations in quality assessment. CONCLUSION: Future studies should present more robust methodology, including bigger samples, the use of controls, and validated methodology.

On suicidal ideation: the need for inductive methodologies to advance the field.

Recent scholarly investigation of suicidal ideation has been largely based on identifying associated factors and using ideation-to-action theories to explain its occurrence. However, this approach may not be sufficient, as many aspects of suicidal ideation fall beyond the reach of such conceptualizations. The overemphasis on explaining rather than understanding this phenomenon is a significant factor in this insufficiency. As such, it is argued that qualitative methods that use data to derive theories could offer a more nuanced understanding of suicidal ideation. By adopting bottom-up approaches, researchers can explore how individuals experience and understand suicidal ideation and how it relates to their lives and experiences. Furthermore, use of qualitative research methods could aid in development of more accurate and inclusive definitions that are more firmly grounded in data.

On suicidal ideation: the need for inductive methodologies to advance the field

Abstract Recent scholarly investigation of suicidal ideation has been largely based on identifying associated factors and using ideation-to-action theories to explain its occurrence. However, this approach may not be sufficient, as many aspects of suicidal ideation fall beyond the reach of such conceptualizations. The overemphasis on explaining rather than understanding this phenomenon is a significant factor in this insufficiency. As such, it is argued that qualitative methods that use data to derive theories could offer a more nuanced understanding of suicidal ideation. By adopting bottom-up approaches, researchers can explore how individuals experience and understand suicidal ideation and how it relates to their lives and experiences. Furthermore, use of qualitative research methods could aid in development of more accurate and inclusive definitions that are more firmly grounded in data.

Latent structure and factor reliability of the National Health Service Community Mental Health Service User Questionnaire.

BACKGROUND: National Health Service use the Community Mental Health Service User Questionnaire (NHS-CMH) to assess care quality. However, its reliability and internal validity is uncertain. AIMS: To test the NHS-CMH structure, reliability and item-level characteristics. METHODS: We used data from 11,373 participants who answered the 2017 NHS-CMH survey. First, we estimated the NHS-CMH structure using Exploratory Factor Analysis (EFA) in half of the dataset. Second, we tested the best EFA-derived model with Confirmatory Factor Analysis (CFA). We tested the internal validity, construct reliability (omega - ω), explained common variance of each factor (ECV), and item thresholds. RESULTS: EFA suggested a 4-factor solution. The structure derived from the EFA was confirmed, demonstrating good reliability for the four correlated dimensions: "Relationship with Staff" (ω = 0.952, ECV = 40.1%), "Organizing Care" (ω = 0.855, ECV = 21.4%), "Medication and Treatments" (ω = 0.837, ECV = 13.3%), and "Support and Well-being" (ω = 0.928, ECV = 25.3%). A second-order model with a high-order domain of "Quality of Care" is also supported. CONCLUSIONS: The NHS-CMH can be used to reliably assess four user-informed dimensions of mental health care quality. This model offers an alternative for its current use (item-level and untested sum scores analysis).

Lithium-induced neuroprotective activity in neuronal and microglial cells: A purinergic perspective.

Lithium is the mainstay of pharmacotherapy for treating bipolar disorder (BD). However, despite its wide use for over 60 years in the clinic, its mechanisms of action are not yet well defined. Elucidating lithium's mechanism of action will not only shed light on the pathophysiology of BD, but also potentially uncover new treatment targets. Previous studies suggest that the purinergic system may be involved in lithium's neuroprotective action; thus, the specific aim of this study is to better understand the neuroprotective action of lithium against ATP-induced cellular effect in both neuronal and microglial cellular lineages. We used PC12 neuronal and N9 microglial cells, evaluating cell death by cell counting and Annexin/PI cytometry assay, P2 × 7R immunocontent and ectonucleotidases activity, together with cytokine and nitrite assessment for microglial activity determination. Our results indicate that cells of different neural origins are responsive to ATP, in the sense of neuronal excitotoxicity and microglial switch into an activated M1-like phenotype respectively. Lithium, in turn, modulates the response in neuronal PC12 cells, preventing ATP-induced cell death. On the other hand, in N9 microglial cells, lithium was unable to prevent ATP-induced activation via P2 × 7R, indicating that lithium protective action against the effects of ATP more likely occurs in neurons rather than in microglia. Further studies are needed to better characterize the involvement of the purinergic system in the mechanism of action of lithium against neuronal death and microglial activation, in order to uncover new therapeutic adjunctive targets, such as antagonism of P2 × 7R, as potential approach for bipolar disorder treatment.

Psychotic depression in hospitalized patients: Longitudinal outcomes of psychotic vs. nonpsychotic depression among inpatients.

Even though psychotic depression is related to worse outcomes than nonpsychotic depression, there is increasing evidence that this greater severity is not solely explained by the depressive symptoms. We evaluated the socio-demographic and clinical characteristics, as well as the differences in clinical outcomes of psychiatric hospitalization between psychotic and non-psychotic depression. Two-hundred-eighty-eight depressive inpatients were assessed within 72 h after hospitalization and 24 h before discharge. We compared scores of Hamilton Depression Rating Scale 17-items (HDRS-17), Clinical Global Impression (CGI), Brief Psychiatric Rating Scale (BPRS), and Global Assessment of Functioning (GAF) between psychotic and nonpsychotic patients. Instruments were compared both cross-sectionally - on admission and discharge - and longitudinally. Longitudinal outcomes were corrected for potential confounders (sex, age, age at disease onset, years of study, previous history of mania/hypomania, electroconvulsive therapy in current hospitalization, history of attempted suicide, number of suicide attempts, and previous hospitalizations). One-hundred-thirty-one depressive inpatients (45.4%) presented psychotic features. Both groups showed similar HDRS-17 scores at admission and discharge. However, psychotic patients had worse scores on BPRS, CGI, and GAF at both timepoints. Both groups had similar improvement on HDRS-17 (P = 0.75), CGI (P = 0.5), and GAF (P = 0.84), but psychotic patients had greater improvement on BPRS (P < 0.001). Psychotic inpatients showed worse clinical and functional parameters. Nonetheless, the groups did not differ in depressive symptom severity. These findings reinforce the hypothesis that depressive episode with psychotic features is a more severe form of the disease irrespective of intensity of affective symptomatology.

Case report on the multiple pathways to posttraumatic stress disorder following suicide.

Trauma pathology is not only a sum of risk factors, but emerges as a result of complex causal interaction. The case presented here illustrates the pathway from suicide exposure to the development of fully-fledged treatment-resistant posttraumatic stress disorder (PTSD), demonstrating how recognized risk factors can act in tandem to generate a difficult to treat syndrome. From a clinical perspective, bottom-up approaches that take into account real coping experiences of people bereaved by suicide are more effective to facilitate recovery and prevent adverse outcomes. Finally, even though treatment is often implemented, the diagnosis can be missed further complicating coping and treatment.

Clinical outcomes and childhood trauma in bipolar disorder: A community sample of young adults.

Childhood trauma is a complex experience, much reported by subjects with bipolar disorder. There are still few studies that assess its consequences in a community sample of bipolar in early stage. The aim of the present study is to assess the association between childhood trauma and clinical outcomes, including the global functioning, in a community sample of young adults with bipolar disorder. This is a cross-sectional study with a community sample of subjects with bipolar disorder, from 23 to 30 years old, with and without childhood trauma. The trauma experiences during childhood were assessed by Childhood Trauma Questionnaire (CTQ). The functioning was assessed by Functioning Assessment Short Test (FAST). Ninety subjects with bipolar disorder were included in the study (30 with childhood trauma and 60 without childhood trauma). Young adults with bipolar disorder and childhood trauma showed higher prevalence of current suicide risk, higher severity of depressive symptoms, and higher functioning impairment as compared to subjects with bipolar disorder without childhood trauma. The childhood trauma experiences appear to be an environmental risk factor for worse clinical outcomes and higher functional impairment.

Age and sex trends for suicide in Brazil between 2000 and 2016.

PURPOSE: To evaluate changes in standardized suicide rates in Brazil between 2000 and 2016, stratified by sex and age. METHODS: Descriptive analyses of data from the Brazilian Mortality Information System were performed. RESULTS: 156,292 suicides were registered in the period, with a standardized rate of 4.82/100,000. The risk for males was 3.81 times higher than for females, without meaningful regional variations. This ratio was 8.2 at the 80+ group. An increase from 2000 to 2016 was demonstrated in nearly all subgroups over the 17, especially men aged 20-39 and women aged 40-59. CONCLUSIONS: Suicide rates continue to rise in Brazil, especially among young men and middle-aged women. Older men remain exposed to the highest absolute risk.

Metabolic syndrome, depression and anhedonia among young adults.

The aim of this study was to assess the association between anhedonia and metabolic syndrome (MetS) in a well-characterized community sample of individuals with a current depressive episode. This is a cross-sectional study with young adults aged 24-30 years old. Depressive episode and the presence of anhedonia was assessed using the Mini International Neuropsychiatric Interview - Plus version (MINI Plus). The MetS was assessed using the National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATP III). The sample included 931 subjects, being 22 had depression without anhedonia, whereas 55 had depression with anhedonia. MetS was more prevalent among subjects with depression and anhedonia (43.6%) when compared to individuals without anhedonia and population control group. Moreover, subjects with depression and anhedonia have a significant increase of levels of glucose, triglycerides, total-cholesterol and LDL-cholesterol, as well as significant decreased in the HDL-cholesterol level. The present study showed that individuals with depression and anhedonia present higher prevalence of MetS. Our study suggests that the use of the concept of anhedonia may contribute to a better understanding of the complex relationship between depression and metabolic syndrome.

The impact of substance use disorders on recovery from bipolar depression: Results from the Systematic Treatment Enhancement Program for Bipolar Disorder psychosocial treatment trial.

OBJECTIVE: Up to 60% of patients with bipolar disorder develop a substance use disorder during their lifetime. The purpose of this paper was to assess the impact of substance use disorders on depression recovery among bipolar patients randomly assigned to different psychotropic medications and psychosocial interventions. We hypothesized that patients with a comorbid substance use disorder would benefit less from psychotherapy regardless of treatment intensity/length compared to patients without a comorbid substance use disorder. METHOD: We conducted post hoc analyses among bipolar disorder patients ( n = 270) with and without comorbid substance use disorders enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder randomized psychosocial intervention trial. All patients entered during or shortly after the onset of a bipolar depressive episode. Logistic regression and Cox proportional hazard models were used to assess whether current or past substance use disorders moderated the response of patients to intensive psychosocial intervention or brief psychoeducation with collaborative care, operationalized as full recovery from an episode of bipolar depression. RESULTS: Current comorbid substance use disorders significantly predicted likelihood of recovery (odds ratio = 2.25, p = 0.025) and time to recovery (odds ratio = 1.71, p = 0.006) from bipolar depression. We found that 74.5% of patients with a current substance use disorder, compared to 56.5% without a current substance use disorder, recovered from bipolar depression. Past substance use disorders did not predict likelihood of recovery or time to recovery. Current substance use disorders did not significantly moderate response to intensive psychotherapy versus collaborative care. CONCLUSION: Contrary to our hypotheses, bipolar disorder participants with a current comorbid substance use disorder were more likely to recover from psychosocial treatment for bipolar depression than patients without a current comorbid substance use disorder. If this finding is replicated, it has implications for the ordering of treatment for patients with comorbid bipolar disorder and substance use disorders.

Prevalence and factors associated with Premenstrual Dysphoric Disorder: A community sample of young adult women.

Premenstrual Dysphoric Disorder (PMDD) was recently included in DSM-5 as a full diagnostic category. Few studies have investigated PMDD in a community sample of young adults, especially in Brazil. Thus, the objective of this study was to evaluate the prevalence and the factors associated with PMDD in a community sample of 727 young adult women between the 18 and 24 years of age in southern Brazil. This was a cross-sectional population-based study. The data were collected from 2012 to 2014. PMDD was assessed using the Mini International Neuropsychiatry Interview (M.I.N.I. - Plus). The prevalence of PMDD was 17.6%. PMDD was significantly higher among older women, and in women from lower socio-economic status. A trend towards significance was found for women without a current occupation (study or work). The comorbidities significantly associated with PMDD were current major depression disorder, agoraphobia, bipolar disorder, current suicide risk, generalized anxiety disorder, social phobia, and specific phobia. The high prevalence found in the present study should be interpreted considering a retrospective report. However, our data showed that clinicians should be alert for PMDD symptoms, especially among young adult women.

Metabolic syndrome in subjects with bipolar disorder and major depressive disorder in a current depressive episode: Population-based study: Metabolic syndrome in current depressive episode.

OBJECTIVE: To assess the differences in the prevalence of the metabolic syndrome (MetS) and their components in young adults with bipolar disorder (BD) and major depressive disorder (MDD) in a current depressive episode. METHODS: This was a cross-sectional study with young adults aged 24-30 years old. Depressive episode (bipolar or unipolar) was assessed using the Mini International Neuropsychiatric Interview - Plus version (MINI Plus). The MetS was assessed using the National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATP III). RESULTS: The sample included 972 subjects with a mean age of 25.81 (±2.17) years. Both BD and MDD patients showed higher prevalence of MetS compared to the population sample (BD = 46.9%, MDD = 35.1%, population = 22.1%, p < 0.001). Higher levels of glucose, total cholesterol and LDL cholesterol, Body Mass Index, low levels of HDL cholesterol, and a higher prevalence of abdominal obesity were observed in both BD and MDD individuals with current depressive episode compared to the general population. Moreover, there was a significant difference on BMI values in the case of BD and MDD subjects (p = 0.016). CONCLUSION: Metabolic components were significantly associated with the presence of depressive symptoms, independently of the diagnosis.

Do Sleep Disturbances Predict or Moderate the Response to Psychotherapy in Bipolar Disorder?

This study examined whether sleep disturbance predicted or moderated responses to psychotherapy in participants who participated in STEP-BD, a national, multisite study that examined the effectiveness of different treatment combinations for bipolar disorder. Participants received either a brief psychosocial intervention called collaborative care (CC; n = 130) or intensive psychotherapy (IP; n = 163), with study-based pharmacotherapy. Participants (N = 243) were defined as current (past week) short sleepers (<6 hours/night), normal sleepers (6.5-8.5 hours/night), and long sleepers (≥9 hours/night), according to reported average nightly sleep duration the week before randomization. Sleep disturbances did not predict the likelihood of recovery nor time until recovery from a depressive episode. There was no difference in recovery rates between IP versus CC for normal sleepers, and medium effect sizes were observed for differences in short and long sleepers. In this study, sleep did not play a major role in predicting or moderating response to psychotherapy in bipolar disorder.

Peripheral adenosine levels in euthymic patients with bipolar disorder.

Recent evidence points to the involvement of the purinergic signaling in the pathophysiology of bipolar disorder. The aim of this study was to assess the serum levels of adenosine and to evaluate its relation to functioning in 24 euthymic patients with bipolar disorder type I and in 25 matched healthy controls. Subjects were evaluated using the functioning assessment short test. Serum purine levels were measured by high pressure liquid chromatography. Our results show a decrease in serum adenosine levels in bipolar disorder patients compared with controls (t= -4.8, df= 43.96, p<0.001). Moreover, a significant negative correlation was found between patient adenosine levels and depression scale scores (r= -0.642, p= 0.001). Higher functional impairment was linked to lower levels of adenosine in patients (rho= -0.551, p= 0.008). Taken together, our results provide evidence for a purinergic imbalance in bipolar disorder, specifically an adenosinergic dysfunction. Our results also indicate a relation between adenosine levels and the functional impairment caused by the disorder, which could demonstrate a potential relation of adenosine levels in worsening of symptoms.

Biological rhythms, metabolic syndrome and current depressive episode in a community sample.

The purpose of this study was to assess the disruption in biological rhythms and metabolic syndrome (MetS) in individuals with depressive episode. This was a cross-sectional, population-based study with a representative sample of 905 young adults. Current depressive episode were confirmed by a psychologist using the Mini International Neuropsychiatric Interview (MINI)-Plus. Self-reported biological rhythms were assessed using the Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN). MetS was defined using modified NCEP/ATPIII criteria. Significant main effects of current depressive episode (p<0.001, η(2)=0.163) and MetS (p=0.001, η(2)=0.011) were observed on total BRIAN score. There was a significant interaction between depression and MetS in total biological rhythm scores (p=0.002, η(2)=0.011) as well as sleep (p=0.001, η(2)=0.016) and social domains (p<0.001, η(2)=0.014). In the depressive group, subjects with MetS had a higher disruption in total BRIAN scores (p=0.010), sleep domain (p=0.004), social domain (p=0.005) and in the eating pattern domain approached the level of significance (p=0.098), when compared to subjects with no MetS. The results of the present study showed that self-reported disruptions in biological rhythms are associated with key components of the MetS in community adults with MDD. The understanding of the complex interactions between biological rhythms, MetS and depression are important in the development of preventive and therapeutic strategies.

SPECIFIC MOOD SYMPTOMS CONFER RISK FOR SUBSEQUENT SUICIDAL IDEATION IN BIPOLAR DISORDER WITH AND WITHOUT SUICIDE ATTEMPT HISTORY: MULTI-WAVE DATA FROM STEP-BD.

BACKGROUND: Little is known about specific mood symptoms that may confer risk for suicidal ideation (SI) among patients with bipolar disorder (BD). We evaluated prospectively whether particular symptoms of depression and mania precede the onset or worsening of SI, among adults with or without a history of a suicide attempt. METHODS: We examined prospective data from a large (N = 2,741) cohort of patients participating in the Systematic Treatment Enhancement Program for BD (STEP-BD). We evaluated history of suicide attempts at baseline, and symptoms of depression and mania at baseline and follow-up visits. Hierarchical linear modeling tested whether specific mood symptoms predicted subsequent levels of SI, and whether the strength of the associations differed based on suicide attempt history, after accounting for the influence of other mood symptoms and current SI. RESULTS: Beyond overall current depression and mania symptom severity, baseline SI, and illness characteristics, several mood symptoms, including guilt, reduced self-esteem, psychomotor retardation and agitation, increases in appetite, and distractibility predicted more severe levels of subsequent SI. Problems with concentration, distraction, sleep loss and decreased need for sleep predicted subsequent SI more strongly among individuals with a suicide attempt history. CONCLUSIONS: Several specific mood symptoms may confer risk for the onset or worsening of SI among treatment-seeking patients with BD. Individuals with a previous suicide attempt may be at greater risk in part due to greater reactivity to certain mood symptoms in the form of SI. However, overall, effect sizes were small, suggesting the need to identify additional proximal predictors of SI.