Non-fatal suicide behaviours across phases in the COVID-19 pandemic: a population-based study in a Catalan cohort.

BACKGROUND: The COVID-19 pandemic has been extensively discussed in the context of its effect on mental health. Although global suicide rates have remained stable during the pandemic, the specific effect on non-fatal suicide behaviours during and after the pandemic remains underexplored. This study aims to investigate patterns of non-fatal suicide behaviours before, during, and after the pandemic. METHODS: In this cohort study, we used data from all hospitals in Catalonia, Spain, collected through the Catalan Suicide Risk Code, which is a specifically designed suicide attempt surveillance protocol, involving a face-to-face, in-depth psychiatric evaluation, after a Catalan resident presents any suicide risk behaviour in any public health-care setting. This evaluation centralises data from suicide registries across the territory. We included non-fatal suicide behaviours, meaning suicidal ideation or attempts that did not result in death, and excluded self-harm behaviours not judged to be linked with suicidal ideation. We considered three periods: the pre-confinement period (Jan 1, 2018, to the enforcement of the lockdown in Spain on March 14, 2020); the confinement period (March 14, 2020, to the end of lockdown on June 21, 2020); and the post-confinement period (June 21, 2020, to Dec 31, 2022). We used Bayesian structural time series models to assess the effect of pandemic phases on non-fatal suicide behaviours, and we ran stratified analyses by sex and age to identify distinct patterns among demographic cohorts. FINDINGS: We obtained 26 482 records from Jan 1, 2018, to Dec 31, 2022. The mean age was 37·94 years (SD 18·07), and the sample included 17 584 (66·4%) women and 8898 (33·6%) men. Data on ethnicity were not collected. Temporal trends showed a mild increase in non-fatal suicide behaviours from Jan 1, 2018, to March 13, 2020; a reduction during the confinement period; and a subsequent rise after confinement. Bayesian models suggested a significant causal effect of lockdown easing, resulting in a 50·77% increase in non-fatal suicide behaviours (95% credible interval [CrI] 26·62-76·58; p<0·0001). Stratified analyses indicated that the easing of lockdown resulted in a significant increase in non-fatal suicide behaviours among women (25·92%; 6·71-44·72; p=0·011) and among individuals aged 18 years and younger (72·75%; 38·81-108·11; p<0·0001). INTERPRETATION: This study provides a comprehensive examination of non-fatal suicide behaviours in Catalonia, Spain, emphasising the dynamics of different COVID-19 pandemic phases. The initial reduction during strict lockdown aligns with Joiner's Interpersonal Theory of Suicide, whereas the post-confinement rise reflects complex factors, including social isolation and economic challenges. Sex-specific and age-specific analyses underscore distinct vulnerabilities, emphasising the need for targeted preventive strategies. FUNDING: Centro de Investigación Biomédica en Red de Salud Mental annual budget of G21, Agència de Gestió d'Ajuts Universitaris i de Recerca of the Generalitat de Catalunya. TRANSLATIONS: For the Catalan and Spanish translations of the abstract see Supplementary Materials section.

Combining emotion regulation and mindfulness skills for preventing depression relapse: a randomized-controlled study.

BACKGROUND: Dialectical behavioral therapy (DBT) skills have become increasingly used to treat several psychiatric conditions, including major depressive disorder (MDD). The aim of the study was to investigate the efficacy of an intervention that combines emotion regulation and mindfulness skills of DBT to prevent depression relapse/recurrence. METHODS: A total of 75 individuals (79% females; mean age, 52 years) with a diagnosis of MDD in complete or partial remission were recruited. Participants were randomly allocated either to an intervention combining emotion regulation and mindfulness skills (ER + M group, n = 37) or to a psychoeducative program (n = 38). After the 10-week treatment period, participants were followed for 1 year. Analyses were run in per-protocol (PP) and intention-to-treat (ITT) samples. The primary outcome measure was time to depression relapse/recurrence. RESULTS: ER + M training was not more effective than the control intervention in preventing depression relapse. However, PP and ITT analyses showed that participants trained in ER + M presented a significant reduction in depressive symptoms and overall psychopathology. Based on the PP and ITT analyses, neither of the interventions were related with an increase in dispositional mindfulness. CONCLUSIONS: More studies are needed to confirm the efficacy of ER + M to decrease depressive symptoms and overall psychopathology. TRIAL REGISTRATION: NCT02747134. Registered on 20 April 2016.

[Brief Suicide Questionnaire. Inter-rater reliability]. / Protocolo breve de evaluación del suicidio: fiabilidad interexaminadores.

INTRODUCTION: Inter-rater agreement is a crucial aspect in the planning and performance of a clinical trial in which the main assessment tool is the clinical interview. The main objectives of this study are to study the inter-rater agreement of a tool for the assessment of suicidal behavior (Brief Suicide Questionnaire) and to examine whether the inter-examiner agreement when multiple ratings are made on a single subject is an efficient method to assess the reliability of an instrument. METHOD: In the context of designing a multicenter clinical trial, 32 psychiatrists assessed a videotaped clinical interview of a patient with suicidal behavior. In order to identify those items in which a greater level of discordance existed and detect the examiners whose ratings differed significantly from the average ratings, we used the DOMENIC method (Detecion of Multiple Examiners Not in Consensus). RESULTS: Inter-rater agreement was between poor (<70%) to excelent (90-100%. Inter-rater agreement in Brugha's list of threatening experiences ranged from 75.5 and 100%; in the Global Assessment of Functioning (GAF) Scale was 82.58%; in the Beck's Suicidal Intent Scale, ranged from 67.5 and 97%; in the Beck's Scale for Suicide Ideation, ranged from 63.5 and 100%; and in the Lethality Rating Scale was 88.39%. On the whole, the level of agreement among raters, both in general scores and in particular items, was appropriate. CONCLUSION: The proposed design allows the assessment of the inter-rater agreement in an efficient way (only in one session). In addition, regarding the Brief Suicide Questionnaire, inter-raters agreement was appropriate.

Protocolo breve de evaluación del suicidio: fiabilidad interexaminadores / Brief Suicide Questionnaire. Inter-rater reliability

Introducción. El acuerdo entre-examinadores es un aspecto fundamental en la planificación de cualquier trabajo de investigación donde la principal herramienta diagnóstica es la entrevista clínica. El objetivo de este estudio es valorar el acuerdo entre-examinadores de un instrumento de evaluación de la conducta suicida (Protocolo breve de evaluación del suicidio) utilizando las valoraciones de múltiples observadores en una sola sesión. Método. Durante la fase piloto de un estudio clínico multicéntrico centrado en la monitorización de intentos de suicidio, 32 examinadores evaluaron el vídeo de la entrevista clínica a un paciente simulado con conducta suicida. Para identificar los ítems en los que existía una mayor discordancia y a los examinadores cuyo criterio se alejaba más del acuerdo general, se utilizó el método Detection Of Multiple Examiners Not In Consensus (DOMENIC). Resultado. El acuerdo interexaminadores osciló entre pobre (<70%) y excelente (90-100%). En la escala de acontecimientos vitales estresantes el nivel de acuerdo osciló entre 48,4 y 97%; en la escala problemas psicosociales del DSM-IV, entre 75,5 y 100%; en la escala de evaluación de la actividad global fue de 82,58%; en la escala de intencionalidad suicida, osciló entre 67,5 y 97%; en la escala de ideación suicida, entre 63,5 y 100% y en la escala de letalidad del intento de suicidio fue de 88,39%. En general, los examinadores mostraron un nivel de acuerdo adecuado tanto en las puntuaciones globales de cada escala como en cada ítem en particular. Conclusiones. El diseño propuesto permite evaluar el acuerdo entre-examinadores de una forma eficiente (en una única sesión). Además, con respecto al Protocolo breve de evaluación del suicidio, el acuerdo entre-examinadores fue apropiado(AU)

Introduction. Inter-rater agreement is a crucial aspect in the planning and performance of a clinical trial in which the main assessment tool is the clinical interview. The main objectives of this study are to study the inter-rater agreement of a tool for the assessment of suicidal behaviour (Brief Suicide Questionnaire) and to examine whether the inter-examiner agreement when multiple ratings are made on a single subject is an efficient method to assess the reliability of an instrument. Method. In the context of designing a multicenter clinical trial, 32 psychiatrists assessed a videotaped clinical interview of a patient with suicidal behaviour. In order to identify those items in which a greater level of discordance existed and detect the examiners whose ratings differed significantly from the average ratings, we used the DOMENIC method (Detecion of Multiple Examiners Not in Consensus). Results. Inter-rater agreement was between poor (<70%) to excellent (90-100%. Inter-rater agreement in Brugha's list of threatening experiences ranged from 75.5% to 100%; in the Global Assessment of Functioning (GAF) Scale was 82.58%; in Beck's Suicidal Intent Scale, ranged from 67.5% to 97%; in Beck's Scale for Suicide Ideation, ranged from 63.5% to 100%; and in the Lethality Rating Scale was 88.39%. On the whole, the level of agreement among raters, both in general scores and in particular items, was appropriate. Conclusion. The proposed design allows the assessment of the inter-rater agreement in an efficient way (only in one session). In addition, regarding the Brief Suicide Questionnaire, inter-raters agreement was appropriate(AU)

[Slow processing in borderline personality disorder: the emotional Stroop paradigm]. / Lentificación del procesamiento de la información en el trastorno límite de la personalidad: el paradigma de Stroop emocional.

BACKGROUND: Emotional instability has been extensively considered the main core of the borderline personality disorder (BPD) that is characterised by an important bias towards emotional information. The aim of this study was to determine the emotional bias in patients with BPD by means of an emotional Stroop paradigm. SAMPLING AND METHODS: Sixty-one women (38 Borderline Personality Disorder outpatients and 23 healthy matched control subjects) were included. All of them underwent a computerised version of an emotional Stroop which included four valences: borderline-related negative, negative, positive and neutral. RESULTS: The results showed that BPD patients were slower in spotting the ink of the words [F(1.59)=4.33; p=0.04], and this effect was mainly for borderline-related and neutral words. Likewise, the more severe the BPD the slower the subjects [F(2.57)=4.81; p=0.012], indicating difficulties in processing information. CONCLUSIONS: The findings suggest that the emotional dysregulation may account for selective processing with emotional stimulus, which in turn triggers emotional responses in BPD patients, rather than to reflect a more general hypervigilance and an attentional bias for any kind of stimulus.

Lentificación del procesamiento de la información en el trastorno límite de la personalidad: el paradigma de Stroop emocional / Slow processing in borderline personality disorder: the emotional Stroop paradigm

Introducción. La inestabilidad emocional se considera la disfunción principal en el trastorno límite de la personalidad (TLP), que se caracteriza por un importante sesgo hacia la información emocional. El objetivo de este estudio fue determinar el sesgo emocional en pacientes con TLP mediante un paradigma de Stroop emocional. Muestra y Método. Se incluyeron en el estudio 61 mujeres (38 pacientes ambulatorias con TLP y 23 controles sanos apareados). Todos los sujetos realizaron una versión informatizada de un Stroop emocional que incluía palabras con cuatro valencias: palabras negativas con contenido límite, palabras negativas, palabras positivas y palabras neutras. Resultados. Los resultados indicaron que los pacientes con TLP era más lentos acertando el color de las palabras [F(1,59)=4,33; p=0,04], y este efecto se observaba principalmente en el caso de las palabras con contenido límite y de las palabras neutras. Además, los pacientes con mayor gravedad del trastorno eran más lentos [F(2,57)=4,81; p=0,012], lo que indica dificultades en el procesamiento de la información. Conclusiones. Los resultados obtenidos indican que la disregulación emocional podría explicarse por un procesamiento selectivo ante estímulos emocionales, lo que desencadenaría respuestas emocionales en los pacientes con TLP, mejor que por una hipervigilancia generalizada o por un sesgo atencional ante cualquier tipo de estímulo (AU)

Background. Emotional instability has been extensively considered the main core of the borderline personality disorder (BPD) that is characterised by an important bias towards emotional information. The aim of this study was to determine the emotional bias in patients with BPD by means of an emotional Stroop paradigm. Sampling and Methods. Sixty-one women (38 Borderline Personality Disorder outpatients and 23 healthy matched control subjects) were included. All of them underwent a computerised version of an emotional Stroop which included four valences: borderline-related negative, negative, positive and neutral. Results. The results showed that BPD patients were slower in spotting the ink of the words [F(1.59)=4.33; p=0.04], and this effect was mainly for borderline-related and neutral words. Likewise, the more severe the BPD the slower the subjects [F(2.57)=4.81; p=0.012], indicating difficulties in processing information. Conclusions. The findings suggest that the emotional dysregulation may account for selective processing with emotional stimulus, which in turn triggers emotional responses in BPD patients, rather than to reflect a more general hypervigilance and an attentional bias for any kind of stimulus (AU)

Axis II comorbidity in borderline personality disorder is influenced by sex, age, and clinical severity.

Borderline personality disorder (BPD) is a severe psychiatric disorder that has a high clinical heterogeneity and frequent co-occurrence with other personality disorders (PDs). Although several studies have been performed to assess axis II comorbidity in BPD, more research is needed to clarify associated factors. The aim of this study was to determine the prevalence of co-occurrent axis II disorders in a large sample of patients with BPD and to investigate the influence of sex, age, and severity on this comorbidity. Data were collected from 484 patients with BPD through 2 semistructured interviews. We analyzed the frequency of axis II comorbidity and assessed differences regarding sex, age, and severity of BPD. About 74% of patients with BPD had at least 1 co-occurrent axis II disorder. The most common were paranoid, passive-aggressive, avoidant, and dependent PDs. Significant sex differences were found. Women presented more comorbidity with dependent PD, whereas men showed higher rates of comorbidity with antisocial PD. We also observed a significant positive correlation between age and the number of co-occurrent axis II disorders in women with BPD. Another finding was the positive correlation between BPD severity and the number of co-occurrent axis II disorders. These findings suggest that comorbidity with other axis II disorders and sex, age, and severity should be taken into account when developing treatment strategies and determining the prognosis of BPD.

A naturalistic study of changes in pharmacological prescription for borderline personality disorder in clinical practice: from APA to NICE guidelines.

Although no psychotropic agents are specifically licensed for the management of borderline personality disorder (BPD), pharmacological treatment appears to be common. This study aimed to examine the drug prescriptions for patients with BPD in clinical practice, analyze the prescription patterns from the appearance of the American Psychiatric Association guidelines in 2001 until the National Institute for Health and Clinical Excellence guidelines in 2009, and identify the factors associated with such prescription of each type of drug. Naturalistic study on 226 consecutive BPD patients admitted to an outpatient BPD program. Socio-demographic, clinical and pharmacological treatment information was collected; factors associated with drug prescription were examined using logistic regression analyses for dichotomous outcomes measures. Changes in prescription patterns over time were also evaluated. Patients received an average of 2.7 drugs; only 6% were drug-free; 56% were taking ≥3 drugs and 30% ≥4 drugs. Over the past 8 years, prescription of antidepressants has remained stable; there has been a significant reduction in prescription of benzodiazepines and an increase in the use of mood stabilizers and atypical antipsychotics. Comorbidity with Axis I disorders was the main factor associated with drug prescription. Drug prescription and polypharmacy are common in the management of BPD in clinical practice.

[Pyschotherapygenetics. Do genes influence psychotherapy adherence?]. / Psicoterapiagenética: ¿influyen los genes en la adherencia a la psicoterapia?

OBJECTIVE: There is probably an association between genetic factors, personality traits and response to psychotherapy. We propose the new concept of "psychotherapygenetics" as a strategy to study how genetic factors may influence psychotherapeutic response. The aim was to examine the association between polymorphisms of the serotonin transporter gene (SERT) and the dopamine 4-receptor gene (DRD4) with adherence to psychotherapy. METHOD: We performed a prospective study of 110 patients with borderline personality disorder (BPD) who participated in dialectical behavioral therapy (DBT). Three polymorphisms were examined: the 5-HTTLPR and the VNTR on the SERT gene and the 7-repeat allele (D4.7) on the DRD4 gene. The dropout rate and the mean number of sessions attended were used as an adherence index. RESULTS: The presence of the 12-repeat allele on the VNTR polymorphism of SERT was associated with higher adherence to psychotherapy. There was no significant association between the 5-HTTLPR or D4.7 polymorphisms and adherence. CONCLUSIONS: Our preliminary results show a correlation between certain genetic variations and adherence to DBT in patients with BPD. A "psychotherapygenetics" approach could be useful to study how genetic variables may influence patients' psychotherapy response.

Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: a 3-month randomised controlled clinical trial.

Dialectical behaviour therapy (DBT) has proven to be an effective treatment in borderline personality disorder (BPD). However, the effectiveness in BPD of DBT skills training (DBT-ST) alone is not known. This study aimed at comparing the efficacy of DBT-ST and standard group therapy (SGT) for outpatients with BPD. Sixty patients meeting the DSM-IV diagnostic criteria for BPD, as assessed by two semi-structured diagnostic interviews, were included in a 3-month, single-blind randomised controlled trial. A total of 13 weekly group psychotherapy sessions of 120 min of either SGT or DBT-ST were conducted. Assessments were carried out every 2 weeks by two blinded evaluators. Observer-rater, self-report scales and behavioural reports were used as outcome measures. DBT-ST was associated with lower dropout rates, 34.5% compared to 63.4% with SGT. It was superior to SGT in improving several mood and emotion areas, such as: depression, anxiety, irritability, anger and affect instability. A reduction in general psychiatric symptoms was also observed. Three-months weekly DBT-ST proved useful. This therapy was associated with greater clinical improvements and lower dropout rates than SGT. DBT-ST seems to play a role in the overall improvement of BPD seen with standard DBT intervention. It allows straightforward implementation in a wide range of mental health settings and provides the additional advantage that it is cost effective.

Ziprasidone in the treatment of borderline personality disorder: a double-blind, placebo-controlled, randomized study.

OBJECTIVE: The aim of this double-blind, placebo-controlled study was to evaluate the efficacy and tolerability of ziprasidone in the treatment of adult patients with borderline personality disorder. METHOD: Sixty DSM-IV borderline personality disorder patients were included from March 2004 to April 2006 in a 12-week, single-center, double-blind, placebo-controlled study. The subjects were randomly assigned to ziprasidone or placebo in a 1:1 ratio following a 2-week baseline period. The Clinical Global Impressions scale for use in borderline personality disorder patients (CGI-BPD) was the primary outcome measure, and other scales and self-reports related to affect, behavior, psychosis, general psychopathology domains, and clinical safety were included. RESULTS: Analysis of variance indicated no statistically significant differences between ziprasidone and placebo in the CGI-BPD. Nor were significant differences observed between groups in depressive, anxiety, psychotic, or impulsive symptoms. The mean daily dose of ziprasidone was 84.1 mg/day (SD = 54.8; range, 40-200). The drug was seen to be safe, and no serious adverse effects were observed. CONCLUSION: This trial failed to show a significant effect of ziprasidone in patients with borderline personality disorder. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00635921.