Suicide risk after discharge from in-patient psychiatric care: A 15-year retrospective cohort study of individual patient data.

BACKGROUND: Suicide rates are known to be increased in patients after discharge from in-patient psychiatric treatment. However, evidence on risk factors for suicide within this patient group are contradictory. Thus, this study aims to investigate suicide after discharge from a sizeable psychiatric care facility to determine associated risk factors. METHODS: Data on individual patient level from a 15-year single-centre cohort were linked to data from the national death registry and cumulative incidence rates were calculated applying competing risk models. Independent variables included the patients' sex, age at admission, diagnosis, and length of admission. For each of these factors, subdistribution hazards ratios were calculated using a Fine-Gray model. RESULTS: In our sample of 18,425 discharges, when using patients with the diagnosis of substance-use-disorders as a comparator, a significant increase in hazard of post-discharge suicide for male sex (SHR = 1.67;p = 0.037) as well as the discharge diagnoses of affective disorders (SHR = 3.56;p = 0.017) and neurotic stress and somatoform disorders (SHR = 3.73;p = 0.024) were found. Interestingly, the hazard of suicide significantly decreased in more recent discharges (SHR = 0.93;p = 0.006). No statistically significant association of the length of admission with the suicide risk was found (SHR = 0.98;p = 0.834). LIMITATIONS: Suicides may have been mis-identified as natural death in the national death register. CONCLUSION: Male sex and distinct diagnoses were associated with an increased risk for suicide after discharge from a psychiatric care institution. The markedly increased suicide risk within this patient collective highlights the need for the development of tools to assess suicidal behaviour in this group of patients reliably.

A country report: impact of COVID-19 lockdowns on involuntary psychiatric treatment in Austria.

BACKGROUND: Coercive measures such as involuntary psychiatric admission are considered a last resort in the treatment of people with psychiatric disorders. So far, numerous factors have been identified that influence their use. However, the link between a pandemic - in particular, restrictions such as lockdowns - and the use of involuntary psychiatric admission is unclear. AIM: To examine the association between COVID-19 lockdowns and involuntary psychiatric admissions in Austria. METHOD: This retrospective exploratory study assessed all involuntary psychiatric admissions and use of mechanical restraint in Austria, except for the federal state of Vorarlberg, between 1 January 2018 and 31 December 2020. Descriptive statistics and regression models were used. RESULTS: During the 3-year study period, 40 012 individuals (45.9% females, mean age 51.3 years) had 66 124 involuntary psychiatric admissions for an average of 10.9 days. Mechanical restraint was used during 33.9% of these admissions. In weeks of nationwide COVID-19 lockdowns (2020 v. 2018/2019), involuntary psychiatric admissions were significantly fewer (odds ratio = 0.93, P = 0.0001) but longer (11.6 (s.d.: 16) v. 10.9 (s.d.: 15.8) days). The likelihood of involuntary admission during lockdowns was associated with year (2020 v. 2018-2019; adjusted odds ratio = 0.92; P = 0.0002) but not with sex (P = 0.814), age (P = 0.310), use of mechanical restraint (P = 0.653) or type of ward (P = 0.843). CONCLUSIONS: Restrictions such as lockdowns affect coercive measures and resulted in fewer but longer involuntary psychiatric admissions during weeks of lockdown in Austria. These results strengthen previous findings that showed the dependence of coercive measures on external factors, highlighting the need to further clarify causality and desired prevention effects when using coercive measures.

Can thiamine substitution restore cognitive function in alcohol use disorder?

AIMS: While clinical consequences of thiamine deficiency in alcohol use disorder (AUD) are severe, evidence-based recommendations on dosage, type of administration and duration of thiamine substitution (TS), and its' target levels remain sparse. This study aimed to compare the effect of two best practice TS regimens on thiamine blood levels (i.e. thiamine pyrophosphate, TPP) and cognitive function. METHODS: In 50 patients undergoing in-patient alcohol-withdrawal treatment, TPP levels were determined at baseline and end of weeks 1, 2 and 8 following administration of oral TS (3 × 100 mg/day for 7 days followed by 1 × 100 mg/day thereafter) either with or without preceding intravenous TS (3 × 100 mg/day for 5 days). An extensive psychiatric assessment was conducted at baseline, including an evaluation of AUD severity and depressive symptoms. Additionally, cognitive function and depressive symptoms were repeatedly evaluated. RESULTS: Relevant increases (mean increase by 100.2 nmol/l [CI 76.5-123.8], P < 0.001) in peripheral blood TPP levels were observed in all patients at the end of weeks 1 and 2. Furthermore, no relevant difference between the intravenous and the oral group was found (average difference between increases: 2.3 nmol/l, P = 0.912). Importantly, an association between the 'extent of the response' to TS and the performance in a memory task was revealed in secondary analyses. CONCLUSION: TS was associated with improving cognitive function in patients with AUD, independently of the substitution regime. Thus, in clinical practice, oral TS might be a sufficient but obligatory medication to prevent cognitive decline in AUD in the absence of Wernicke-Korsakoff Syndrome.

Cognitive decline and alcohol consumption in the aging population-A longitudinal analysis of the Survey of Health, Ageing and Retirement in Europe.

BACKGROUND: Prevalence of cognitive decline and dementia is rising globally, with more than 10 million new cases every year. These conditions cause a significant burden for individuals, their caregivers, and health care systems. As no causal treatment for dementia exists, prevention of cognitive decline is of utmost importance. Notably, alcohol is among the most significant modifiable risk factors for cognitive decline. METHODS: Longitudinal data across 15 years on 6,967 individuals of the Survey of Health, Ageing and Retirement in Europe were used to analyze the effect of alcohol consumption and further modifiable (i.e., smoking, depression, and educational obtainment) and non-modifiable risk factors (sex and age) on cognitive functioning (i.e., memory and verbal fluency). For this, a generalized estimating equation linear model was estimated for every cognitive test domain assessed. RESULTS: Consistent results were revealed in all three regression models: A nonlinear association between alcohol consumption and cognitive decline was found-moderate alcohol intake was associated with overall better global cognitive function than low or elevated alcohol consumption or complete abstinence. Furthermore, female sex and higher educational obtainment were associated with better cognitive function, whereas higher age and depression were associated with a decline in cognitive functioning. No significant association was found for smoking. CONCLUSION: Our data indicate that alcohol use is a relevant risk factor for cognitive decline in older adults. Furthermore, evidence-based therapeutic concepts to reduce alcohol consumption exist and should be of primary interest in prevention measures considering the aging European population.

Dysregulated Methylation Patterns in Exon IV of the Brain-Derived Neurotrophic Factor (BDNF) Gene in Nicotine Dependence and Changes in BDNF Plasma Levels During Smoking Cessation.

Introduction: Several studies reported dysregulated protein levels of brain-derived neurotrophic factor (BDNF) in smokers and during cessation. However, the epigenetic regulation of the BDNF gene has not yet been investigated. We measured the plasma levels of BDNF and the epigenetic regulation of exon IV of the BDNF gene in smokers compared to healthy controls over a cessation period of 14 days. Method: We measured BDNF plasma levels and BDNF promoter methylation in 49 smokers and 51 non-smokers at baseline, day 7, and day 14 of smoking cessation. Mean methylation levels of 11 Cytosine Guanosine dinucleotides of exon IV of the BDNF gene were determined via bisulfite sequencing. Results: BDNF plasma and methylation levels were significantly lower in healthy controls when compared with smokers across all time points. BDNF levels for smokers decreased significantly during the cessation period. Comparing the sexes, female smokers showed significantly lower plasma BDNF levels than healthy controls at baseline and over 14 days of cessation. Male and female smokers showed significantly higher mean methylation rates than non-smokers at baseline. In male smokers, mean methylation levels decreased significantly during the cessation period. Conclusion: Our findings replicate the findings of previous studies that BDNF plasma levels are altered in smokers. Furthermore, BDNF expression and gene methylation are altered during the first 14 days of cessation. Our novel findings of dysregulated methylation patterns in exon IV of the BDNF gene further support the thesis that BDNF plays a role in nicotine dependence.

Sex Disparities in Outcome of Patients with Alcohol-Related Liver Cirrhosis within the Eurotransplant Network-A Competing Risk Analysis.

Alcohol use disorder (AUD) is one of the most important risk factors for the development of alcohol-related liver cirrhosis (ALC). Importantly, psychiatrists are an integral part of the interdisciplinary care for patients with AUD and ALC. The aim of the current study was to investigate whether sex influences the outcome within this group of patients. For this purpose, data of all registrations for liver transplantations due to ALC within the Eurotransplant region from 2010 to 2019 were analyzed for sex disparities using competing risk models and in-between group comparisons. Relevant sex differences in registration numbers (24.8% female) and investigated outcomes were revealed. Risk ratios for a positive outcome, i.e., transplantation (0.74), and those of adverse outcomes, i.e., removal from waiting list (1.44) and death on waiting list (1.10), indicated a relative disadvantage for female patients with ALC. Further, women listed for liver transplantations were significantly younger than their male counterparts. Notably, sex disparities found in registration and outcome parameters were independent of differences found in the prevalence of AUD and liver transplantations. Further research is necessary to identify the underlying mechanisms and establish strategies to ensure equity and utility in liver transplantations due to ALC.

Seasonality in Major Depressive Disorder: Effect of Sex and Age.

BACKGROUND: Aside from the concept of seasonal affective disorder, the evidence for a seasonal pattern (SP) of major depressive disorder (MDD) is controversial. Furthermore, the effect of sex and age is still unclear. METHODS: This is a nationwide, registry-based study assessing all inpatient admissions in mental health hospitals due to MDD episodes according to ICD-10 (moderate (F32/33.1), severe (F32/33.2) and severe with psychotic features (F32/33.3)) in Austria across 14 years. Calculations were based on deviations from expected monthly admissions. RESULTS: The sample comprised 231,824 hospitalisations (36.8% men) for MDD. A significant SP (p=0.001) in moderate and severe depressive episodes in both women and men with decreased admission rates in the summer months and December was detected. In psychotic depression a significant SP was only evidenced in women (p = 0.002, men: p = 0.291). Patients older than 55 years had a reduced SP compared to those being younger. LIMITATIONS: Only anonymised admission data of inpatient treatments were available. Hospitalization rates cannot fully be equated to the occurrence of MDD. CONCLUSIONS: The current study indicates a seasonal variation in MDD symptoms that may go beyond seasonal affective disorder. Knowledge about the predictability of depressive symptoms in patients should encourage preventive strategies.

[Announced assisted suicide in Switzerland: a case report]. / Angekündigter assistierter Suizid in der Schweiz ­ Ein Fallbericht.

Assisted suicide is currently still prohibited in Austria. However, following a finding of the Austrian Constitutional Court it would be completely legal from 2022. A statutory regulation defining the limits between legal ways of assistance and the conditions therefor on the one hand and, on the other hand, assistive actions that shall remain prohibited is currently not in sight. However, a suicidal action performed upon the request of the person willing to die solely by someone else will remain illegal; this also applies if the person willing to commit suicide is physically unable to participate in her or his killing. In several European countries euthanasia and/or assisted suicide has already been legalized and in some countries, Switzerland for example, assisted suicide is a legal option even for patients without suffering from a life-limiting disease, unbearable suffering and insufficient treatment options are the only criteria. In this case report the clinical case of an Austrian patient will be presented, suffering from a personality disorder, who planed an assisted suicide in Switzerland. Ethic and legal backgrounds are discussed.The possibility of assisted suicide bears the danger that people suffering from psychiatric disorders, especially current major depressive episode, could refuse treatment options and choose suicide trough a commercial provider of assisted suicide.In particular it must be considered that currently severely depressed people usually suffer from limited insight and judgement as well as from limited freedom of choice.

Hazardous alcohol consumption among older adults: A comprehensive and multi-national analysis of predictive factors in 13,351 individuals.

BACKGROUND: Older adults exhibit heightened vulnerability for alcohol-related health impairments. Increases in the proportion of older adults within the European Union's total population and prevalence rates of alcohol use disorders in this age group are being observed. This large scale international study was conducted to identify those older adults with an increased risk to engage in hazardous drinking behaviour. METHODS: Socio-demographic, socio-economic, personality characteristics (Big Five Inventory, BFI-10), and alcohol consumption patterns of 13,351 individuals from 12 different European countries, collected by the Survey of Health, Aging, and Retirement in Europe, were analyzed using regression models. RESULTS: Age, nationality, years of education, as well as personality traits, were significantly associated with alcohol intake. For males, extraversion predicted increased alcohol intake (RR = 1.11, CI = 1.07-1.16), whereas conscientiousness (RR = 0.93, CI = 0.89-0.97), and agreeableness (RR = 0.94, CI = 0.90-0.99), were associated with a reduction. For females, openness to new experiences (RR = 1.11, CI = 1.04-1.18) predicted increased alcohol intake. Concerning excessive drinking, personality traits, nationality, and age-predicted consumption patterns for both sexes: Extraversion was identified as a risk factor for excessive drinking (OR = 1.15; CI = 1.09-1.21), whereas conscientiousness was identified as a protective factor (OR = 0.87; CI = 0.823-0.93). CONCLUSION: Hazardous alcohol consumption in the elderly was associated with specific personality characteristics. Preventative measures, crucial in reducing deleterious health consequences, should focus on translating the knowledge of the association of certain personality traits and alcohol consumption into improved prevention and treatment.

The effect of sex on suicide risk during and after psychiatric inpatient care in 12 countries-An ecological study.

BACKGROUND: Suicide risk in patients is markedly elevated during psychiatric inpatient care, as well as after discharge. However, it is unclear whether, and to what extent, this increased suicide risk varies between sex. Thus, the aim of this study was to analyze sex differences for suicides during and after psychiatric hospitalization in various countries. METHODS: National suicide mortality rates and inpatient-related suicide rates (three intervals: during psychiatric inpatient treatment, 1 month, and 1 year after discharge) from 12 countries for 2000-2016 were analyzed, and a logistic model was used to quantify the effect of sex. RESULTS: Persons admitted to or discharged from psychiatric inpatient care exhibited significantly increased rates of suicide compared to those in the general population. Furthermore, increase of suicide risk was significantly higher for females than for males for all investigated time intervals (inpatient suicide odds ratio [OR] 1.85; suicide within 1 month after discharge-OR 1.94; suicide within 1 year after discharge-OR 2.04). CONCLUSION: Analysis confirmed the time during and after psychiatric inpatient care to be significantly associated with an elevated risk for suicide. Further, a significant sex effect was observed, with females in this population being at a proportionally higher risk for suicide during psychiatric inpatient treatment as well as the year following discharge. Our study implicates that more effective suicide preventive measures during inpatient stay, focusing on female patients, are needed.

Does thiamine protect the brain from iron overload and alcohol-related dementia?

Alcohol-related dementia (ARD) is a common and severe co-morbidity in alcohol use disorder (AUD). We propose brain iron overload (BIO) to be an important and previously neglected pathogenic process, accelerating cognitive decline in AUD. Furthermore, we suggest thiamine, which is frequently depleted in AUD, to be a key modulator in this process: Thiamine deficiency impairs the integrity of the blood-brain barrier, thereby enabling iron to pass through and accumulate in the brain. This hypothesis is based on findings from animal, translational, and neuroimaging studies, discussed in this article. To validate this hypothesis, translational studies focusing on brain iron homeostasis in AUD, as well as prospective clinical studies investigating prevalence and clinical impact of BIO in AUD, should be conducted. If proven right, this would change the understanding of ARD and may lead to novel therapeutic interventions in prevention and treatment of ARD.

Pattern of inpatient care for depression: an analysis of 232,289 admissions.

BACKGROUND: The prevalence of major depressive disorder (MDD) in women is up to 50% higher as compared to men. However, little is known about discrepancies in health care utilization between depressed female and male patients. Consequently, the aim of the present study was to elucidate gender differences regarding the frequency of hospital admissions and the length of inpatient treatment for MDD across the lifespan. METHODS: This nationwide, registry-based study analyzed all inpatient admissions in psychiatric hospitals due to recurrent/non-recurrent MDD episodes according to ICD-10 (moderate (F32/33.1), severe (F32/33.2), severe with psychotic features (F32/33.3)) in Austria across 14 years. We calculated weekly admission rates per 100,000 patients by directly age-standardized rates. RESULTS: Across 232,289 admissions (63.2% female) the population based admission rates in MDD were significantly higher in women (p < 0.001). Female to male ratios across subgroups were 1.65 (F32/33.1), 1.58 (F32/33.2), 1.73 (F32/33.3), and peaked around 65 years (ratio ≥ 2 for all subgroups). Length of hospital stay for women was significantly longer in all depression subtypes (p < 0.001). CONCLUSIONS: Elevated rates of inpatient treatment in women cannot solely be explained by a higher MDD prevalence and are dependent on age and type of depressive episode. Irrespective of the type and severity of the mood episode, women exhibit longer hospitalisation times.

Screening for post-traumatic stress disorders in 1017 cancer patients and correlation with anxiety, depression, and distress.

OBJECTIVE: Post-traumatic stress disorder (PTSD) is a severe psychiatric disorder, which might develop after a traumatic event, like cancer diagnosis, and threatens the patient's psychological and/or physiological integrity. Anxiety, depression, and mental distress are known to be common in cancer patients; however, the frequency of PTSD was not investigated thoroughly in this patient group so far. Here, we aim to screen cancer patients for PTSD symptoms and determine a possible correlation with anxiety, depression, and distress. METHODS: The study was performed at the Divisions of Hematology and Oncology of the Medical University of Vienna from 2010 to 2018. Following written consent, patients were asked to fill out the validated self-assessment questionnaire for PTSS-10 and HADS. The study was approved by the institutional ethics committee of the Medical University of Vienna (EC Nr: 2255/2016). RESULTS: A total of 1017 adult cancer patients (513 male, 504 female) were included in a cross-sectional single-center study. Mean age was 57.6 years (SD 14.4 years); 31.7%, 14.6%, 13.2%, and 27.4% of patients outscored the predefined thresholds for self-assessed cases of PTSD, anxiety, depression, and distress, respectively. Compared with men, women showed a higher prevalence of symptoms for PTSD (38.9% vs 24.5%; P < .001) and anxiety (20.4% vs 8.6%; P < .001). The scores of HADS-A, HADS-D, and the combined HADS score (distress) were significantly correlated with PTSS-10 scores (P < .01). No differences in age were observed among the different score groups. CONCLUSION: The study shows a significant prevalence as well as a correlation of PTSD symptoms with anxiety, depression, and distress among cancer patients. Findings underscore the necessity of a serious screening for psychiatric disorders, especially in female patients. In order to enable multidisciplinary care for cancer patients and to reduce the burden for psychiatric disorders, interdisciplinary screening and treatment concepts, which take into account gender aspects, are urged.

Alcohol-Related Mortality in the WHO European Region: Sex-Specific Trends and Predictions.

AIMS: Alcohol is an important risk factor for morbidity and mortality, especially within the European region. Differences in per capita consumption and drinking patterns are possible reasons for regional differences and diverging trends in alcohol-related health outcomes. METHODS: Twenty-nine countries within the World Health Organization (WHO) European region were evaluated for trends and predictions in alcohol-related deaths within the last four decades using data available from the WHO Health for All database. RESULTS: Between 1979 and 2015, age-standardised death rates due to selected alcohol-related causes decreased significantly for both sexes in all assessed countries of the WHO European region, but regional differences are still pronounced. Assuming a similar trend in the future, the model predicted a further decrease until the year 2030. CONCLUSION: Even though alcohol-related mortality may have decreased within the last decades, the detrimental effects of alcohol consumption and alcohol dependence remain a considerable burden of disease within Europe.

Clustering suicides: A data-driven, exploratory machine learning approach.

Methods of suicide have received considerable attention in suicide research. The common approach to differentiate methods of suicide is the classification into "violent" versus "non-violent" method. Interestingly, since the proposition of this dichotomous differentiation, no further efforts have been made to question the validity of such a classification of suicides. This study aimed to challenge the traditional separation into "violent" and "non-violent" suicides by generating a cluster analysis with a data-driven, machine learning approach. In a retrospective analysis, data on all officially confirmed suicides (N = 77,894) in Austria between 1970 and 2016 were assessed. Based on a defined distance metric between distributions of suicides over age group and month of the year, a standard hierarchical clustering method was performed with the five most frequent suicide methods. In cluster analysis, poisoning emerged as distinct from all other methods - both in the entire sample as well as in the male subsample. Violent suicides could be further divided into sub-clusters: hanging, shooting, and drowning on the one hand and jumping on the other hand. In the female sample, two different clusters were revealed - hanging and drowning on the one hand and jumping, poisoning, and shooting on the other. Our data-driven results in this large epidemiological study confirmed the traditional dichotomization of suicide methods into "violent" and "non-violent" methods, but on closer inspection "violent methods" can be further divided into sub-clusters and a different cluster pattern could be identified for women, requiring further research to support these refined suicide phenotypes.

Maternal suicide during pregnancy and the first postpartum year in Austria: Findings from 2004 to 2017.

Suicide is one of the leading causes of maternal death during pregnancy and the first postpartum year. This retrospective investigation aimed at characterizing suicides in Austria during pregnancy and the first postpartum year between 2004 and 2017. We identified 10 suicides of pregnant/ postpartal women in that period, all of whom used violent methods, resulting in a maternal suicide rate of 0.89 per 100,000 birth events. The comparably low number of found suicides is arguably attributable to methodological issues in identifying perinatal suicides. Hence, a more comprehensive inquiry into perinatal deaths and further improvements in perinatal mental health care are called for.

End-stage liver disease in alcohol-dependent patients : Case report and overview on clinical management.

This case report is about a 44-year-old woman with alcohol-related end-stage liver disease. Initial contact with the patient was made in the alcohol-outpatient clinic of the Department of Psychiatry and Psychotherapy, Clinical Division of Social Psychiatry, Medical University of Vienna. Due to a particularly poor general condition, Child Pugh Score C/MELD Score 20, the patient was admitted to ward 4A, with the clinical and scientific focus of treating patients with alcohol use disorder. The withdrawal process was complicated by a multitude of factors associated with end-stage liver disease. By explaining the theoretical background of possible somatic as well as psychiatric complications of end-stage liver disease and elaborating on treatment options a comprehensive overview of the psychiatric and somatic management of this patient population is given.

[Descriptive examination of inpatient stays of patients with emotionally unstable personality disorder in Austria between 2001 and 2016 with special consideration of age, gender and length of stay]. / Deskriptive Untersuchung der stationären Aufenthalte von Patienten mit emotional instabiler Persönlichkeitsstörung in Österreich zwischen 2001 und 2016 mit besonderer Berücksichtigung von Alter, Geschlecht und Aufenthaltsdauer.

BACKROUND: Emotionally unstable personality disorder (EUPD) has a high prevalence worldwide and especially in in-patient psychiatric settings, varying in age and gender. Due to the complex clinical picture, repeated admissions and high costs, health systems are facing great challenges. METHODS: For the calculations Statistik Austria data of inpatient stays of patients with mental and behavioral disorders with special regard to EUPD as main discharge diagnosis in Austria in the period 2001-2016 were used. Included were patients with age over 14 years, admission to a psychiatric clinic in acute care and maximum length of stay of 365 days. Age, gender and length of stay were analyzed with SPSS®, evaluated in descriptive form and related to each other. RESULTS: The prevalence of EUPD within all mental and behavioral disorders was 4.0%. Of all personality and behavioral disorders, as well as specific personality disorders, EUPD had the highest prevalence (65.3% and 79.3%). About four times more women (79.8%) than men (20.2%) received inpatient treatment. Most patients (23.1%) were admitted at the age of 20-24 years. From 40 years of age the number of admissions clearly decreased. The largest percentage of men was found to be in the age group over 45 years (27.0%) and 183-365 inpatient days (27.0%), those of women aged 15-19 (83.4%) and 0 and 14-182 inpatient days (81.4% each). The average length of stay was 13 days for women and 12 days for men. 11.3% of patients left the clinic on the day of admission, 61.2% were treated for 1-13 days, 27.2% for 14-182 days, and 0.2% for 183-365 days.