High depression symptomatology and mental pain characterize suicidal psychiatric patients

Are visual analogue scales valid instruments to measure psychological pain in psychiatric patients?

OBJECTIVE

The Psychological-Physical-Pain Visual Analogue Scale (PPP-VAS) was thought to probably help in identifying patients at risk of suicide. However, no data on its validity to measure psychological pain was available. Our main aim was to investigate the convergent validity of the PPP-VAS using two well-validated scales of psychological pain, the Orbach and Mikulincer Mental Pain scale (OMMP) and the Holden et al. Psychache Scale.

METHODS

This multicentre study recruited a total of 1618 adult psychiatric inpatients and outpatients in Italy. Psychological pain was evaluated using the OMMP, Holden et al., and PPP-VAS scales. Psychiatric status, suicidal status, physical pain, depression, and hopelessness were also assessed.

RESULTS

A structural equation model (SEM) using the items of psychological pain from the PPP-VAS showed that items loaded significantly on the psychological pain factor and showed good fit. Similarly, a second SEM model using the three scales of psychological pain showed acceptable fit and converged into a psychological pain construct. Correlations between the PPP-VAS and depression, hopelessness, and physical pain showed moderate correlations (r = 0.43 to r = 0.67). Finally, psychological pain evaluated with the PPP-VAS was significantly related with recent suicidal ideation in all patients (OR [95 % CI] = 1.07 [1.05, 1.09]) and recent suicide attempts in moderately to severely depressed patients, OR [95 % CI] = 1.01 [1.02, 1.03].

CONCLUSION

The PPP-VAS showed good psychometric properties in evaluating psychological pain. The characteristics of the PPP-VAS makes this scale a great option for its use in clinical practice to detect patients at risk of suicide.

The relationship between chronotype and food addiction: Serial mediation of social jetlag and psychological pain

This study evaluates how food addiction is related to chronotype, social jetlag, and psychological pain. Of the participants (n = 1,035 university students), 16.6% had a morning chronotype, 25.1% had an evening chronotype, and 25.1% were clinically addicted to eating. The mean sleep durations for participants were 7.41 ± 2.18 h and 8.95 ± 3.0 h on weekdays and weekends, respectively. The mean misalignment time for social jetlag was 1.45 ± 1.5 h. Food addiction, psychological pain, and social jetlag levels were high among participants with the evening chronotype. The risk factors for food addiction included being female, having an evening chronotype, and having high body mass index levels and psychological pain. The total indirect effect of psychological pain and social jetlag on the relationship between chronotype and food addiction was 20.6%. However, the social jetlag effect is relatively minor compared to psychological pain. The significant conclusions of this study are as follows. Clinical food addiction is prevalent among students, and a strong direct correlation between chronotype and food addiction was observed. The study emphasizes the importance of being aware of chronotype and mental status in establishing a healthy diet and lifestyle.

The relationship between psychological pain and suicidality in patients with major depressive disorder: A meta-analysis

OBJECTIVE

To systematically review the association between psychological pain and suicidality in patients with major depressive disorder (MDD).

METHOD

The databases of PubMed, Web of Science and PsycINFO were used to search and articles were screened for inclusion and exclusion criteria until February 2022. Two researchers independently screened the papers, extracted data, and evaluated the risk of bias of the included studies. Comprehensive Meta-Analysis software (CMA) was used for meta-analysis and the combined OR (95 % CI) values were calculated.

RESULTS

A total of 7 articles were included, with a sample size of 1364. The present study showed that psychological pain was a risk factor for suicidality in patients with MDD (OR = 1.322, 95 % CI:1.165-1.500). After Duval and Tweedie trim and fill to rectify potential publication bias, psychological pain was still a risk factor for suicidality in patients with MDD [OR = 1.196 (95 % CI: 1.030-1.388), P < 0.001]. Subgroup analyses showed that average age ≥ 40 [r = 0.57 (95 % CI: 0.32-0.81), P < 0.001] was moderating variable for psychological pain and suicidality.

CONCLUSIONS

Reducing psychological pain in MDD patients is somewhat important for preventing their suicidality, especially for the patients with advancing age.

The state-trait sense of self inventory: A psychometric study of self-experience and its relation to psychosis-like manifestations

The sense of self is a fundamental construct in the study of the mind, yet its psychological nature remains elusive. We introduce a novel 25-item inventory to investigate selfhood both as an enduring trait and a temporary state. We hypothesized two foundational aspects of the self: identity (related to self-referencing and continuity over time) and agency (the perception of controlling own's actions and thoughts). Results from two population studies highlight a singular self-trait factor combining agency and identity. In contrast, self-state measures revealed a bifactorial structure with a high-order factor and three lower-order subfactors: state-identity, state-agency, and state-technology. These factors were predictive of psychosis-like experiences, schizotypal traits, and hopelessness. Mediation analysis demonstrated that the negative association between the sense of self and hopelessness is mediated by depressive manifestations. Our research provides a tool to shed new light on the complexity of the sense of self and its mental health implications.

Prevalence and correlates of severe anxiety in patients with first hospitalization for major depressive disorder combined with dyslipidemia: a large sample cross-sectional study

Background

Anxiety symptoms and dyslipidemia are common co-morbidities in patients with major depressive disorder (MDD), and there are complex pathophysiologic as well as clinical mechanisms underlying the association between the three. In this study, we investigated the prevalence and associated factors of severe anxiety in first-time hospitalized patients with MDD with dyslipidemia.

Methods

We included 708 patients with major depressive disorder with comorbid dyslipidemia and collected their sociodemographic and general clinical data as well as biochemical parameters such as lipids, thyroid function, and blood glucose. We also completed the Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), Positive Symptom Scale (PSS), and Clinical General Impression Scale (CGI) to assess their clinical symptoms.

Results

The prevalence of severe anxiety disorder was 11.02% in patients with MDD with comorbid dyslipidemia. Suicidal history, female gender, body mass index (BMI), HAMD score, PSS score, and FT4 level were risk factors for the development of severe anxiety symptoms. Higher HAMD scores, higher PSS scores, and suicidal history were influential factors in exacerbating severe anxiety symptoms.

Conclusion

This study reports and identifies the prevalence of severe anxiety symptoms in first-time hospitalized MDD patients with dyslipidemia, as well as risk factors for anxiety symptoms and factors influencing their severity, and these identified factors may be potentially helpful and informative in preventing and intervening in severe anxiety disorders in this target population.

On mental pain and suicide risk in modern psychiatry

Facing suicide risk is probably the most difficult task for clinicians when dealing with patients in crisis. It requires professional, intellectual, and emotional efforts. Suicide risk assessment can sometimes be distressing for clinicians, and such a state may favour the avoidance of an in-depth exploration of suicidal thoughts and behaviour. Patients often feel subjected to interpersonal assessments with little opportunity to explore their perspectives. The "One size fits all" approach tends to create distance and paradoxically contributes to an increase in the risk of suicide. Traditional clinical factors may be of limited value if a shared understanding of the patient's suicide risk is missed. To understand the suicidal mind, it is necessary to take the point of view of the subject in crisis. In this essay, the "operational model of mental pain as a main ingredient of suicide" provided by Edwin Shneidman' is overviewed with the aim of a better empathic understanding of patients' sufferance. With a phenomenological approach, the suicidal crisis appears as a complex, pervasive state rather than as a symptom of a mental disorder, as the new paradigm also suggests. In this regard, the "mentalistic" aspects of suicide propose a broader insight into the suicidal scenario far beyond the diagnosis of psychiatric disorders. In this article, the perspective of individuals who deem their mental pain to be intolerable is described to make sense of their ambivalence between the wish to die and the wish to live that can prevail if relief is provided.

The developmental process of suicidal ideation among adolescents: social and psychological impact from a nation-wide survey

Suicidal ideation is a multifactorial phenomenon that is increasingly prevalent among adolescents, especially following the impact of Covid 19 pandemic on their mental health. Its analysis necessitates an interdisciplinary approach that simultaneously considers sociological and psychological perspectives, especially looking at the role of interpersonal relationships and structural inequalities. The present study, based on a face-to-face survey conducted with a representative sample of 4288 adolescents, aims to identify the factors that most differentiate individuals with and without suicidal ideation, proposing a descriptive model of development process of this phenomenon with reference to the Italian context. We analysed variables related to socio-demographic status, relational status, social interactions, and psychological well-being using multiple correspondence analysis and logistic regression models. The results provide evidence for the existence of a direct association between negative psychological status and suicidal ideation but clarify that the psychological aspects are associated with sociodemographic characteristics and have their origins in the social sphere.

Suicide Attempts in an Italian Population with Cannabis Use Disorders: Results of a Follow-Up Study

The relationship between cannabis use and suicidal behavior is complex, with no consensus in the literature. We used electronic health records of national health services to identify individuals who received a diagnosis of Cannabis Use Disorder in the Metropolitan area of Bologna from 2009 to 2019. In this cohort we identified accesses to Emergency Departments for suicide attempts from 2009 to 2019. The Crude Suicide Rate for 1,000 Person Years was 2.5, higher in females, in patients with Alcohol Use Disorders, with any psychiatric diagnosis, within one year from the first visit, and during the COVID-19 period. The risk was over 22 times higher than in the general population. Considering the high prevalence of cannabis use in the general population and the consequent risk of Cannabis Use Disorders, these data suggest the importance of a clinical evaluation for suicidal risk.

Suicidal ideation across depressive episodes: 9-year longitudinal cohort study

BACKGROUND

Depression is a highly recurrent disorder, with more than 50% of those affected experiencing a subsequent episode. Although there is relatively little stability in symptoms across episodes, some evidence indicates that suicidal ideation may be an exception. However, these findings warrant replication, especially over longer periods and across multiple episodes.

AIMS

To assess the relative stability of suicidal ideation in comparison with other non-core depressive symptoms across episodes.

METHOD

We examined 490 individuals with current major depressive disorder (MDD) at baseline and at least one subsequent episode during 9-year follow-up within the Netherlands Study of Depression and Anxiety (NESDA). The Inventory of Depressive Symptomatology (IDS) was used to assess DSM-5 non-core MDD symptoms (fatigue, appetite/weight change, sleep disturbance, psychomotor disturbance, concentration difficulties, worthlessness/guilt, suicidal ideation) at baseline and 2-, 4-, 6- and 9-year follow-up. We examined consistency in symptom presentation (i.e. whether the symptom met the diagnostic threshold, based on a binary categorisation of the IDS) using kappa (κ) and percentage agreement, and stability in symptom severity using Spearman correlation, based on the continuous IDS scores.

RESULTS

Out of all non-core depressive symptoms, insomnia appeared the most stable across episodes (r = 0.55-0.69, κ = 0.31-0.47) and weight decrease the least stable (r = 0.03-0.33, κ = 0.06-0.19). For suicidal ideation, correlations across episodes ranged from r = 0.36 to r = 0.55 and consistency ranged from κ = 0.28 to κ = 0.49.

CONCLUSIONS

Suicidal ideation is moderately stable in recurrent depression over 9 years. Contrary to prior reports, however, it does not exhibit substantially more stability than most other non-core symptoms of depression.

Interpersonal Needs, Mental Pain, and Hopelessness in Psychiatric Inpatients with Suicidal Ideation

INTRODUCTION

Suicide is a leading cause of death worldwide and models may help the understanding of the phenomenon and ultimately reduce its burden through effective suicide prevention strategies. The Interpersonal Theory of Suicide and Shneidman's Model have tried to describe different unmet needs related to suicidal ideation. The study aims to assess the association between thwarted belongingness, perceived burdensomeness, and suicidal ideation in a sample of psychiatric inpatients and the mediating role of hopelessness and mental pain in this association.

METHODS

112 consecutive adult psychiatric inpatients were administered the Columbia Suicide Severity Rating Scale (C-SSRS), the Italian version of the Interpersonal Needs Questionnaire-15-I (INQ-15-I), the Physical and Psychological Pain Scale, and the Beck Hopelessness Scale (BHS).

RESULTS

Mediation models indicated a significant indirect effect of perceived burdensomeness (with thwarted belongingness as covariates) on suicidal ideation intensity with hopelessness as a mediator. When thwarted belongingness (controlling for perceived burdensomeness as a covariate) was included in a model as an independent variable, direct and indirect effects on suicidal ideation intensity were not significant.

CONCLUSIONS

Psychosocial interventions focusing on identifying and decreasing the perception of being a burden for others and the feeling hopeless could represent a powerful pathway for reducing suicidal ideation. Moreover, the attention toward unmet interpersonal needs may help increase and focus clinical discussions on risk factors, which may help engagement toward psychiatric care and downsize the stigma related to suicide. Raising awareness toward mental health topics is a goal of healthcare services globally.

Complex post-traumatic stress disorder (cPTSD) and suicide risk: A multigroup mediation analysis exploring the role of post-traumatic symptomatology on hopelessness

Complex post-traumatic stress disorder (cPTSD) is a clinical condition that features not only PTSD symptoms, but also disturbances in self-organization. Patients with cPTSD have a higher incidence of psychiatric comorbidities, including suicidality. A key construct tightly related to suicidality is hopelessness, described as a feeling of despair, with a state of mind giving low or negative expectancies regarding one's future. Since there is a paucity of studies investigating the link between cPTSD and hopelessness as a risk factor for suicidality, the aim of this study was to examine the role of post-traumatic symptomatology as the primary driver of suicidality, as measured by hopelessness. 211 patients were enrolled and divided into two groups: PTSD (143 patients) and cPTSD (78 patients). A set of standardized measures was administered to study post-traumatic symptomatology, depression, and hopelessness. The results showed that compared to PTSD, cPTSD patients experienced more severe symptoms in all clinical outcomes (p < 0.001). The mediation analysis revealed a significant positive association between post-traumatic symptomatology and hopelessness in the cPTSD group, which was not significant in the PTSD group. Among PTSD patients, depression mediated 43.37% of the impact of post-traumatic symptomatology on suicidal ideation. Our results contribute to a better understanding of complex post-traumatic symptomatology, further highlighting its role in the pathogenesis of suicidality. Hence, these findings have important clinical implications, suggesting that targeted, trauma-focused interventions might effectively prevent hopelessness and therefore suicide risk in patients with cPTSD.

Association of family function and suicide risk in teenagers with a history of self-harm behaviors: mediating role of subjective wellbeing and depression

Background

A history of self-harm behaviors is closely associated with subsequent suicide death. Although many factors associated with suicide have been identified, it remains unclear how these factors interact to influence suicide risk, especially among teenagers with a history of self-harm behaviors.

Methods

Data were collected from 913 teenagers with a history of self-harm behaviors through a cross-sectional study. The Family Adaptation, Partnership, Growth, Affection, and Resolve index was used to assess teenagers' family function. The Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 were used to evaluate depression and anxiety in teenagers and their parents, respectively. The Delighted Terrible Faces Scale was used to assess teenagers' perception of subjective wellbeing. The Suicidal Behaviors Questionnaire-Revised was used to evaluate teenagers' suicide risk. Student's t-test, one-way ANOVA, multivariate linear regression, Pearson's correlation, and a structural equation model (SEM) were applied to data analysis.

Results

Overall, 78.6% of teenagers with a history of self-harm behaviors were at risk for possible suicide. Female gender, severity of teenagers' depression, family function, and subjective wellbeing were significantly associated with suicide risk. The results of SEM suggested that there was a significant chain mediation effect of subjective wellbeing and depression between family function and suicide risk.

Conclusion

Family function was closely associated with suicide risk in teenagers with a history of self-harm behaviors, and depression and subjective wellbeing were sequential mediators in the association between family function and suicide risk.

Sensitivity to ostracism is blunted in suicide attempters only when they report suicidal ideation

BACKGROUND

Modified pain perception is at the core of many theories on suicide; however, studies on the relationship between pain perception and suicidal behavior (attempt) have produced contradictory results. In this experimental study, we investigated whether physical pain and social pain are concomitantly influenced by suicidal ideation (SI) and past suicidal behavior.

METHODS

155 inpatients with depression (90 with and 65 without past history of suicide attempt) were included. They underwent thermal stimulation of the skin to assess physical pain tolerance and played the Cyberball game to assess their sensitivity to ostracism (social pain). Participants self-assessed current SI through the specific item in the Beck Depression Inventory.

RESULTS

Pain tolerance was not associated with history of suicide attempt, current SI, and their interaction. Social pain was associated with the interaction between history of suicide attempt and current SI. Social pain was decreased in suicide attempters, compared with non-attempters, only when they reported current SI.

LIMITATIONS

Cyberball game may not be representative of everyday stress and ecological social context.

CONCLUSIONS

Unlike what suggested by many theories, pain tolerance does not seem to be necessary to attempt suicide. Suicide attempters with current SI displayed blunted sensitivity to ostracism and could be less willing to restore social affiliation compared with non-attempters.

Clinical experiences with intranasal esketamine for major depressive disorder resistant to treatment and with a psychiatric emergency: case presentations

Recently, esketamine became availableas an intranasal formulation, proposed for treatment-resistant depression (TRD). Three cases of TRD are presented, two with features of a psychiatric emergency. The first case is a 35-year-old man with MDD onset at the age of 27 years, with five previous failed therapies. The second patient is a middle-aged man with a 21-year MDD onset and six previous antidepressant treatments discontinued for poor therapeutic effects and tolerability. He also presented suicidal ideation with intent and a history of a failed suicide attempt by self-cutting his forearms. The third case is a 28-year-old female with a first MDD episode in 2020, treated first with amitriptyline and then with intravenous clomipramine. She had a history of a previous suicide attempt by self-cutting and, by her admission, showed active suicidal ideation with intent. In all three cases, a rapid reduction of depressive symptoms was observed with a subsequent complete resolution of suicidal ideation and intent in the two patients with such risk. Intranasal esketamine treatment was carried out with concomitant oral antidepressant therapy. The third patient reported the only recorded side effect: dissociation 20 min after every esketamine administration. Our preliminary experience proved esketamine's effectiveness on TRD symptoms and successful outcomes in psychiatric emergencies such as suicide risk.

Low global frontal brain activity is associated with non-planned or impulsive suicide attempts. A preliminary study

BACKGROUND

Suicide prevention is limited by the frequent non-planned or impulsive nature of suicidal behavior. For instance, 25-62 % of suicide attempts, occur within 30 min of the onset of suicidal ideation. We aimed to examine frontal brain activity in depressed patients following a suicide attempt and its relationship with the duration of the suicidal process.

METHODS

We recruited 35 adult patients within three days of a suicide attempt of at least moderate lethality. Duration of the suicidal process was recorded in a semi-structured interview, including suicide contemplation (time from onset of suicidal ideation to decision to kill oneself) and suicide action intervals (time from the decision to kill oneself to suicide attempt). Resting state EEG data from AF7, AF8, TP9 and TP10 leads was collected with a portable MUSE 2 headband system. The average frequency values throughout a 5-minute portable EEG recording were extracted for delta (1-4 Hz), theta (4-8 Hz), alpha (8-13 Hz), and beta (13-30 Hz) waves.

RESULTS

Delta (r = 0.450, p = 0.021) and theta power (r = 0.395, p = 0.044) were positively correlated with the duration of the suicide action interval. There were no significant correlations of the suicide contemplation interval with clinical or EEG measures. Patients with suicide action interval shorter than 30 min showed lower delta power (U = 113, p = 0.049) compared with those with longer duration.

CONCLUSIONS

Lower theta and delta activity may reflect hindered cognitive control and inhibition in impulsive suicide attempters. Portable EEG may provide a valuable tool for clinical research and in the management of acutely suicidal patients.

The Impact of Affective Temperaments on Suicidal Ideation and Behaviors: Results from an Observational Multicentric Study on Patients with Mood Disorders

Suicide ideation and behaviors are major health issues in the field of mental health. Several psychological and psychosocial factors have been taken into account as possible predictors of suicidality. Only recently affective temperaments have been considered as possible factors linked to suicide. This study aims to investigate the relationship between affective temperaments and suicidality, including the lifetime onset of suicide ideation, lifetime presence of suicide attempts and the total number of lifetime suicide attempts. This is a naturalistic multicentric observational study, involving outpatient units of seven University sites in Italy. Patients were administered with the short version of TEMPS-M and the Columbia Suicide Severity Rating Scale. A total of 653 participants were recruited, with a diagnosis of bipolar (55.7%), unipolar (35.8%) and cyclothymic disorder (8.4%). Regression models showed that the presence of lifetime suicide behaviors was increased in patients presenting trait related impulsivity (p < 0.0001), poor free-interval functioning (p < 0.05), higher number of affective episodes (p < 0.01), higher number of hospitalizations (p < 0.0001), cyclothymic and irritable affective temperaments (p < 0.05 and p < 0.05, respectively). Conversely, the presence of hyperthymic affective disposition reduced the likelihood of having suicidal behaviors (p < 0.01). Lifetime suicidal ideation was associated with trait-related impulsivity (p < 0.001), poor free-interval functioning (p < 0.05), higher number of affective episodes (p < 0.001) and of hospitalizations (p < 0.001). Depressive temperaments increased the likelihood of presenting suicidal ideation (p < 0.05), along with irritable temperaments (p < 0.01), contrary to hyperthymic affective (p < 0.05). Results of the present study confirm that affective disposition has a significant impact on the onset of suicidal ideation and behaviors, and that affective dispositions should be assessed in clinical settings to identify people at risk of suicide. Moreover, a wider clinical evaluation, including different clinical psychopathological dimensions, should be taken into consideration to develop effective preventive interventions.

What influences psychological functioning in patients with mood disorders? The role of clinical, sociodemographic, and temperamental characteristics in a naturalistic study

BACKGROUND

The present study aims to assess clinical and psychological correlates of psychological functioning in patients with mood disorders, in a naturalistic setting. In particular, we aimed to describe which sociodemographic, clinical, and temperamental dispositions are more frequently associated with poor psychological functioning, and to describe the association between cognitive and psychological functioning in euthymic patients with major depression and bipolar disorder.

METHODS

Inclusion criteria were as follows: (1) diagnosis of major depression, or bipolar disorder type I or II; (2) age between 18 and 65 years; and (3) being in a stable phase of the disorder. Patients' psychiatric symptoms, quality of life, affective temperaments, and impulsivity were investigated with validated assessment instruments.

RESULTS

166 patients have been recruited, mainly female (55.4%), whose mean age was 47.1 ± 14.2 years. 42.6% of individuals reported a diagnosis of major depression. According to regression analyses, poor cognitive performance (p < 0.05), reduced perceived quality of life (p < .0001), lifetime suicide attempts (p < 0.01), and increased trait-related impulsivity (p <0 .001) strongly correlated with poor psychological functioning. Moreover, cyclothymic and irritable dispositions were also associated with poor social functioning (p < 0.01), whereas hyperthymic affective disposition was associated to a better psychological performance (p < 0.01).

CONCLUSIONS

Our results support the evidence that patients with mood disorders should be assessed for psychological functioning and affective dispositions, to identify patients at higher risk to develop worse long-term outcomes and to develop targeted interventions.