Comparison of Suicide Risk by Mental Illness: a Retrospective Review of 14-Year Electronic Medical Records

Risk of retinal disease and visual impairment in individuals with psychiatric disorders

BACKGROUND/OBJECTIVES

Individuals with a psychiatric disease have been reported to have structural variations in the retina, but how this affects retinal disease risk and vision loss is poorly understood. This study evaluated the risk of retinal disease and visual impairment in individuals with psychiatric disorders.

SUBJECTS/METHODS

An exploratory retrospective cohort study was conducted through a federated health research network that aggregates de-identified EHR data of over 95 million individuals across 50 healthcare organizations. Individuals ages 50-89 were identified for schizophrenia, bipolar disorder (BD), major depressive disorder (MDD), retinal disease, and visual impairment defined by vision loss or blindness using ICD-10 codes. Individuals were propensity score matched (PSM) on age, sex, race, ethnicity, hypertension, diabetes, and dyslipidaemias. Risk ratio calculation and statistical analyses were conducted through the network's analytics tool utilizing 95% confidence intervals.

RESULTS

After PSM, the schizophrenia cohort had 160,414 matched individuals (average age 65), 391,440 in the BD cohort (64), and 1,962,380 in the MDD cohort (67). A recorded diagnosis of schizophrenia was associated with a decreased likelihood of having a retinal disease diagnosis, while recorded diagnoses of BD and MDD were associated with an increased likelihood. Across all psychiatric disorders, individuals with a retinal disease diagnosis had an increased risk of visual impairment compared to individuals with a retinal disease alone.

CONCLUSION

Recorded diagnoses of BD and MDD were associated with an increased likelihood of having a retinal disease diagnosis. Across all psychiatric disorders, individuals with a concurrent retinal disease were more likely to have a visual impairment diagnosis.

Anti-Suicidal Effects of Lithium, Ketamine, and Clozapine-A 10-Year Systematic Review

Background/Objectives: Suicide is a complex issue resulting in approximately 700,000 deaths annually. Individuals with mood disorders or schizophrenia are at an increased risk. Pharmacological interventions, such as lithium, clozapine, and ketamine, show promise in reducing suicidality. Methods: A systematic search was conducted across Google Scholar, Scopus, and PubMed to identify studies evaluating the effects of lithium, clozapine, and ketamine on suicidality. Peer-reviewed articles published between 2014 and 2024 that focused on adult populations were included. After screening 1297 records, 49 studies met the eligibility criteria: 14 on lithium, 23 on ketamine, and 12 on clozapine. Results: Multiple studies highlight lithium's significant anti-suicidal effects in patients with bipolar disorder, showing superior suicide risk reduction compared to valproate and other mood stabilizers. Ketamine has been shown to rapidly reduce suicidal ideation, with effects observable within hours and lasting up to a week. While most studies support its short-term efficacy, findings regarding its long-term benefits and the impact of repeated dosing remain inconsistent. Clozapine has consistently demonstrated a reduction in suicide risk for individuals with schizophrenia. Large-scale cohort studies report a significant decrease in suicide attempts and mortality when compared to other antipsychotics. Conclusions: Lithium, ketamine, and clozapine were proven to be effective in reducing suicidality. However, limited data, adherence challenges, and methodological differences across studies highlight the need for more robust, large-scale experimental research. Effective suicide prevention is an extremely complex topic and also requires consideration of healthcare and social system factors.

Neuroimaging as a Tool for Advancing Pediatric Psychopharmacology

Neuroimaging, specifically magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), and positron emission tomography (PET), plays an important role in improving the therapeutic landscape of pediatric neuropsychopharmacology by detecting target engagement, pathway modulation, and disease-related changes in the brain. This review provides a comprehensive update on the application of neuroimaging to detect neural effects of psychotropic medication in pediatrics. Additionally, we discuss opportunities and challenges for expanding the use of neuroimaging to advance pediatric neuropsychopharmacology. PubMed and Embase were searched for studies published between 2012 and 2024 reporting neural effects of attention deficit hyperactivity disorder (ADHD) medications (e.g., methylphenidate, amphetamine, atomoxetine, guanfacine), selective serotonin reuptake inhibitors (e.g., fluoxetine, escitalopram, sertraline), serotonin/norepinephrine reuptake inhibitors (e.g., duloxetine, venlafaxine), second-generation antipsychotics (e.g., aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone), and others (e.g., lithium, carbamazepine, lamotrigine, ketamine, naltrexone) used to treat pediatric psychiatric conditions. Of the studies identified (N = 57 in 3314 pediatric participants), most (86%, total participants n = 3045) used MRI to detect functional pathway modulation or anatomical changes. Fewer studies (14%, total participants n = 269) used MRS to understand neurochemical modulation. No studies used PET. Studies that included healthy controls detected normalization of disease-altered pathways following treatment. Studies that focused on affected youth detected neuromodulation following single-dose and ongoing treatment. Neuroimaging is positioned to serve as a biomarker capable of demonstrating acute brain modulation, predicting clinical response, and monitoring disease, yet biomarker validation requires further work. Neuroimaging is also well suited to fill the notable knowledge gap of long-term neuromodulatory effects of psychotropic medications in the context of ongoing brain development in children and adolescents. Future studies can leverage advancements in neuroimaging technology, acquisition, and analysis to fill these gaps and accelerate the discovery of novel therapeutics, leading to more effective prescribing and ensuring faster recovery.

Mood disorders and suicide: pilot study on postmortem toxicologic evidence and adherence to psychiatric therapy by determining blood levels of medications

Suicide is one of the leading causes of death today, and among all mental illness, mood disorders account for one of the main risk factors. It is well known and proven that suicides are very common among people undergoing treatment and prescribed psychiatric medication. So far, however, there have only been a few studies dealing with this particular phenomenon. For this reason, autopsy patients who died by suicide, suffered from a mood disorder, and were known to be taking psychiatric medication at the time of death were selected for this study. The blood and urine samples taken during the autopsy underwent toxicological analysis and the results were compared with the prescribed therapy. A total of 22 people were included in the study: 12 presenting with depression and 10 with bipolar disorder. The toxicological analysis revealed that only 6 cases (27%) showed a qualitative match with the prescribed medication. In 5 cases (22.7%) the medication was only partially complied with and in 11 cases (50%) it was not complied with at all. Furthermore, even when medication was present, the value was often below the therapeutic range. Overall, more than 70% of the test subjects adhered to their medication only partially or not at all. Since treatment adherence is considered as a key factor in reducing the risk of suicide, this inevitably raises relevant clinical and forensic questions. Against this background, prospective monitoring of post-mortem medication levels in suicidal individuals and synergistic collaboration between clinicians and forensic pathologists could help to evaluate the effectiveness of specific medical interventions, highlight existing critical problems and develop new approaches to suicide prevention.

Suicide Rates and Subgroups With Elevated Suicide Risk Among Patients With Psychiatric Disorders: A Nationwide Cohort Study in Korea

BACKGROUND

Despite the distinctly high risk of suicide among patients with psychiatric disorders, little is known regarding the nationwide rates and risk factors for suicide among individual subgroups of patients with psychiatric disorders. This study aimed to assess differences in suicide rates and identify risk factors for suicide across multiple psychiatric diseases using data from a nationally representative cohort in Korea.

METHODS

Six groups of incident patients with psychiatric disorders, namely those with drug use disorder (DUD), alcohol use disorder (AUD), schizophrenia (SCZ), bipolar disorder (BD), depressive disorder (DD), or other affective disorders (OADs), were extracted from the National Health Information Database and followed up. Suicide rates and risk factors were then determined for each disease group.

RESULTS

Patients with psychiatric disorders had higher suicide rates than did the general population, with standardized mortality ratios (SMRs) ranging from 2.5 to 16.6. In particular, patients with DUD showed markedly higher suicide rate (584.0 per 100,000 person-years [PYs]; SMR, 16.6) than did patients with affective disorders, including DD (119.8 per 100,000 PYs; SMR, 3.1). AUD, DUD, SCZ, and BD showed lower male/female suicide rate ratios (1.1-1.4) than did depressive and OADs (2.2-2.4). Old age increased the risk for suicide among those with DUD and OADs, while medical aid recipients exhibited the lowest suicide risk among those with the AUD and SCZ. Male sex and the presence of multiple psychiatric comorbidities were consistently identified as suicide risk factors across mental illness subgroups.

CONCLUSION

The current study observed substantial variations in suicide rates and risk factors across psychiatric disorders and patient characteristics, which have significant implications for suicide prevention strategies.

Substance use and risk of suicide among adults who sought mental health and addiction specialty services through a centralised intake process in Nova Scotia: a cross-sectional study

OBJECTIVES

The objectives of this study are as follows: (1) to estimate the prevalence of suicide risk among individuals seeking mental health and addiction (MHA) services in Nova Scotia; (2) to examine the relationship between substance use and suicide risk among this population.

SETTING

MHA intake programme, a province-wide centralised intake process established in 2019 by the Department of Health and Wellness of Nova Scotia.

PARTICIPANTS

We included 22 500 MHA intake clients aged 19-64 years old who contacted MHA intake from 2020 to 2021.

PRIMARY OUTCOME MEASURES

During the intake assessment, clients were assessed for suicide risk (past suicide attempt, suicidal ideation during the interview or 2 weeks before the interview).

RESULTS

The lifetime prevalence of suicide attempt was 25.25% in the MHA clients. The prevalence of mild and moderate/high suicide risk was 34.14% and 4.08%, respectively. Clients who used hallucinogens had the highest prevalence of mild and moderate/high suicide risk (61.3% and 12.9%, respectively), followed by amphetamine/methamphetamine (47.6% and 13.3%, respectively) and sedative/hypnotics (47.2% and 8.9%, respectively) users. Stimulant (aOR=1.84, 95% CI 1.23 to 2.75) and hallucinogen (aOR=3.54, 95% CI 1.96 to 6.43) use were associated with increased odds of moderate/high suicide risk compared with denying current use. Additionally, alcohol (aOR=1.17, 95% CI 1.06 to 1.30) and tobacco (aOR=1.20, 95% CI 1.10 to 1.30) use were associated with increased odds of mild suicide risk.

CONCLUSION

Suicide behaviours were prevalent among clients seeking MHA services. Substance use is an important factor associated with suicide risk in this population. This result underscored the importance of considering substance use patterns when assessing suicide risk and highlighted the need for targeted interventions and preventive measures for individuals engaging in substance use. Future interventional studies are needed to identify and evaluate effective strategies for reducing substance use and suicide risk among clients of MHA central intake.

Evaluation of a student pharmacist-led depression screening program in a community pharmacy

Introduction

One in 5 adults in the United States have depression and are at risk for suicide, the 11th leading cause of death in the United States. Community pharmacy settings are ideal for increasing access to mental health services. Our objectives were to assess PHQ-9 scores and evaluate participant satisfaction in a student pharmacist-led depression screening program in a community pharmacy.

Methods

Student pharmacists trained in mental health first aid recruited participants 18 to 90 years old in a community pharmacy to complete the PHQ-9 and provided mental health education, referrals, and resources. A 2-week follow-up was completed, and participants reported on actions taken since the initial visit. Descriptive statistics, independent t tests, and χ 2 tests were used in data analysis.

Results

Twelve depression screening events were held, and 70 participants completed the screenings. The mean age was 52 years, and 75.7% were female. PHQ-9 scores ranged from 0 to 24 with an average of 3.96. Most participants (92.9%) reported the depression screening program was helpful. More than 90% of participants completed the 2-week follow-up, and 92.3% reported being comfortable seeking mental health services from a pharmacist. About half (53.8%) reported reading the educational materials, 24.6% helped a friend or family member, and 16.9% made an appointment with their health care provider.

Discussion

Student pharmacists successfully provided depression screenings and mental health education in a community pharmacy. Most participants had low PHQ-9 scores, found the program helpful, and are willing to utilize mental health services in a community pharmacy.

Development of a Clinical Guideline for Suicide Prevention in Psychiatric Patients Based on the ADAPTE Methodology

OBJECTIVE

Suicide is a significant public health issue, with South Korea having the highest suicide rate among Organisation for Economic Cooperation and Development countries. This study aimed to develop clinical guidelines for suicide prevention in psychiatric patients in Korea using the ADAPTE methodology.

METHODS

The development process involved a comprehensive review of literature, expert consultations, and consensus-building using the Nominal Group Technique and Delphi method. The guidelines focus on evidence-based psychiatric treatments, including both pharmacological and non-pharmacological approaches, tailored to the Korean context. Key findings underscoring the need for standardized treatment protocols for patients with major psychiatric disorders, including bipolar disorder, major depressive disorder, and schizophrenia.

RESULTS

The guidelines incorporate treatments like lithium, clozapine, atypical antipsychotics, electroconvulsive therapy, and cognitive behavioral therapy, which have shown effectiveness in suicide prevention. Applicability and acceptability within Korea's healthcare system were addressed, ensuring feasibility given the country's medical insurance coverage and accessibility. The guidelines were validated through expert reviews and Delphi rounds, achieving consensus on the final recommendations.

CONCLUSION

The developed guidelines provide a structured, evidence-based approach to reducing suicide rates among psychiatric patients in Korea. Future research will focus on expanding these guidelines to include screening protocols for high-risk groups.

Comparing suicide completion rates in bipolar I versus bipolar II disorder: A systematic review and meta-analysis

BACKGROUND

Bipolar disorder (BD) has a high disease burden and the highest mortality risk in BD comes from suicide. Bipolar disorder type II (BD-II) has been described as a milder form of bipolar disorder; however, extant literature is inconsistent with this description and instead describe illness burden and notably suicidality comparable to persons with bipolar I disorder (BD-I). Towards quantifying the hazard of BD-II, herein we aim via systematic review and meta-analysis to evaluate the rates of completed suicide in BD-I and BD-II.

METHOD

We conducted a literature search on PubMed, OVID (Embase, Medline) and PsychINFO databases from inception to June 30th, 2023, according to PRISMA guidelines. Articles were selected based on the predetermined eligibility criteria. A meta-analysis was performed, comparing the risk of completed suicide between individuals diagnosed with BD-I to BD-II.

RESULTS

Four out of eight studies reported higher suicide completion rates in persons living with BD-II when compared to persons living with BD-I; however, two of the studies reported non-significance. Two studies reported significantly higher suicide completion rates for BD-I than BD-II. The pooled odds ratio of BD-II suicide rates to BD-I was 1.00 [95 % CI = 0.75, 1.34].

LIMITATIONS

The overarching limitation is the small number of studies and heterogeneity of studies that report on suicide completion in BD-I and BD-II.

CONCLUSION

Our study underscores the severity of BD-II, with a risk for suicide not dissimilar from BD-I. The greater propensity to depression, comorbidity and rapid-cycling course reported in BD-II are contributing factors to the significant mortality hazard in BD-II.

Psychotropic Medications Promote Time-Dependent Reduction of Suicidal Ideation in Mood Disorder: A Prospective Cohort Study

BACKGROUND

Despite a plethora of research on the topic, there is still no solid evidence that pharmacological treatment actually reduces the risk of suicide in patients with mental illness. In this study, we aimed to assess the effect of psychotropic medications on suicidal ideation in patients with major depressive disorder (MDD) and bipolar disorder (BPD) in two age groups: less than 25 years and 25 years and older.

METHODS

We analyzed 312 patients with mood disorders with current suicidal thoughts or recent suicide attempts. We followed the participants from baseline for 6 months and assessed changes in suicidal ideation with Columbia-Suicide Severity Rating Scale (C-SSRS). The effect of psychotropic drug administration on suicidal ideation over time was analyzed using a linear mixed model.

RESULTS

In patients aged 25 years and older with mood disorders, suicidal ideation was more severe when using psychotropic drugs than when not using them. However, suicidal ideation decreased rapidly over time. The time-dependent reduction in suicidal ideation was accelerated when using antidepressants and sedatives/hypnotics in adult MDD, and when using mood stabilizers in adult BPD. However, this effect was not observed in participants aged less than 25 years.

CONCLUSION

Adequate psychotropic medication may reduce suicidal ideation in patients with mood disorders aged 25 years and older. Additional research on psychotropic drugs is needed to effectively reduce the risk of suicide among children and adolescents with mood disorders.

Suicide Probability Among Patients With Schizophrenia and Bipolar Disorder

PURPOSE

To evaluate the possibility of suicide and related factors among individuals with schizophrenia and bipolar disorder (BD).

METHOD

Data were collected for 270 individuals registered in a community mental health center using the Suicide Probability Scale (SPS). Subsequently, t test and multiple linear regression analyses were conducted on independent samples.

RESULTS

There was no statistically significant difference found between mean SPS scores of participants with schizophrenia and BD. However, hostility subscale mean scores of participants with schizophrenia were higher than those of participants with BD, and the difference was statistically significant. Sex, family history of mental illness, need for help with medication, suicidal ideation in the past 10 days, and number of suicide attempts were important predictors of suicide probability.

CONCLUSION

Individuals with schizophrenia and BD and in remission should be evaluated periodically for the possibility of suicide. [Journal of Psychosocial Nursing and Mental Health Services, 62(8), 37-45.].

Bing Neel Syndrome: A Rare Contributing Factor of Psychosis and Suicidality

ABSTRACT

Suicide rapidly increased in the United States by 30% from 2000 to 2020, accounting for more than 800,000 deaths ( Neurosci Res Program Bull . 1972; 10: 384-8). Studies have shown that there are a multitude of underlying issues, including mental illness, that elevate an individual's risk of dying by suicide ( CDC WONDER: Underlying cause of death, 1999-2019 . Atlanta, GA: US Department of Health and Human Services, CDC; 2020). Presented here is a case of Bing Neel syndrome (BNS) found in a 69-year-old man who died by suicide by jumping off a 135' bridge. His medical history was significant for traumatic brain injury, Waldenstrom macroglobulinemia (WM), major depressive disorder, suicidal ideation, and anxiety. Bing Neel syndrome is a rare central nervous system complication of WM. His wife reported an abrupt mental deterioration starting 5 years before his death, characterized by paranoia, depression, and insomnia. He had been a high-functioning university professor. His decline culminated with the loss of independence in his activities of daily living. At autopsy, it was found that he experienced blunt force injuries related to the fall, causing his death. A neuropathologic examination revealed a brisk and fulminant clonal CD20 + /immunoglobulin M+ lymphocytic infiltrate, involving all sampled regions of his brain, consistent with WM. This workup was critical to obtaining an accurate pathologic diagnosis of BNS and understanding his full clinical status before death. Although BNS was not the proximate cause of death, this diagnosis aided the death investigation as a causal factor in his suicidality and was vital to providing his family closure.

The Effect of Herbal Medicine on Suicidal Behavior: A Protocol for Systematic Review and Meta-Analysis

Suicide is an important social and medical problem worldwide, including in countries that use traditional East Asian medicine (TEAM). Herbal medicine (HM) has been reported to be effective against several suicide-related conditions. This systematic review aimed to investigate the efficacy and safety of HM in reducing suicidal behavior including suicidal ideation, attempts, or completed suicide. We conduct a comprehensive search in 15 electronic bibliographic databases from inception to September 2022. All types of prospective clinical studies-including randomized controlled clinical trials (RCTs)-involving HM without or with routine care are included. The primary outcomes of this review are validated measures of suicidal ideation including the Beck scale for suicidal ideation. The revised Cochrane's risk of bias tool and other tools including the ROBANS-II tool are used to assess the methodological quality of RCTs and non-RCTs, respectively. A meta-analysis is performed using RevMan 5.4 in cases of homogeneous data from controlled studies. The results of the systematic review provide high-quality evidence to determine the efficacy and safety of HM for suicidal behavior. Our findings are informative for clinicians, policymakers, and researchers, aimed at reducing suicide rates, especially in countries that use TEAM.

Association between Self-Stigma and Suicide Risk in Individuals with Schizophrenia: Moderating Effects of Self-Esteem and Perceived Support from Friends

This cross-sectional study assessed the moderating effects of self-esteem and perceived support from friends on the association between self-stigma and suicide risk in individuals with schizophrenia. We included 300 participants (267 with schizophrenia and 33 with schizoaffective disorder). Suicide risk was assessed using items adopted from the suicide module of the Mini-International Neuropsychiatric Interview; self-stigma was assessed using the Self-Stigma Scale-Short; perceived support from friends was assessed using the Friend Adaptation, Partnership, Growth, Affection, and Resolve Index; and self-esteem was assessed using the Rosenberg Self-Esteem Scale. A moderation analysis was performed to examine the moderating effects of self-esteem and perceived support from friends on the association between self-stigma and suicide risk. The results indicated that self-stigma was positively associated with suicide risk after the effects of other factors were controlled for. Both perceived support from friends and self-esteem significantly reduced the magnitude of suicide risk in participants with self-stigma. Our findings highlight the value of interventions geared toward ameliorating self-stigma and enhancing self-esteem in order to reduce suicide risk in individuals with schizophrenia.

Discordance between family report and clinical assessment of suicide attempts: a prospective study from the emergency department

Background

Developing accurate identification methods for individuals with suicide attempts and providing them with follow-up care and supports can be a vital component of all comprehensive suicide prevention strategies. However, because of the difficulties concerning one’s intentions behind injurious behaviour, identifying suicide attempts is a challenge for families and clinicians.

Aims

The aim of this study was to investigate the differences between family report and clinical assessment for suicide attempts in the emergency department (ED).

Methods

A total of 148 patients with suspected suicide attempts (SSAs) and 148 family caregivers in the ED were enrolled. The suicide risk module of the Chinese version of the MINI International Neuropsychiatric Interview and the self-report measure were used to assess those with SSA’s suicidal behaviours. The Family Adaptability and Cohesion Evaluation Scales and semi-structured interviews were used to investigate the characteristics of suicide risk and demographics of patients with SSA, as well as the rate and influencing factors of omitted suicide attempts reported by family caregivers.

Results

The underreporting rate for family reported suicide attempts in the ED was 69.0%. The suicide attempts group indicated lower mean scores on perceptions of family resources, adaptability and cohesion. Patients' suicide risk rating (OR=0.152, 95% CI: 0.037 to 0.620, p=0.009), adult-children relationship (OR=5.037, 95% CI: 1.478 to 17.167, p=0.010) and caregiver’s age (OR=0.279, 95% CI: 0.103 to 0.757, p=0.012) might be associated with underreporting by families. If patients committed suicide attempts through a falling injury or medication overdose, their families may have misreported the suicide attempt.

Conclusions

The discordance of suicide attempt records between family report and clinical assessment reveals the limitations of family self-reports when identifying suicide attempts. Interviews and observations, together with information from certain diagnoses, should be combined to accurately identify suicide attempters in the ED.

Association of the COVID-19 Pandemic and Low-rescue Suicide Attempts in Patients Visiting the Emergency Department after Attempting Suicide

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic may increase the total number of suicide attempts and the proportion of low-rescue attempts. We investigated the factors affecting low-rescue suicide attempts using the risk-rescue rating scale (RRRS) among patients who visited the emergency department (ED) after attempting suicide before or during the COVID-19 pandemic.

METHODS

We retrospectively investigated suicide attempts made by patients who visited our ED from March 2019 to September 2020. Patients were classified into two groups based on whether they attempted suicide before or during the COVID-19 pandemic. Data on demographic variables, psychiatric factors, suicide risk factors and rescue factors were collected and compared.

RESULTS

A total of 518 patients were included in the study, 275 (53.1%) of whom attempted suicide during the COVID-19 pandemic. The proportion of patients who made low-rescue suicide attempts differed before and during the COVID-19 pandemic (37.1% vs. 28.8%) (P = 0.046). However, the proportions of patients who made high-risk suicide attempts and high-lethality suicide attempts did not significantly differ between the two periods. The independent risk factors for low-rescue suicide attempts were age and the COVID-19 pandemic (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.03; P = 0.006) (OR, 1.52; 95% CI, 1.03-2.25; P = 0.034).

CONCLUSION

The COVID-19 pandemic was associated with low-rescue suicide attempts in patients visiting the ED after attempting suicide. Thus, we need to consider the implementation of measures to prevent low-rescue suicide attempts during similar infectious disease crises.