Cognition As a Therapeutic Target in the Suicidal Patient Approach

Building a neurocognitive profile of suicidal risk in severe mental disorders

BACKGROUND

Research on the influence of neurocognitive factors on suicide risk, regardless of the diagnosis, is inconsistent. Recently, suicide risk studies propose applying a trans-diagnostic framework in line with the launch of the Research Domain Criteria Cognitive Systems model. In the present study, we highlight the extent of cognitive impairment using a standardized battery in a psychiatric sample stratified for different degrees of suicidal risk. We also differentiate in our sample various neurocognitive profiles associated with different levels of risk.

MATERIALS AND METHODS

We divided a sample of 106 subjects into three groups stratified by suicide risk level: Suicide Attempt (SA), Suicidal Ideation (SI), Patient Controls (PC) and Healthy Controls (HC). We conducted a multivariate Analysis of Variance (MANOVA) for each cognitive domain measured through the standardized battery MATRICS Consensus Cognitive Battery (MCCB).

RESULTS

We found that the group of patients performed worse than the group of healthy controls on most domains; social cognition was impaired in the suicide risk groups compared both to HC and PC. Patients in the SA group performed worse than those in the SI group.

CONCLUSION

Social cognition impairment may play a crucial role in suicidality among individuals diagnosed with serious mental illness as it is involved in both SI and SA; noteworthy, it is more compromised in the SA group fitting as a marker of risk severity.

[Belief updating and mood congruence in depressive disorder]

Depressive disorder is characterized by a polymorphic symptomatology associating emotional, cognitive and behavioral disturbances. One of the most specific symptoms is negative beliefs, called congruent to mood. Despite the importance of these beliefs in the development, the maintenance, and the recurrence of depressive episodes, little is known about the processes underlying the generation of depressive beliefs. In this paper, we detail the link between belief updating mechanisms and the genesis of depressive beliefs. We show how depression alters information processing, generating cognitive immunization when processing positive information, affective updating bias related to the valence of belief and prediction error, and difficultie to disengage from negative information. We suggest that disruption of belief-updating mechanisms forms the basis of belief-mood congruence in depression.

Decision-making in suicidal behavior: A systematic review and meta-analysis

Impaired decision-making (DM) is well-known in suicidal behavior (SB). We aimed to review the evidence on DM and its mediating factors in SB and perform a meta-analysis on DM assessed using the Iowa Gambling Task (IGT). We conducted a search on databases of papers published on DM and SB up to 2020: 46 studies were included in the systematic review, and 18 in the meta-analysis. For meta-analysis, we compared DM performance between suicide attempters (SAs) and patients (PCs) or healthy controls (HCs). The systematic review showed that SAs have greater difficulties in all DM domains. The meta-analysis found worse IGT performance among SAs in comparison with PCs and HCs. A meta-regression did not find differences for age, gender, psychiatric disorder, and clinical status. Our findings indicate that SAs exhibited deficits in DM under conditions of risk though not ambiguity. Worse DM was independent of age, gender, psychiatric disorder, and suggested that DM impairment could be considered a cognitive trait of suicidal vulnerability, a risk factor and an attribute of SAs.

Leite V, Porto DM, Robis KP, Fidalgo TM, Rocha GA, Diaz AP, Meleiro A, Correa H, Tung TC, Malloy-Diniz L, Quevedo J, da Silva AG. Brazilian Psychiatric Association guidelines for the management of suicidal behavior. Part 2. Screening, intervention, and prevention

This article continues our presentation of the Brazilian Psychiatric Association guidelines for the management of patients with suicidal behavior, with a focus on screening, intervention, postvention, prevention, and promotion. For the development of these guidelines, we conducted a systematic review of the MEDLINE (via PubMed), Cochrane Database of Systematic Reviews, Web of Science, and SciELO databases for research published from 1997 to 2020. Systematic reviews, clinical trials, and cohort/observational studies on screening, intervention, and prevention in suicidal behavior were included. This project involved 14 Brazilian psychiatry professionals and 1 psychologist selected by the Psychiatric Emergencies Committee of the Brazilian Psychiatric Association for their experience and knowledge in psychiatry and psychiatric emergencies. Publications were evaluated according to the 2011 Oxford Center for Evidence-Based Medicine (OCEBM) Levels of Evidence Classification. Eighty-five articles were reviewed (of 5,362 initially collected and 755 abstracts on the drug approach). Forms of screening, intervention, and prevention are presented. The intervention section presents evidence for psychotherapeutic and drug interventions. For the latter, it is important to remember that each medication is effective only for specific groups and should not replace treatment protocols. We maintain our recommendation for the use of universal screening plus intervention. Although the various studies differ in terms of the populations evaluated and several proposals are presented, there is already significant evidence for certain interventions. Suicidal behavior can be analyzed by evidence-based medicine protocols. Currently, the best strategy is to combine several techniques through the Safety Plan. Nevertheless, further research on the topic is needed to elucidate some approaches with particular potential for intervention and prevention. Systematic review registry number: CRD42020206517.

The Interaction Effects of Suicidal Ideation and Childhood Abuse on Brain Structure and Function in Major Depressive Disorder Patients

Suicidal ideation (SI) is a direct risk factor for suicide in patients with depression. Regarding the emergence of SI, previous studies have discovered many risk factors, including childhood abuse as the major public problem. Previous imaging studies have demonstrated that SI or childhood abuse has effects on brain structure and function, respectively, but the interaction effects between them have not been fully studied. To explore the interaction effect between SI and childhood abuse, 215 patients with major depressive disorder completed the Childhood Trauma Questionnaire to evaluate childhood abuse and Beck's Scale for Suicidal Ideation to evaluate SI. Then, they completed magnetic resonance imaging (MRI) within one week after completing questionnaires. Respectively, we preprocessed the structural and functional images and analyzed gray matter volumes (GMV) and mean fractional amplitude of low-frequency fluctuation (mfALFF) values. Results showed that the changes of GMV in the cuneus, precuneus, paracentric lobule, inferior frontal gyrus, and caudate nucleus and local activity in cuneal and middle temporal gyrus are in relation with SI and childhood abuse. And in left caudate, SI and childhood abuse interact with each other on the influence of GMV. That is, the influence of SI in GMV was related to childhood abuse, and the influence of childhood abuse in GMV was also related to SI. Therefore, the combination of SI and childhood abuse based on imaging should help us better understand the suicide ideation developing mechanism and propose more effective targeted prevention strategies for suicide prevention.

Low MoCA performances correlate with suicidal ideation in late-life depression

Late-life depression remains an underdiagnosed clinical entity, mainly because the presence of cognitive impairment in the elderly leads clinicians to suspect dementia rather than depression. Our objective was to analyze the cognitive abilities of elderly depressed patients using the Montreal Cognitive Assessment (MoCA) in relation to the presence or absence of suicidal ideation. The MoCA, Beck Scale of Suicidal Ideation, Hamilton Anxiety Scale, and Hamilton Depression Scale were administered to 72 patients with a recent history of late life depression: 43 with suicidal ideation and 29 non-suicidal controls. The results show that suicidal patients demonstrated significantly worse performance on the MoCA total score and the delayed recall subtest in comparison to non-suicidal controls. In addition, after adjusting for age and depression, poorer performance on the MoCA total score correlated to the presence of suicidal ideation. We found that the MoCA total score is able to predict the presence of suicidal ideation in depressed elderly patients in a fair-to-good manner. As late-life depression is already established as a potential prodrome of dementia, longitudinal follow-up may determine whether depressed individuals with suicidal ideation are at higher risk of converting to dementia.

Repeating a suicide attempt during adolescence: risk and protective factors 12 months after hospitalization

Suicide attempts (SAs) are a public health concern in adolescence. A brief hospitalization is recommended, but access to inpatient wards is often not available. In addition, numerous risk factors for SA recurrence have been identified, but few studies have explored protective factors. Here, we aimed to assess the role of both risk and protective factors on SA relapse in a context of free access to inpatient services. We performed a prospective follow-up study of 320 adolescents who were hospitalized for an SA between January 2011 and December 2014 in France. Assessments at baseline included socio-demographics, clinical characteristics, temperament, reasons for living, spirituality, and coping. Patients were re-evaluated at 6 months and 12 months for depression severity and SA relapse. A total of 135 and 91 patients (78 girls, 12 boys, aged 13-17) were followed up at 6 and 12 months, respectively. At the 12-month follow-up, 28 (30%) subjects had repeated an SA. Adolescents who either had a history of SA or were receiving psychotropic treatment at baseline were at higher risk of recurrence. Several variables had a protective effect: (1) productive coping skills, namely, working hard and achieving, physical recreation, and seeking relaxing diversions; (2) a particular temperament trait, namely, cooperativeness; and (3) having experienced more life events. We also found a significant interaction: the higher the depression score during follow-up, the lower the protective effect of productive coping. Our findings confirm that a history of SA and seeking psychiatric care with medication are risk factors for SA relapse. However, productive coping strategies and cooperativeness are protective factors, and the improvement of such strategies as well as treatment of persisting depression should be a goal of psychotherapy treatment offered to suicidal adolescents.

Subjective cognitive dysfunction in patients with bipolar disorder: The prevalence, related factors and effects on predicting psychosocial functioning and suicidal ideation

Persistent cognitive deficits are prevalent during all stages of bipolar disorder (BD). However, few studies have examined subjective cognitive complaints in patients with BD. This study aimed to investigate the prevalence and relevant factors of subjective cognitive functioning and its potential effects on predicting psychosocial functioning and suicidal ideation in BD. Ninety-two patients with BD type I (including 42 depressed patients and 50 euthymic patients) and 60 healthy individuals were recruited for this study. All participants were assessed with a battery of neuropsychological tests examining attention and processing speed, visual memory, working memory and executive functions, as well as the Cognitive Complaints in Bipolar Disorder Rating Assessment, the Global Assessment of Functioning scale and the Beck Scale for Suicide Ideation. Bipolar patients exhibited worse subjective cognitive dysfunction compared with healthy individuals, and depressed patients expressed more cognitive complaints than euthymic bipolar patients. In bipolar group, psychosocial functioning, suicidal ideation and occupational status were the main relevant factors of subjective cognitive functioning. Subjective cognitive functioning could also predict psychosocial functioning and suicidal ideation. Depressive symptoms moderated the associations between objective cognitive functioning and suicidal ideation, but could not moderate the correlations between cognitive functioning and psychosocial functioning. These findings suggest that subjective cognitive assessment should be further emphasized in clinical practice.

Lower estimated intelligence quotient is associated with suicide attempts in pediatric bipolar disorder

BACKGROUND

Approximately 20% of individual with pediatric bipolar disorder (PBD) have a lifetime history of suicide attempt. Some cognitive measures were associated with a suicide attempt, but no study has assessed the association of this event with the estimated intelligence quotient (IQ) in PBI. In adult Bipolar Disorder no association between IQ and suicidality was found, with different correlations between cognitive measures. There are studies in general population showing a negative correlation and others did not find any association. In Schizophrenia, IQ had a positive correlation with suicide attempt. So, the correlation between IQ and suicidality still controversial.

METHODS

We recruited 63 children and adolescents younger than 18 years of age with PBD based on DSM-IV criteria from an outpatient clinic in Brazil. Manic and depressive symptoms were assessed with the YMRS and CDRS, respectively. Estimated IQ was assessed with the WISC-III. The presence or absense of suicidal attempt, clinical and demographic variables were assessed with the K-SADS-PL-W.

RESULTS

Patients who attempted suicide had lower estimated IQ compared to patients who did not attempt suicide (82.72 ± 18.70 vs. 101.0 ± 14.36; p = 0.009). This finding remained after correction for depressive symptoms and family income (OR = 0.94; 95% CI = 0.89 - 0.99; p = 0.029).

LIMITATIONS

Small sample, reverse causality could not be discarded, we only used two subscales of the WISC-III to estimate intelligence.

CONCLUSION

Estimated IQ and suicide attempts were negative correlated in PBD. Future longitudinal and larger studies may confirm our findings.

High-Gamma: A biological marker for suicide attempt in patients with depression

BACKGROUND

Quantitative EEG (qEEG) analysis can be used to evaluate brain correlates of human psychology in all aspects. As the gamma oscillations of qEEG rhythms are related to depression, and particularly to treatment resistance, they may also be related to suicidality.

AIM

The present study aimed to identify the neural correlates of suicidal ideation and suicide attempt in depression using qEEG, based on the hypothesis that gamma rhythm in patients with depression would be higher in patients with suicidal ideation and suicide attempt.

METHOD

qEEG were recorded in 533 participants (276 female). Groups were divided into the following: Non-suicidal (n = 218), Suicide Ideation (n = 211), Suicide Attempt (n = 74), and control (n = 30).

RESULTS

High-gamma power at the F4, Fz, C4, Cz, O2, F8, T5 and T6 regions was significantly higher in the Suicide Ideation than the other groups.

CONCLUSION

If confirmed by further studies, high-gamma rhythm has the potential to be used as a biomarker for screening suicidality.