Prenatal diagnosis and postnatal outcome of fetal congenital knee dislocation: systematic review of literature

OBJECTIVES

Congenital knee dislocation (CKD) is a rare condition, affecting 1 in 100 000 newborns. Its prenatal diagnosis is challenging and not well described in the literature, especially when it appears isolated and not as part of a complex malformation or syndromic pattern. The purpose of this study was to provide a comprehensive review of the available literature on the prenatal diagnosis and postnatal outcome of CKD and to summarize the current evidence on this topic.

METHODS

A systematic review of the literature on the prenatal diagnosis of CKD was performed in PubMed, Scopus and EMBASE. A predefined combination of specific keywords was used, focusing on intrauterine manifestations, diagnostic methods, prenatal behavior, postnatal treatment and neonatal outcome as well as long-term outcome in terms of ambulation, motion and joint stability. The quality of studies was assessed using the National Institutes of Health tool for quality assessment of case series. A summary of results was carried out providing proportions and rates of diagnostic and prognostic features associated with this rare condition.

RESULTS

In total, 20 cases were retrieved for analysis, of which 19 were obtained from the identified eligible studies (n = 16) and one was an unpublished case from our center. The median gestational age at prenatal diagnosis, which was made using ultrasound in most cases, was 20 weeks (range, 14-38 weeks). Bilaterality was observed in 11/20 (55%) cases. The condition was isolated in 7/20 (35%) cases and associated with other anomalies in 13/20 (65%) cases. An association was observed with oligohydramnios (4/20 (20%)), and an invasive procedure was performed in 13/20 (65%) cases, including 11 cases with an invasive procedure performed for diagnostic purposes. Genetic testing was normal in all isolated cases for which information was available (4/7), while a genetic syndrome was present in 10/13 (77%) non-isolated cases (Larsen, Noonan, Grebe, Desbuquois or Escobar syndrome). There were seven terminations of pregnancy, of which six were performed in cases with associated anomalies and one in an isolated case, 11 cases of postnatal survival, one case of intrauterine death and one of neonatal death. The fetal and neonatal deaths occurred in cases with associated anomalies or abnormal genetic findings. Postnatal treatment was mostly conservative, with only two reports (18% of the 11 surviving neonates) of surgical intervention, both in cases with associated anomalies. Postnatal follow-up was up to 1 year in most cases, and motor outlook appeared normal in all isolated cases.

CONCLUSIONS

CKD is a rare fetal anomaly with a prenatal diagnosis achievable from the early second trimester, for which a favorable outcome can be expected when no associated anomalies are present. Prenatal diagnosis should include detailed ultrasound assessment and amniocentesis for extensive genetic studies, particularly in non-isolated cases. Early postnatal treatment achieves success in most cases without surgical intervention and leads to a normal motor outlook. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Effect of Strongly Magnetized Electrons and Ions on Heat Flow and Symmetry of Inertial Fusion Implosions

This Letter presents the first observation on how a strong, 500 kG, externally applied B field increases the mode-two asymmetry in shock-heated inertial fusion implosions. Using a direct-drive implosion with polar illumination and imposed field, we observed that magnetization produces a significant increase in the implosion oblateness (a 2.5× larger P2 amplitude in x-ray self-emission images) compared with reference experiments with identical drive but with no field applied. The implosions produce strongly magnetized electrons (ω_{e}τ_{e}≫1) and ions (ω_{i}τ_{i}>1) that, as shown using simulations, restrict the cross field heat flow necessary for lateral distribution of the laser and shock heating from the implosion pole to the waist, causing the enhanced mode-two shape.

Identifying environmental pathways between irritability during childhood and suicidal ideation and attempt in adolescence: findings from a 20-year population-based study

BACKGROUND

Irritable children are at increased risk of suicidal ideation and suicide attempt, but the underlying environmental mechanisms accounting for these associations are largely unknown. We aimed to investigate the mediating role of peer victimization and harsh parenting in the association between childhood irritability and adolescent suicidal ideation and attempt.

METHOD

N = 1,483 participants from the Québec Longitudinal Study of Child Development followed up from 5 months until 20 years of age (2018) with annual or biannual assessments. Irritability was operationalized using assessments of teacher-reported temper tantrums and reactive aggression. Suicidal ideation and suicide attempt at ages 13, 15, 17, and 20 years were self-reported. Peer victimization (self-reported at age 13) and harsh parenting (mothers reported at age 13) were considered as potential mediators.

RESULTS

We identified four trajectories of teacher-reported irritability symptoms from 6 to 12 years: low (74.8%), rising (12.9%), declining (7.3%), and persistent (4.9%). In adjusted models, children in the persistent and rising trajectories had, respectively, 2.81-fold (CI, 1.27-6.22) and 2.14-fold (CI, 1.20-3.81) increased odds of suicide attempt in adolescence, but not suicidal ideation. We found that a significant proportion of the association between irritability trajectories and suicide attempt was mediated by peer victimization (33% and 35% for rising and persistent, respectively), but there was no mediation via harsh parenting.

CONCLUSIONS

Our findings suggest that peer victimization may be a key mechanism explaining the increased suicide attempt risk of children presenting with persistently high or increasing irritability. Interventions to reduce peer victimization may be helpful to reduce suicide risk among irritable children.

Use of antidepressants and risk of repeat self-harm in older adults 75+ with nonfatal self-harm: A 1-year prospective national study

PURPOSE

To assess exposure to antidepressants (AD) before and after nonfatal self-harm (SH) in older adults and to examine 1-year rates and risk factors for subsequent SH.

METHODS

Longitudinal national register-based retrospective cohort study of Swedish residents aged 75+ (N = 2775) with treatment at hospital or specialist outpatient clinic in connection with SH between January 1, 2006, and December 31, 2013. The cohort was followed for 1 year after the index episode. Exposure to AD was assessed at index and at subsequent SH. Cox regression analysis was used to assess factors associated with 1-year repeat SH.

RESULTS

At the index episode, 51% were prevalent AD users; 23% started AD during the following year. Overall 12% of prevalent AD users, 8% of AD nonusers, and 6% of AD new users repeated SH or died by suicide. About two-thirds of these subsequent behaviors occurred within 3 months after the index episode. Men had increased risk of subsequent SH (Hazard ratio [HR] 1.38, 95% CI: 1.09-1.74); older age (>85 years) was associated with a lower risk (HR 0.72, CI 95% 0.55-0.93). Users of AD did not have an increased risk of repeat SH.

CONCLUSIONS

Half of older adults who self-harmed were prevalent AD users and a further one fourth started an AD within 1 year after the index SH. Antidepressant use was not associated with increased risk of subsequent SH in this high-risk cohort of older adults.

Effects on suicidal risk: Comparison of clozapine to other newer medicines indicated to treat schizophrenia or bipolar disorder

BACKGROUND

Clozapine is the only treatment with regulatory-recognition of lowering suicidal risk, at least in schizophrenia patients. It remains uncertain whether such effects extend to other drugs for psychosis.

METHODS

We searched for reports on rates of suicidal behavior during treatment with clozapine and other modern drugs for psychosis (aripiprazole, olanzapine, risperidone, quetiapine, and ziprasidone) versus comparison or control treatments and analyzed the contrasts by random-effect meta-analysis to obtain pooled odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

We identified 35 paired comparisons of modern drugs for psychosis versus comparison or control treatments in 18 reports. There was moderate overall superiority of all agents tested over alternatives (OR = 0.522, p = 0.004). With clozapine, this effect was large (OR = 0.229, p < 0.0001) and consistent (7/7 trials), but significant antisuicidal effects were not found with other drugs for psychosis in 28 other trials (OR = 0.941, p = 0.497). Apparent efficacy of specific agents ranked: risperidone ⩾ olanzapine ⩾ aripiprazole ⩾ ziprasidone ⩾ mixed drugs for psychosis ⩾ quetiapine, but none of these differences was significant.

CONCLUSIONS

An ability of clozapine to reduce risk of suicides and attempts in schizophrenia patients appears to be a unique effect not shared with other modern medicines indicated for schizophrenia or bipolar disorder.

Determinants of dynamic inspiratory muscle strength in healthy trained elderly

BACKGROUND

The S-Index assessed by means of electronic devices is a measure of Inspiratory Muscle Strength (IMS) that highly correlates with the maximal inspiratory pressure (MIP). The variables involved when using regression models for the prediction of IMS/MIP depend on both the sample characteristics and the device or protocol used. In light of the scarce information on the influence of physical activity (PA) on IMS in healthy older adults (OA), together with the incorporation of new assessment devices, the objectives of this research are: 1) to determine which factors influence the IMS in a group of trained OA, using a portable electronic device; and 2) to propose a regression model to improve its assessment and training.

METHODS

One hundred and fifty-nine individuals were assessed for body composition, lung capacity, IMS, and PA. A total of 92 individuals (72.73 ± 4.99 years) were considered for the final sample.

RESULTS

Using age, sex, and weight as control variables, forced expiratory volume in the first second (FEV₁) is the variable which is most likely to be included in the model (80%), without physical fitness appearing to be decisive. In the absence of spirometric variables, cardiorespiratory fitness (6MWT) takes on this role in a predictive model (16%).

CONCLUSIONS

This is the first study proposing IMS predictive formulas considering spirometry and/or physical fitness results for a Spanish, healthy, and trained OAs population. A predictive formula including also the spirometric variables (mainly the FEV₁) might better predict the inspiratory muscle strength. In addition, physical and respiratory functions confirm to be different, so it is necessary for the inspiratory muscles to be trained in a specific way.

Trends in suicides among italian youth aged 10 to 25: A nationwide register study

Introduction

Suicide continues to be a significant cause of mortality in most countries worldwide, especially among youth. Documenting current trends and sources of variation in youth suicide rates is critical to inform prevention strategies.

Objectives

We aimed to 1. document suicide mortality trends among Italian youth from 1981 to 2016 2. describe age, sex, and urbanization specific suicide rates in this period, and 3. describe suicide methods and their change over time.

Methods

We relyed on official mortality data for the period 1981-2016 for adolescents and young adults (ages 10-25 years). We estimated standardized all-cause and suicide mortality rates per 100,000 individuals and used Joinpoint regression analysis to determine annual mortality trends and statistically significant changes in rate trends. Analyses were reported by sex, age group, urbanization level and suicide method.

Results

From 1981 to 2016, 1,752 suicides were identified among youth aged 10-17 (boys/girls ratio in 2016, 5.3) and 9,897 among youth aged 18-25 years (boys/girls ratio in 2016, 4.0). While the all-cause mortality rate decreased over time for both boys and girls, overall suicide rates remained stable for boys and showed a small decrease for girls. For boys, suicide was most common in rural than to metropolitan areas, while it was the opposite for girls. The most common method for boys was hanging, while for girls was fall.

Conclusions

Differently from other countries, youth suicides were stable (boys) or slightly declining (girls). We found differences according to the urban vs. rural areas. Factors influencing these trends and sex differences are crucial in delivering prevention strategies.

Disclosure

No significant relationships.

New technologies as tools to prevent suicide in adolescence: A literature overview

Introduction

Suicide in adolescents represents a major public health concern. To date, a growing number of suicide preventive strategies based on the use of new technologies are emerging.

Objectives

The purpose of the present paper is to provide an overview of the present literature on the use of new technologies in adolescent suicide prevention.

Methods

A systematic electronic search was run using the following keywords: Technology OR Technologies OR APP OR Application OR mobile application) AND (Adolescent OR youth OR puberty) AND (Suicid* OR Self-harm OR self-destruction).

Results

We found 12 studies on the use of telemedicine, 7 on mobile applications, and 3 on language detection. Heterogeneity regarding the study design was found: 3 Randomized Controlled Trial (RCT), 13 are Open-label single group trials, 2 Randomized studies, and 1 Cross-sectional study. Telemedicine was the most adopted tool, especially web-based approaches. Mobile applications mostly focused on screening of depressive symptoms and suicidal ideation, and for clinical monitoring through the use of text messages.

Conclusions

Despite telepsychiatry and mobile applications can provide a fast and safe tool, only a few studies demonstrated efficacy in preventing suicide among adolescents through the use of these interventions. Some studies suggested sophisticated algorithms able to recognize people at risk for suicide from language detection on social media posts. To date, only a few data support the use of such interventions in clinical practice and preventive strategies. Further studies are needed to test their efficacy in suicide prevention among adolescents and young adults.

Trends and ecological results in suicides among Italian youth aged 10-25 years: A nationwide register study

BACKGROUND

Documenting current trends and sources of variation in youth suicide rates is critical to inform prevention strategies. We aimed to document suicide mortality trends among Italian youth from 1981 to 2016 and to describe age-, gender- and urbanization-specific suicide rates.

METHODS

We used official mortality data for the period 1981-2016 for adolescents and young adults aged 10-25 years. We estimated standardized all-cause and suicide mortality rates per 100,000 individuals and used joinpoint regression analyses to determine annual mortality trends and significant changes in rate trends. Analyses were reported according to gender, age group (10-17 and 18-25 years), urbanization and suicide method.

RESULTS

From 1981 to 2016, 1,752 suicides were identified among youth aged 10-17 years (boy/girl ratio of 5.80 in 2016) and 9,897 suicides among youth aged 18-25 years (boy/girl ratio of 3.97 in 2016). Overall suicide rates remained stable for boys and showed a small decrease for girls. Suicide was most common in rural areas for boys and in metropolitan areas for girls. We observed a significant decrease in the use of firearms and poisoning; the most common suicide method was hanging for boys and falls for girls.

LIMITATIONS

We did not control for regional-level sociodemographic, economic and health care system characteristics.

CONCLUSIONS

Youth suicides were either stable (for boys) or slightly declining (for girls). We found differences according to urban versus rural areas, suggesting the need for a broader view of the phenomenon. Factors influencing these trends and gender differences in the geographical areas are important in delivering suicide prevention strategies.

The Role of New Technologies to Prevent Suicide in Adolescence: A Systematic Review of the Literature

Background and objectives: Suicide in adolescents represents a major public health concern. To date, a growing number of suicide preventive strategies based on the use of new technologies are emerging. We aimed to provide an overview of the present literature on the use of new technologies in adolescent suicide prevention. Materials and methods: An electronic search was run using the following keywords: Technology OR Technologies OR APP OR Application OR mobile application) AND (Adolescent OR youth OR puberty) AND (Suicid* OR Self-harm OR self-destruction). Inclusion criteria were: English language, published in a peer-reviewed journal, suicide prevention with the use of new technologies among adolescents. Results: Our search strategy yielded a total of 12 studies on the use of telemedicine, 7 on mobile applications, and 3 on language detection. We also found heterogeneity regarding the study design: 3 are randomized controlled trials (RCT), 13 are open-label single group trials, 2 are randomized studies, and 1 is a cross-sectional study. Telemedicine was the most adopted tool, especially web-based approaches. Mobile applications mostly focused on screening of depressive symptoms and suicidal ideation, and for clinical monitoring through the use of text messages. Although telepsychiatry and mobile applications can provide a fast and safe tool, supporting and preceding a face-to-face clinical assessment, only a few studies demonstrated efficacy in preventing suicide among adolescents through the use of these interventions. Some studies suggested algorithms able to recognize people at risk of suicide from the exploration of the language on social media posts. Conclusions: New technologies were found to be well accepted and tolerated supports for suicide prevention in adolescents. However, to date, few data support the use of such interventions in clinical practice and preventive strategies. Further studies are needed to test their efficacy in suicide prevention among adolescents and young adults.

Pharmacologic Treatment of Mixed States

Despite the relatively high prevalence of mixed symptoms and features among patients with mood disorders, the current literature supporting the specific efficacy of second-generation antipsychotics and mood stabilizers for the treatment of mixed symptoms is limited. Several studies have demonstrated that acute affective episodes with mixed symptoms or features tend to respond unsatisfactory to treatments that are usually more effective for the management of other affective phases. There is clearly a need for clinical trials in order to determine the more adequate pharmacologic option for the treatment of individuals suffering from affective episodes with mixed features.

Developmental trajectories of childhood symptoms of hyperactivity/inattention and suicidal behavior during adolescence

Hyperactive/inattentive symptoms (ADHD symptoms) are associated with suicidal behavior in clinical studies, but there is still a lack of population-based longitudinal investigations on the developmental aspects of this association. Additionally, it is unclear whether the association is similar for boys and girls. The objectives of the study were to test the association between the ADHD symptoms during childhood and suicidal ideation and attempt during adolescence, and to investigate sex differences. 1407 children from the Québec Longitudinal Study of Child Development were followed up from 5 months to 17 years of age. We used teacher-reports of ADHD symptoms from 6 to 12 years, and self-report of suicidal ideation and attempt at 13, 15, and 17 years. We identified three ADHD symptoms trajectories: low (boys: 32.2%, girls: 48.7%), moderate (boys: 44.6%; girls: 42.2%) and high (boys: 23.2%; girls: 9.1%). Compared to boys on a low trajectory, boys on a moderate trajectory were at higher risk for suicidal ideation (OR 4.2, 95% CI 1.2-14.8), and boys on a high trajectory were at higher risk for suicide attempts (OR 4.5, 95% CI 1.1-17.9). Girls on moderate or high ADHD symptoms trajectories were not at higher risk for suicidal ideation or attempts than girls on low trajectories. For boys, but not for girls, moderate-to-high ADHD symptoms increased the suicidal risk in adolescence. Interventions with boys showing ADHD symptoms should include a suicide prevention component.

Clinical Differences Between Single and Multiple Suicide Attempters, Suicide Ideators, and Non-suicidal Inpatients

Single suicide attempters (SSAs) and multiple suicide attempters (MSAs) represent distinct subgroups of individuals with specific risk factors and clinical characteristics. This retrospective study on a sample of 397 adult psychiatric inpatients analyzed the main sociodemographic and clinical differences between SSAs and MSAs and the possible differences between SSAs, MSAs, and psychiatric patients with and without suicidal ideation (SI). Clinical variables collected included psychiatric diagnoses (Mini International Neuropsychiatric Interview), presence of substance use, current suicide risk status (Columbia Suicide Severity Rating Scale), Clinical Global Impression at admission, Global Assessment of Functioning improvement between admission and discharge, age at onset of psychiatric illness, duration of untreated illness in years, number of hospitalizations in psychiatric settings, and lethality of the most severe suicide attempt. A multinomial logistic regression model with groups showed that MSAs had a higher lethality of their last suicide attempt as compared to SSAs. In addition, MSAs had distinct sociodemographic characteristics compared to both SSAs and patients with SI. Although the study was limited by the relatively small sample size and retrospective nature, the present results suggest that identifying MSAs could be useful in predicting suicide risk and designing ad hoc prevention strategies.

Posttraumatic stress reactions of underground drivers after suicides by jumping to arriving trains; feasibility of an early stepped care outpatient intervention

Objective: Underground drivers face a considerable risk of running over suicide jumpers on the tracks during their career. These traumatic exposures may lead to major psychological sequelae. Methods: Within an outpatient setting, 50 drivers were consecutively enrolled in a prospective non-controlled trial. A low-intensity, stepped-care approach included: emergency care immediately after the critical accident, comprehensive assessment with a structured clinical interview using the following scales within three days: Composite International Diagnostic Interview (CIDI), Impact of Event Scale (IES), Screening for Somatoform Disorders (SOMS), and Cologne Trauma Inventory (KTI). Results: During a 2-year period, 50 subway drivers were exposed to 66 serious critical accidents (deaths: 39, severe injuries: 27). Rate of acute stress reactions was 48%; rate of acute stress disorders was 30%. Scores of IES and SOMS were significantly increased correspondingly. At 1-month follow-up, PTSD was diagnosed in 24 (ICD-10) and in 9 drivers (DSM-IV), respectively. Major depression (n = 15) and somatoform disorder (n = 10) were diagnosed as coexistent to PTSD. Acute stress reaction/acute stress disorder, IES- and SOMS-scores, and previous traumatic exposures during adulthood, but not during childhood, were significantly associated with the risk of PTSD. A majority of drivers (n = 43) succeeded in reaching complete symptomatic remission and returning to work again within a 6-month period. Seven drivers suffered from long-lasting posttraumatic symptoms causing severe social impairment. Conclusions: A low-intensity, outpatient stepped-care approach may provide support to traumatized underground drivers in their process of posttraumatic remission and recovery.

Tryptophan and Kynurenine Metabolites: Are They Related to Depression?

BACKGROUND

Some previous studies found decreased concentrations of L-tryptophan (TRY) and increased L-kynurenine (KYN), or its metabolites, in the body fluids of subjects with major depressive disorder (MDD), sometimes in association with suicidal behavior. Such changes might indicate a shift of TRY away from serotonin production, possibly via the effects of inflammatory peptides which activate indoleamine-2,3-dioxygenase. However, these findings have been inconsistent and require replication.

METHODS

We used sensitive liquid-chromatography mass spectrometry methods to assay plasma concentrations of TRY, 5-hydroxyindoleacetic acid (5-HIAA), and KYN and its metabolites (anthranilic acid and xanthurenic acid). We compared 49 hospitalized, depressed subjects diagnosed with MDD (n = 37) or bipolar disorder (BD, n = 12), with (n = 22) or without (n = 27) previous suicide attempts, to 78 healthy, ambulatory controls of similar age and sex (total n = 127).

FINDINGS

Contrary to expectation, TRY plasma concentrations were higher, KYN plasma concentrations were lower, and their ratio much higher in depressed subjects, with no relationship to suicidal history. Concentrations of 5-HIAA and the kynurenine metabolites did not differ between depressed and healthy subjects.

CONCLUSIONS

These findings are opposite to expectations and not consistent with a hypothesized increased conversion from TRY to KYN in depressed subjects. In addition, we found no evidence of altered production of serotonin as 5-HIAA concentration was unchanged. None of the observed changes was associated with a history of suicide attempt.

Suicide Risk among Immigrants and Ethnic Minorities: A Literature Overview

Recent studies have demonstrated that immigrants and ethnic minorities may be at higher risk of suicidal behaviour as compared to the general population. We conducted a literature search to identify studies in English from 1980 to 2017 related to suicide risk among immigrants and ethnic minorities. Six hundred and seventy-eight reports were screened, and 43 articles were included in the qualitative synthesis of the review. Some studies reported lower rates of suicide attempts, while other findings suggested higher rates of suicidal behaviour and deaths among immigrants as compared to the native population. Also, a positive correlation was found between suicidal behaviour and specific countries of origin. Non-European immigrant women were at the highest risk for suicide attempts, a group which included young women of South Asian and black African origin. Risk factors among migrants and ethnic minorities were found to be: language barriers, worrying about family back home, and separation from family. The lack of information on health care system, loss of status, loss of social network, and acculturation were identified as possible triggers for suicidal behaviour. Overall, results suggest that specific migrant populations and ethnic minorities present a higher risk of suicidal behaviour than native populations, as well as a higher risk of death by suicide.

Secondary school teachers and mental health competence: Italy-United Kingdom comparison

AIM

The aim of this study was to evaluate the differences between teachers' knowledge about early psychosis among three different Italian cities and a UK sample.

METHODS

The sample consisted of 556 secondary school teachers from three different cities in Italy (Milan, Rome and Lamezia Terme) and London (UK). The research was based on the Knowledge and Experience of Social Emotional Difficulties Among Young People Questionnaire. The Italian version of the questionnaire was used in Italy.

RESULTS

Overall, 67.6% of English teachers, 58.5% of Milan's teachers, 41.8% of Rome's teachers and 33.3% of Lamezia Terme's teachers were able to recognize psychotic symptoms from a case vignette. Logistic regression analysis showed that 'city' was the only independent variable significantly related to the correct/wrong answer about diagnosis.

CONCLUSIONS

We found statistically significant differences between the three Italian samples and the UK sample regarding teachers' knowledge about first signs of psychosis. English teachers showed a better knowledge than Italian teachers in general. Teachers from Milan, where a specific early detection program was established in 2000, seemed to be more familiar with early signs of psychosis than teachers in the other two Italian towns.

Association of Childhood Irritability and Depressive/Anxious Mood Profiles With Adolescent Suicidal Ideation and Attempts

IMPORTANCE

Suicidal ideation and suicide attempt (suicidality) are common in adolescence and a public health concern. Childhood depression is a key risk factor for later suicidality and often co-occurs with irritability. No study to date has examined the joint association of depressive mood and irritability during childhood with later suicidality.

OBJECTIVE

To investigate the association of childhood irritability and depressive/anxious mood profiles with adolescent suicidality.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included 1430 participants in the Québec Longitudinal Study of Child Development. Participants underwent assessment yearly or bi-yearly (5 months to 17 years). Data were collected from March 16, 1998, through July 17, 2015.

EXPOSURES

Profiles defined by the joint developmental trajectories of irritability and depressive/anxious mood at 6 to 12 years of age.

MAIN OUTCOMES AND MEASURES

Self-reported past-year suicidality (ie, serious suicidal ideation or suicide attempt) at 13, 15, and 17 years of age. Irritability and depressive/anxious mood were assessed using teacher report 5 times from 6 to 12 years of age.

RESULTS

The study included 1430 participants (676 boys [47.3%] and 754 girls [52.7%]) followed up to 17 years of age. Group-based multitrajectory modeling identified the following profiles: combined no irritability and low depressive/anxious mood with low irritability and low depressive/anxious mood (831 [58.1%]; reference group), moderate irritability and low depressive/anxious mood (353 [24.7%]), high depressive/anxious mood only (94 [6.6%]), and high irritability and depressive/anxious mood (152 [10.6%]). Children with high irritability and high depressive/anxious mood reported higher rates of suicidality (25 of 152 [16.4%]) compared with the group with the lowest symptom levels (91 of 831 [11.0%]). In logistic regression analyses, the high irritability and depressive/anxious mood profile (odds ratio [OR], 2.22; 95% CI, 1.32-3.74; number needed to be exposed [NNE], 18) was associated with suicidality. To a lesser extent, the moderate irritability and low depressive/anxious mood profile was also associated with suicidality (OR, 1.51; 95% CI, 1.02-2.25; NNE = 48). The high depressive/anxious mood only profile was not associated with later suicidality (OR, 0.96; 95% CI, 0.47-1.95; NNE = -320). The high irritability and depressive/anxious mood profile was associated with a higher suicidal risk compared with the depressive/anxious mood only profile (OR, 2.28; 95% CI, 1.02-5.15). Girls with the high irritability and high depressive/anxious mood profile had higher risk for suicidality (OR, 3.07; 95% CI, 1.54-6.12; NNE = 5).

CONCLUSIONS AND RELEVANCE

Children with high irritability and depressive/anxious mood and, to a lesser extent, with moderate irritability only had a higher suicidal risk during adolescence compared with children with low symptom levels. Early manifestation of chronic irritability during childhood, especially when combined with depressive/anxious mood, may be associated with an elevated risk for adolescent suicidality. The putatively causal role of irritability should be investigated.

Temperaments in psychotic and major affective disorders

BACKGROUND

Assessment of affective temperaments with the extensively validated, 110-item TEMPS-A autoquestionnaire has been used to characterize patients with mood disorders, and its scores have been associated consistently with suicidal behavior. Much less has been reported about comparisons of characteristics of such assessments in psychotic and other psychiatric disorders.

METHODS

We analyzed results of TEMPS-A assessments in 1081 psychiatrically hospitalized patients in Rome and compared subscale scores (anxious [anx], cyclothymic [cyc], depressive [dep], irritable [irr], hyperthymic [hyp]) and a composite score (anx+cyc+dep+irr - hyp) among diagnoses and subjects with vs. without a suicide attempt.

RESULTS

TEMPS-A subscale scores differed significantly among diagnoses and were higher with major affective than psychotic or other disorders. Suicide attempts were 1.5-times more frequent among women than men and with affective versus nonaffective disorders, ranking: bipolar-II > major depression > bipolar-I > other disorders > psychotic disorders. TEMPS-A subscores were significantly higher among suicidal subjects (ranking: anx ≥ cyc ≥ dep > irr) except hyp (lower), but the composite score differed most (1.37-fold higher). Multivariable logistic regression modeling indicated that suicide attempt was significantly and independently associated with: TEMPS-A composite score > female sex > affective disorder > older age.

CONCLUSIONS

TEMPS-A scores, particularly a composite score (anx+cyc+dep+irr - hyp) may help effectively evaluate suicidal risk in association with nonaffective as well as affective disorders.

Mediators in the Association Between Affective Temperaments and Suicide Risk Among Psychiatric Inpatients

BACKGROUND

Affective temperaments have been shown to be related to psychiatric disorders and suicidal behaviors. Less is known about the potential contributory role of affective temperaments on suicide risk factors. In the present study, we investigated whether the effect of affective temperaments on suicide risk was mediated by other variables, such as hopelessness, mentalization deficits, dissociation, psychological pain, and depressive symptoms.

METHODS

Several assessment instruments, including the Mini International Neuropsychiatric Interview (MINI); the Temperament Evaluation of Memphis, Pisa, and San Diego Autoquestionnaire (TEMPS-A); the Beck Hopelessness Scale (BHS); the Gotland Male Depression Scale (GMDS); the Dissociative Experiences Scale (DES); the Psychological Pain Assessment Scale (PPAS); and the Mentalization Questionnaire (MZQ), were administered to 189 psychiatrically hospitalized patients (103 women, 86 men) in Rome, Italy.

RESULTS

In single-mediator models, hopelessness, depressive symptoms, and mentalization, but not psychological pain or dissociation, were significant mediators in the association between prevalent temperament and suicide risk. In a multiple-mediator model, a significant indirect effect was found only for depression. Results demonstrated that patients with negative temperaments reported higher suicide risk, psychological pain, hopelessness, and depression, and less mentalization than patients with no prevalent temperament or hyperthymic temperaments.

CONCLUSIONS

Hopelessness, depression, and mentalization are all factors that mediate the relation between affective temperaments and suicide risk. Identifying factors that mediate the effects of affective temperamental makeup on suicide risk should enhance screening and intervention efforts.

Psychiatric comorbidity and suicidal ideation in psoriasis, melanoma and allergic disorders

OBJECTIVE

Psychiatric disorders and suicide risk (especially in psoriasis) are frequent and disabling conditions in patients with skin diseases. The aim of this study was to examine the risk of suicide and stressful life events in a sample of patients with skin disease.

METHODS

A sample of 242 dermatological patients (142 women and 100 men), 112 of which had psoriasis, 77 had melanoma, and 53 were suffering with chronic allergic diseases. Patients were administered the MINI International Neuropsychiatric Interview (MINI), Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), and the Columbia-Suicide Severity Rating Scale (C-SSRS). Patients were also asked about their experiences with stressful life events.

RESULTS

Patients with psoriasis were more likely to have a history of psychiatric disorders (36.6% vs. 13.2% χ²₍₁₎ = 9.55; p = 0.002) compared to patients with allergies. Specifically, patients with psoriasis more likely had a diagnosis of a mood disorder (16.1% vs. 3.9% χ²₍₁₎ = 6.85; p = 0.009; 16.1% vs. 0% χ²₍₁₎ = 9.56; p = 0.002) and reported past suicidal ideation (33.9% vs. 15.6% χ²₍₁₎ = 7.89; p = 0.005; 33.9% vs. 18.9% χ²₍₁₎ = 3.96; p = 0.047) as compared to those with melanoma and allergy.

CONCLUSIONS

The results from this study suggest that patients affected by psoriasis have an increased risk of psychiatric comorbidities and suicidal ideation compared to those who have other dermatological disorders.

Genetic association analysis of serotonin and signal transduction pathways in suicide attempters from an Italian sample of psychiatric patients

Genetic factors have been reported to contribute to the liability of suicide. We aimed to investigate functional polymorphisms in eight genes (serotonin transporter, SLC6A4; receptors, 5HTR1A, 1B, 5HTR2A; Tryptophan Hydroxylase, TPH1, TPH2; Monoamine Oxidase, MAOA and G Protein Subunit Beta 3, GNB3) to investigate their predictive value for suicide. The possible confounding effects of gender and phenotypic patients dissection were also valued. A sample of 111 consecutive psychiatric inpatients was recruited and assessed using specific psychometric instruments. Genomic DNA was isolated from peripheral white blood cell samples and polymorphisms were genotyped by pyrosequencing technology. Although no differences were observed between allele and genotype frequencies for all polymorphisms and suicide attempt (SA), a polygenic risk score was detected for three genes HTR2A (A-1438G), TPH1 and TPH2 increasing the prediction of SA risk (Thresh=0.43, p=0.038, R²=0.053). Moreover some nominal associations were obtained after gender and phenotypic dissection stratification (TEMPS-A, TEMPs-H, GSMD, SHSS, GAF, CGI) for SLC6A4 (5-HTTLPR), HTR1A (C-1019G), HTR2A (A-1438G), TPH1 (A799C) and GNB3 (C825T) genes, that were lost after Bonferroni correction. This is a first evidence that specific additive combinations of genes could increase the prediction of SA risk and that gender and phenotypic dissection could influence the association of the genes with SA. This could represent a further study also for future meta-analyses on larger samples.

Advantages of second-generation long-acting injectable anti-psychotics: Focus on hospital admission rates in southeast Tuscany

Introduction

Several studies suggested that second-generation long-acting injectable anti-psychotics (SGA-LAIs) might be effective on preventing relapse and admission/readmission rates among patients affected by schizophrenic and bipolar disorders. Moreover, studies highlighted that SGA-LAIs may reduce costs and healthcare resource utilization (HRU) among community psychiatric settings.

Objectives

The objective of the present study was to evaluate whether the increased use of SGA-LAIs among community psychiatric services in southern Tuscany was related to:

– reduced costs and HRU;

– reduced hospital admission/readmission.

Methods

Data consisted of both regional registry and data prospectively collected at admission and/or follow up assessments. Patients included were: patients affected by schizophrenia/schizoaffective or bipolar disorders, treated with SGA-LAIs.

Results

The increased use of SGA-LAIs was related to a significant reduction of admission and/or readmission rates, as long as a significant reduction in costs and HRU among the community services included in the study.

Conclusions

The present findings suggest that SGA-LAIs might have a positive cost/effectiveness profile and could reduce hospitalizations, costs and HRU among a community sample. This could be related to a better tolerability of SGA-LAIs compared to FGA-LAIs, and less adverse effects. More studies on community samples should focus on the cost/effectiveness profile of SGA-LAIs.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Suicide risk and psychiatric comorbidity in patients with psoriasis

Objectives

To examine the occurrence of stressful life events, psychological comorbidity and suicide risk in patients with psoriasis or other dermatological conditions.

Methods

Consecutive adult outpatients with psoriasis or other dermatological conditions completed a sociodemographic questionnaire and the Hamilton scales for depression and anxiety.

Results

The study included 157 patients (91 with psoriasis; 66 with other conditions [melanoma; allergy]). Patients with psoriasis were significantly more likely to have experienced major life events in the 12 months before diagnosis, have had a psychiatric diagnosis and to have experienced past suicidal ideation than patients with other dermatological conditions.

Conclusions

Patients with psoriasis have an increased risk of psychiatric comorbidities, suicidal ideation, and long-term course of the disease compared with patients who have other dermatological conditions. Psychiatric assessment is highly recommended in patients with psoriasis.

Bayesian joint ordinal and survival modeling for breast cancer risk assessment

We propose a joint model to analyze the structure and intensity of the association between longitudinal measurements of an ordinal marker and time to a relevant event. The longitudinal process is defined in terms of a proportional‐odds cumulative logit model. Time‐to‐event is modeled through a left‐truncated proportional‐hazards model, which incorporates information of the longitudinal marker as well as baseline covariates. Both longitudinal and survival processes are connected by means of a common vector of random effects.

General inferences are discussed under the Bayesian approach and include the posterior distribution of the probabilities associated to each longitudinal category and the assessment of the impact of the baseline covariates and the longitudinal marker on the hazard function. The flexibility provided by the joint model makes possible to dynamically estimate individual event‐free probabilities and predict future longitudinal marker values.

The model is applied to the assessment of breast cancer risk in women attending a population‐based screening program. The longitudinal ordinal marker is mammographic breast density measured with the Breast Imaging Reporting and Data System (BI‐RADS) scale in biennial screening exams. © 2016 The Authors. Statistics in Medicine Published by John Wiley & Sons Ltd.

Suicide attempts in bipolar disorders: comprehensive review of 101 reports

OBJECTIVE

Assess reported risk of suicide attempts by patients with bipolar disorder (BD).

METHOD

Systematic searching yielded 101 reports from 22 countries (79 937 subjects). We analyzed for risk (%) and incidence rates (%/year) of attempts, comparing sex and diagnostic types, including by meta-analysis.

RESULTS

Attempt risk averaged 31.1% [CI: 27.9-34.3] of subjects, or 4.24 [3.78-4.70]%/year. In BD-I (43 studies) and BD-II subjects (30 studies), risks (29.9%, 31.4%) and incidence rates (4.01, 4.11%/year) were similar and not different by meta-analysis. Among women vs. men, risks (33.7% vs. 25.5%) and incidence (4.50 vs. 3.21%/year) were greater (also supported by meta-analysis: RR = 1.35 [CI: 1.25-1.45], P < 0.0001). Neither measure was related to reporting year, % women/study, or to onset or current age. Risks were greater with longer exposure, whereas incidence rates decreased with longer time at risk, possibly through 'dilution' by longer exposure.

CONCLUSION

This systematic update of international experience underscores high risks of suicide attempts among patients with BD (BD-I = BD-II; women > men). Future studies should routinely include exposure times and incidence rates by diagnostic type and sex for those who attempt suicide or not.

Kynurenine pathway metabolites and suicide attempters among psychiatric inpatients: Preliminary results

Introduction

Increased concentrations of kynurenine (KYN) pathway metabolites have been associated to several groups of psychiatric disorders. As for suicide risk literature is still inconclusive due to the limited evidence.

Objectives

to test the hypothesis of Increased concentrations of kynurenine as related to suicide attempter.

Aims

We aim to investigate the association between kynurenine pathway metabolites blood levels and suicidal behaviour, in affective disorder patients, in order to explore if kynurenine pathway metabolites could be potential diagnostic biomarkers.

Sample

We enrolled a sample of affective disorder patients and perform detailed diagnoses, as well as detailed assessment of suicidal behaviour using validated questionnaires. We also aim to follow-up individuals included in the current study.

Methods

Plasma KYN was assayed by high performance liquid chromatography in three groups: healthy volunteers (n = 90), patients with mood disorders with a recent suicide attempt (n = 44) and without (n = 44) history of suicide attempt. Analysis of variance tested for group differences in KYN levels. Each was evaluated with psychometric scales. Patients were sampled for 10 cc of venous blood for assay. The preparation of blood samples and assay was processed by a specialist using high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS).

Results

Preliminary results will be presented as to shed light if KYN levels differed across groups. According to preliminary calculations we expect that KYN is higher in suicide attempters compared with non-attempters, who did not differ from healthy volunteers.

Conclusions

Our work-in-progress study suggests that KYN and related molecular pathways may be implicated in the precipitation of suicidal behavior.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Determinants of between-hospital variations in outcomes for patients admitted with COPD exacerbations: findings from a nationwide clinical audit (AUDIPOC) in Spain

BACKGROUND

Previous studies have demonstrated significant variability in the processes of care and outcomes of chronic obstructive pulmonary disease (COPD) exacerbations. The AUDIPOC is a Spanish nationwide clinical audit that identified large between-hospital variations in care and clinical outcomes. Here, we test the hypothesis that these variations can be attributed to either patient characteristics, hospital characteristics and/or the so-called hospital-clustering effect, which indicates that patients with similar characteristics may experience different processes of care and outcomes depending on the hospital to which they are admitted.

METHODS

A clinical audit of 5178 COPD patients consecutively admitted to 129 Spanish public hospitals was performed, with a 90-day follow-up. Multilevel regression analysis was conducted to model the probability of patients experiencing adverse outcomes. For each outcome, an empty model (with no independent variables) was fitted to assess the clustering effect, followed by a model adjusted for the patient- and hospital-level covariables. The hospital-clustering effect was estimated using the intracluster correlation coefficient (ICC); the cluster heterogeneity was estimated with the median odds ratio (MOR), and the coefficients of predictors were estimated with the odds ratio (OR).

RESULTS

In the empty models, the ICC (MOR) for inpatient mortality and the follow-up mortality and readmission were 0.10 (1.80), 0.08 (1.65) and 0.01 (1.24), respectively. In the adjusted models, the variables that most represented the patients' clinical conditions and interventions were identified as outcome predictors and further reduced the hospital variations. By contrast, the resource factors were primarily unrelated with outcomes.

CONCLUSIONS

This study demonstrates a noteworthy reduction in the observed crude between-hospital variation in outcomes after accounting for the hospital-cluster effect and the variables representing patient's clinical conditions. This emphasises the predictor importance of the patients' clinical conditions and interventions, and understates the impacts of hospital resources and organisational factors.

Parvovirus B19 associated acute cholestatic hepatitis

There are few reports in the literature of hepatitis as a manifestation of Parvovirus B19 infection. We describe a case of Parvovirus B19 associated acute cholestatic hepatitis diagnosed based on a positive serologic test (IgM) and molecular detection of parvovirus B19 DNA in peripheral blood. Parvovirus B19 infection should be considered in the differential diagnosis of patient presenting with acute hepatitis of unknown etiology.

Subjectivism as an unavoidable feature of ecological statistics

We approach here the handling of previous information when performing statistical inference in ecology, both when dealing with model specification and selection, and when dealing with parameter estimation. We compare the perspectives of this problem from the frequentist and Bayesian schools, including objective and subjective Bayesians. We show that the issue of making use of previous information and making a priori decisions is not only a reality for Bayesians but also for frequentists. However, the latter tend to overlook this because of the common difficulty of having previous information available on the magnitude of the effect that is thought to be biologically relevant. This prior information should be fed into a priori power tests when looking for the necessary sample sizes to couple statistical and biological significances. Ecologists should make a greater effort to make use of available prior information because this is their most legitimate contribution to the inferential process. Parameter estimation and model selection would benefit if this was done, allowing a more reliable accumulation of knowledge, and hence progress, in the biological sciences.

Impact of living with bipolar patients: Making sense of caregivers' burden

The aim of the present review was to examine objective and subjective burdens in primary caregivers (usually family members) of patients with bipolar disorder (BD) and to list which symptoms of the patients are considered more burdensome by the caregivers. In order to provide a critical review about caregiver's burden in patients with bipolar disorder, we performed a detailed PubMed, BioMedCentral, ISI Web of Science, PsycINFO, Elsevier Science Direct and Cochrane Library search to identify all papers and book chapters in English published during the period between 1963 and November 2011. The highest levels of distress were caused by the patient's behavior and the patient's role dysfunction (work, education and social relationships). Furthermore, the caregiving role compromises other social roles occupied by the caregiver, becoming part of the heavy social cost of bipolar affective disorder. There is a need to better understand caregivers' views and personal perceptions of the stresses and demands arising from caring for someone with BD in order to develop practical appropriate interventions and to improve the training of caregivers.

Suicide risk in dialysis: review of current literature

BACKGROUND

Studies have shown that patients with end-stage kidney disease (ESKD) are at risk of experiencing suicidal ideation and suicide attempt.

STUDY DESIGN

The aim of the present review was to investigate whether there was a relationship between dialysis and suicide. A careful systematic review of the literature was conducted to determine the potential association between dialysis and suicide.

SELECTION CRITERIA FOR STUDIES

Abstracts that did not explicitly mention suicide and dialysis were excluded. We identified as specific fields of interest in the analysis of dialysis or ESRD and suicidal behavior.

RESULTS

A total of 26 articles from peer-reviewed journals were considered and the most relevant articles (N = 13) were selected for this review.

OUTCOMES

It has been posited that suicidal ideation, occurring in dialysis, may arise from co-morbid depression and psychiatric symptoms are frequent in patients who underwent dialysis.

LIMITATIONS

The present review should be considered in the light of some limitations. We did not carry out a meta-analysis because data from most of the studies did not permit it. Samples included different measurements and different outcomes, and they assessed patients at different time points.

CONCLUSIONS

The available data suggest that the risk of self-harm may be higher than expected in dialysis patients especially in those who suffer by depression and anxiety. Moreover, although the majority of deaths among dialysis patients is preceded by withdrawal from treatment, suicide remains a separate phenomenon.

Insomnia as a predictor of high-lethality suicide attempts

INTRODUCTION

Research has demonstrated that patients with insomnia are at an increased risk of experiencing suicidal ideation and/or making a suicide attempt.

OBJECTIVES

To evaluate the relation between insomnia and suicidal behaviour.

AIMS

To examine factors associated with a diagnosis of insomnia in patients admitted to an Emergency Department (ED) and assessed by the psychiatrist in charge.

METHODS

Participants were 843 patients consecutively admitted to the ED of Sant'Andrea Hospital in Rome, between January 2010 and December 2011. All patients admitted were referred to a psychiatrist. A clinical interview based on the Mini International Neuropsychiatric Interview (MINI) and a semi-structured interview was conducted. Patients were asked about 'ongoing' suicidal ideation or plans for suicide.

RESULTS

Forty-eight percent of patients received a diagnosis of bipolar disorder (BD), major depressive disorder (MDD) or an anxiety disorder; whereas, 17.1% were diagnosed with Schizophrenia or other non-affective psychosis. Patients with insomnia (compared to patients without insomnia) more frequently had a diagnosis of BD (23.9% vs. 12.4%) or MDD (13.3% vs. 9.5%; p < 0.001). Moreover, patients with insomnia less frequently had attempted suicide in the past 24 h (5.3% vs. 9.5%; p < 0.05) as compared with other patients, but those patients with insomnia who attempted suicide more frequently used a violent method (64.3% vs. 23.6%; p < 0.01) compared to other suicide attempters.

CONCLUSIONS

Our results do not support an association between insomnia and suicidal behaviour. However, suicide attempters with insomnia more frequently used violent methods, and this phenomenon should be taken into serious consideration by clinicians.

Affective temperaments and psychopathological dimensions of personality in bipolar and cyclothymic patients

The aims of the study were: (1) to study possible associations between temperament, personality dimensions, and psychopathological variables in a clinical sample of euthymic patients with bipolar disorder (BD) and cyclothymia; and (2) to assess how Cloninger's temperament and personality dimensions were associated with affective temperaments. Participants, consisting of 60 patients with BD (type I or II) and cyclothymia in the euthymic phase, completed Akiskal's Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A), and Cloninger's Temperament and Character Inventory-revised version (TCI-R). The diagnostic groups differed in past hospitalization, for age at onset of the disorder, and on two affective temperaments: the TEMPS-A Hyperthymia, and the TEMPS-A Irritability. There were six significant associations between affective temperaments and Cloninger's personality dimensions, ranging from 0.26 to 0.54. The measures of Akiskal and of Cloninger tap common behavioral features in patients with bipolar disorder and cyclothymia, yet the differences indicate that the two measures are not redundant. BD and cyclothymic patients differed significantly in temperament and personality, differences that may have important implications for treatment.

Suicide risk in multiple sclerosis: a systematic review of current literature

BACKGROUND

Studies have shown that suicidal ideation is often revealed among patients suffering from Multiple Sclerosis (MS). Mental health assessment of physically ill patients should form part of routine clinical evaluation, particularly in chronic illness.

OBJECTIVE

The aim of the present paper was to investigate whether there was a relationship between MS and suicidal behavior.

METHODS

A systematic review of the literature was conducted to determine the potential association between MS and suicidal behavior. A total of 12 articles from peer-reviewed journals were considered and selected for this review.

RESULTS

Most studies have documented a higher suicide rate in patients with MS compared to the general population, and suicide was associated with several risk factors: Depression severity, social isolation, younger age, progressive disease subtype, lower income, earlier disease course, higher levels of physical disability, and not driving.

CONCLUSIONS

Clinicians should be aware of the fact that suicidality may occur with higher frequency in MS patients, the available data suggest that the risk of self-harm is higher than expected in MS patients.

Evaluation of secondary school teachers' knowledge about psychosis: a contribution to early detection

AIMS

We sought to evaluate secondary school teachers' knowledge about psychosis and their level of interest in this topic given the key role they may be able to play in the early detection of psychosis.

METHODS

A questionnaire survey of 268 secondary school teachers from eight secondary schools within the Azienda Sanitaria Locale Rome/E and Rome/A catchment areas (two of the five city health districts) in Rome. Teachers were asked to complete the Italian version Esperienza e Conoscenza delle Difficoltò Sociali ed Emotive dei Giovani of the Knowledge and Experience of Social Emotional Difficulties among Young people self-report questionnaire that investigates the diagnosis, age of onset, aetiology, prognosis and treatment of psychosis. They were also asked about their experience with pupils with possible psychosis.

RESULTS

Most of teachers were able to recognize psychotic symptoms from a case vignette. Approximately 25% of the teachers had experienced a pupil with possible symptoms of psychosis. However, teachers displayed little awareness of psychiatric community services available for young people.

CONCLUSIONS

Our study shows that teachers may play an important role in early detection and psychosis prevention strategies. The teachers also displayed a keen interest in gaining a deeper knowledge of early psychotic signs and in cooperating closely with a mental health specialist to obtain guidance and support when faced with serious mentally ill pupils.