Suicide risk after psychiatric discharge: study protocol of a naturalistic, long-term, prospective observational study

Background

Suicide risk of psychiatric patients has proven to be strongly increased in the months after discharge from a psychiatric hospital. Despite this high risk, there is a lack of systematic research on the causes of this elevated suicide risk as well as a lack of treatment and intervention for patients at high risk after discharge. The main objective of this pilot study is, firstly, to examine the factors contributing to the elevated suicide risk and, secondly, to investigate whether an additional setting of care starting at discharge may reduce suicidality.

Methods

In this multi-centre pilot study, treatment as usual is complemented by an additional 18-month post-discharge setting of care for psychiatric patients at high risk for suicide. Two groups of patients differing in the amount of post-discharge personal contacts will be compared. One group of patients will be offered continuous personal contacts after discharge (months 1–6: monthly contacts; months 6–18: every 2 months) while another group of patients will receive contacts only at months 6, 12, and 18 after discharge. Data on suicidality, as well as associated with other symptoms, treatment, and significant events, will be collected. In the case of health-related severe events, the setting of care allows the patient to have the opportunity to connect with the doctor or therapist treating the patient.

Discussion

The results of this study will contribute to identifying critical factors raising suicide risk after discharge and will demonstrate the potential influence on suicide prevention of a setting of care with regular personal contact after discharge.

Trial registration

ZMVI1-2517FSB135 – funded by the German Federal Ministry of Health.

Prevention of suicidal behaviour: Results of a controlled community-based intervention study in four European countries

The 'European Alliance Against Depression' community-based intervention approach simultaneously targets depression and suicidal behaviour by a multifaceted community based intervention and has been implemented in more than 115 regions worldwide. The two main aims of the European Union funded project "Optimizing Suicide Prevention Programmes and Their Implementation in Europe" were to optimise this approach and to evaluate its implementation and impact. This paper reports on the primary outcome of the intervention (the number of completed and attempted suicides combined as 'suicidal acts') and on results concerning process evaluation analysis. Interventions were implemented in four European cities in Germany, Hungary, Portugal and Ireland, with matched control sites. The intervention comprised activities with predefined minimal intensity at four levels: training of primary care providers, a public awareness campaign, training of community facilitators, support for patients and their relatives. Changes in frequency of suicidal acts with respect to a one-year baseline in the four intervention regions were compared to those in the four control regions (chi-square tests). The decrease in suicidal acts compared to baseline in the intervention regions (-58 cases, -3.26%) did not differ significantly (χ2 = 0.13; p = 0.72) from the decrease in the control regions (-18 cases, -1.40%). However, intervention effects differed between countries (χ2 = 8.59; p = 0.04), with significant effects on suicidal acts in Portugal (χ2 = 4.82; p = 0.03). The interviews and observations explored local circumstances in each site throughout the study. Hypothesised mechanisms of action for successful implementation were observed and drivers for 'added-value' were identified: local partnership working and 'in-kind' contributions; an approach which valued existing partnership strengths; and synergies operating across intervention levels. It can be assumed that significant events during the implementation phase had a certain impact on the observed outcomes. However, this impact was, of course, not proven.

Altered task-specific deactivation in the default mode network depends on valence in patients with major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is a highly prevalent psychiatric condition in which patients often have difficulties regulating their emotions. Prior studies have shown that attention bias towards negative emotion is linked to activation in regions of the default mode network (DMN) in MDD individuals. Furthermore, MDD patients showed increased resting-state functional connectivity (FC) between the medial prefrontal cortex and other DMN structures.

METHODS

Twenty-one MDD patients that currently experiencing depressive episodes and twenty-five healthy control participants performed the current emotional expectancy paradigm in a gradient-echo SENSE-SPIRAL fMRI. Whole brain and psycho-physiological interaction (PPI) analysis were applied to explore the task-related brain activity and FCs.

RESULTS

Relative to healthy participants, we found MDD patients had greater activity in dorsal medial prefrontal cortex as a function of positive vs. neutral expectancy conditions. PPI results revealed a significant group difference of MDD patients having relatively decreased task-dependent decoupling from dorsal medial prefrontal cortex (DMPFC) towards posterior cingulate cortex (PCC) and parieto-occipital cortex during positive vs. neutral expectancy conditions, and patients exhibited a positive correlation between PPI (DMPFC and PCC) and anhedonia as measured via SHAPS during the same conditions.

LIMITATIONS

Modest sample size and lack of concurrent depressive episodes limit the generalizability of our findings.

CONCLUSIONS

In MDD patients, insufficient DMN decoupling might occur in response to positive expectancy conditions. Our findings are consistent with the hypothesis that high intrinsic DMN connectivity in MDD patients interfere with the down-regulation of intrinsic focus in order to incorporate information derived from external positive events.

What Are Reasons for the Large Gender Differences in the Lethality of Suicidal Acts? An Epidemiological Analysis in Four European Countries

Background

In Europe, men have lower rates of attempted suicide compared to women and at the same time a higher rate of completed suicides, indicating major gender differences in lethality of suicidal behaviour. The aim of this study was to analyse the extent to which these gender differences in lethality can be explained by factors such as choice of more lethal methods or lethality differences within the same suicide method or age. In addition, we explored gender differences in the intentionality of suicide attempts.

Methods and Findings

Methods. Design: Epidemiological study using a combination of self-report and official data. Setting: Mental health care services in four European countries: Germany, Hungary, Ireland, and Portugal. Data basis: Completed suicides derived from official statistics for each country (767 acts, 74.4% male) and assessed suicide attempts excluding habitual intentional self-harm (8,175 acts, 43.2% male).

Main Outcome Measures and Data Analysis. We collected data on suicidal acts in eight regions of four European countries participating in the EU-funded “OSPI-Europe”-project (www.ospi-europe.com). We calculated method-specific lethality using the number of completed suicides per method * 100 / (number of completed suicides per method + number of attempted suicides per method). We tested gender differences in the distribution of suicidal acts for significance by using the χ²-test for two-by-two tables. We assessed the effect sizes with phi coefficients (φ). We identified predictors of lethality with a binary logistic regression analysis. Poisson regression analysis examined the contribution of choice of methods and method-specific lethality to gender differences in the lethality of suicidal acts.

Findings Main Results

Suicidal acts (fatal and non-fatal) were 3.4 times more lethal in men than in women (lethality 13.91% (regarding 4106 suicidal acts) versus 4.05% (regarding 4836 suicidal acts)), the difference being significant for the methods hanging, jumping, moving objects, sharp objects and poisoning by substances other than drugs. Median age at time of suicidal behaviour (35–44 years) did not differ between males and females. The overall gender difference in lethality of suicidal behaviour was explained by males choosing more lethal suicide methods (odds ratio (OR) = 2.03; 95% CI = 1.65 to 2.50; p < 0.000001) and additionally, but to a lesser degree, by a higher lethality of suicidal acts for males even within the same method (OR = 1.64; 95% CI = 1.32 to 2.02; p = 0.000005). Results of a regression analysis revealed neither age nor country differences were significant predictors for gender differences in the lethality of suicidal acts. The proportion of serious suicide attempts among all non-fatal suicidal acts with known intentionality (NFSAi) was significantly higher in men (57.1%; 1,207 of 2,115 NFSAi) than in women (48.6%; 1,508 of 3,100 NFSAi) (χ² = 35.74; p < 0.000001).

Main limitations of the study

Due to restrictive data security regulations to ensure anonymity in Ireland, specific ages could not be provided because of the relatively low absolute numbers of suicide in the Irish intervention and control region. Therefore, analyses of the interaction between gender and age could only be conducted for three of the four countries. Attempted suicides were assessed for patients presenting to emergency departments or treated in hospitals. An unknown rate of attempted suicides remained undetected. This may have caused an overestimation of the lethality of certain methods. Moreover, the detection of attempted suicides and the registration of completed suicides might have differed across the four countries. Some suicides might be hidden and misclassified as undetermined deaths.

Conclusions

Men more often used highly lethal methods in suicidal behaviour, but there was also a higher method-specific lethality which together explained the large gender differences in the lethality of suicidal acts. Gender differences in the lethality of suicidal acts were fairly consistent across all four European countries examined. Males and females did not differ in age at time of suicidal behaviour. Suicide attempts by males were rated as being more serious independent of the method used, with the exceptions of attempted hanging, suggesting gender differences in intentionality associated with suicidal behaviour. These findings contribute to understanding of the spectrum of reasons for gender differences in the lethality of suicidal behaviour and should inform the development of gender specific strategies for suicide prevention.

Dissociation of glutamate and cortical thickness is restricted to regions subserving trait but not state markers in major depressive disorder

BACKGROUND

The anterior cingulate cortex (ACC) plays an important role in the neuropathology of major depressive disorder (MDD). So far, the effect of local cortical alteration on metabolites in multiple subdivisions of ACC has not been studied. We aimed to investigate structural and biochemical changes and their relationship in the pregenual ACC (pgACC), dorsal ACC (dACC) in MDD.

METHODS

We obtained magnetic resonance spectroscopy (MRS) in two investigated regions for 24 depressed patients and matched controls. In each region, cortical thickness (CTh) was calculated within a template mask based on its MRS voxel. We investigated neurotransmitter concentrations of Glx, N-acetyl aspartate (NAA), and myo-inositol (m-Ins) in two investigated regions, as well as their relationships with CTh in depressed individuals and healthy controls.

RESULTS

Patients showed significantly lower cortical thickness in dACC compared to controls. Glx in dACC significantly correlated with CTh in healthy controls but not MDD patients, while NAA and CTh in dACC significantly correlated in both groups. A marginal decrease of Glx in pgACC was found in the subgroup of more severely depressive patients, compared to the mildly depressed patients.

LIMITATIONS

Modest sample size and lack of episodes of depression may limit the generalizability of our findings.

CONCLUSION

Our results indicate an abolished CTh-MRS relation in dACC-associated with structural decline-but not in pgACC, where acute MRS alterations prevailed. Our study provides the first evidence of a neurochemical basis explaining some of the inter-individual variability in CTh in MDD.

In Heavy Drinkers, Fatty Acid Ethyl Esters Remain Elevated for Up to 99 Hours

BACKGROUND

Both medical and forensic needs require reliable detection of earlier ethanol intake after the disappearance of ethanol from blood. The esters of ethanol with free fatty acids (FAEEs) are candidate markers of this kind. However, it is unknown whether FAEEs can serve as a marker for a single prior ethanol intake. In addition, the period for which FAEEs are elevated is unknown. Therefore, we measured FAEEs in heavy drinkers admitted to detoxification, and in healthy subjects after a drinking experiment.

METHODS

Blood from 30 heavy drinkers was obtained for up to 5 days during a detoxification period in a psychiatric hospital. In addition, 17 healthy subjects who participated in a drinking experiment and who were abstinent thereafter gave blood during a similar time period for analysis of FAEEs. Fatty acid ethyl esters were measured by gas chromatography-mass spectroscopy.

RESULTS

Heavy drinkers had much higher ethanol and FAEEs concentrations than healthy subjects; however, in both groups, FAEEs decreased rapidly during the first day. Only in heavy drinkers, elevated concentrations of FAEEs were observed at days 2 to 4. Concentrations of FAEEs were not associated with serum triglycerides or patients' body mass index.

CONCLUSIONS

It is concluded that kinetics of FAEEs are different in heavy drinkers compared with healthy subjects and that FAEEs are of limited value for the detection of prior single ethanol intake.

Serum Concentrations of Haloperidol Pyridinium Metabolites and the Relationship with Tardive Dyskinesia and Parkinsonism: A Cross-Section Study in Psychiatric Patients

INTRODUCTION

The objective of this study was to provide more clinical data of the potential neurotoxic metabolite haloperidol pyridinium (HP+) in psychiatric patients during long-term treatment with haloperidol and to investigate a possible relationship with extrapyramidal adverse effects.

METHODS

Serum concentrations of HP+, reduced haloperidol pyridinium (RHP+), haloperidol (H), and reduced haloperidol (RH) were measured for 41 psychiatric patients of a nursing residence (27 females, 14 males, 34-79 years of age). Severity of tardive dyskinesia (TD) and parkinsonism were rated with the Tardive Dyskinesia Rating Scale (TDRS) and Extrapyramidal Symptom Rating Scale (EPS), respectively. In addition, several patient- and treatment-related variables were investigated, for example cumulative dose (Dcum) of haloperidol.

RESULTS

Serum concentration were 0.69 microg/L (0-1.53) for HP+ and 0.41 microg/L (0-1.50) for RHP+ with ratios HP+/H of 0.072 (0.017-0.18) and RHP+/RH of 0.094 (0-0.36) at doses of 10.6 mg/day (3.6-30) [mean (range) in each case]. Multiple regression revealed decreased clearance of HP+ with age. One third of patients with more severe TD (TDRS > or = 10, n = 14) had an increased relative body burden of HP+ and H, as calculated by HP+/H * Dcum of haloperidol than patients with less severe or no TD (TDRS < 10, n = 27), i. e. 5.8 g (2.0-11.9) and 3.3 g (0-9.5), respectively [mean (range), p = 0.005, U test]. Patients with mild to severe parkinsonism (EPS > 0.3, n = 16) had a significantly higher aromatization ratio HP+/H than patients with no or minimal parkinsonism (EPS < or = 0.3, n = 25), i. e. 0.14 (0.04-0.36) and 0.06 (0-0.16), respectively [mean (range), p = 0.003, U test].

CONCLUSION

In psychiatric patients treated with haloperidol for the long-term, the severity of TD and parkinsonism is associated with an increased ratio HP+/H. This is explained by the neurotoxicity of HP+ according to the pyridinium hypothesis.

Water quality transformations during soil aquifer treatment at the Mesa Northwest Water Reclamation Plant, USA

Water quality transformations during soil aquifer treatment at the Mesa Northwest Water Reclamation Plant (NWWRP) were evaluated by sampling a network of groundwater monitoring wells located within the reclaimed water plume. The Mesa Northwest Water Reclamation Plant has used soil aquifer treatment (SAT) since it began operation in 1990 and the recovery of reclaimed water from the impacted groundwater has been minimal. Groundwater samples obtained represent travel times from several days to greater than five years. Samples were analyzed for a wide range of organic and inorganic constituents. Sulfate was used as a tracer to estimate travel times and define reclaimed water plume movement. Dissolved organic carbon concentrations were reduced to approximately 1 mg/L after 12 to 24 months of soil aquifer treatment with an applied DOC concentration from the NWWRP of 5 to 7 mg/L. The specific ultraviolet absorbance (SUVA) increased during initial soil aquifer treatment on a time-scale of days and then decreased as longer term soil aquifer treatment removed UV absorbing compounds. The trihalomethane formation potential (THMFP) was a function of the dissolved organic carbon concentration and ranged from 50 to 65 micrograms THMFP/mg DOC. Analysis of trace organics revealed that the majority of trace organics were removed as DOC was removed with the exception of organic iodine. The majority of nitrogen was applied as nitrate-nitrogen and the reclaimed water plume had lower nitrate-nitrogen concentrations as compared to the background groundwater. The average dissolved organic carbon concentrations in the reclaimed water plume were less than 50% of the drinking water dissolved organic concentrations from which the reclaimed water originated.

Right lower prefronto-parietal cortical dysfunction in akinetic catatonia: a combined study of neuropsychology and regional cerebral blood flow

BACKGROUND

Catatonia is a psychomotor syndrome that can be characterized by behavioural, affective and motor abnormalities. In order to reveal further underlying pathophysiological mechanisms of psychomotor disturbances in catatonia we investigated neuropsychological function and regional cerebral perfusion (r-CBF) in a combined study.

METHODS

Ten catatonic patients were investigated with Tc-99mECD brain SPECT and compared with 10 psychiatric (similar age, sex, medication and underlying psychiatric diagnosis but without catatonic syndrome) and 20 healthy controls. Neuropsychological measures included tests for general intelligence, attention, executive functions and right parietal visual-spatial abilities. Correlational analyses were performed between neuropsychological measures, catatonic symptoms and r-CBF.

RESULTS

Catatonic patients showed a significant decrease of r-CBF in right lower and middle prefrontal and parietal cortex compared with psychiatric and healthy controls as well as significantly poorer performance in visual-spatial abilities associated with right parietal function. Correlational analysis revealed significant correlations between visual-spatial abilities and right parietal r-CBF only in psychiatric and healthy controls but not in catatonic patients. In contrast, attentional measures correlated significantly with motor symptoms, visual-spatial abilities and right parietal r-CBF in catatonia only but not in psychiatric or in healthy controls.

CONCLUSION

Findings are preliminary but suggest right lower prefronto-parietal cortical dysfunction in catatonia, which may be closely related to psychomotor disturbances.

Effectiveness of transcutaneous electrical nerve stimulation (TENS) for analgesia during biliary lithotripsy

The effectiveness of transcutaneous electrical nerve stimulation (TENS) in controlling pain during biliary extracorporeal shockwave lithotripsy (BESWL) was assessed in 100 patients with symptomatic gallbladder calculi. Patients were divided into four groups: TENS electrodes were placed on the back at cutaneous anesthesia sites and on the right leg and the gallbladder acupuncture site in groups A and B. Electrodes were "turned on" only in group A. In groups C and D, electrodes were placed only on the back at cutaneous dermatomes. Electrodes were "turned on" in group C only. The TENS unit was stimulated at the pulse rate of 60 to 100 microseconds and frequency of 80 to 125 Hz. Lithotripsy was performed with the Lithostar Plus overhead module. The differences in the amount of analgesic used and the pain experiences by the patients in all groups were not statistically significant. The proportion of patients requiring intravenous analgesia in each group was also not significantly different (72%, 80%, 68%, 76% in groups A to D, respectively). Thus, TENS did not help in reducing the amount of intravenous analgesia required or the average pain perceived by the patient during lithotripsy treatment.

[Aggressive behavior in the psychiatric clinic]

Self and other directed violence of male psychiatric patients have been registered. The diagnostic analysis revealed an unequivocal correlation to delusional diseases and cerebroorganic hamper. Few patients caused a high percentage of all registered aggressions. Due to limited possibilities of drug treatment, changes of organization of communication and of the socio-organisational framework are aspired for the future.

[Prospective study of the late sequelae of electroconvulsive treatment]

In a prospective pilot study 1-3 years after no less than 5 ECT. 12 patients were examined clinically, and by means of psychological tests and computer-aided tomography. Convincing indications of lasting therapy-determined brain damages could not be found.

[Tardive dystonia--a case report on therapy and metaphylaxis]

The article deals with a case of tardive dystonia describing grave complications as result of long-term recidive-fluphenacindepot-treatment; therapy and metaphylaxy-problematic are being discussed as well.

[Electroconvulsive treatment of psychotic patients with organic brain damage]

It is reported about 2 patients in whom the decision on electroconvulsive therapy was rendered more problematic by proven organic defects of the brain or a seizure disease. In our opinion, the electroconvulsive therapy is, in exceptional cases, also practicable under these conditions after an exact risk-benefit analysis.

[Monozygotic twins with schizoform psychosis and hypothalamic-induced hypogonadotropic hypogonadism]

It is reported about an uniovular male pair of twins which has been permanently hospitalized because of an intermittently progressing schizoform psychosis. A hypothalamically conditioned hypogonadotropic hypogonadism provable beyond that substantiates the possibility of the common causal genetic embodiment of both the clinical pictures which is disputed in literature.

The influence of cholesterol on the main phase transition of unilamellar dipalmytoylphosphatidylcholine vesicles. A differential scanning calorimetry and iodine laser T-jump study

The influence of cholesterol (CHOL) on the main phase transition in single shell dipalmytoylphosphatidylcholine (DPPC) vesicles was investigated in equilibrium and kinetic experiments. CHOL increases the optical density and causes a slight hysteresis in turbidity transition curves. Static fluorescence anisotropy measurements showed interesting differences for three probes sensing different parts in the hydrophobic region of the phospholipid bilayer. Differential scanning calorimetry (DSC) peaks can be separated into a narrow and a broad component. The narrow component, which decreases linearly with increasing CHOL content and disappears at 20 mol %, is attributed to the transition of free phospholipid, while the broad component, being associated with the transition of CHOL-lipid units, increases monotoniously from 0 to 20%. Kinetic experiments were performed on our iodine-laser T-jump arrangement with turbidity detection. Three cooperative relaxation signals in the microsecond and millisecond time range were detected for pure DPPC vesicles as well as vesicles containing 7.5 and 16.5 mol % CHOL. All three relaxation processes were changed by CHOL: the superposition of the three relaxation amplitudes can be separated into a narrow and a broad component, as in DSC experiments. A speculative model is presented which assumes an inhomogeneous CHOL distribution fluctuating on a millisecond time scale in the temperature region of the main phase transition.

Dynamic fluorescence measurements on the main phase transition of dipalmytoylphosphatidylcholine vesicles

The kinetics of the main phase transition in dipalmytoylphosphatidylcholine (DPPC) vesicles have been investigated using our iodine laser-T-jump technique with fluorescence detection. A set of three fluorescent probes has been used to sense different parts of the bilayer hydrocarbon chain region. The well established membrane probes DPH and TMADPH as well as DPHPC, a labelled DPPC molecule. We report three relaxation signals in the microseconds and ms time range, which are detected with all three probes. This result supports our model of the main phase transition in DPPC vesicles.

[Side effects of bilateral electroconvulsive therapy--comparative clinico-computer tomographic study]

The side effects of a five-times bilateral electric shock therapy were clinically and computer-tomographically investigated. A connection exists between the number of electric shock treatments which are carried out and the expression of a transitory organic psychosyndrome. However, no significant differences in relation to the initial findings were established a week after the completion of the treatment series despite great interindividual differentiation. Neither cerebral oedema or other signs of disturbances were computer-tomographically detectable as results of treatment. CT and clinic findings do not correspond to each other.

[Multidimensional studies of circadian biorhythm in psychoses]

Subject of the report is methodics for a circadian analysis in case of psychotical diseases. Acquisition and filing of psychopathological phenomenona is effected by means of Strukturiertes Psychopathologisches Erfassungssystem (SPES) and other self-or outside-rating-scales. The diurnal variation of body-temperature is taken as physiological reference function. The results of the analysis, which show an internal rhythmic desynchronization in case of phasic as well as in case of non-phasic psychoses, are given by way of exemplary instances.

[Multiple recurrence in progressive paralysis]

In case of progressive paralysis of the insane, repeated recurrence can be explained only by the survival of pathogens inspite of optimal therapeutic conditions, the persistence of the pathogens being possibly produced by turning of the treponemas into L-type forms. In order that the possibilities and limits of recurrence verification will become apparent, reference is made to humoral and immunological changes of state given by way of example.

[Electronic data processing-assisted epicrisis in clinico-psychiatric documentation of findings]

The medical profession is using computers to an increasing extent, and the graphic epicrises described here, which is intended mainly to augment the conventional epicrisis, is another useful application. It is based on a standardised psychopathological examination and documentation procedure and permits the course of psychopathological syndromes to be demonstrated in an illustrative way.