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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Role of Emotion Dysregulation in Understanding Suicide Risk: A Systematic Review of the Literature

Suicide prevention represents a global imperative, and efforts to identify potential risk factors are intensifying. Among these, emotional regulation abilities represent a transdiagnostic component that may have an impactful influence on suicidal ideation and behavior. Therefore, the present systematic review aimed to investigate the association between emotion dysregulation and suicidal ideation and/or behavior in adult participants. The review followed PRISMA guidelines, and the research was performed through four major electronic databases (PubMed/MEDLINE, Scopus, PsycInfo, and Web of Science) for relevant titles/abstracts published from January 2013 to September 2023. The review included original studies published in peer-reviewed journals and in English that assessed the relationship between emotional regulation, as measured by the Difficulties in Emotional Regulation Scale (DERS), and suicidal ideation and/or behavior. In total, 44 studies were considered eligible, and the results mostly revealed significant positive associations between emotion dysregulation and suicidal ideation, while the findings on suicide attempts were more inconsistent. Furthermore, the findings also confirmed the role of emotion dysregulation as a mediator between suicide and other variables. Given these results, it is important to continue investigating these constructs and conduct accurate assessments to implement effective person-centered interventions.

Characterization of Psychiatric Inpatients: The Role of Gender Differences in Clinical and Pharmacological Patterns

BACKGROUND

Severe mental disorders that require hospitalization are disabling conditions that contribute to the burden of mental diseases. They pose increased clinical challenges and highlight the need to thoroughly explore variables emerging from daily clinical practice. In this study, we assessed to what extent gender differences may characterize a large population of psychiatric inpatients.

METHODS

We conducted a cross-sectional study in 2 Italian teaching medical centers, which included 2358 patients who were consecutively admitted to the psychiatric emergency units. We explored and characterized gender differences for variables such as prevalence of psychiatric diagnosis, presence of suicidal ideation, suicide attempts, age at onset of psychiatric illness, presence of substance or alcohol abuse, length of stay, number of hospitalizations, presence of involuntary admission, type of discharge from the hospital, and pharmacological treatment at discharge.

RESULTS

Female patients were primarily diagnosed with bipolar disorder or personality disorders. Female patients had a significantly higher prevalence of lifetime suicide attempts (23.1% vs. 16.5%, P<0.001) and a longer length of hospitalization (11.43±10.73 d vs. 10.52±10.37 d, t=-2.099, gl=2356, P=0.036) compared with male patients. Male patients had more involuntary admissions (25.1% vs. 19.7%, χ2=9.616, gl=1, P=0.002), more use of illicit substances (34.1% vs. 20.9%, χ2=51.084, gl=1, P<0.001), and higher rates of alcohol abuse (21.3% vs. 14.7%, χ2=17.182, gl=1, P<0.001) compared with female patients. Finally, antidepressants and lithium were prescribed more frequently to the female patients, whereas other mood stabilizers were more often prescribed to the male patients.

CONCLUSIONS

Our real-world results highlighted gender differences among patients with severe mental disorders admitted to psychiatric units, and suggest further investigations that may help in understanding trajectories accompanying disabling clinical conditions.

Lithium treatment versus hospitalization in bipolar disorder and major depression patients

BACKGROUND

Preventing hospitalization of major affective disorder patients is a fundamental clinical challenge for which lithium is expected to be helpful.

METHODS

We compared hospitalization rates and morbidity of 260 patients with DSM-5 bipolar or major depressive disorder in the 12 months before starting lithium versus 12 months of its use. We evaluated duration of untreated illness, previous treatments, substance abuse, suicidal status, lithium dose, and use of other medicines for association with new episodes of illness or of symptomatic worsening as well as hospitalization, using bivariate and multivariate analyses.

RESULTS

Within 12 months before lithium, 40.4 % of patients were hospitalized versus 11.2 % during lithium treatment; other measures of morbidity also improved. Benefits were similar with bipolar and major depressive disorders. Independently associated with hospitalization during lithium treatment were: receiving an antipsychotic with lithium, suicide attempt during lithium treatment, lifetime substance abuse, and psychiatric hospitalization in the year before starting lithium, but not diagnosis.

LIMITATIONS

Participants and observation times were limited. The study was retrospective regarding clinical history, lacked strict control of treatments and was not blinded.

CONCLUSIONS

This naturalistic study adds support to the effectiveness of lithium treatment in preventing hospitalization in patients with episodic major mood disorders.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Suicide risk and suicide risk factors among immigrants in Italy: A bi-center matched sample study

Italy has the third-largest immigrant population of European Union countries, but only a few research papers have examined suicide risk in immigrant psychiatric patients in Italy. The main aim of this paper was to compare suicidal ideation and suicide attempts in a sample of 304 psychiatric patients. We included 152 immigrant patients matched with 152 Italian patients admitted to the same wards during the same time period by age, gender, and diagnosis. We also investigated sociodemographic and clinical characteristics of the two samples including psychiatric diagnosis, age of illness onset, duration of illness, previous hospitalizations, length of hospitalization, previous suicide attempts, and substance and alcohol abuse. There were no differences between immigrant and Italian patients in either suicidal ideation (previous or current) or suicide attempts (previous or current). Immigrant patients were more likely to have a shorter duration of illness than the Italian patients and Italian patients were more likely to report substance abuse than were immigrant patients. Despite similar suicide rates between immigrants and Italian psychiatric inpatients, appropriate assessment of suicide risk in these patients is essential in implementing therapeutic suicide prevention strategies.

Exploring risk factors for re-hospitalization in a psychiatric inpatient setting: a retrospective naturalistic study

BACKGROUND

The reduction of multiple psychiatric hospitalizations is an important clinical challenge in mental health care. In fact, psychiatric re-hospitalization negatively affects the quality of life and the life expectancy of patients with psychiatric disorders. For these reasons, identifying predictors of re-hospitalization is important for better managing psychiatric patients. The first purpose of the present study was to examine the readmission rate in a large sample of inpatients with a psychiatric disorder. Second, we investigated the role of several demographical and clinical features impacting re-hospitalization.  METHOD: This retrospective study enrolled 1001 adult inpatients (510 men and 491 women) consecutively admitted to the University Psychiatric Clinic, Sant'Andrea Hospital, Sapienza University of Rome between January 2018 and January 2022. To identify risk factors for psychiatric re-hospitalization, we divided the sample into 3 subgroups: the Zero-Re group which had no readmission after the index hospitalization, the One-Re group with patients re-admitted only once, and the Two-Re with at least two re-admissions.  RESULTS: The groups differed according to previous hospitalizations, a history of suicide attempts, age at onset, and length of stay. Furthermore, the results of the regression model demonstrated that the Two-Re group was more likely to have a history of suicide attempts and previous hospitalizations.

DISCUSSION

These results indicate the importance of assessing risk factors in psychiatric hospitalized patients and implementing ad hoc prevention strategies for reducing subsequent re-hospitalizations.

Is Lethality Different between Males and Females? Clinical and Gender Differences in Inpatient Suicide Attempters

According to the gender paradox in suicidology, an important sex difference has been reported with a preponderance of females in nonfatal suicidal behavior and a preponderance of males in completed suicide. Furthermore, females and males present different risk factors for suicide. The present study explored possible clinical differences between male and female psychiatric inpatients who had recently attempted suicide. The study included 177 adult inpatients hospitalized following a suicide attempt at the University Psychiatric Clinic, Sant'Andrea Hospital, Sapienza University of Rome. Clinical features assessed included psychiatric diagnosis, method and lethality of suicide attempts using the Risk/Rescue Rating Scale, the history of suicide attempts, age at onset of psychiatric illness, the presence of substance or alcohol use, and the length of stay. The results found that males and females differed in the method used for the suicide attempt, the scores for risk and rescue, and the length of hospitalization post-suicide attempt. In conclusion, identifying gender characteristics of patients at higher risk of suicide is important for implementing specific suicide prevention strategies and reducing the risk of future suicidal behavior in psychiatric inpatients.

High depression symptomatology and mental pain characterize suicidal psychiatric patients

BACKGROUND

Symptoms of depression are transdiagnostic heterogenous features frequently assessed in psychiatric disorders, that impact the response to first-line treatment and are associated with higher suicide risk. This study assessed whether severe mental pain could characterize a specific phenotype of severely depressed high-risk psychiatric patients. We also aimed to analyze differences in treatments administered.

METHODS

2,297 adult patients (1,404 females and 893 males; mean age = 43.25 years, SD = 15.15) treated in several Italian psychiatric departments. Patients were assessed for psychiatric diagnoses, mental pain, symptoms of depression, hopelessness, and suicide risk.

RESULTS

More than 23% of the patients reported high depression symptomatology and high mental pain (HI DEP/HI PAIN). Compared to patients with lower symptoms of depression, HI DEP/HI PAIN is more frequent among females admitted to an inpatient department and is associated with higher hopelessness and suicide risk. In addition, HI DEP/HI PAIN (compared to both patients with lower symptoms of depression and patients with higher symptoms of depression but lower mental pain) were more frequently diagnosed in patients with personality disorders and had different treatments.

CONCLUSIONS

Patients reporting severe symptoms of depression and high mental pain presented a mixture of particular dangerousness (high trait hopelessness and the presence of suicide ideation with more frequency and less controllability and previous suicide behaviors). The presence of severe mental pain may act synergically in expressing a clinical phenotype that is likewise treated with a more complex therapeutic regime than that administered to those experiencing symptoms of depression without mental pain.

The Relationship Between Mental Pain, Suicide Risk, and Childhood Traumatic Experiences: Results From a Multicenter Study

Objective: Mental pain and exposure to maltreatment are significant risk factors for suicidal behavior. This study aimed to investigate whether mental pain could be associated with a recent suicide attempt and whether it could mediate the relationship between childhood traumatic experiences and suicide risk in psychiatric patients. Methods: A multicenter observational study was organized as a joint project with representatives of numerous mixed Italian academic and clinical settings. Between December 2017 and March 2020, batteries of tests were administered to patients, assessing suicidal ideation and behavior, mental pain (usual and worst mental pain in the past 15 days), depression, and childhood maltreatment. Results: A total of 2,137 psychiatric patients (1,313 women and 824 men) were included in the final sample, and 315 reported having attempted suicide in the last 3 months. Suicide attempters (compared to nonattempters) had higher odds of reporting worse mental pain (odds ratios [ORs] between 1.02 and 1.17; P < .001) and suicidal intent with/without a specific plan (ORs between 11.57 and 11.77; P < .001). They also had higher odds of having a personality disorder (borderline personality disorder: ORs between 2.65 and 3.01; P < .001; other personality disorders: ORs between 1.96 and 2.28; P < .01) and major depression (ORs between 1.62 and 1.70; P < .05). Childhood trauma was associated with suicide risk directly (standardized effects between 0.06 and 0.07; P < .01) and indirectly through mental pain (usual mental pain: standardized indirect effect = 0.11, P < .001; worst mental pain in the past 15 days: standardized indirect effect = 0.12, P < .001). Conclusions: Mental pain constitutes a crucial framework for assessing the individual need for psychiatric help. Assessing mental pain allows identification of the main ingredient of suicide risk and puts the clinician in a strategic position to unlock some motives behind the wish to die. Further research is needed to learn if childhood adversities may interact with adult mental pain and thus foster suicide risk.

Association between Childhood Maltreatment and Suicidal Ideation: A Path Analysis Study

Epidemiological studies have suggested that childhood maltreatment increases suicidal ideation, and dissociative symptoms and hopelessness are involved in this relation. To better address this issue, we used a path analysis model to examine the role of different types of childhood maltreatment on suicidal ideation, investigating whether hopelessness and dissociative symptoms mediated this relation. A sample of 215 adult psychiatric inpatients was enrolled between January 2019 and January 2020, at the psychiatric unit of Sant’Andrea Medical Center in Rome, Italy. The Childhood Trauma Questionnaire (CTQ), Beck Hopelessness Scale (BHS), Dissociative Experiences Scale (DES-II), and Columbia-Suicide Severity Rating Scale (C-SSRS) were used to test the hypotheses. Results revealed that the presence of sexual abuse directly affected suicidal ideation (β = 0.18, SE = 0.8, p < 0.05), while emotional abuse and neglect indirectly increased suicidal ideation via dissociation (β = 0.05, SE = 0.02, 95% C.I. 0.01/0.09) and hopelessness (β = 0.10, SE = 0.03, 95% C.I. = 0.04/0.16). Professionals working with children should be aware of the long-term consequences of childhood maltreatment, particularly suicide risk. Furthermore, professionals working with adults should inquire about past childhood maltreatment.

The impact of Covid-19 on unemployment across Italy: Consequences for those affected by psychiatric conditions

BACKGROUND

Severe psychological and psychosocial consequences of the COVID-19 pandemic are expected, especially for people already vulnerable to biological or psychosocial stressors, including those with mental health problems. The study aimed to investigate factors associated with the loss of jobs and unemployment during the COVID-19 pandemic. In particular, we investigated whether mental illness was associated with a higher risk of losing one's job because of the COVID-19 pandemic.

METHODS

Nineteen thousand four hundred ninety-six adults living in Italy were administered an online protocol including a sociodemographic checklist and questionnaires investigating suicide ideation and risk, mental health status and general distress (stress, anxiety, and depression), resilience, and perceived support.

RESULTS

One thousand two hundred seventy-four reported having lost their job because of the COVID-19 pandemic, and 5.4% of the sample reported a mental illness (mostly a depressive disorder). Unemployment was independently associated with mental illness, poor mental health, and depression. Mental illness was associated with the risk of losing one's job because of the COVID-19 pandemic, but not at the multivariate analyses. Those who lost their job because of the COVID-19 pandemic (compared to others) reported worse mental health and depression.

LIMITATIONS

The presence of mental illness was self-reported by respondents and the administered measures were self-reported questionnaires affected by social desirability and other response bias.

CONCLUSIONS

The COVID-19 pandemic and social isolation measures and lockdown used to contain its spread among the Italian population were associated with occupational insecurity, especially among the more vulnerable social categories.

Demographic and Clinical Correlates of High-lethality Suicide Attempts: A Retrospective Study in Psychiatric Inpatients

Assessment of the lethality of suicide attempts is a neglected topic in the literature in this area. Based on the hypothesis that suicide attempters who choose a highly lethal method differ from those who use less lethal methods, we analyzed the characteristics of suicide attempters who used different suicide methods to determine demographic and clinical risk factors for the lethality of suicide methods. For this purpose, we used the Risk-Rescue Rating Scale to assess the lethality of the suicide method in a consecutive sample of 107 psychiatric inpatients with a recent suicide attempt (in 6 mo before hospitalization). The results demonstrated that patients who used a highly lethal method were younger and more frequently single. A novel finding of this study was that earlier age of onset of psychiatric symptoms and a higher number of previous hospitalizations were associated with the use of more lethal methods. In conclusion, patients who used more lethal methods differed from those who used less lethal methods. Identification of these differences may be necessary to implement specific suicide prevention strategies in patients with psychiatric conditions.

Affective temperaments and depressive symptoms: The mediating role of attachment

BACKGROUND

Studies showed that affective temperaments and attachment are associated with depressive symptoms, and that they bi-directionally influence each-other. The aim of this study is to explore mechanisms underlying the relationship between the affective temperaments (i.e., depressive, cyclothymic, irritable, hyperthymic and anxious), interview-based attachment, and depressive symptoms.

METHODS

A sample of 61 adolescents and young adults outpatients were asked to complete the Temperament Evaluation of Memphis, Pisa, and San Diego Autoquestionnaire (TEMPS-A) and the Hamilton Rating Scale for Depression (HAM-D). Attachment was assessed through the Adult Attachment Interview (AAI) and employing a dimensional approach to obtain continuous measures. Mediation models were performed with the affective temperaments as predictor, depressive symptoms as the criterion variable, and attachment dimensions as mediators.

RESULTS

Findings showed significant direct effects between all the affective temperaments and depressive symptoms. Only the cyclothymic (β = 0.22; SE = 0.1; 95% IC = 0.05, 0.42) and irritable (β = 0.21; SE = 0.09; 95% IC = 0.04, 0.4) temperaments showed an indirect effect on depressive symptoms through secure-insecure attachment. Dismissing attachment did not predict either the affective temperaments nor depressive symptoms. Preoccupied attachment significantly predicts depressive symptoms and, when controlling for it, the hyperthymic temperament no longer directly associates with depressive symptoms.

LIMITATIONS

The cross-sectional study design limit conclusion about causation and directionality.

CONCLUSIONS

Secure attachment could be a protective factor for depressive symptoms for individuals with a cyclothymic or irritable temperament. Differently, the hyperthymic temperament loses its protective role toward depressive symptoms when accounting for preoccupied attachment.

The impact of the COVID-19 pandemic on suicide ideation and suicide attempts in a sample of psychiatric inpatients

There has been little research reported regarding both suicide ideation and suicide attempts during the COVID-19 pandemic and government lockdown restrictions in Italy, one of the countries most affected by the pandemic. We investigated whether the frequency of suicide ideation and suicide attempts differed between psychiatric patients admitted to a psychiatric unit before and during the COVID-19 pandemic and government lockdown restrictions. We also assessed psychiatric diagnosis, length of hospitalization, and types of admission. We collected data on 632 psychiatric patients admitted to a public psychiatric clinic. Patients were divided into two different groups according to their admission before or during the COVID-19 pandemic. Our results showed that only suicide attempts, but not suicide ideation, were more frequent in psychiatric patients admitted during the COVID-19 pandemic than before. Furthermore, mood disorder diagnoses were more frequent during the COVID-19 pandemic than before the pandemic. The types of admission and the mean length of hospitalization did not differ between the two groups. In conclusion the present study results adds consistent knowledge on the phenomenon of suicide during the challenging time of the pandemic, pointing to continuing effort in suicide prevention measures.

The COVID-19 Outbreak and Subjects With Mental Disorders Who Presented to an Italian Psychiatric Emergency Department

ABSTRACT

We performed a retrospective study from January to May 2020 to establish the sociodemographic and clinical characteristics of patients with mental health problems who arrived at an Italian emergency department during the COVID-19 outbreak. We divided the sample into two groups taking as a watershed March 11, when the World Health Organization announced COVID-19 outbreak as a pandemic. Chi-square/t-tests, adjusted p values (Bonferroni method), and regression analysis were performed. Patients who arrived at the emergency department during the lockdown decreased by 56%; showed greater active suicidal ideation, more tension, and more severe psychopathological state; were living alone more frequently; and were taking home treatment mainly based on second-generation antipsychotics. According to our study, it seems that patients with mental disorders have consulted psychiatric services less frequently during the pandemic, but the economic, health, and social distress may be linked with an increase in suicidal risk and the severity of the psychopathological state.

Are demoralization and insight involved in suicide risk? An observational study on psychiatric inpatients

Introduction

Although several authors have investigated the relationship between demoralization, insight, and suicide risk, the role of these factors in determining suicide risk in patients with psychiatric disorders is still unclear [Berardelli et al., 2019; Costanza et al., 2020].

Objectives

The main aim of this study was therefore to determine whether suicide risk was associated with better insight and worse demoralization in a sample of 100 adult psychiatric inpatients.

Methods

The study was performed on 100 psychiatric hospitalized adult patients consecutively enrolled between January 2019 and April 2020 at psychiatric units of Sant’Andrea Medical Center, Sapienza University of Rome. The Columbia Suicide Severity Rating Scale (C-SSRS) was used to assess suicide risk, Demoralization was assessed using the Demoralization Scale (DS) [Kissane et al., 2004] and for the assessment of insight we used the The Insight Scale (IS).

Results

Only age was significantly associated with higher suicide risk (χ2=9.07, p<0.01). The variable mood disorder was significantly associated with higher suicide risk (χ22=7.50, p<0.05). Non-suicidal self-harm behaviors in the last 3 months (χ2=5.89, p<0.05) and lifetime suicide attempts (χ2=21.80, p<0.001) were significantly associated with higher suicide risk. Only the insight-high dimension (χ2=8.01, p<0.01) and lifetime suicide attempts (χ2=12.33, p<0.001) were significantly associated with higher suicide risk.

Conclusions

Our results don’t confirm the role of demoralization in suicide risk. In our sample of patients, only high insigth of illness and other psychological variables are involved in suicide risk.

Disclosure

No significant relationships.

Negative emotion dysregulation is linked to the intensity of suicidal ideation in a mixed inpatient sample

BACKGROUND

Suicide has been associated with dysfunctional strategies for emotion regulation but, so far, research findings have been inconclusive.

METHODS

To investigate how difficulties in emotion regulation impact suicidal ideation (SI) and behavior, 111 psychiatric inpatients were enrolled. Affective instability (AI), emotional impulsivity (EI), and negative and positive emotionality (NE and PE) were measured by the RIPoSt-40 questionnaire; the first three subscales have been summed to form a total negative emotion dysregulation (NED) score.

RESULTS

In the sample, 55 subjects reported at least one-lifetime suicide attempt; 50 patients were diagnosed with mood-disorder (MD), 30 with the schizophrenia-spectrum disorder (SSD), and 15 with personality-disorder (PD). Diagnostic groups differed for NED scores (p=.008) but not for PE (p>0.05), with patients suffering from PD having higher scores (p=0.03). Compared to non-attempters, lifetime-suicide attempters were 6.5 times more likely to have a personality disorder (95% CI=1.34/31.83). Partial correlation analyses, controlling for the presence of suicide attempts, showed that lifetime SI-intensity score was significantly and positively associated with NED (r=.39, p<.001), AI (r=.40, p<.001), and NE (r=.42, p<.001). NED scores (p=.001) and the presence of lifetime suicide attempts (p<.001) were independently associated with lifetime SI-intensity scores.

LIMITATIONS

The lack of a non-clinical control group and the cross sectional nature of the study limits the generalizability of the results.

CONCLUSION

Our findings support the hypothesis that negative emotion dysregulation is independently associated with SI and behavior. Negative emotion dysregulation should be targeted in suicide prevention.

The Importance of Suicide Risk Formulation in Schizophrenia

Suicide is a cause of early mortality in nearly 5% of patients with schizophrenia, and 25-50% of patients with schizophrenia attempt suicide in their lifetime. Evidence points to numerous individual, clinical, social, and psychological risk factors for suicide in patients with schizophrenia. Although recognizing suicidal risk factors in schizophrenia is extremely important in suicidal risk assessment, we have recently witnessed a change in suicide risk management that shifts the focus from suicide risk assessment to suicide risk formulation. Suicide risk formulation is dependent on the data gathered in the suicide risk assessment and assigns a level of suicide risk that is indispensable for the choice of treatment and the management of patients with a high suicidal risk. In this article, we extend the suicide risk formulation model to patients with schizophrenia. Suicide risk formulation results from four different areas that help clinicians collect as much information as possible for the management of suicidal risk. The four distinct judgments comprise risk status (the risk relating to the specific group to which the patient belongs), risk state (the risk for the person compared with his baseline or another reference point in the course of his life), available resources (on whom the person can count during a crisis) and foreseeable events (which can exacerbate the crisis). In schizophrenia, the suicide risk formulation model allows the clinician to evaluate in depth the clinical context of the patient, the patient's own history and patient-specific opportunities for better choosing and applying suicide prevention strategies.

Are Demoralization and Insight Involved in Suicide Risk? An Observational Study on Psychiatric Inpatients

INTRODUCTION

Several features contribute to determining suicide risk. This study was designed with the aim of evaluating whether insight into illness and demoralization are involved in suicide risk (active suicidal ideation or behavior).

METHODS

For this purpose, in a sample of 100 adult psychiatric inpatients, we used the Columbia Suicide Severity Rating Scale to assess suicide risk, the Demoralization Scale for demoralization symptoms, and the Insight Scale to assess illness insight. We also investigated several demographic and clinical features, including gender, age, duration of untreated illness, previous suicide attempts, and nonsuicidal self-injurious behavior.

RESULTS

The results demonstrated that patients with higher scores on the insight-high dimension had 1.35 greater odds of having a higher suicide risk, and those with lifetime suicide attempts had 7.45 greater odds of having a higher suicide risk. Among the various clinical factors, the study indicated that only nonsuicidal self-harm behaviors in the last 3 months was a risk factor for suicide risk.

CONCLUSIONS

The results indicated that greater illness insight is involved in suicide risk regardless of demoralization.

Influence of Spiritual Dimensions on Suicide Risk: The Role of Regional Differences

The field of suicide prevention has been enriched by research on the association between spirituality and suicide. Many authors have suggested focusing on the various dimensions of religiosity in order to better understand the association between religion and suicidal risk, but it is unclear whether the relationship between spirituality and suicidality differs between countries with different cultures, life values, and sociohistorical experiences. To explore this, the aim of this multicenter study was to investigate the possible relationship between suicide and spirituality in Italy and Austria. In the two countries, two different groups of subjects participated: psychiatric patients and university students. The patients were evaluated with the Mini International Neuropsychiatric Interview. In addition, the following measures were used: a sociodemographic questionnaire, the Columbia-Suicide Severity Rating Scale-B, the Symptom-Checklist-90-Standard, and the Multidimensional Inventory for Religious/Spiritual Well-Being. Our results confirmed the multifactorial nature of the relation between suicide risk and the various religious/spiritual dimensions, including religious/spiritual well-being and hope immanent. However, regional differences moderated this relationship in both the clinical and nonclinical samples.

Making Sense of the Unique Pain of Survivors: A Psychoeducational Approach for Suicide Bereavement

Grief, guilt, abandonment, anger, shame, and rejection are the most common feelings experienced by suicide survivors, who differ from other bereaved individuals for the intensity of these feelings. Moreover, suicide risk and psychiatric disorders associated with suicidality are more frequent in people who have lost a loved person by suicide. Given the complexity and the consequences linked to the suicide of a loved person, it is necessary to act promptly. Among the various strategies, psychoeducation has proved effective for several mental disorders and for suicide bereavement. It is a therapeutic intervention aimed at identifying and understanding the psychological features associated with the mental pain of suicide survivors, to facilitate the management of the illness and the recognition of relationships in the social environment. We developed a psychoeducational group that took place at the Suicide Prevention Center of the Sant'Andrea Hospital in Rome. It was a homogeneous, finite-group composed of 8-12 suicide survivors and conducted by two trained psychologists supervised weekly by the Director of the Suicide Prevention Center. The intervention comprised 21 weekly sessions of 90 min. Each session concerned a determined topic and began with the presentation of the issue, continued with specific exercises, and finished with a group discussion. The main goals of the group were to provide support, normalize the reactions of the survivors, and assist them in reducing their emotional suffering and their thoughts about suicide, investigate the potential presence of suicide risk, implement prevention strategies, and integrate the loss of the loved person. The psychoeducational approach we delivered for suicide survivors allows individuals to interact with other individuals in the same situation in order to help them resume the normal course of life, placing the suicide of a loved person in a broader perspective.

Deficits in Mentalization Predict Suicide Risk Among Psychiatric Inpatients

Introduction

Suicide is a major public health issue.

Objectives

Mentalization is a form of imaginative mental activity about others or oneself that may shed light on the phenomenology of suicide.

Aims

To assess the role of a number of variables in suicide risk.

Methods

Participants were 156 (73 men and 83 women) adult psychiatric inpatients (age range = 18/74 year). Most of the patients had a major mood disorder (26.3% BD-I, 3.2% BD-II, and 11.5 MDD), psychosis (16.7%), or a schizoaffective disorder (20.5%). All the patients were administered the Mini International Neuropsychiatric Interview (MINI) for assessing diagnosis and suicide risk, and the Impact of event scale, Mentalization Questionnaire, Childhood Trauma Questionnaire. Some patients (18.6%) were admitted for a recent suicide attempt and 34.6% had attempted suicide in the past.

Results

At the MINI, 44.9% of the patients resulted at a moderate to high risk of suicide, and 55.1% at no or low risk of suicide with no difference for sociodemographic variables (sex and age) and diagnosis, but they differed for mentalization and symptoms of intrusions and avoidance caused by a traumatic event. Groups also did not differ for self-reported childhood trauma. Only mentalization was independently associated with higher suicide risk, and patients with moderate to severe risk of suicide were 1.7 times more likely to report more mentalization deficits than those with no or low risk of suicide.

Conclusions

Our study supports the notion that the investigation of mentalization among patients may help in proper assessment of suicide risk.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Relationship between aberrant salience and positive emotion misrecognition in acute relapse of schizophrenia

INTRODUCTION

Aberrant salience is the incorrect assignment of salience or significance to innocuous stimuli, and been hypothesized to be a central mechanism in the development of psychosis. In addition to aberrant salience, social-cognitive models of psychosis suggest that the way people process information about the self is important in all stages of psychosis. The aim of the present study is to explore the relationship between aberrant salience and emotion processing in schizophrenia patients with psychotic relapse.

METHODS

A sample of 42 patients with relapse was recruited. Aberrant salience was measured with the Aberrant Salience Inventory (ASI). Assessment of social cognition was carried out using the Facial Emotion Identification Test (FEIT). Partial correlations were controlled for possible confounding variables.

RESULTS

The ASI factors "increase in meaning" and "heightened cognition" positively correlated with impaired recognition of positive emotions, and ASI total score inversely correlated to time to response to task. Most of incorrect answers corresponded to misclassification of positive emotions.

CONCLUSION

Our findings show that there is evidence for a relationship between aberrant salience and emotion processing during a psychotic episode; we propose that aberrant salience and alterations in emotion processing trigger the loss of modulating feedback from the external world to produce a self-referential mental state.

Suicide and Personality Traits: A Multicenter Study of Austrian and Italian Psychiatric Patients and Students

OBJECTIVE

The aim of this multicenter study was to investigate the differences in personality traits, particularly Neuroticism, in three clinical samples and three student samples in Austria and Italy and their impact on suicide.

METHODS

In total, 1,043 people (410 psychiatric inpatients and 633 university students) were tested in three regions of Europe: central Italy, northeast Italy, and eastern Austria. Psychiatric diagnoses were evaluated using the Mini-International Neuropsychiatric Interview, and the following instruments were used: Sociodemographic Questionnaire, Columbia-Suicide Severity Rating Scale-B, Symptom-Checklist-90-Standard, and Big Five Inventory.

RESULTS

The study found that the intensity of Suicidal Ideation was associated with the personality traits of Neuroticism, Anxiety, and Extraversion but also with Depression.

CONCLUSIONS

In conclusion, without the presence of Depression symptoms, neuroticism was a protective factor against Suicidal Ideation, whereas neuroticism when comorbid with Depression symptoms increased suicide risk in psychiatric patients. In all three regions, the clinical samples had higher scores for Neuroticism and for Depression symptoms than the student sample and consequently higher scores for Suicide. Furthermore, we demonstrated an interaction between gender and culture on personality traits, supporting the hypothesis that the distribution of self-reported personality traits is organized geographically.

Anxiety, Prenatal Attachment, and Depressive Symptoms in Women with Diabetes in Pregnancy

The purpose of this study was to evaluate the relationship between anxiety, prenatal attachment, and depressive symptoms among women with diabetes in pregnancy. Participants were 131 consecutive pregnant women between the ages of 20 and 45 with a diagnosis of gestational or pregestational type 1 or type 2 diabetes. Data on previous psychiatric symptoms were obtained from the Anamnestic and Social Questionnaire and the Mini-International Neuropsychiatric Interview (MINI). Information on prenatal attachment was collected using The Prenatal Attachment Inventory (PAI), and The Edinburgh Postnatal Depression Scale (EPDS) assessed depressive symptoms in the third trimester of pregnancy (at a mean of 25 weeks). Results demonstrated that in women affected by diabetes in pregnancy, two facets of prenatal attachment (anticipation, interaction) were negatively correlated with depressive symptoms, and a history of anxiety, assessed with the MINI, moderated the relation between the prenatal attachment interaction factor and depressive symptoms during pregnancy.

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.

Cytomegalovirus Seropositivity and Suicidal Behavior: A Mini-Review

Background and objectives: In recent years, a growing body of research has focused on identifying possible biological markers for suicidal behavior, including infective and immunological markers. In this paper, our aim was to review available evidence concerning the association between cytomegalovirus (CMV) infection and suicide. Materials and Methods: A systematic search according to the PRISMA statement was performed on Pubmed. After the screening procedure, we identified five relevant papers. Results: We found inconsistent evidence linking CMV infection and suicide, with some papers reporting an association between CMV seropositivity and suicidal behavior, and others not finding the association. Conclusions: With the evidence available presently, it is not possible to infer whether there is a correlation between suicide and CMV infection.

The Role of Demoralization and Hopelessness in Suicide Risk in Schizophrenia: A Review of the Literature

Background and Objectives: Demoralization has been defined by hopelessness and helplessness attributable to a loss of purpose and meaning in life. Demoralization is a meaningful mental health concern, frequently associated with suicide risk in medical and psychiatric patients. The aim of this systematic review was to synthesize the recent empirical evidence on demoralization in patients with schizophrenia and to better understand the relationship between demoralization and suicide risk in patients with schizophrenia. Methods: A comprehensive literature search using key words and subject headings was performed following PRISMA guidelines with several bibliographic databases, resulting in the identification of 27 studies. Results: The findings suggested that demoralization is prevalent in patients with schizophrenia and supported the hypothesis that the association between depression and suicide is moderated by hopelessness. In clinical practice, it is important to recognize symptoms of demoralization using appropriate psychological tools to better understand the suffering of patients with schizophrenia and to implement suicide prevention programs.

Unmet Needs in Schizophrenia

BACKGROUND

Schizophrenia is a complex psychiatric disorder that represents a challenge for all clinicians. Although treatment must address both positive and negative symptoms, several authors have reported the importance of managing unmet needs among patients with schizophrenia. Unmet needs in schizophrenia include difficulties at various clinical, psychosocial, relational, economic, and occupational levels. An important unmet need is represented by insight into the illness that is associated with treatment adherence and compliance with medical prescriptions.

CONCLUSION

In order to improve our understanding and management of schizophrenia, it is critically important to address the complexity of needs among patients with schizophrenia.

Illness Perception and Job Satisfaction in Patients Suffering from Migraine Headaches: Trait Anxiety and Depressive Symptoms as Potential Mediators

BACKGROUND AND OBJECTIVES

Migraine headache is the seventh leading cause of disability worldwide causing adverse outcomes in many aspects of an individual's life. Many psychological aspects affect chronic migraine (CM): illness perception, anxiety, depressive symptoms, and job satisfaction. This observational study aimed to examine the association among illness perception, anxiety, depressive symptoms, and job satisfaction, connected to migraine and its features.

METHODS

Ninety-eight individuals with CM treated with OnabotulinumtoxinA were recruited from the Regional Referral Headache Centre of Sant'Andrea Hospital in Rome. They completed 4 questionnaires (Brief Illness Perception Quality of Life, Enjoyment and Satisfaction Questionnaire, State-Trait Anxiety Inventory, Beck Depression Inventory-II) and a socio-anamnestic form.

RESULTS

This cross-sectional study examined 2 mediational models. The first one demonstrated an indirect mediating effect of trait anxiety on the association between illness perception and job satisfaction (ab = -0.217, 95% CI [-0.37, -0.09]). In the second model, depressive symptoms mediated the association between illness perception and job satisfaction (ab = -0.186, 95% CI [-0.33, -0.04]).

CONCLUSIONS

In our study, levels of anxiety and depressive symptoms showed a mediational effect on the association between illness perception and job fulfillment. It is important to develop interventions aimed at improving the quality of life of individuals with CM and to increase knowledge about headache and psychological consequences.

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.

Lifestyle Interventions and Prevention of Suicide

Over the past years, there has been a growing interest in the association between lifestyle psychosocial interventions, severe mental illness, and suicide risk. Patients with severe mental disorders have higher mortality rates, poor health states, and higher suicide risk compared to the general population. Lifestyle behaviors are amenable to change through the adoption of specific psychosocial interventions, and several approaches have been promoted. The current article provides a comprehensive review of the literature on lifestyle interventions, mental health, and suicide risk in the general population and in patients with psychiatric disorders. For this purpose, we investigated lifestyle behaviors and lifestyle interventions in three different age groups: adolescents, young adults, and the elderly. Several lifestyle behaviors including cigarette smoking, alcohol use, and sedentary lifestyle are associated with suicide risk in all age groups. In adolescents, growing attention has emerged on the association between suicide risk and internet addiction, cyberbullying and scholastic and family difficulties. In adults, psychiatric symptoms, substance and alcohol abuse, weight, and occupational difficulties seems to have a significant role in suicide risk. Finally, in the elderly, the presence of an organic disease and poor social support are associated with an increased risk of suicide attempt. Several factors may explain the association between lifestyle behaviors and suicide. First, many studies have reported that some lifestyle behaviors and its consequences (sedentary lifestyle, cigarette smoking underweight, obesity) are associated with cardiometabolic risk factors and with poor mental health. Second, several lifestyle behaviors may encourage social isolation, limiting the development of social networks, and remove individuals from social interactions; increasing their risk of mental health problems and suicide.

Suicide risk in attention-deficit/hyperactivity disorder

BACKGROUND

ADHD (Attention-deficit/hyperactivity disorder) is a common neurodevelopmental disorder that manifests itself during childhood with various combinations of symptoms, including inattention, hyperactivity and impulsivity. Research has shown that psychiatric comorbidities play an important role in the development of suicidal behavior and, recently, there has been a growing interest in a possible association between ADHD and suicide during both childhood and adulthood. Furthermore, some authors have shown a relationship between pharmacological treatments and suicide in patients affected by ADHD.

AIMS

We conducted a selective review of current literature to explore the factors which contribute to suicidal behavior and self-harm in those with ADHD.

METHODS

We performed a PubMed/MEDLINE, Scopus, PsycLit, and PsycINFO search to identify all articles and book chapters on the topic up to 2017.

RESULTS

Several studies have showed that ADHD may be correlated with an increased suicide ideation and attempts.

CONCLUSIONS

Although differences in studies design and samples made the results difficult to compare and interpret, many studies indicate an association between ADHD and suicidal behavior. It remains controversial whether there is a direct relationship or whether the association depends on the increased prevalence of pre-existing comorbid conditions and individual and family dysfunctional factors.

Nightmares and suicide risk in psychiatric patients: The roles of hopelessness and male depressive symptoms

Although nightmares have been shown to increase the risk for suicide, less is known about the mechanisms underlying this relationship. In order to address this gap and guided by the hopelessness theory of suicide risk, we examined hopelessness and male depressive symptoms as risk factors for suicide while considering the frequency of and impairment due to nightmares. Data were collected from 172 psychiatrically hospitalized, adult patients (91 women, 81 men) with an average age of 39.15 (SD = 13.48) years. Patients were administered self-report measures of nightmare frequency/impairment, hopelessness, and male depressive symptoms, as well as undergoing a fully structured diagnostic clinical interview to determine diagnoses and suicide risk. Compared to patients with yearly or no nightmares, those with monthly or weekly nightmares reported nightmares reported higher levels of hopelessness, male depressive symptoms, and suicide risk. Male depressive symptoms significantly mediated the relation between hopelessness and suicide risk in patients who reported monthly to weekly nightmares, but not in those who reported yearly or no nightmares. Moreover, impairment due to nightmares was significantly and positively associated with male depression, but not hopelessness or suicide risk. The results also provide evidence and further understanding about possible mechanisms of emerging suicide.

Number of illness episodes as predictor of residual symptoms in major depressive disorder

Notwithstanding major depressive disorder (MDD) is a recurring and chronic condition, relatively few variables have consistently been shown to predict its course. Residual depressive symptoms may be associated with disability and functional impairment but few studies evaluated clinical correlates associated with these symptoms and their impact on functioning after adjustment for potential confounders. Therefore, our study aimed to investigate factors associated with residual depressive symptoms and their impact on the course of MDD. The sample consisted of 210 consecutive MDD euthymic outpatients (67.6% females; mean age = 52.1 ± 15.5), admitted to the Section of Psychiatry, University of Genoa (Italy). Residuals depressive symptoms were significantly associated with female gender; use of short half-life benzodiazepines; longer duration of the current depressive episode; higher number of illness episodes; and higher duration of illness. Conversely, prior treatment with first-generation antipsychotics, later age of illness onset and first hospitalization were less frequently observed among patients with residual symptoms. After multivariate analyses, only duration of current illness episodes (ß = 0.003; p = <0.005) and substance abuse (ß = 0.042; p = <0.05) remained significantly associated with residual symptoms. Our findings indicate that residual depressive symptoms conferred a pernicious illness course in this specific cohort of MDD patients. Future trials mainly targeting these burdensome symptoms are warranted.

Depression, Hopelessness, and Complicated Grief in Survivors of Suicide

Suicide often has a severe impact on the surviving family and friends. There is a need to better understand the psychological and psychopathological consequences of losing a significant other by suicide. The aim of the present study was to assess hopelessness, depression, suicide risk, complicated grief, intrusive memories, and avoidance in a sample of suicide survivors. In this observational study, 35 bereaved individuals were recruited at the Suicide Prevention Centre of Sant’Andrea Hospital in Rome. Individuals were administered a series of validated instruments: the Beck Depression Inventory II (BDI), the Beck Hopelessness Scale (BHS), the Inventory of Complicated Grief (ICG), the Impact of Event Scale (IES), the Subjective Happiness Scale (SHS), and the Satisfaction With Life Scale (SWLS). Most survivors (62.8%) obtained high scores on measures of complicated grief. Scores on the measure of complicated grief were associated with intrusiveness of thoughts and memories, attempts to prevent the thoughts and emotions related to the event, depressive symptoms and hopelessness, and lower scores for feelings of happiness and satisfaction with life. A subgroup of suicide survivors may be at risk of severe psychological distress and suicidal behavior. Identification of these survivors is a necessary step for providing appropriate counseling and psychotherapy.

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.

Taking care of suicidal patients with new technologies and reaching-out means in the post-discharge period

Suicide is a global public health problem with over one million people dying by suicide each year worldwide. Research efforts have focused on developing and testing novel suicide prevention strategies employing recent technological advances. In order to provide a review regarding the role of new technologies (e.g., postcards/letters, text messages, crisis cards, telephone contacts, online interventions) in suicide prevention, we searched PubMed, ScienceDirect, ResearchGate, and Crisis to identify all papers in English from 1977 to 2016. Our results indicated that brief contact interventions show promise in reducing the number of episodes of repeated self-harm and/or suicide attempts following discharge from the Emergency Department or psychiatric units. Innovative methods of contact (e.g., text messages) are easily implemented by clinicians and received by patients in the period of post discharge and have been shown to be beneficial. However, more research employing randomized clinical trials investigating the potential benefits of these novel suicide prevention methods is warranted. Future researchers should continue improving and testing new technologies in the prevention of suicide.

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.

Suicide and drug and alcohol addiction: Self-destructive behaviours. An observational study on clinic hospital population

Introduction

Suicidal behaviour and drug and alcohol dependence represent two different aspects of self-destructive behavior.

Objectives

We evaluated the relationship between suicidal behavior and substance and alcohol addiction. It was investigated the role of childhood trauma in these self-destructive behaviors and in the development of the two mental constructions of hopelessness and mentalization.

Aims

We also assessed how a high level of hopelessness could affect suicidal ideation and how low or absent capacity of mentalization could influence the development of substance and/or alcohol addiction.

Methods

This naturalistic, observational study included 50 patients (mean age = 46.54; S.D = 14.57) recruited from the department of psychiatry (n = 18) and the centre for suicide prevention (n = 32) of Sant’Andrea Hospital (Rome). Different questionnaires were administered to each patient from February to May 2016.

Results

There was not a statistically significant relationship between suicidal behavior and addict behavior. Childhood trauma resulted a risk factor for alcohol abuse with a relationship that tended to significance (P = 0.07). Physical and sexual abuses were significantly associated with addiction (respectively P = 0.014; P = 0.033). It was showed a statistically significant interaction between high level of hopelessness and suicidal ideation (P = 0.037). The absence of mentalization was related to the absence of alcohol abuse (P = 0.061). Finally, trauma experienced during childhood was associated with high level of hopelessness (P = 0.005).

Conclusions

Suicidal behavior is influenced indirectly by a childhood traumatic experience that conditioning the level of hopelessness. Childhood trauma affected directly the development of drug abuse and alcoholism. The capacity of mentalization was not related with childhood trauma.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Assessment of Suicide-related Knowledge and Skills in a Sample of Health Professionals and Students

Objective

Assessment of suicide risk is of paramount importance for proper prevention.

Aims

To examine the association between gatekeeper training and suicide-related knowledge among a diverse set of health care workers (psychiatrists, nurses, psychologists, and educators) and students enrolled in medical and psychological schools who took part in the world suicide prevention day 2015 conference.

Method

Among 223 participants who completed the assessment, 204 provided complete data for analyses. Participants were administered the applied suicide intervention skills training (ASIST), a 13-item survey questionnaire to assess participants’ knowledge about suicidal behavior and comfort dealing with suicidal clients. There were 62 psychiatrists; 23 nurses, 51 psychologists, 11 educators, and 57 university students.

Results

Among participants, 57.1% of the sample had experiences of suicide a patient (students were excluded from these analyses). Those who reported a suicide among patients (compared with others) less frequently answered that suicide risk is more alarming in older adults than youths. They also less frequently disagreed with questions asking if they had the training to deal with suicidal patients. Students more frequently answered correctly on the association between depression and suicide risk, and less frequently chose the correct answer on the seriousness of suicide intent in borderline personality disorder. Students also more frequently disagreed with questions asking on their suicide assessment skill.

Conclusions

Our study highlights that differences exist when it comes to knowledge and skills related to suicide risk assessment both among health professionals and students. Our results also indicate that suicide awareness among these groups should be promoted.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Differential associations of affective temperaments and diagnosis of major affective disorders with suicidal behavior

BACKGROUND

Affective temperaments are associated with suicidal risk, but their predictive value relative to diagnosis of major affective disorder is uncertain.

METHODS

We compared diagnoses, affective-temperament ratings (TEMPS-A), and other potential risk factors in 956 psychiatric inpatients, using bivariate analyses and multivariable logistic regression modeling for associations with suicidal status.

RESULTS

Lifetime suicide-attempt rates were high (43.9% overall), ranking by diagnosis: bipolar-II (58.4%), major depressive (50.0%), bipolar-I (44.6%), other (38.0%), and psychotic (33.9%) disorders. TEMPS-A scores for depressive (dep), cyclothymic (cyc), irritable (irr), and anxious (anx) temperaments and their sum were strongly associated with suicidal risk; hyperthymic (hyp) temperament scores were inversely associated; and a composite measure (dep+cyc+irr+anx - hyp), even more strongly associated. The composite score was highly, independently associated with suicidal behavior (p<0.0001), as was female sex (p=0.0002), but older age and diagnosis of major affective disorder, much less (both p=0.02).

CONCLUSIONS

Measures of affective temperament-types were independently and more strongly associated with lifetime suicide attempt than was diagnosis of a major affective disorder. However, in this hospitalized cohort, suicide rates were high across diagnoses, possibly limiting the predictive value of diagnosis.

Arsenic: Association of regional concentrations in drinking water with suicide and natural causes of death in Italy

Arsenic, as a toxin, may be associated with higher mortality rates, although its relationship to suicide is not clear. Given this uncertainty, we evaluated associations between local arsenic concentrations in tapwater and mortality in regions of Italy, to test the hypothesis that both natural-cause and suicide death rates would be higher with greater trace concentrations of arsenic. Arsenic concentrations in drinking-water samples from 145 sites were assayed by mass spectrometry, and correlated with local rates of mortality due to suicide and natural causes between 1980 and 2011, using weighted, least-squares univariate and multivariate regression modeling. Arsenic concentrations averaged 0.969 (CI: 0.543-1.396) µg/L, well below an accepted safe maximum of 10µg/L. Arsenic levels were negatively associated with corresponding suicide rates, consistently among both men and women in all three study-decades, whereas mortality from natural causes increased with arsenic levels. Contrary to an hypothesized greater risk of suicide with higher concentrations of arsenic, we found a negative association, suggesting a possible protective effect, whereas mortality from natural causes was increased, in accord with known toxic effects of arsenic. The unexpected inverse association between arsenic and suicide requires further study.

Emotion Regulation and Mentalization in People at Risk for Food Addiction

Researchers investigated the association among food addiction, difficulties in emotion regulation, and mentalization deficits in a sample of 322 Italian adults from the general population. All participants were administered the Italian versions of the Yale Food Addiction Scale (I-YFAS), the Difficulties in Emotion Regulation Scale, the Mentalization Questionnaire, the Binge Eating Scale, and the Michigan Alcohol Screening Test. Of respondents, 7.1% reported high food-addiction symptoms (ie, 3 or more symptoms of food addiction on the I-YFAS). In bivariate analyses, high food-addiction symptoms were associated with more difficulties in emotion regulation and mentalization deficits. In the multivariate analysis, high food-addiction symptoms remained independently associated with mentalization deficits, but not with difficulties in emotion regulation. Our data suggest that mentalization may play an important role in food addiction by making it difficult for an individual to understand his or her own inner mental states as well as the mental states of others, especially when powerful emotions arise.