Entrapment and social problem-solving in suicidal behavior across the adult lifespan

BACKGROUND

Feelings of entrapment and deficits in social problem-solving skills have been associated with risk for suicidal behavior in the context of depression. However, few studies have examined the effect of age on the association between these risk factors and suicidal behavior across most of the adult lifespan.

METHODS

In a three-site study, we tested interactions of age with feelings of entrapment and social problem-solving style in 105 depressed patients with a recent suicide attempt, 95 depressed patients with no history of suicide attempt, and 97 demographically similar non-psychiatric participants (age 16-80). Attempter/non-attempter differences, age interactions, and the relative contribution of entrapment and social problem-solving style to past attempter were examined.

RESULTS

Entrapment significantly interacted with age such that it discriminated past attempters from depressed non-attempters better at older ages. Social Problem-Solving Inventory (SPSI) total score and most subscales did not distinguish past attempters, but the SPSI Impulsive Style Problem-Solving was an effective discriminator of past suicide attempts across the full adult lifespan and did not interact with age. In a multipredictor model, both the entrapment by age interaction and SPSI Impulsive Style Problem-Solving score were significant predictors for the classification of attempters.

LIMITATIONS

The cross-sectional nature of our research design limited conclusions that may be drawn about individual change over time or cohort effects.

CONCLUSIONS

Entrapment did not distinguish past attempters at younger ages but became a better discriminator in middle to late adulthood. An impulsive problem-solving style was associated with past suicide attempts across the full adult lifespan.

Clinical efficacy, drug sustainability and serum drug levels in Crohn's disease patients treated with ustekinumab - A prospective, multicenter cohort from Hungary

INTRODUCTION

Although efficacy of ustekinumab (UST) has been demonstrated through randomized trials, data from real-life prospective cohorts are still limited. Our aim was to evaluate clinical efficacy, drug sustainability, dose intensification and results from therapeutic drug monitoring in UST treated patients with Crohn's disease (CD) using a prospective, nationwide, multicenter cohort.

METHODS

Patients from 10 Inflammatory Bowel Disease centers were enrolled between 2019 January and 2020 May. Patient demographics, disease phenotype, treatment history, clinical disease activity (Crohn's Disease Activity Index(CDAI), Harvey Bradshaw Index(HBI)), biomarkers, and serum drug levels were obtained. Evaluations were performed at week8 (post-induction), w16-20, w32-36, and w52-56 follow-up visits.

RESULTS

A total of 142 patients were included [57.4% female; complex disease behavior (B2/B3):48%, previous anti-TNF exposition:97%]. Clinical response and remission rates after induction(w8) were 78.1% and 57.7% using CDAI, and 82.5% and 51.8% based on HBI scores. The one-year clinical remission rate was 58%/57.3%(CDAI/HBI). Composite clinical and biomarker remission (CDAI<150 and C-reactive protein<10 mg/L) rates were 35.4%; 33.3%; 38.6% and 36.6% at w8/w16-20/w32-36 and w52-56. Drug sustainability was 81.9%(standard deviation(SD): 3.4) at 1 year(1y). Probability of dose intensification was high and introduced early, 42.2%(SD:4.2) at ~w32 and 51.9%(SD:4.4%) at 1y.

CONCLUSION

Ustekinumab showed favorable drug sustainability and clinical efficacy in a patient population with severe disease phenotype and previous anti-tumor necrosis factor (anti-TNF) failure, however frequent dose intensification was required.

Age effects on clinical and neurocognitive risk factors for suicide attempt in depression - Findings from the AFSP lifespan study

BACKGROUND

Studies of risk factors for suicidal behavior are typically restricted to narrow age ranges, making it difficult to determine if they have the same relevance or potency across the full adult lifespan.

METHODS

This study examined selected clinical and neurocognitive risk factors for suicidal behavior - borderline personality traits, aggression, depressive rumination, memory performance, and language fluency- in a multi-site sample (N = 309, ages 16-80) of depressed patients with a recent (last 5 years) suicide attempt or no history of attempt, and demographically similar non-psychiatric controls. We examined cross-sectional age and attempter/non-attempter differences on these risk factors, and whether certain risk factors were more prominent discriminators of past suicide attempt earlier or later in the lifespan. Correlations with age were computed, and logistic regression was used to classify attempter status based on each risk factor and its interaction with age.

RESULTS

Nearly all risk factors were negatively correlated with age. Borderline traits, aggression, memory, and category fluency each predicted attempter status (p < 0.05), but these effects were not different across ages. In contrast, the association between rumination and suicide attempt status differed across the lifespan, becoming a stronger discriminator of past suicidal behavior at older ages.

LIMITATIONS

The cross-sectional design limits our developmental findings.

CONCLUSIONS

Despite age-related changes in symptom severity or neurocognitive performance, key risk factors for suicidal behavior previously identified in studies with more restricted age-ranges are salient throughout the adult lifespan. In contrast, depressive rumination may be particularly salient in later life.

A lifetime of challenges: real-life decision outcomes in early- and late-onset suicide attempters

Background

People who have attempted suicide display suboptimal decision-making in the lab. Yet, it remains unclear whether these difficulties tie in with other detrimental outcomes in their lives besides suicidal behavior. We hypothesize that this is more likely the case for individuals who first attempted suicide earlier than later in life.

Methods

A cross-sectional case-control study of 310 adults aged ≥ 50 years (mean: 63.9), compared early- and late-onset attempters (first attempt < 55 vs. ≥ 55 years of age) to suicide ideators, non-suicidal depressed controls and non-psychiatric healthy controls. Participants reported potentially avoidable negative decision outcomes across their lifetime, using the Decision Outcome Inventory (DOI). We employed multi-level modeling to examine group differences overall, and in three factor-analytically derived domains labeled Acting Out, Lack of Future Planning, and Hassles.

Results

Psychopathology predicted worse decision outcomes overall, and in the more serious Acting Out and Lack of Future Planning domains, but not in Hassles. Early-onset attempters experienced more negative outcomes than other groups overall, in Lack of Future Planning, and particularly in Acting Out. Late-onset attempters were similar to depressed controls and experienced fewer Acting out outcomes than ideators.

Limitations

The cross-sectional design precluded prospective prediction of attempts. The assessment of negative outcomes may have lacked precision due to recall bias.

Conclusions

Whereas early-onset suicidal behavior is likely the manifestation of long-lasting decision-making deficits in several serious aspects of life, late-onset cases appear to function similarly to non-suicidal depressed adults, suggesting that their attempt originates from a more isolated crisis.

Outcomes of Patients With Inflammatory Bowel Diseases Switched From Maintenance Therapy With a Biosimilar to Remicade

BACKGROUND & AIMS

There is evidence that it is safe and effective for patients with inflammatory bowel diseases (IBD) to switch from maintenance therapy with an original infliximab drug to a biosimilar, but little is known about outcomes of reverse switches and/or multiple switches. We aimed to evaluate the effects of a reverse switch (from a biosimilar to Remicade) in a real-life cohort.

METHODS

We performed a prospective observational study of 174 unselected and consecutive patients with IBD (136 with Crohn's disease [CD] and 38 with ulcerative colitis [UC]) who received maintenance therapy with the biosimilar in Hungary. In September 2017, patients were switched from the biosimilar (CT-P13) to Remicade, due to reimbursement policies. In our cohort, 8% (n = 14) patients had been previously exposed to the originator Remicade. We collected clinical and biochemical information from patients at baseline (time of the switch) and 16 and 24 weeks thereafter. Clinical remission was defined as a Crohn's disease activity index <150 points or no fistula drainage, or a partial Mayo score <3 points for patients with UC. Serum drug trough levels and anti-drug antibodies were measured at baseline and week 16.

RESULTS

There was no significant difference in the proportion of patients in clinical remission at week 8 before the switch (82.5% with CD and 82.9% with UC), at baseline (80.6% with CD and 81.6% with UC), at week 16 (77.5% with CD and 83.7% with UC), or at week 24 (CD 76.3% with CD and 84.9% with UC) (P = .60 among groups for patients with CD and P = .98 among groups for patients with UC). For all patients, mean serum trough levels of infliximab were 5.33 ± 4.70 μg/mL at baseline and 5.69 ± 4.94 μg/mL at week 16 (P = .71); we did not find significant differences in prevalence of anti-drug antibody at baseline (16.2%) compared with week 16 (16.9%) (P = .87). Four infusion reactions occurred, until week 24 of follow up. There was no difference in outcomes or trough or antidrug antibody levels between patients with or without previous exposure to Remicade.

CONCLUSIONS

We collected data from a real-life cohort of patients with CD or UC who were switched from maintenance therapy with a biosimilar to Remicade or were treated with only Remicade. No significant changes were observed in remission, trough levels, or antidrug antibodies in patients switched from the biosimilar to Remicade. No new safety signals were detected.

Paralimbic and lateral prefrontal encoding of reward value during intertemporal choice in attempted suicide

BACKGROUND

Alongside impulsive suicide attempts, clinicians encounter highly premeditated suicidal acts, particularly in older adults. We have previously found that in contrast to the more impulsive suicide attempters' inability to delay gratification, serious and highly planned suicide attempts were associated with greater willingness to wait for larger rewards. This study examined neural underpinnings of intertemporal preference in suicide attempters. We expected that impulsivity and suicide attempts, particularly poorly planned ones, would predict altered paralimbic subjective value representations. We also examined lateral prefrontal and paralimbic correlates of premeditation in suicidal behavior.

METHOD

A total of 48 participants aged 46-90 years underwent extensive clinical and cognitive characterization and completed the delay discounting task in the scanner: 26 individuals with major depression (13 with and 13 without history of suicide attempts) and 22 healthy controls.

RESULTS

More impulsive individuals displayed greater activation in the precuneus/posterior cingulate cortex (PCC) to value difference favoring the delayed option. Suicide attempts, particularly better-planned ones, were associated with deactivation of the lateral prefrontal cortex (lPFC) in response to value difference favoring the immediate option. Findings were robust to medication exposure, depression severity and possible brain damage from suicide attempts, among other confounders. Finally, in suicide attempters longer reward delays were associated with diminished parahippocampal responses.

CONCLUSIONS

Impulsivity was associated with an altered paralimbic (precuneus/PCC) encoding of value difference during intertemporal choice. By contrast, better-planned suicidal acts were associated with altered lPFC representations of value difference. The study provides preliminary evidence of impaired decision processes in both impulsive and premeditated suicidal behavior.

Corticostriatothalamic reward prediction error signals and executive control in late-life depression

BACKGROUND

Altered corticostriatothalamic encoding of reinforcement is a core feature of depression. Here we examine reinforcement learning in late-life depression in the theoretical framework of the vascular depression hypothesis. This hypothesis attributes the co-occurrence of late-life depression and poor executive control to prefrontal/cingulate disconnection by vascular lesions.

METHOD

Our fMRI study compared 31 patients aged ⩾60 years with major depression to 16 controls. Using a computational model, we estimated neural and behavioral responses to reinforcement in an uncertain, changing environment (probabilistic reversal learning).

RESULTS

Poor executive control and depression each explained distinct variance in corticostriatothalamic response to unexpected rewards. Depression, but not poor executive control, predicted disrupted functional connectivity between the striatum and prefrontal cortex. White-matter hyperintensities predicted diminished corticostriatothalamic responses to reinforcement, but did not mediate effects of depression or executive control. In two independent samples, poor executive control predicted a failure to persist with rewarded actions, an effect distinct from depressive oversensitivity to punishment. The findings were unchanged in a subsample of participants with vascular disease. Results were robust to effects of confounders including psychiatric comorbidities, physical illness, depressive severity, and psychotropic exposure.

CONCLUSIONS

Contrary to the predictions of the vascular depression hypothesis, altered encoding of rewards in late-life depression is dissociable from impaired contingency learning associated with poor executive control. Functional connectivity and behavioral analyses point to a disruption of ascending mesostriatocortical reward signals in late-life depression and a failure of cortical contingency encoding in elderly with poor executive control.

The temptation of suicide: striatal gray matter, discounting of delayed rewards, and suicide attempts in late-life depression

BACKGROUND

Converging evidence implicates basal ganglia alterations in impulsivity and suicidal behavior. For example, D2/D3 agonists and subthalamic nucleus stimulation in Parkinson's disease (PD) trigger impulse control disorders and possibly suicidal behavior. Furthermore, suicidal behavior has been associated with structural basal ganglia abnormalities. Finally, low-lethality, unplanned suicide attempts are associated with increased discounting of delayed rewards, a behavior dependent upon the striatum. Thus, we tested whether, in late-life depression, changes in the basal ganglia were associated with suicide attempts and with increased delay discounting.

METHOD

Fifty-two persons aged ≥ 60 years underwent extensive clinical and cognitive characterization: 33 with major depression [13 suicide attempters (SA), 20 non-suicidal depressed elderly] and 19 non-depressed controls. Participants had high-resolution T1-weighted magnetization prepared rapid acquisition gradient-echo (MPRAGE) magnetic resonance imaging (MRI) scans. Basal ganglia gray matter voxel counts were estimated using atlas-based segmentation, with a highly deformable automated algorithm. Discounting of delayed rewards was assessed using the Monetary Choice Questionnaire (MCQ) and delay aversion with the Cambridge Gamble Task (CGT).

RESULTS

SA had lower putamen but not caudate or pallidum gray matter voxel counts, compared to the control groups. This difference persisted after accounting for substance use disorders and possible brain injury from suicide attempts. SA with lower putamen gray matter voxel counts displayed higher delay discounting but not delay aversion. Secondary analyses revealed that SA had lower voxel counts in associative and ventral but not sensorimotor striatum.

CONCLUSIONS

Our findings, although limited by small sample size and the case-control design, suggest that striatal lesions could contribute to suicidal behavior by increasing impulsivity.

Treatment outcome in suicidal vs. non-suicidal elderly patients

The authors investigated treatment outcome in elderly suicidal and non-suicidal patients with recurrent major depression. Patients without suicidal ideation in the current episode (Non-Ideators; n=150) were compared with 30 patients who expressed suicidal ideation (Ideators). Patients received combined pharmacotherapy and psychotherapy during acute and continuation treatment. Ideators had higher numbers of lifetime suicide attempts and reported significantly higher levels of depression, anxiety, and hopelessness before starting treatment. Ideators and Non-Ideators had almost identical remission rates (77% vs. 78%), but Ideators had higher relapse rates during continuation treatment (26% vs. 13%) and were more likely to receive augmentation pharmacotherapy. Anxiety and use of adjunctive medication, but not suicidal ideation, were negatively related to both remission and relapse. Our data suggest that elderly suicidal patients have an overall favorable treatment outcome. However, treatment response may be more brittle and may require the continuing use of adjunctive medications to prevent early relapse.

Suicidal ideation in elderly bereaved: the role of complicated grief

This study examined whether symptoms of complicated grief at baseline predicted suicidal ideation during a depressive episode in elderly bereaved individuals. Over a 17-month period, serial ratings of suicidal ideation, hopelessness, and symptoms of depression, anxiety, and complicated grief were obtained from 130 elderly participants who had lost their spouses within the past 2 years. Groups of active and passive suicidal ideators, as well as nonideator controls, were compared via analysis of variance (ANOVA) with respect to levels of complicated grief, depression, and anxiety. Elderly bereaved with both active and passive suicidal ideation were found to have higher symptomatic levels of depression, hopelessness, complicated grief, and anxiety, as well as lower levels of perceived social support, than nonideators at study entry. Fifty-seven percent of the patients with high complicated grief scores were found to be ideators during the follow-up versus 24% of the patients with low complicated grief scores. Patients with any suicidal ideation had higher symptom levels of depression, anxiety, and complicated grief when they were ideators as compared with periods when they denied ideation. Fifteen out of the 39 ideators had recurrent depressive episodes versus 5 of the 91 nonideators. Patients with a history of suicide attempts were more likely to be ideators after loss than other bereaved. Thus, the condition of having high levels of complicated grief symptoms and depressive symptoms appears to make bereaved individuals vulnerable to suicidal ideation. Detection of high levels of complicated grief could help clinicians identify patients who may be at heightened risk for suicide.

High levels of hopelessness persist in geriatric patients with remitted depression and a history of attempted suicide

OBJECTIVE

To determine whether a high level of hopelessness after treatment of a depressive episode is an indicator of a history of lifetime suicide attempts in older people.

DESIGN

Groups of suicide attempters, suicidal ideators, and nonsuicidal patients were compared via analysis of variance with respect to levels of hopelessness, depression, anxiety, and global functioning before and after treatment of depression.

SETTING

An outpatient research clinic providing two treatment protocols of late-life mood disorders.

PARTICIPANTS

A total of 107 consecutive outpatients (mean age 67) with major depression who responded to treatment.

MEASUREMENTS

Levels of hopelessness, severity of depression, anxiety, and global functioning were compared across the three groups at the beginning of treatment and at remission.

RESULTS

After remission there were no differences between the three groups in depression severity, anxiety, and global functioning. Hopelessness remained significantly higher in the attempter group than among ideators or nonsuicidal patients.

CONCLUSIONS

Suicide attempts, the most important risk factor for subsequent suicide, are associated with persistent, high levels of hopelessness following remission of depression in late-life patients. These findings suggest that treatments designed specifically to lower hopelessness (such as cognitive, behavioral or interpersonal therapy) may be effective in reducing suicide risk.

Clinical assessment versus research methods in the assessment of suicidal behavior

OBJECTIVE

This study examined how accurately routine inpatient clinical assessments documented a history of overt suicidal behavior in inpatients with a diagnosis of major depressive episode. Secondary questions involved the exploration of possible factors influencing the quality of routine clinical documentation of suicidal behavior, such as lethality of attempts, axis II comorbidity, and presence of recent suicidal behavior.

METHOD

Hospital records for 50 patients, known to have a history of suicidal behavior on the basis of research ratings, were reviewed to assess reporting of the number of lifetime suicide attempts, suicidal ideation and planning behavior, most medically lethal suicide attempt, and family history of suicidal behavior. These measures of suicidal behavior were compared with a comprehensive research assessment, completed concurrently and independently.

RESULTS

At admission clinicians failed to document a history of suicidal behavior in 12 of 50 patients identified by research assessment as depressed and as having attempted suicide. Fewer total suicide attempts were clinically reported than in research data. Documentation of suicidal behavior was least accurate in the physician discharge summary and was most accurate on hospital intake assessment, which employed a semistructured format for recording clinical information including suicidal behavior.

CONCLUSIONS

A significant degree of past suicidal behavior is not recorded during routine clinical assessment, and the use of semistructured screening instruments may improve documentation and detection of lifetime suicidal behavior. The physician discharge summary must accurately document suicidal behavior, since it best identified a high-risk population for out-patient clinicians responsible for follow-up.