Capability for suicide: Discrimination as a painful and provocative event

OBJECTIVE

Developing the capability to die by suicide, and overcoming one's natural instinct of self-preservation, is thought to occur as a result of habituation to the fear and pain surrounding suicide. However, investigations of suicide capability have yet to examine whether perceived discrimination serves as a painful and provocative event that contributes to capability for suicide. The purpose of the current study was to examine the association of perceived discrimination and suicide capability for Black and White adults.

METHOD

The study sample included 173 Black adults (67.6% female; M_age  = 23.18, SD = 5.74) and 272 White adults (60.7% female; M_age  = 22.80, SD = 5.90). Participants completed a questionnaire battery that included measures of perceived discrimination, depression, and suicide ideation.

RESULTS

Regression analyses revealed for Black adults (but not White adults), perceived discrimination was associated with an increased capability for suicide after accounting for depressive symptomatology, suicide ideation, non-discriminatory painful and provocative events experienced, age, and gender (β = .226, t = 3.154, p = .002).

CONCLUSIONS

These findings provide preliminary evidence that perceived discrimination may play a role in suicide capability for Black adults and highlight the importance of considering contextual experiences when examining suicidality in underserved groups.

Non-Suicidal Self-Injury, Neuroticism, and Ethnic Identity in Young Latina Adults

Rates of non-suicidal self-injury (NSSI) are elevated among Latinas; however, few studies have examined patterns of NSSI and associated risk in this population. The purpose of this study was to examine the association between neuroticism and NSSI, along with the conditional effect of ethnic identity on such an association for first-, second-, and third-generation Latina young adults. Participants were 701 emerging adult Latinas who completed measures of self-harm, personality traits, and ethnic identity. Results showed ethnic identity as moderating the association between neuroticism and self-harm in second-generation Latinas. These findings provide some insight into the cultural impact of both ethnic identity and generational status on self-harm for Latinas with high levels of neuroticism.

Représentations culturelles de la maladie mentale

Les troubles psychiatriques présentés par les personnes migrantes et réfugiées s’expriment pendant l’entretien par le biais de représentations culturelles (illness). Il est souvent nécessaire pour le thérapeute, en dehors de la maîtrise d’une langue en commun, de confronter ses propres modèles explicatoires à ceux des patient(e)s. C’est d’une certaine manière la garantie d’échapper aux deux obstacles classiques dans cette prise en charge transculturelle, c’est-à-dire la non prise en compte des formulations du patient et les effets pervers de la stigmatisation.

Perceived Discrimination and Suicide Ideation: Moderating Roles of Anxiety Symptoms and Ethnic Identity among Asian American, African American, and Hispanic Emerging Adults

Suicide is a leading cause of death for vulnerable ethnic minority emerging adults in the United States (Web-based injury statistics query and reporting system [WISQARS], 2015). Perceived discrimination (Journal of Youth and Adolescence, 40, 2011, 1465) and anxiety symptoms (Asian American Journal of Psychology, 1, 2010, 18) are two predictors that are theoretically and conceptually related, but have yet to be examined in a simultaneous model for suicide ideation. Existing theory and research suggest that these variables activate similar pathways (American Behavioral Scientist, 51, 2007, 551). This study sought to address this gap in the literature by examining the simultaneous relationship between perceived discrimination and anxiety symptoms as predictors of suicide ideation. The moderating effect of anxiety symptoms on the relationship between perceived discrimination and suicide ideation was examined in a multiethnic sample of emerging adults. Results indicated that anxiety symptoms moderated the perceived discrimination-suicide ideation relationship for Hispanic emerging adults, but not for their Asian American and African American counterparts. Furthermore, ethnic identity has been shown to mitigate suicide risk in the face of other stressors (Cultural Diversity and Ethnic Minority Psychology, 14, 2008, 75). Ethnic identity emerged as a protective factor for Hispanic emerging adults by further interacting with perceived discrimination and anxiety symptoms to negatively predict suicide ideation. The implications of these findings are discussed.

Ethnic Differences in Suicidal Ideation and its Correlates among South Asian American Emerging Adults

Prior research on suicidal ideation and its correlates among South Asian American individuals has been limited. Given that South Asian American individuals are a burgeoning ethnic subgroup in the United States population, research regarding these factors is necessary to inform culturally competent suicide screening, prevention, and intervention among this increasingly prominent group. We examined depressive symptoms, hopelessness, and suicidal ideation among a sample of 204 undergraduate South Asian American (96 Bangladeshi American, 67 Asian Indian, and 41 Pakistani American) emerging adult students (66% female), ages 18 to 24 (M = 18.52, SD = 0.93). Participants completed measures of hopelessness, depressive symptoms, and suicidal ideation. Bangladeshi American ethnicity was associated with significantly lower levels of suicidal ideation than Asian Indian ethnicity. There was a non-significant trend for Pakistani American ethnicity to be associated with lower levels of suicidal ideation than Asian Indian ethnicity. Additionally, Bangladeshi American ethnicity and Pakistani American ethnicity each interacted with hopelessness, such that hopelessness was associated with lower levels of suicidal ideation among these groups than among their Asian Indian peers. Being of Asian Indian ethnicity may deleteriously influence vulnerability to suicidal ideation, while being of other South Asian American ethnicities may buffer against suicidal ideation, both independently and in interaction with hopelessness. Such contingencies should be considered during suicide screening, prevention, and intervention.

Racial differences in adherence and response to combined treatment for full and subthreshold post-traumatic stress disorder and alcohol use disorders: A secondary analysis

We conducted a secondary data analysis to examine whether there were racial differences in adherence and treatment outcomes for participants with co-occurring full and subthreshold post-traumatic stress disorder (PTSD) and alcohol/substance use disorders (A/SUD) who were treated with Seeking Safety (a cognitive-behavioral therapy) and sertraline or Seeking Safety and placebo as part of a clinical trial. Bivarate analyses examined the association between race and adherence, and generalized estimating equations assessed whether race moderated the effect of combination treatment on PTSD and alcohol use outcomes. Except for education, there were no statistically significant racial differences in baseline demographic and psychiatric characteristics. African Americans and Caucasians were equally adherent in number of psychotherapy and medication sessions attended and medication compliance. After controlling for baseline demographics and psychiatric symptoms, however, a race by treatment condition interaction emerged suggesting that African Americans who received the Seeking Safety and sertraline treatment had significantly lower PTSD symptom severity posttreatment and at six months follow-up compared to their counterparts who received Seeking Safety and placebo. No differential effect of treatment condition was found for Caucasians. Moreover, results indicated that a diagnosis of major depressive disorder negatively impacted PTSD symptom recovery for African American participants but not for Caucasians. In conclusion, no differences emerged between African Americans and Caucasians in adherence to combination treatments for PTSD and A/SUD. Findings also suggest assessment and treatment of MDD among African Americans may improve treatment outcomes. More research is needed to determine whether the differential response to Seeking Safety and sertraline among African Americans compared to Caucasians can be replicated.

Suicidal ideation among racial/ethnic minorities: moderating effects of rumination and depressive symptoms

Among emerging adults and college students, racial and ethnic minorities experience greater risk for suicidal ideation and behavior than their White counterparts. Research has identified numerous cognitive risk factors for suicidal ideation. However, they have not been well studied among racial and ethnic minorities. The present study examined the association between these factors (brooding rumination, reflective rumination, hopelessness, and depressive symptoms) and suicidal ideation among 690 Black, Latino, and biracial college students. Among all groups, hopelessness was positively associated with suicidal ideation. Brooding was negatively associated with suicidal ideation, after adjusting for reflection and hopelessness, although only at low levels of depressive symptoms. Black race/ethnicity and Latino race/ethnicity, compared with biracial race/ethnicity, each separately interacted with reflection to predict lower levels of suicidal ideation at moderate to high levels of reflection. Furthermore, Latino race/ethnicity, compared with biracial race/ethnicity, interacted with both reflection and depressive symptoms, such that reflection was negatively associated with suicidal ideation among Latino individuals reporting depressive symptoms above the 39th percentile. Biracial race/ethnicity, compared with monoracial race/ethnicity, also interacted with reflection and depressive symptoms, with reflection associated with greater amounts of suicidal ideation at depressive symptom levels above the 39th percentile. Our findings suggest reflective rumination differentially affects racial and ethnic groups and should be considered in conjunction with depressive symptoms among Latino and biracial individuals in suicide risk assessment and treatment.

At the crossroads: the intersection of substance use disorders, anxiety disorders, and posttraumatic stress disorder

The co-occurrence of substance use disorders with anxiety disorders and/or posttraumatic stress disorder has been widely documented and when compared to each disorder alone, consistently linked to increased risk for a host of negative outcomes including greater impairment, poorer treatment response, and higher rates of symptom relapse. This article focuses on recent advances in the understanding and effective treatment of this common and highly complex comorbidity. Prevalence and epidemiological data are introduced, followed by a review of contemporary models of etiology and associative pathways. Conceptualizations of effective treatment approaches are discussed alongside evidence from the past decade of clinical research trials. Highlighted are ongoing questions regarding the benefit of sequential, parallel, and integrated approaches and the necessity of further investigation into the mechanisms underlying treatment efficacy. Lastly, recent contributions from neuroscience research are offered as a promising bridge for the development and testing of novel, interdisciplinary treatment approaches.

Antipsychotiques et troubles bipolaires

This article is a review of the various treatments that are currently available, in particular in France, for the treatment of bipolar disorders. This article specifically addresses the use of novel antipsychotic agents as alternative therapy to a lithium therapy and/or the use of conventional antipsychotics. The prevalence of bipolar disorder over a lifetime is around 1% of the general population. Bipolar disorder consists of alternating depressive and manic episodes. It mainly affects younger subjects, and is often associated with alcohol and drug addictions. There are two main subtypes of bipolar disorder. According to the DSM IV-R, type 1 of bipolar disorder is characterised when at least one manic episode (or a mixed episode) has been diagnosed. Type 2 of bipolar disorder is related to patients enduring recurrent depressive episodes but no manic episode. Type 2 affects women more frequently as opposed to type 1 affecting individuals of both sexes. Manic-depressive disorder (or cyclo-thymic disorder) appears in relation to patients who has never suffered manic episode, mixed episode or severe depressive episode but have undergone numerous periods with some symptoms of depression and hypomanic symptoms over a two-year period during which any asymptomatic periods last no longer than two months. The average age of the person going through a first episode (often a depressive one) is 20 years-old. Untreated bipolar patients may endure more than ten manic or depressive episodes. Finally, in relation to 10 to 20% of patients, the bipolar disorder will turn into a fast cycle form, either spontaneously or as a result of certain medical treatments. Psychiatrists are now able to initiate various treating strategies which are most likely to be effective as a result of the identification of clinical subtypes of the bipolar disorder. Lithium therapy has been effectively and acutely used for patients with pure or elated mania and its prophylaxis. However, lithium medication may worsen depressive symptoms when used for a long term maintenance therapy. Additionally, mixed mania, rapid cycling type patients and bipolar disorder associated with substance abuse do not respond well to lithium therapy. In addition to the lithium therapy or in place of a lithium therapy, one can report the frequent use of antipsychotic agents in respect of patients with bipolar disorder during both the acute and maintenance phases of treatment. Antipsychotic agents have been used for almost forty years and may be used in combination with a lithium therapy. Conventional antipsychotics are effective but they may induce late dyskinesia, weight gain, sedation, sexual dysfunction and depression. These adverse side effects often lead to non compliance in particular in circumstances where antipsychotic agents are combined with a lithium therapy. A number of alternative somatic treatment approaches have been reported for patients who do not respond well or who are intolerant to lithium therapy. As such, valproate has received regulatory approval for the acute treatment of mania and carbamazepine has been indicated for this condition in a number of countries. Divalproex (Depakote) has recently obtained the authorization to market in France and may be prescribed for manic states or hypomanic states that do not tolerate lithium therapy or for which lithium therapy is contraindicated. A number of other anticonvulsants (lamotrigine, gabapentin and topiramate) are currently being tested. Because of the side effects of the conventional antipsychotic agents, atypical antipsychotic agents are currently on trial and appear to be of interest in the treatment of bipolar disorders. Currently, a number of prospective studies are available with clozapine, risperidone and olanzapine in the treatment of bipolar disorder. Most are short-term studies. Recent randomised, double-blind, placebo-controlled studies have shown clozapine, risperidone and olanzapine to be effective with antimanic and antidepressive effects, both as monotherapy and as add-on maintenance therapy with lithium or valproate. They also have a favorable side effect profile and a positive effect on overall functioning. Similarly, valproate combined with antipsychotics provides greater improvement in mania than antipsychotic medication alone and results in lower dosage of the antipsychotic medication. There is currently no double-blind study regarding the use of clozapine for bipolar disorders. However, based on the results of a number of open-label studies, clozapine appears to be effective in relation to schizo-affective and bipolar patients including those with rapid cycling or those who respond inadequately to mood stabilizers, carbamazepine, valproate or conventional antipsychotics. Clozapine seems to be more appropriate for bipolar and schizo-affective patients than schizophrenics. In particular, studies show that patients with manic and mixed-psychotic state of illness are better responders than patients with major depressive syndromes. Four open studies suggest the efficacy of clozapine in the maintenance treatment of bipolar disorder and three prospective, open-label studies show the efficacy of clozapine in the manic state of the illness. However, the number of patients in the studies was not important and these studies are not controlled. Clozapine has also adverse side affects, one of which consisting of a major risk of agranulocytosis and, potentially, death. In addition, clozapine has been shown to produce significant weight gain and sialorrhea as well as significant anticholinergic effects. As a result, clozapine should not be prescribed in the first place. As opposed to clozapine, there are open-label reports and controlled studies in respect of risperidone and olanzapine. Two recent double-blind studies of acute mania found olanzapine to be more effective than placebo. Based on these two studies, olanzapine has recently been approved for the indication of mania. The effects of olanzapine and divalproex in the treatment of mania have also been compared in a large randomized clinical trial. The olanzapine treatment group had significantly greater mean improvement of mania ratings and a significantly greater proportion of patients achieving protocol-defined remission. Significantly more weight gain and cases of dry mouth, increased appetite and somnolence were reported with olanzapine while more cases of nausea were reported with divalproex. The comparison of olanzapine with lithium for the treatment of mania has also been the subject of a double-blind randomized controlled trial. That study shows no differences between the two drugs. While these studies support the idea that olanzapine has direct acute anti-manic effects, a number of authors are of the opinion that olanzapine may have specific prophylactic mood-stabilizing properties. Olanzapine would appear to be effective in the maintenance treatment, as it exhibited both antimanic and antidepressant effects. Systematic trials have shown that risperidone may be effective and safe in the treatment of acute mania, as an add-on therapy with lithium or valproate (open studies and two controlled double-blind studies) and as monotherapy (open studies). In an open, multi-center, 6-month study, risperidone seems to be effective and safe as long-term adjunctive therapy in treatment-resistant bipolar and schizo-affective disorders, with no exacerbation of manic symptoms. Risperidone had few adverse side effects (and where there were any, they were mostly mild), mostly consisting of APS and weight gain. A naturalistic comparison of clozapine, risperidone and olanzapine in the treatment of bipolar disorder suggests that the efficacy and tolerability of the three treatments are similar. One major differentiation factor of these drugs appears to be weight gain, particularly between olanzapine and risperidone. However, this may partially be caused by the use of mood-stabilizing agents. Bipolar and schizo-affective patients now require combination therapy approach because of the cyclic nature of these disorders. Many studies report the combination of mood-stabilizing agents with conventional antipsychotics and atypical antipsychotics. Combination therapies produce a number of adverse side effects. Atypical antipsychotics (other than clozapine) are now rated as first-line agents for adjunctive treatment of mania because they produce less adverse side effects. Atypical antipsychotics are also rated as first-line agents for combined treatment of psychotic depression and they are strongly preferred when an antipsychotic is required for long-term maintenance.

[A case report of mania precipitated by use of DHEA]

Dehydroepiandrosterone (DHEA) and its sulfate ester metabolite (DHEA-S) are precursors to testosterone and, to a lesser extent, to estrogen, and, for both sexes, they are produced in the adrenal cortex. They are among the most abundant steroids in the human body, yet their physiological roles remain unknown. DHEA and DHEA-S appear to have diverse biochemical activities, including actions within the central nervous system. So DHEA is produced in the central nervous system as well as the human adrenals and is present in the brain, concentrated in limbic regions, in levels much higher than other steroids. DHEA has been postulated to function as an excitory neuroregulator, antagonizing g-aminobutyric acid transmission. The main characteristic of DHEA is that its level of concentration in plasma varies throughout life, such level being low during the early childhood and after the age of 60 years. Adrenal production and serum concentrations of DHEA are then known to peak between ages 25 and 30 years and thereafter decrease with age, severe illness and chronic stress. The decrease of DHEA over time would appear to be responsible for morbidity related to aging process. Previous reports have found low levels of DHEA in association with physical and with frailty in the elderly (immunosenescence, increased incidence of osteoporosis, atherosclerosis and cancer, decreased cognitive functions and/or well-being). As it has been touted as a fountain of youth and a sexual tonic and promoted for a variety of illnesses associated with aging, DHEA is widely available over all the United States (since 1994) as a dietary supplement. In France, as a result of a massive advertising campaign, DHEA is already the subject of a widespread use and a growing demand although it has not yet been approved by the relevant authorities for sale as drug to the public. In practice, DHEA is prescribed and delivered under the sole responsibility of both doctor and chemist who ascertain the benefit-risk ratio and the quality of the product. DHEA may then be purchased on the internet or in the form of magistral preparations delivered on the basis of such prescription. Accordingly, there is little information or data on efficacy, drug interactions, results of long-term use, abrupt discontinuation or potential adverse effects related to the use of DHEA. We report a case of mania possibly precipitated by the use of high doses of DHEA (150-200 mg/day at the time of presentation) during several weeks in a 68 years old man who had already been hospitalized for an acute mania many years ago. Although, in this case, the patient suffered a bipolar diathesis in the past, oral DHEA may have played a role in the induction of his acute manic episode. Further research is required to assess the mood effects of DHEA, including its potential risk for patients with bipolar disorder.

[Chloral hydrate: a hypnotic best forgotten?]

Synthesised by Justin Liebig in 1832 chloral hydrate is one of the oldest synthetic agents. Since 1869 it has been in use for hypnotic or sedative purposes. Chloral hydrate was used a lot from the end of the 19th century to the middle of the 20th century. Since then chloral hydrate has been less frequently in use as a hypnotic. In the 1990's, the principal use of chloral hydrate in pediatrics was the sedation of children for minor surgery during dental or diagnostic procedures. In general practice, it is an analgesia found in topical preparations. It was known as safe and easy to use. Now it is shown to be potentially dangerous (risk of death in case of intoxication) and there is doubt about genotoxicity and carcinogenecity. The pharmacological property was known in 1948 when Butler discovered the principal active metabolite, trichloroethanol. The gastro-intestinal tract rapidly absorbs chloral hydrate after oral or rectal use. The sedative and hypnotic effects appear in 20 to 60 minutes. The main metabolites [trichloroethanol (TCE) and trichloroacetic acid (TCA)] are formed by hepatocytes and erythrocytes. The half-life of chloral hydrate is short (a few minutes), the half lives of the metabolics are longer, 8 to 12 hours for TCE and 67 hours for TCA. The affinity for lipids is high. It is eliminated principally by the kidneys. Its mechanism of action is unknown. It is a depressor of the SNC, and the sedation is attributed to chloral hydrate and the hypnotic effect to TCE. The interactions appear with: alcohol, anticoagulants, amitriptyline and furosemide. The use of flumazenil (a gaba antagonist), in case of intoxication, indicates a possible action of GABA. The posology is usually between 0.5 to 2 g per day. Chloral hydrate is taken during meals to prevent gastric irritation. The main side effects are digestive, cardiologic (risk of rhythm disorder), dermatologic, neuropsychiatric (withdrawn, delusions, hallucination, dependence) and ophthalmologic. Death occurs after absorption of doses of around 10 g of hydrate chloral, some cases were reported with 5 g. The use of hydrate chloral is contra-indicated in cases of gastric ulcers, hepatic insufficiency, porphyry, respiratory insufficiency, association with anticoagulants and hyper sensibility. Nowadays should we be using chloral hydrate in cases of insomnia in adult and older people? A recent preclinical working group of the French Agency for evaluation of medicinal products reassessed the benefit/risk ratio of chloral hydrate. Many references are found about genotoxicity and carcinogenicity in recent literature. In France, since the end of 2000, chloral hydrate has been withdrawn from many medications for external use in dermatology and in stomatology. Chloral hydrate can be used as a pediatric sedative only once in a lifetime. The psychiatric indication for insomnia is no longer justified and especially in older people.

[Use of methylphenidate in adults with attention deficit disorder with hyperactivity]

Attention deficit, hyperactivity disorder was recently described in adults. The clinical individualization of this syndrome progressed but the categorical approach remains to be entirely completed. The residual form of the childhood disorder does not generate diagnostic problem when childhood previous history is known. ADHD without childhood history refer us to retrospective difficulties of diagnosis and various evolutions of the infantile form linked or not, with other psychiatric pathologies. Etiology remains unknown, hypothesis of an hereditary disfunction of neurotransmitters is the more studied. These patients can benefit from a psychostimulant treatment. Four controlled studies with methylphenidate demonstrated to be significantly superior to placebo. Even if there are methodological difficulties not resolved (comorbidity, homogeneous population) results are encouraging.