Tolerability and safety of fluvoxamine and other antidepressants

Selective serotonin [5-hydroxytryptamine (5-HT)] reuptake inhibitors (SSRIs) and the 5-HT noradrenaline reuptake inhibitor, venlafaxine, are mainstays in treatment for depression. The highly specific actions of SSRIs of enhancing serotonergic neurotransmission appears to explain their benefit, while lack of direct actions on other neurotransmitter systems is responsible for their superior safety profile compared with tricyclic antidepressants. Although SSRIs (and venlafaxine) have similar adverse effects, certain differences are emerging. Fluvoxamine may have fewer effects on sexual dysfunction and sleep pattern. SSRIs have a cardiovascular safety profile superior to that of tricyclic antidepressants for patients with cardiovascular disease; fluvoxamine is safe in patients with cardiovascular disease and in the elderly. A discontinuation syndrome may develop upon abrupt SSRI cessation. SSRIs are more tolerable than tricyclic antidepressants in overdose, and there is no conclusive evidence to suggest that they are associated with an increased risk of suicide. Although the literature suggests that there are no clinically significant differences in efficacy amongst SSRIs, treatment decisions need to be based on considerations such as patient acceptability, response history and toxicity

The relationship between non-fatal overdose of pharmaceutical medications, suicidality and depression

This thesis examines three main themes; depression, suicidality, and non-fatal overdose involving pharmaceutical and over-the-counter (OTC) medications. At any given time depression affects approximately one in every twenty adults in Australia. People with depression are at elevated risk of attempted and completed suicide compared to those without. Medication overdose is a frequently chosen method of suicidal behaviour, and accounts for one in ten suicide deaths and close to nine out of ten non-fatal episodes of suicidal behaviour for which hospital treatment is sought. The study reported here had six primary aims; (i) to quantify medication overdose presentations over a 12-month period to the Emergency Department (ED) of a major metropolitan public hospital in Melbourne, Australia, (ii) to describe the medication overdose patient group, including comparison with two other relevant types of presentation, illicit drug overdose, and actual or potential self-harm by means other than overdose, (iii) to explore the relationship between depression, suicidal ideation and medication overdose, (iv) to identify the medications typically used in overdose and their means of acquisition, (v) to explore patient experiences of emergency care following a medication overdose, and (vi) to comment on the feasibility of introducing a brief intervention within the ED with the intention of addressing the issue of medication overdose. Three data sources were employed: computerised ED records, interviews with a sub-sample of patients attending the ED following a medication overdose, and observation of ED processes in relation to these cases.One of the most important findings of the study was the large contribution made by benzodiazepine medications to the overall medication overdose statistics. When considered in conjunction with the patient interview data, it appeared that many patients included in the study were prescribed benzodiazepines in a manner that contradicts current national prescribing guidelines. The problem of medication overdose could be partially addressed by working with doctors to ensure the appropriateness of their prescribing practices, to encourage them to more closely monitor the treatment progress of at-risk patients, and to increase awareness of other evidence-based forms of treatment for depression and anxiety

Gambling Disorder – Suicidality, Mortality and Comorbidity

Background: Gambling disorder (GD) is a behavioural addiction in which a person faces negative consequences due to uncontrolled gambling, such as financial, personal, or relational difficulties. GD more often affects men but both men and women face severe consequences of GD. Psychiatric comorbidity is the rule rather than the exception and suicidality is abundant. Health issues such as obesity and cardiovascular disease are also common. Financial difficulties are common and might be both a consequence of and a risk factor for GD.Aim and methods: To examine, through registry and qualitative research, comorbidity, intentional self-harm, suicide and mortality in GD. In Study I, standardized mortality ratios for men and women with GD were compared to the general population and potential risk factors for suicidality and mortality were investigated (N=2099). In Study II, the effect of comorbid alcohol and drug use disorders on intentional self-harm in individuals with GD was examined (N=2099). In Study III, the effects of psychiatric and socioeconomic risk factors on intentional self-harm (N=848) were examined, and in Study IV, a gender- and age-matched cohort was utilized to investigate the association between GD,suicide, and general mortality in relation to known risk factors in men and women (N=10,792). Finally,a qualitative interview study (V) investigated, through qualitative content analysis (N=7), experiences of suicidality in women with GD and potential mediators of suicidality. Results: In the first study, mortality and suicide levels were greatly elevated in GD. Depression was associated with suicide death, and age and cardiovascular disease predicted general mortality. However,in the fourth study, GD did not appear to be a significant risk factor for the increase in suicide and general mortality when controlling for previously known risk factors. In the second and third studies,female gender, and psychiatric comorbidity such as substance use diagnoses, anxiety and depression were important risk factors for intentional self-harm. In the fifth study, the themes “internal shame and stigma”, “chaotic life circumstances due to gambling (such as eviction)” and “external stigmatization” appeared important in the development of suicidality.Conclusion: Individuals with GD suffer from increased suicide levels as well as high rates of intentional self-harm. Shame, stigma, and chaotic life circumstances might be mediators for suicidality in women with GD. Psychiatric comorbidity including substance use disorders appears to increase the risk of intentional self-harm and depression might increase the risk of suicide. This research could no tdetermine whether GD is an independent risk factor for suicide and further research is needed.Mortality levels are higher and might be due to cardio-vascular comorbidity

Suicidal behaviour in childbearing women

The first postnatal year is a period when the rate of psychiatric disorder is high, and a correspondingly high rate of suicide might be expected. Age-adjusted mortality ratios for suicide by women in the first postnatal year were therefore calculated from population data for England and Wales for a twelve-year period. The overall mortality ratio was found to be 17 - that is, the actual total was one sixth of that expected. The low rate was not found after stillbirth which was associated with a rate of suicide six times that in all women after childbirth. Women who committed suicide after childbirth most often did so in the first postnatal month and there was a tendency to use violent methods. One explanation of the low rate of suicide is that motherhood exerts a protective effect, and further studies were carried out to explore this possibility. In study two, the age-standardised mortality ratio for suicide during pregnancy was calculated by the same method to be 5 - that is, the actual rate was one twentieth of that expected. In study three, the rate of parasuicide by women in the first postnatal year was calculated from catchment area data to be less than half that of age-matched women (odds ratio 0.43). In study four, a cognitive explanation for these results was studied. Women with postnatal depression were found to score less on a questionnaire measuring cognitions related to worthlesness, hopelessness and self-harm than women with depression arising at other times. This result suggests that childbearing women, despite their risk of psychiatric disorder, are protected against suicide and self-harm by their relative absence of suicide-related cognitions, and that such cognitions should be a focus for the treatment of other groups at risk of suicide

INTERPRETABLE ESTIMATION OF SUICIDE RISK AND SEVERITY FROM COMPLETE BLOOD COUNT PARAMETERS WITH EXPLAINABLE ARTIFICIAL INTELLIGENCE METHODS

Background: The peripheral inflammatory markers are important in the pathophysiology of suicidal behavior. However, methods for practical uses haven’t been developed enough yet. This study developed predictive models based on explainable artificial intelligence (xAI) that use the relationship between complete blood count (CBC) values and suicide risk and severity of suicide attempt. Subjects and methods: 544 patients who attempted an incomplete suicide between 2010-2020 and 458 healthy individuals were selected. The data were obtained from the electronic registration systems. To develop prediction models using CBC values, the data were grouped in two different ways as suicidal/healthy and attempted/non-attempted violent suicide. The data sets were balanced for the reliability of the results of the machine learning (ML) models. Then, the data was divided into two; 80% of as the training set and 20% as the test set. For suicide prediction, models were created with Random Forest, Logistic Regression, Support vector machines and XGBoost algorithms. SHAP, was used to explain the optimal model. Results: Of the four ML methods applied to CBC data, the best-performing model for predicting both suicide risk and suicide severity was the XGBoost model. This model predicted suicidal behavior with an accuracy of 0.83 (0.78-0.88) and the severity of suicide attempt with an accuracy of 0.943 (0.91-0.976). Lower levels of NEU, WBC, MO, NLR, MLR and, age higher levels of HCT, PLR, PLT, HGB, RBC, EO, MPV and, BA contributed positively to the predictive created model for suicide risk, while lower PLT, BA, PLR and RBC levels and higher MO, EO, HCT, LY, MLR, NEU, NLR, WBC, HGB and, age levels have a positive contribution to the predictive created model for violent suicide attempt. Conclusion: Our study suggests that the xAI model developed using CBC values may be useful in detecting the risk and severity of suicide in the clinic

Clinical diagnoses, characteristics of risk behaviour, differences between suicidal and non-suicidal subgroups of Hungarian adolescent outpatients practising self-injury

Objective: Self-injury (SI), self-injurious behaviour (SIB), including suicidal or non-suicidal self-injury (SSI, NSSI) represent an increasing problem among teenagers amounting to a 6–17% prevalence rate in adolescence, yet little data exists on detailed characteristics and associated factors of SI reaching clinical severity. There is also a scarcity of data distinguishing between suicidal and non-suicidal subsamples of self-injuring patients, i.e. showing which predictors contribute to develop self-injurious behaviour with a previous suicidal history (SSI). Method: Clinical diagnoses and characteristics of risk behaviour were examined in a crosssectional design in suicidal and non-suicidal subgroups of Hungarian adolescent outpatients practising self-injurious behaviour. From the total pool of 708 new patients consecutively referred with various psychiatric problems in five regional child psychiatric centres in Western-Hungary over an 18-month period, 105 adolescent outpatients suffering from self-injurious behaviour participated in the study (28 males and 77 females aged from 14 to 18 years, mean age 15.97, SD 1.05). The Ottawa/Queen’s self-injury questionnaire (OSI) was used to measure the characteristics of risk behaviour, while the comorbid clinical diagnoses were confirmed by the M.I.N.I. Plus International Neuropsychiatric Interview. Descriptive statistics presented the frequencies of the characteristics of SI, bilateral comparisons were used to reveal relevant items to differentiate between sex, duration of practice and SSI versus NSSI and logistic regression was performed to identify significant predictors of suicidal subtype of self-injuring practice. Results: A total of 60% of the clinical SI population experienced a present or past episode of major depression. The motivation of patients to resist impulses and to discontinue malpractice was low. Cutting and scratching was the most common self-injuring methods. Two-thirds of the sample practised the impulsive type of SI, while 30% practised premeditated SI having an incubation time from 30 min to days and weeks before carrying out SI. Although duration of SI did not distinguish the sample in important aspects, girls and boys differed in several aspects of SI practice. SSI adolescents differed from their NSSI peers in a number of important characteristics including the frequency of actions, injured areas, methods, specific stresses and motivations. SSI adolescents were more likely to favour cutting of the lower leg and drug overdose as modes of SI. SSI adolescents were more likely to report addictive features than their peers with no suicidal motivation. From the aspect of self-injurious practice, logistic regression analysis found only two significant predictors for the combined pathology

The Prevalence of Axis I Mental Disorders in perpetrators of Murder-suicide in Minnesota in a Three-Year Period

Background: Murder-suicide is an uncommon but devastating act for everyone associated with the event. World-wide, murder-suicide occurs at a constant rate, between 0.2-0.3 per 100,000 people. One explanation for this constancy of murder-suicide incidence is a consistent underlying level of mental illness in all populations. Methods: Death certificates, The Femicide Report, newspaper articles, and supplemental homicide reports identified 30 murder-suicide cases involving 68 individuals within a three year period (1999,2000,2001) in Minnesota. Medical examiner records and the aforementioned sources provided data which was recorded on the Minnesota Violent Death Reporting System abstract form (MVDRS), adapted from the National Violent Death Reporting System (NVDRS) abstract form. Results: Evidence supporting mental illness was found in 30% of the perpetrators; this was probably an underestimate due to limited sources of information. Case commonalities were: an older Caucasian male killing a younger Caucasian female; violence between intimate partners; and the use of firearms. Discussion: Minnesota murder-suicide incidences were comparable to other studies Demographic and situational factors characterizing the Minnesota cases concurred with previous findings. The MVDRS was effective for gathering information about murder suicides in a consistent and comparable manner. The NVDRS is a positive start toward a national violent death recording system

Study of Suicide Attempts in Schizophrenia.

INTRODUCTION: Schizophrenia is a chronic disease characterized by remissions and Exacerbations. It reduces the life expectancy of those afflicted by approximately 10 years, And suicide accounts for the majority of premature deaths among patients suffering from Schizophrenia. Suicide is the most devastating possible outcome of a schizophrenic Illness. In addition to the finality for the patients, suicide has an intense and long-lasting Impact on families, other patients, and professional staff (Allebeck 1989, Black et al 1985). The risk of suicide in schizophrenia exceeds that of all psychiatric disorders other Than major depression (Asnis et al). The rate of suicide in schizophrenia has been Reported to be some 20-50 times greater than suicide rate in general population (Black 1988). It has been found that 20% to 40% of patients suffering from schizophrenia make Suicide attempts. The completed suicide rate in schizophrenia ranges from 9% to 12.9% (Tsuang et al 1980). Approximately 1% to 2 % of patients suffering from schizophrenia Who attempt suicide are reported to complete suicide within a year after their initial Attempt, with an additional 1% doing so each year thereafter (Vanessa Raymont). Suicide attempts are associated with protracted, non-regressive symptomatology, The majority occurring before 30 years of age. Chronicity, incapacity and complaints of Social isolation even though they are not being abandoned, are characteristic of those who Die by suicide. Suicide attempts in individuals with schizophrenia are serious, typically requiring Medical attention. Intent is strong and the majority of those who attempt make multiple Attempts, having a higher rate of more lethal methods (Radomsky et al). Risk factors including previous attempts are however found to be having limited Value in the prediction of eventual suicide and traditional risk scales are considered Ineffective (Heila et al, 1997). There has been a paucity of Indian studies on this subject which promoted us to take Up this study. In this study, we have tried to find differences in the groups of suicide attempters And non-attempters in schizophrenia in search for a possible recognition of risk factors. The question looming large is: “IS THERE PREVENTION?

Risk factors for fatal and nonfatal repetition of suicide attempts: a literature review

Objectives: This review aimed to identify the evidence for predictors of repetition of suicide attempts, and more specifically for subsequent completed suicide. Methods: We conducted a literature search of PubMed and Embase between January 1, 1991 and December 31, 2009, and we excluded studies investigating only special populations (eg, male and female only, children and adolescents, elderly, a specific psychiatric disorder) and studies with sample size fewer than 50 patients. Results: The strongest predictor of a repeated attempt is a previous attempt, followed by being a victim of sexual abuse, poor global functioning, having a psychiatric disorder, being on psychiatric treatment, depression, anxiety, and alcohol abuse or dependence. For other variables examined (Caucasian ethnicity, having a criminal record, having any mood disorders, bad family environment, and impulsivity) there are indications for a putative correlation as well. For completed suicide, the strongest predictors are older age, suicide ideation, and history of suicide attempt. Living alone, male sex, and alcohol abuse are weakly predictive with a positive correlation (but sustained by very scarce data) for poor impulsivity and a somatic diagnosis. Conclusion: It is difficult to find predictors for repetition of nonfatal suicide attempts, and even more difficult to identify predictors of completed suicide. Suicide ideation and alcohol or substance abuse/dependence, which are, along with depression, the most consistent predictors for initial nonfatal attempt and suicide, are not consistently reported to be very strong predictors for nonfatal repetition