Effectiveness of Psychotherapy on Suicidal Risk: A Systematic Review of Observational Studies

Background: Suicidal behavior is a major public health concern worldwide, and the interest in the development of novel and more efficient treatment strategies and therapies to reduce suicidal risk is increasing. Some recent studies have summarized the results of randomized clinical trials (RCTs) assessing the efficacy of psychotherapeutic tools designed to treat patients at suicidal risk. However, observational studies, which reflect real-world effectiveness and may use original approaches, have not been reviewed.Method: The aim of this study is to systematically review the available scientific evidence issued from observational studies on the clinical effectiveness of psychotherapeutic tools designed to treat patients at suicide risk. We have thus performed a systematic search of PubMed and Web of Science databases.Results: Out of 1578 papers, 40 original observational studies fulfilled our selection criteria. The most used psychotherapeutic treatments were dialectical behavioral therapy (DBT, 27.5%) and cognitive behavioral therapy (CBT, 15.0%) in patients with a diagnosis of borderline personality disorder (32.5%) and depression (15.0%). Despite the between-study heterogeneity, interventions lead to a reduction in suicidal outcomes, i.e., suicidal ideation (55.0%) and suicide attempts (37.5%). The content and reporting quality varied considerably between the studies.Conclusion: DBT and CBT are the most widely used psychotherapeutic interventions and show promising results in existing observational studies. Some of the included studies provide innovative approaches. Group therapies and internet-based therapies, which are cost-effective methods, are promising treatments and would need further study

Characteristics of Suicide Attempts in Anorexia and Bulimia Nervosa: A Case–Control Study

Objective: Compared to other eating disorders, anorexia nervosa (AN) has the highest rates of completed suicide whereas suicide attempt rates are similar or lower than in bulimia nervosa (BN). Attempted suicide is a key predictor of suicide, thus this mismatch is intriguing. We sought to explore whether the clinical characteristics of suicidal acts differ between suicide attempters with AN, BN or without an eating disorders (ED). Method: Case-control study in a cohort of suicide attempters (n = 1563). Forty-four patients with AN and 71 with BN were compared with 235 non-ED attempters matched for sex, age and education, using interview measures of suicidal intent and severity. Results: AN patients were more likely to have made a serious attempt (OR = 3.4, 95 % CI 1.4–7.9), with a higher expectation of dying (OR = 3.7,95 % CI 1.1–13.5), and an increased risk of severity (OR = 3.4,95 % CI 1.2–9.6). BN patients did not differ from the control group. Clinical markers of the severity of ED were associated with the seriousness of the attempt. Conclusion: There are distinct features of suicide attempts in AN. This may explain the higher suicide rates in AN. Higher completed suicide rates in AN may be partially explained by AN patients ’ higher desire to die and their more severe and lethal attempts

Collaborative meta-analysis finds no evidence of a strong interaction between stress and 5-HTTLPR genotype contributing to the development of depression

The hypothesis that the S allele of the 5-HTTLPR serotonin transporter promoter region is associated with increased risk of depression, but only in individuals exposed to stressful situations, has generated much interest, research, and controversy since first proposed in 2003. Multiple meta-analyses combining results from heterogeneous analyses have not settled the issue. To determine the magnitude of the interaction and the conditions under which it might be observed, we performed new analyses on 31 datasets containing 38 802 European-ancestry subjects genotyped for 5-HTTLPR and assessed for depression and childhood maltreatment or other stressful life events, and meta-analyzed the results. Analyses targeted two stressors (narrow, broad) and two depression outcomes (current, lifetime). All groups that published on this topic prior to the initiation of our study and met the assessment and sample size criteria were invited to participate. Additional groups, identified by consortium members or self-identified in response to our protocol (published prior to the start of analysis1) with qualifying unpublished data were also invited to participate. A uniform data analysis script implementing the protocol was executed by each of the consortium members. Our findings do not support the interaction hypothesis. We found no subgroups or variable definitions for which an interaction between stress and 5-HTTLPR genotype was statistically significant. In contrast, our findings for the main effects of life stressors (strong risk factor) and 5-HTTLPR genotype (no impact on risk) are strikingly consistent across our contributing studies, the original study reporting the interaction, and subsequent meta-analyses. Our conclusion is that if an interaction exists in which the S allele of 5-HTTLPR increases risk of depression only in stressed individuals, then it is not broadly generalizable, but must be of modest effect size and only observable in limited situations

Psychological pain and sensitivity to rejection in suicidal behavior

Les conduites suicidaires (CS) sont considérées comme des entités pathologiques à part entière avec une neurobiologie propre, abordées selon un modèle stress-vulnérabilité et pouvant bénéficier de la recherche de biomarqueurs. Nous proposons l'ébauche d'un modèle clinico-biologique de la vulnérabilité aux CS en considérant la douleur au coeur du processus suicidaire. Les stress psychosociaux sont sources de douleur psychologique. Leur maintien ou leur émergence perpétuerait ou majorerait la douleur psychologique via un dysfonctionnement du système vasopressinergique et des régions cérébrales impliqués dans les cognitions sociales. Nos données suggèrent une modification du seuil douloureux chez les sujets vulnérables pour le suicide qui percevraient une douleur psychologique accrue, associée aux idées suicidaires. Aussi les difficultés interpersonnelles sont associées une altération de prise de décision sous tendue par un dysfonctionnement du cortex préfrontal, associé à la vulnérabilité suicidaire. Ceci entrainerait le sujet à favoriser un choix (suicide) associé à une récompense immédiate (sédation de la douleur), même s'il est associé à les conséquences délétères (mort). Ainsi la douleur psychologique serait centrale dans les CS en tant que conséquence immédiate des stress psychosociaux, et en influençant les facteurs de vulnérabilité, qui favorisent sa perception et augmentent la sensibilité à certains événements sociaux via des processus neuroanatomiques et biochimiques. Nos travaux ouvrent de nouvelles voies de compréhension physiopathologiques et permettent d'envisager la douleur psychologique comme une potentielle cible thérapeutique de prévention suicidaire.Current knowledge suggests that suicidal behavior: 1) are pathological entities per se, with a specific neurobiology, 2) may be studied according to a stress-diathesis model, 3) may be better characterized by identifying biomarkers. Emphasizing that pain is the core of the suicidal process, we propose an outline of a model of suicide based on clinical neuropsychological and neuroimaging data. Psychosocial stressors cause psychological pain. Through dysfunctional vasopressinergic system and cerebral regions involved in social cognitions, psychosocial stress would be maintained or give rise to new stresses, perpetuating or increasing psychache. We suggest a modification of pain thresholds in vulnerable subjects for suicide leading to an increased perception of psychache, which is associated with suicidal ideation. Then, interpersonal difficulties are associated with impaired decision-making underpinned by prefrontal dysfunction that has been associated with suicidal vulnerability. This would cause the subject to promote a choice (suicide) associated with immediate reward (pain relief), although it is associated with deleterious consequences (death). Thus, psychological pain is central to suicidal behavior as an immediate consequence of psychosocial stressors, and influencing the suicidal vulnerability favoring pain perception and increasing susceptibility to social events, based on neuroanatomical and biochemical bases. Finally the hypothesis that a change of pain perception is involved in the suicidal process would open new avenues for understanding suicidal pathophysiology. It allows considering the psychological pain as a potential therapeutic target to prevent suicid

The advocates of euthanasia in patients with mental illness are going in the wrong direction

International audienceShaw et al argue that it's wrong to assume that patients suffering from mental health issues (including depression) cannot consent to assisted suicide. But being depressed is the strongest correlate of decision instability, of changing from acceptance of euthanasia to rejecting it at follw up. As a matter of fact, the rate of psychiatric patients who, after seeking euthanasia or assisted suicide(EAS), no longer wished to die and/or withdrew their requests is quite high. In general, caregivers should be aware of the risks for patients with a mental health issue

The Controversial Issue of Euthanasia in Patients With Psychiatric Illness

International audienc

Interest of neuroimaging of social exclusion in suicide

International audienceWith one million deaths worldwide, suicide is a major health issue. The frequency of life events preceding suicidal act is high and raises the question of their role in suicidal process. At biological level, dysfunctional neural processing of social exclusion may participate in suicidal risk through an increased perception of social adversity in vulnerable subjects. The purpose of this narrative review is to discuss neuroimaging findings related to social exclusion and loneliness, and to open new perspectives to investigate sensitivity to social stress in suicide

Génétique et épigénétique des conduites suicidaires

International audienceWith more than 10 000 deaths each year in France, suicide is a major public health problem. Despite many known risk factors, suicide prediction remains extremely difficult in daily clinical practice. The identification of biomarkers, including genetic and epigenetic factors, is needed in suicidology in order to better understand pathophysiology of such behaviors and to improve the screening of individuals at high suicidal risk. Numerous studies have reported candidate genes involved in serotonergic system, HPA axis and neurotrophic system. Moreover, an interaction between genetic factors and environment is now admitted, facilitating emergence of a psychobiological vulnerability leading to the suicidal act. For instance, polymorphism of the serotonin transporter (5-HTTLPR) as well as its interaction with early life events (childhood abuse) are involved in suicidality in adulthood. Unfortunately pangenomic studies are not conclusive yet. Beyond serotonergic genes, the SKA-2 gene, which is involved in stress response, deserves more attention. SKA-2 genic expression and methylation level have been associated with the suicidal act. In the future, the combination of clinical, biological and genetic risk factors will probably improve detection of suicide risk