Suicidal Symptoms Research Articles

Single, Fixed-Dose Intranasal Ketamine for Alleviation of Acute Suicidal Ideation. An Emergency Department, Trans-Diagnostic Approach: A Randomized, Double-Blind, Placebo-Controlled, Proof-of-Concept Trial

Background Suicidal patients often present to the emergency department, where specific anti-suicidal treatment is lacking. Ketamine, a Glutamate modulator and a rapidly acting antidepressant with anti-suicidal properties, might offer relief. Aims Evaluation of single, fixed-dosed intranasal ketamine for acute suicidal ideation in the emergency department. Methods Between August 2016 and April 2018, 30 eligible suicidal subjects, scheduled for psychiatric hospitalization, independently of their psychiatric diagnosis, were randomized to intranasal ketamine 40 mg or saline placebo. Safety and efficacy evaluations were scheduled for 30, 60, 120 and 240 min post administration and on days 1, 2, 3, 4, 5, 7, 21 and 28. Primary outcome was suicidal ideation. Results Fifteen subjects were randomized for each study group. All were analyzed for primary and secondary outcomes. Four hours post administration, the mean difference in suicidal symptoms between the groups, measured by the Montgomery-Åsberg Depression Rating Scale (MADRS) item of suicidal thoughts (MADRS-SI), was 1.267 (95% confident interval 0.1–2.43, p < 0.05) favoring treatment. Remission from suicidal ideation was evident in 80% for the ketamine group compared with 33% for the controls (p < 0.05). The mean difference in depressive symptoms, measured by MADRS, at the same time was 9.75 (95% confident interval 0.72–18.79, p < 0.05) favoring ketamine. Treatment was safe and well-tolerated. Conclusions Single, fixed-dose, intranasal ketamine alleviated suicidal ideation and improved depressive symptoms four hours post administration. We present here an innovative paradigm for emergency department management of suicidal individuals. Future larger-scale studies are warranted. ClinicalTrials.gov Identifier: NCT02183272.

Young adults with epilepsy: Relationships between psychosocial variables and anxiety, depression, and suicidality

BackgroundPeople with epilepsy (PWE) are at an increased risk of anxiety, depression, and suicidality. Young adulthood is a critical developmental period which can be complicated by the unique challenges of having epilepsy. The risk factors of mental health difficulties in young adults with epilepsy (YAWE) have not been investigated. AimsTo examine the relationships between psychosocial variables (coping strategies and sources of social support) and mental health outcomes in YAWE, and determine whether these psychosocial variables independently predict mental health outcomes after controlling for sociodemographic and epilepsy-related factors. MethodAn online survey was completed by 144 YAWE (18–25-year-olds), which measured sociodemographic and epilepsy-related factors, coping strategies, sources of social support, and current mental health symptoms (anxiety, depression, and suicidality). ResultsAvoidant-focused coping was positively correlated, and problem-focused coping and meaning-focused coping were negatively correlated, with symptoms of anxiety, depression, and suicidality. Social support from family, friends, and a special person all negatively correlated with mental health outcomes. Using multiple regression analyses, greater use of avoidant-focused coping strategies independently predicted higher symptoms of anxiety, depression, and suicidality. Greater support from friends independently predicted significantly lower anxiety and depression, whereas greater support from family independently predicted significantly lower suicidality. Clinical implicationsThese findings have implications for clinical practice in YAWE and suggest that screening for mental health symptoms and psychosocial variables to identify those at risk would be beneficial. Access to tailored psychological support is also needed.

The effect of childhood maltreatment on suicidal ideation through cognitive emotion regulation strategies and specific obsessive-compulsive symptoms in obsessive-compulsive disorder.

Childhood maltreatment is thought to be associated with suicidality in patients with obsessive-compulsive disorder (OCD). Although the underlying mechanism of this relationship is not clear, cognitive emotion regulation strategies (CERSs) and the specific OC symptoms including unacceptable obsessional thoughts (UOTs) and responsibility for harm (RFH) may underlie this link. Accordingly, the study aimed to assess the effect of childhood maltreatment on suicidal ideation through UOTs, RFH and adaptive and maladaptive CERSs in OCD patients. Three hundred patients meeting a DSM-5 diagnosis of OCD were selected and completed the scales measuring childhood maltreatment, OCD, suicidality and depressive symptoms. After controlling for depressive symptoms and OCD severity, childhood maltreatment was shown to affect suicidal ideation directly. Also, the indirect effect of childhood maltreatment on suicidal ideation was mediated by adaptive CERSs, UOTs and RFH. The findings show that OCD patients with a history of childhood maltreatment, less use of adaptive CERSs and the experiences of UOTs and RFH should be carefully considered regarding suicidal risk.

The Use of ECT in a Geriatric Patient with a Deep Brain Stimulator

<h3>Introduction</h3> Electroconvulsive therapy (ECT) is a commonly used and effective treatment for major depressive disorder with psychosis, especially in the geriatric population. Depressive disorders have significant prevalence in those with movement disorders including Parkinson's disease. Deep-brain stimulators are an effective treatment for Parkinson's disease, however, few cases in the literature exist about the use of ECT in patients with deep-brain stimulators. <h3>Methods</h3> A 68-year-old man with Parkinson's disease with a deep-brain stimulator (DBS) is seen in an outpatient geriatric psychiatry clinic. He has severe major depressive disorder with psychosis. The patient's clinical features include depressed mood, hopelessness, anhedonia, poor sleep, and poor appetite with weight loss. He endorses delusions of worsening physical and functional ability as well as delusions of abandonment and impoverishment. The patient experienced suicidal thinking and had impulsive para-suicidal behavior. The patient's symptoms are minimally responsive to treatment with antidepressants (Escitalopram, Mirtazapine, and Duloxetine) as well as psychotherapy. The patient's Parkinson's disease is treated with carbidopa-levodopa and a St. Jude DBS in his subthalamic nucleus, which was placed almost two years earlier. An ECT consultation was pursued in conjunction with discussion with the patient's neurologist. The patient begins undergoing acute bifrontal ECT with his DBS switched off for his treatments. <h3>Results</h3> The patient has, thus far, had 12 bifrontal acute phase ECT treatments, with the first 10 treatments occurring biweekly and then weekly. He is tolerating ECT well with minimal cognitive impairment immediately after the treatment and no complications relating to his DBS. After three treatments, the patient began experiencing significant improvements in mood, appetite, and sleep noted by himself and collateral sources. After 10 treatments the patient's suicidality and psychotic symptoms had resolved. The patient is much more active and has an improved level of functioning. His family notes that after over a year of severe depression, he finally is "back to himself." <h3>Conclusions</h3> ECT is an appropriate and effective treatment for major depressive disorder with psychosis in patients with concomitant Parkinson's disease who have a DBS. Although there are very few case reports of prescribing ECT to treat patients with Parkinson's disease that have a DBS device, this case demonstrates that it is a safe and efficacious treatment that should be considered. It is especially important to consider this treatment if there is a lack of response to antidepressants. When patients with DBS are not offered ECT due to reluctance and safety concerns, these patients are deprived of a valuable treatment option. <h3>Funding</h3> Not applicable

Health-related quality of life among patients with bipolar disorder in rural southwestern Uganda: a hospital based cross sectional study

BackgroundBipolar disorder is a psychiatric disorder that alters mood and affects over 55 million people globally with an estimated lifetime prevalence of approximately 0.8–1.1%. In Africa, the lifetime prevalence of the bipolar spectrum disorders is slightly lower at 0.1–0.6%. Bipolar disorder is ranked the sixth leading cause of disability with high rates of morbidity and mortality and negatively impacts quality of life of those affected.MethodsThe aim of the study was to determine the health-related quality of life of patients with bipolar disorder attending a mental health clinic in south western Uganda. We enrolled a consecutive sample of 169 participants and evaluated their health-related quality of life using the medical outcomes health survey short form-36 (SF-36) scale. We used bivariate and multivariable logistic regression to determine associations between quality of life, sociodemographic and clinical factors setting the physical and mental component categories of quality life scale as the main outcome variables.ResultsThe mean age of the participants was 37.23 (12.83) and slightly over half (54.4%) were females. More than half (66.86%) of the participants had poor physical component summary (mean = 45.06, SD = 8.44) while 81% of the participants had poor mental component summary (mean = 41.95, SD = 8.45). Poor physical quality of life had a statistically significant association with history of suicidal thoughts (OR = 2.75, 95% CI = 1.14–6.63, P = 0.02), while poor mental quality of life had a statistically significant association with history of suicidal thoughts (OR = 3.94, CI = 1.22–12.71, P = 0.02) and history of psychotic symptoms (OR = 2.46, CI = 1.07–5.64, P = 0.03).ConclusionThe mental and physical quality of life of our participants was poor and history of suicidal thoughts and psychotic symptoms were associated with poor quality of life. There is need to address psychotic symptoms and suicidal thoughts in the management of patients with bipolar disorder to improve health related outcomes and quality of life.

Ethnic Representation and Willingness to Seek Help as Moderators Between Peer Victimization and Mental Health Outcomes among Latinx Adolescents

Peer victimization, also referred to as bullying victimization, is associated with deleterious mental health outcomes including depression and suicidality. However, most of the bullying literature in the USA is centered around the experiences of non-Latinx White and African American adolescents. To center Latinx experiences, this cross-sectional study includes a sample of Latinx students from 19 Colorado high schools (n = 2554). School-level ethnic peer representation (proportion of Latinx peers) and individual student’s willingness to seek help were examined independently as moderators between bullying victimization and mental health outcomes (depression and suicidality) separately by gender. Results indicated that Latinx youth who experienced peer victimization also reported higher symptoms of depression and suicidality. A greater willingness to seek help was associated with less symptoms of depression and suicidality among young Latinx youth, while school-level ethnic peer representation was only associated with lower symptoms of depression for Latinx adolescent females. Among Latinx youth who were victimized, a greater willingness to seek help was protective for symptoms of depression and suicidality. Results suggest that school-based programs for bullying prevention and mental health promotion need to examine culturally specific protective factors to reduce victimization and promote help-seeking norms among Latinx youth.

Religiosity and prevalence of suicide, psychiatric disorders and psychotic symptoms in the French general population.

We aimed to examine the association between religious beliefs and observance and the prevalence of psychiatric disorders, psychotic symptoms and history of suicide attempts in the French general population. The cross-sectional survey interviewed 38,694 subjects between 1999 and 2003, using the MINI. Current religious beliefs and observance were identified by means of two questions: "are you a believer?" and "are you religiously observant?". We studied the association between religiosity and psychiatric outcomes using a multivariable logistic regression model adjusted for sociodemographic characteristics, including migrant status. Religious beliefs were positively associated with psychotic symptoms and disorders [OR = 1.37, 95% CI (1.30-1.45) and OR = 1.38, 95% CI (1.20-1.58)], unipolar depressive disorder [OR = 1.15, 95% CI (1.06-1.23)] and generalized anxiety disorder [OR = 1.13, 95% CI (1.06-1.21)], but negatively associated with bipolar disorder [OR = 0.83, 95% CI (0.69-0.98)], alcohol use disorders [OR = 0.69, 95% CI (0.62-0.77)], substance use disorders [OR = 0.60, 95% CI (0.52-0.69)] and suicide attempts [OR = 0.90, 95% CI (0.82-0.99)]. Religious observance was positively associated with psychotic symptoms and disorders [OR = 1.38, 95% CI (1.20-1.58) and OR = 1.25, 95% CI (1.07-1.45)], but negatively associated with social anxiety disorder [OR = 0.87, 95% CI (0.76-0.99)], alcohol use disorders [OR = 0.60, 95% CI (0.51-0.70)], substance use disorders [OR = 0.48, 95% CI (0.38-0.60)] and suicide attempts [OR = 0.80, 95% CI (0.70-0.90)]. Among believers, religious observance was not associated with psychotic outcomes. Religiosity appears to be a complex and bidirectional determinant of psychiatric symptoms and disorders. In this respect, religiosity should be more thoroughly assessed in epidemiological psychiatric studies, as well as in clinical practice.

Low dose oral ketamine treatment in chronic suicidality: An open-label pilot study

Recently, low-dose ketamine has been proposed as a rapid-acting treatment option for suicidality. The majority of studies to date have utilised intravenous (IV) ketamine, however, this route of administration has limitations. On the other hand, oral ketamine can be administered in a range of settings, which is important in treating suicidality, although studies as to safety and feasibility are lacking. n = 32 adults (aged 22–72 years; 53% female) with chronic suicidal thoughts participated in the Oral Ketamine Trial on Suicidality (OKTOS), an open-label trial of sub-anaesthetic doses of oral ketamine over 6 weeks. Participants commenced with 0.5 mg/kg of ketamine, which was titrated to a maximum 3.0 mg/kg. Follow-up assessments occurred at 4 weeks after the final dose. The primary outcome measure was the Beck Scale for Suicide Ideation (BSS) and secondary measures included scales for suicidality and depressive symptoms, and measures of functioning and well-being. Mean BSS scores significantly reduced from a high level of suicidal ideation at the pre-ketamine (week 0) timepoint to below the clinical threshold at the post-ketamine (week 6) timepoint. The proportion of participants that achieved clinical improvement within the first 6 weeks was 69%, whereas 50% achieved a significant improvement by the follow-up (week 10) timepoint. Six weeks of oral ketamine treatment in participants with chronic suicidality led to significant reduction in suicidal ideation. The response observed in this study is consistent with IV ketamine trials, suggesting that oral administration is a feasible and tolerable alternative treatment for chronic suicidality.

Mental health burden among Black adolescents: the need for better assessment, diagnosis and treatment engagement

ABSTRACT This study examines mental health symptoms among Black adolescents who were currently in mental health treatment and those who were not in treatment. The study uses a sample of Black adolescents (N= 154) and logistic regression was performed to determine which psychological factors were associated with exhibiting mental health symptoms. Both groups experienced high amounts of trauma exposure history, recent suicidality, substance use, and depressive symptoms. Nearly one in four adolescents in the out of treatment group met diagnostic criteria for anxiety disorders. Implications include better screening for mental health symptoms to ensure Black adolescent have access to mental health treatment.

Negative self-appraisal: Personal reasons for dying as indicators of suicidality

Reasons for dying (RFD) are one of the most authentic factors illustrating the lived experience of suicidal individuals. However, the field has been criticized for inadequate evaluation of risk factors and suicidal symptoms, such as RFD, to develop more robust theoretical models and risk assessments. In this study, we aimed to critically examine RFD themes as predictors of suicidal symptoms to improve our understanding of the suicidal mind, test suicide theory validity and improve risk assessment. This cross-sectional mixed-method study included anonymous survey data (N = 713) with a subsample (n = 474; 77% female; age M = 31.48, SD = 13.53) who provided RFD. Participants were asked to write down five RFD (ranked 1st to 5th most important) and completed the Suicidal Affect-Behavior-Cognition Scale (SABCS). Thematic analysis revealed eight valid RFD themes—Negative Self-appraisal, Hopelessness, Desire to Escape, Escape Pain, Relationships, Loneliness, Financial Hardship, and Physical Health. Themes were quantified by rank and total endorsements of the theme. Hierarchical regression modelling, statistically controlling for demographics, showed all RFD themes, except Physical Health, were positive predictors of suicidality, accounting for 26% of variance in suicidal symptoms. Negative Self-appraisal was the strongest predictor. RFD differences were also found by gender, age and education. From these findings, we determined current suicide theories do not fully account for suicidal persons’ RFD. There is a pressing need for more critical review of current theories, as current theories only partially represent this key attribute of the suicidal mind, and none of the reviewed theories accurately reflected suicidal participants’ RFD. Clinical implications include integrating financial therapies into suicide prevention treatments and incorporating RFD into assessments and treatments. To aid research and risk assessment efforts, we propose a new RFD Index, with eight five-point response items.

Female Veterans' Willingness to Seek Veterans Health Administration and Non-Veterans Health Administration Services for Suicidal Thoughts and Mental Health Concerns.

The extent to which female veterans are willing to seek Veterans Health Administration (VHA) and non-VHA care when they are suicidal or experiencing mental health (MH) concerns is unknown. The objectives of this study were to: (1) examine whether current, past, and never VHA using female veterans' willingness to seek VHA care differs from their willingness to seek non-VHA care if suicidal or experiencing MH symptoms; (2) examine if VHA use, military sexual trauma, and suicidal ideation and attempt are associated with female veterans' willingness to use VHA and non-VHA care when experiencing suicidal thoughts or MH symptoms. A cross-sectional anonymous survey. Four hundred thirty nine female veterans, including current, past, and never VHA users were included. General Help-Seeking Questionnaire, Self-Injurious Thoughts and Behaviors Interview, and the VA Military Sexual Trauma Screening Questions. Current VHA users reported more willingness to use VHA than non-VHA care; conversely, past and never VHA users reported less willingness to use VHA care relative to non-VHA care. Military sexual assault and none or past VHA use were associated with lower willingness to use VHA care if suicidal or experiencing MH symptoms. In contrast, those with none or past VHA use reported greater willingness to use non-VHA care if suicidal or experiencing MH symptoms, while prior suicide attempt was associated with lower willingness. Ensuring that acceptable and effective suicide prevention services are available to female veterans in both VHA and community settings is critical. Increasing help-seeking intentions among female veterans who have attempted suicide or experienced military sexual assault is also essential.

Differential Risks for Suicidality and Mental Health Symptoms Among Transgender, Nonbinary, and Cisgender Sexual Minority Youth Accessing Crisis Services.

Purpose: We examined whether health risks among sexual minority youth (SMY) differ by gender identity (transgender, nonbinary, and cisgender). Methods: Data were collected on suicide attempts (lifetime and someday), depression and post-traumatic stress disorder (PTSD), and minority stress among SMY accessing crisis services. Results: In the multivariate regression models, compared to their cisgender peers, transgender and nonbinary youth were at higher risk for suicide attempt (lifetime and someday), depression, and PTSD. Minority stress was a significant predictor for all the models. Conclusion: Crisis service organizations working to reduce suicidality among SMY should be sensitive to diverse experiences of gender identity.

Can lifetime exposure to intimate partner violence predict suicidality in a sample of Egyptian pregnant women: a cross-sectional study?

Background and objectivesResearch on suicidal behaviors during pregnancy in Egypt is limited; being apparently rationalized by pregnancy is a protective period. This study aimed to address the current suicide risk (CSR), and evaluate its correlates of among pregnant women in Egypt. MethodsIt is a cross-sectional study which included 835 of Egyptian pregnant women who were receiving their antenatal care at Zagazig University Obstetrics and Gynecology Outpatient clinics, during the period from 1 October 2017 to 30 September 2018. The sociodemographic and clinical data were collected by a simple semi-structured questionnaire. The psychometric assessment included Beck Suicidal Ideation Scale (BSS), Zagazig Depression Scale (ZDS), Hamilton Anxiety Rating Scale (HAM-A), and Structured Clinical Interview for DSM-IV-TR Axis II Personality Disorders (SCID-II) for assessment of CSR, and comorbid depression, anxiety and personality disorders, respectively. ResultsAmong pregnant women, 23.4% reported CSR. This included suicidal ideation of 21.6% and suicidal attempt of 1.8%. Predictors of CSR were history of intimate partner violence (IPV) exposure (OR 8.8, 95% CI: 2.8, 27.7), identification of their current pregnancy as a female baby (OR 6.9, 95% CI: 2.0, 23.5), previous history of fetal loss (OR 3.9, 95% CI: 1.5, 10.6), and moderate-to-severe depression (OR 3.0, 95% CI: 1.0, 8.7). ConclusionsOur findings suggest that CSR, including suicidal ideation and attempts, is not rare during pregnancy. Exposure to IPV is the most robust predictor of CSR. Pregnant women should be routinely screened for suicidal behaviors, violence exposure and depressive symptoms, as part of their antenatal assessments.

Adolescents With Attention-Deficit/Hyperactivity Disorder: Adverse Behaviors and Comorbidity

Purpose and ObjectiveThere is growing evidence that adolescents with ADHD develop long-term impairments and adverse outcomes, yet less is known about their adverse behaviors. To quantify rates of mental health comorbidities in adolescents with ADHD and compare the risks of adverse behaviors among adolescents with and without ADHD. MethodsWe performed a cohort analysis of 6,483 youth from the National Comorbidity Survey Adolescent Supplement (NCS-A), a nationally representative in-person structured diagnostic interview of adolescents aged 14–18 years focusing on mental, emotional, and behavioral disorders. Main Outcomes: (1) Percentages with comorbid anxiety, mood, disruptive behavior, and substance use disorders. (2) Strength of associations of ADHD with several adverse behaviors, including suicidal symptoms, aggression, behavior regulation, life events, education, and substance use. Odds ratios were adjusted for age, sex, and race. ResultsAmong the sample of 6,483 adolescents, overall, 9.5% met the criteria for ADHD. Most (69.5%) of adolescents with ADHD had at least one comorbid mental health condition. As compared to adolescents without ADHD, those with ADHD were significantly more likely to have had a suicide attempt (aOR 2.9, 95% CI = 1.3–6.6) and to have had perpetrated physical aggression (aOR 2.3, 95% CI = 1.7–3.2). Adolescents with ADHD were also more likely to have been expelled from school or fired from a job (aOR 3.3, 95% CI = 1.7–6.5) and to have had problems related to drinking alcohol (95% CI = 1.2–2.9). ConclusionsADHD in adolescents is a complicated disorder with elevated risks for a wide range of adverse behaviors.

Considerations in the assessment of help-seeking and mental health service use in suicide prevention research.

The connection of individuals at elevated suicide risk to mental healthcare services represents a critical component of suicide prevention efforts. This article provides recommendations for enhancing the assessment of help-seeking and mental health service use within the context of suicide prevention research. We discuss evidence-based and theoretical rationale for improving current approaches to assessing help-seeking and mental health service use among at-risk individuals. Recommendations are offered within three domains: (a) consideration of the spectrum of connection to care, (b) assessment of the degree to which mental healthcare services seek to and effectively target suicidal symptoms, and (c) evaluation of the sources and types of treatment and care sought and received by at-risk individuals. To further our understanding of how to bolster connection to care and improve experiences with mental healthcare services among individuals at elevated suicide risk, it is imperative that stakeholders precisely capture the degree, efficacy/effectiveness, and nature of care sought and received by individuals. In so doing, research gaps might be better identified and, ultimately, mental healthcare services might be better leveraged as tools to prevent suicide and support individuals in creating lives they perceive to be worth living.

Emerging New Psychiatric Symptoms and the Worsening of Pre-existing Mental Disorders during the COVID-19 Pandemic: A Canadian Multisite Study: Nouveaux symptômes psychiatriques émergents et détérioration des troubles mentaux préexistants durant la pandémie de la COVID-19: une étude canadienne multisite.

The coronavirus disease 2019 (COVID-19) pandemic has caused global disruptions with serious psychological impacts. This study investigated the emergence of new psychiatric symptoms and the worsening of pre-existing mental disorders during the COVID-19 pandemic, identified factors associated with psychological worsening, and assessed changes in mental health service use. An online survey was circulated between April 3 and June 23, 2020. Respondents were asked to complete mental health questionnaires based on 2 time referents: currently (i.e., during the outbreak) and in the month preceding the outbreak. A total of 4,294 Canadians between 16 and 99 years of age were subdivided based on the presence of self-reported psychiatric diagnoses. The proportion of respondents without prior psychiatric history who screened positive for generalized anxiety disorder and depression increased by 12% and 29%, respectively, during the outbreak. Occurrences of clinically important worsening in anxiety, depression, and suicidal ideation symptoms relative to pre-outbreak estimates were significantly higher in those with psychiatric diagnoses. Furthermore, 15% to 19% of respondents reported increased alcohol or cannabis use. Worse psychological changes relative to pre-outbreak estimate were associated with female sex, younger age, lower income, poorer coping skills, multiple psychiatric comorbidities, previous trauma exposure, deteriorating physical health, poorer family relationships, and lower exercising. Reductions in mental health care were associated with increased suicidal ideation. The worsening in mental health symptoms and the decline in access to care call for the urgent development of adapted interventions targeting both new mental disorders and pre-existing psychiatric conditions affected by the COVID-19 pandemic.

A qualitative study of patients' experience of ketamine treatment for depression: The ‘Ketamine and me’ project

• Ketamine infusion causes an initial ‘high’, enhanced perception, and dissociation. • People may have a reduction in or removal of suicidal ideation & depression symptoms. • People can experience an increase in motivation, socialisation, and activity. • The treatment environment affects ketamine experience. • People who have experience of ketamine for depression advocate the treatment. There has been a lack of in-depth interviews investigating patient experience of ketamine treatment for depression. We examined participants’ pathways to receiving ketamine infusion to treat their depression, and their responses to, lived experiences of, and attitudes towards ketamine treatment. Qualitative methods were used to conduct in-depth interviews with 13 patients (6 male; 7 female) diagnosed with treatment resistant depression (TRD) with experience of receiving ketamine treatment for depression. Interpretative phenomenological analysis (IPA) was employed. For the majority of participants ketamine infusion causes a reported initial ‘high’, enhanced perception, and dissociative experience; followed by a lifting of mood and a reduction in or removal of suicidal ideation and depression symptoms lasting around 3–6 days. This leads to a reported increase in motivation, socialisation, and activity. All participants valued the therapeutic alliance with clinicians which enhanced the treatment experience and all advocated treatment access for those with depression who have not responded to other treatments. Small numbers, purposive sample, participant self-selection, and single site recruitment limit generalisability. Ketamine for depression can have many beneficial effects, and it is potentially life-transforming for some. Ketamine may be a source of hope for patients for whom other treatments have not been effective. For some, ketamine is not tolerated or does not have anti-depressive effects. Further qualitative in-depth exploration of patient experience and consideration of how ketamine depression treatment access can be appropriately made available are warranted.

Continuous Identity Cognitive Therapy: Feasibility and Acceptability of a Novel Intervention for Suicidal Symptoms.

We introduce continuous identity cognitive therapy (CI-CT), a novel suicide intervention. CI-CT was developed based on evidence that suicidal individuals have difficulty viewing and experiencing continuity with their perceived future self, and having meaningful and achievable personal goals. CI-CT integrates aspects of cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) with modality-specific techniques focusing on the individual's perceived present-to-future life story. The intervention guides the development of a meaningful life story with a vivid and positive future self. The results of an open-label pilot/feasibility trial (N = 17) for U.S. Veterans with a serious mental illness indicate that CI-CT is feasible, acceptable to Veterans, and may help with suicidality, depression, hopelessness, and future self-continuity. Reductions in clinical symptoms were associated with improvement in future self-continuity and were largely maintained at the 1-month follow-up. These results, along with high retention rates and positive Veteran feedback, support further exploration of the utility of CI-CT.

Is Valproate Reasonable? Response to Leistikow et al.

Back to table of contents Previous article Next article Letters to the EditorFull AccessIs Valproate Reasonable? Response to Leistikow et al.Rita Suri, M.D., Donna Kanar Socol, J.D., Michael Gitlin, M.D.Rita SuriSearch for more papers by this author, M.D., Donna Kanar SocolSearch for more papers by this author, J.D., Michael GitlinSearch for more papers by this author, M.D.Published Online:1 Jan 2021https://doi.org/10.1176/appi.ajp.2020.20030350rAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: We appreciate the comments by Drs. Leistikow, Smith, Payne, and Osborne and agree that, in this day and age, the field of reproductive psychiatry views valproate as a last resort for treatment in women of childbearing age, potentially justifiable when it is the only option for treating severe mental illness. We also agree that in utero valproate exposure has been associated with an increased risk of lower IQ, attention deficit hyperactivity disorder, and behavioral issues in exposed children and an increased risk of polycystic ovary syndrome, hyperandrogenism, and menstrual irregularities in women.The case presented in our Clinical Case Conference, “Standard of Care: Reasonable But Not Perfect,” occurred more than 13 years ago, well before the risks of valproate use during pregnancy were understood to the extent that they are today. At the time, valproate was commonly used as a treatment modality, with more than 900,000 prescriptions written annually for women of reproductive age (1). The patient in the case presented was using a reliable form of birth control, placing her risk of having an infant with a neural tube defect at less than one in a thousand. She had severe mental illness, with symptoms of suicidality and thoughts of harming her children and her husband, necessitating a rapid treatment response. Her symptoms had failed to respond to other pharmacologic treatments, and the atypical features of her case suggested a more favorable response to valproate than to lithium (2, 3).At the time this case occurred, the treating clinicians met the standard of care; nevertheless, at trial, they lost the malpractice case. The purpose of our Clinical Case Conference was to clarify that standard of care requires that the threshold of reasonable care, not optimal care, is provided, and to understand the decisions that the treating clinicians made at the time of the case, as well as to highlight areas where alternative decisions, precautions, and actions could have been considered.Drs. Leistikow, Smith, Payne, and Osborne accurately point out “a changing standard of care” regarding the use of valproate in reproductive-age women and suggest that the doctors’ decision, in this case, to “treat with valproate instead of other options, such as lithium, may look less reasonable in years to come.” However, clinicians can be responsible only for making treatment decisions and be held to a standard of care based on the information and the body of knowledge available at the time. Therefore, it may be time for current practice guidelines in the treatment of bipolar disorder to address the issue of whether valproate should be used at all, and if so, the specific circumstances and criteria for use, in the treatment of reproductive-age women.Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California Los Angeles, Los Angeles (Suri, Gitlin); Hughes Socol Piers Resnick & Dym, Ltd., Chicago (Socol).Send correspondence to Dr. Suri ([email protected]).The authors’ disclosures accompany the original article.References1 Meador KJ, Loring DW: Risks of in utero exposure to valproate. JAMA 2013; 309:1730–1731Crossref, Medline, Google Scholar2 Pfennig A, Schlattmann P, Alda M, et al.: Influence of atypical features on the quality of prophylactic effectiveness of long-term lithium treatment in bipolar disorders. Bipolar Disord 2010; 12:390–396Crossref, Medline, Google Scholar3 Bowden CL: Clinical correlates of therapeutic response in bipolar disorder. J Affect Disord 2001; 67:257–265Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited byNone Volume 178Issue 1 January 01, 2021Pages 100-100 Metrics KeywordsWomenPre/Peri/Postnatal IssuesEducation-PsychiatricForensic PsychiatryPDF download History Accepted 27 July 2020 Published online 1 January 2021 Published in print 1 January 2021

Associations between insecure attachment styles to parents and suicidal ideation in adolescents with depression.

Objective:Suicidal ideation and depressive symptoms are often interrelated in clinical settings. Insecure attachment may be a risk factor for suicidal ideation in depressed adolescents. To our knowledge, this study is the first to examine the association between self-reported insecure attachment styles to both parents and suicidal ideation in a clinical sample of adolescents with depression.Methods:Fifty clinically depressed adolescents (13-17 years, 84% girls) completed self-reported measures of suicidal ideation, depressive symptoms, and attachment style to parents.Results:There was a statistically significant bivariate association between higher levels of attachment anxiety in relation to mothers and fathers and higher levels of suicidal ideation. When attachments to both parents were included in the same multivariate model, only attachment anxiety to the mother was significantly associated with the level of suicidal ideation. Self-reported depressive symptoms remained significantly associated with the level of suicidal ideation in all analyses. Younger adolescents with attachment anxiety reported higher levels of suicidal ideation than older adolescents.Conclusion:Conclusions about directionality and causality of associations between insecure attachment and suicidal ideation are limited due to the cross-sectional design. Our findings suggest that attachment anxiety in relation to the mother and father is associated with increased levels of suicidal ideation. Implication of these findings for treatment selection is discussed.