Journal articles on the topic 'Depression; attempted suicide; short-term follow-up'

ObjectivesThe overall aim of this study is to gain greater knowledge about the risk of suicide among suicide attempters in a very long-term perspective. Specifically, to investigate possible differences in clinical risk factors at short (≤5 years) versus long term (>5 years), with the hypothesis that risk factors differ in the shorter and longer perspective.DesignProspective study with register-based follow-up for 21–32 years.SettingMedical emergency inpatient unit in the south of Sweden.Participants1044 individuals assessed by psychiatric consultation when admitted to medical inpatient care for attempted suicide during 1987–1998.Outcome measuresSuicide and all-cause mortality.ResultsAt follow-up, 37.6% of the participants had died, 7.2% by suicide and 53% of these within 5 years of the suicide attempt. A diagnosis of psychosis at baseline represented the risk factor with the highest HR at long-term follow-up, that is, >5 years, followed by major depression and a history of attempted suicide before the index attempt. The severity of a suicide attempt as measured by SIS (Suicide Intent Scale) showed a non-proportional association with the hazard for suicide over time and was a relevant risk factor for suicide only within the first 5 years after an attempted suicide.ConclusionsThe risk of suicide after a suicide attempt persists for up to 32 years after the index attempt. A baseline diagnosis of psychosis or major depression or earlier suicide attempts continued to be relevant risk factors in the very long term. The SIS score is a better predictor of suicide risk at short term, that is, within 5 years than at long term. This should be considered in the assessment of suicide risk and the implementation of care for these individuals.

AbstractObsessive compulsive disorder (OCD) is a severe, often long-term mental disorder. It may be independent from, or comorbid with other mental disorders, especially depression and anxiety disorders. Suicidal thoughts, ideations and ruminations are prevalent in subjects with OCD, but it is not yet clear if the incidences of attempted and completed suicides have increased in comparison with the general population and with other psychiatric disorders.MethodsWe conducted a systematic literature search on the incidence of suicide attempts and completed suicides in subjects with OCD. Search terms for Pubmed and Medline were OCD and suicide. We selected papers providing follow-up data on the incidence of attempted and completed suicide in OCD.Results404 papers were initially identified. Only 8 papers covering six studies provided prospective data on attempted or completed suicide over a defined period in subjects with OCD, four studies included control subjects. Two studies providing follow-up data were limited to high-risk samples and did not provide enough data on the incidence of suicide in comparison with the general population. The conclusion that there is an increased risk of attempted and completed suicides in OCD can only be based on one large Swedish National Registry sample with an up to 44 year follow up. Psychiatric comorbidity is the most relevant risk factor for suicide.ConclusionsEven though some studies report an increased incidence of attempted and completed suicides in OCD patients from selected high risk samples, the evidence from population based studies is mostly based on one large Swedish study. More long-term studies in the general population with a reduced risk of subject attrition are needed. Using a clear definition and assessment of suicidal behaviour and a common time-frame would improve the comparability of future studies.

BackgroundDespite the high suicide rate in the elderly, there is a relative lack of information on the longer-term outcome of elderly people who have attempted suicide, particularly their psychiatric and physical morbidity and mortality.MethodComprehensive demographic and psychiatric data were available on 100 consecutive referrals to a liaison psychiatric service of patients over 65 years of age who attempted suicide between 1989 and 1992. Detailed follow-up in 1994 included the interviewing of survivors using GMS–AGECAT.ResultsOf the 64 women and 36 men, with a mean age of 75.8 years, 42 subjects were dead at follow-up; 12 were suspected suicides, five having died as a delayed result of their index attempt. Twelve women made a further non-lethal suicide attempt. All five male repeat attempts proved fatal.ConclusionsElderly people who attempt suicide have a high mortality both from completed suicide and death from other causes. The completed suicide rate is at least 1.5% per year, and the repetition rate is 5.4% per year. Those at risk of further self-harm are likely to be in contact with psychiatric services and to be suffering from persistent depression.

BackgroundStrong links exist between juvenile and adult depression, but comorbid conduct disorder may be associated with worse adult social difficulties.AimsTo test the impact of comorbid conduct disorder on social adjustment and dysfunction, suicidality and criminality of adults who had had depression as youths.MethodSubjects (n=149) assessed at the Maudsley Hospital in 1970–1983 and meeting DSM–IV criteria for major depressive disorder with (CD–MDD; n=53) or without (MDD; n=96) conduct disorder were interviewed 20 years later. Data were collected on lifetime psychiatric disorders and adult social/personality functioning. Death certificates and criminal records were obtained.ResultsThe suicide risk was 2.45%, and 44.3% of the sample had attempted suicide once in their lives. Compared with the MDD group, the CD–MDD group had higher rates of suicidal behaviours and criminal offences, and exhibited more pervasive social dysfunction.ConclusionsAdolescent depression is associated with raised risks of adult suicidality and with persistent interpersonal difficulties. Youths with CD–MDD show more severe and pervasive social dysfunction.

According to contemporary suicidology, mental pain represents one of the main suicide risk factors, along with more traditional constructs such as depression, anxiety and hopelessness. This work aims to investigate the relationship between the levels of mental pain and the risk to carry out suicide or suicide attempt in the short term in order to understand if a measurement of mental pain can be used as a screening tool for prevention. For this purpose, 105 outpatients with psychiatric diagnosis were recruited at the university hospital of Varese during a check-up visit and were assessed by using psychometric scales of mental pain levels, hopelessness, anxiety and depression. Clinical and sociodemographic variables of the sample were also collected. A period of 18 months following the recruitment was observed to evaluate any suicides or attempted suicides. Subjects numbering 11 out of 105 committed an attempted suicide. From statistical analyses, high values of the Beck Depression Inventory (BDI-II), Mental Pain Questionnaire (OMMP) and Hamilton Rating Scale for Depression (HAM-D) scales showed a significant association with the risk of carrying out a suicide attempt and, among these, OMMP and BDI-II showed characteristics of good applicability and predictivity proving suitable to be used as potential tools for screening and primary prevention of suicidal behavior.

Summary: The cathartic effect of suicide is traditionally defined as the existence of a rapid, significant, and spontaneous decrease in the depressive symptoms of suicide attempters after the act. This study was designed to investigate short-term variations, following a suicide attempt by self-poisoning, of a number of other variables identified as suicidal risk factors: hopelessness, impulsivity, personality traits, and quality of life. Patients hospitalized less than 24 hours after a deliberate (moderate) overdose were presented with the Montgomery-Asberg Depression and Impulsivity Rating Scales, Hopelessness scale, MMPI and World Health Organization's Quality of Life questionnaire (abbreviated versions). They were also asked to complete the same scales and questionnaires 8 days after discharge. The study involved 39 patients, the average interval between initial and follow-up assessment being 13.5 days. All the scores improved significantly, with the exception of quality of life and three out of the eight personality traits. This finding emphasizes the fact that improvement is not limited to depressive symptoms and enables us to identify the relative importance of each studied variable as a risk factor for attempted suicide. The limitations of the study are discussed as well as in particular the nongeneralizability of the sample and setting.

SummaryThe prevalence of anxiety disorders and associated DSM-III-R diagnoses were measured in a sample of 80 female adolescents aged between 15 to 20 years consulting an outpatient psychiatric service for adolescents. The suicide attempt group (SA) included 40 patients evaluated within 24 h after attempted suicide. This is compared to 40 consecutive patients consulting the same center but without any history of suicide attempt (the no attempt group, NA).The global prevalence of anxiety disorders was similar in both groups (SA: 65% vs. NA: 60%, NS) as was the relative importance of the different disorders in each group, generalized anxiety being the most frequent specific anxiety disorder. The most striking difference between the two groups was in the prevalence of affective disorders in 90% (SA) vs. 32.5% (NA) (P < 0.001), leading to high rates of comorbidity on axis I in the SA group. Of the 24 patients with anxiety disorders who attempted suicide, 21 (95%) fulfilled criteria for associated major depression, compared to five out of 21 (24%) patients with anxiety disorders who had not attempted suicide.Adolescents with anxiety disorders developing major depression are at a high risk for suicide. The depression may be of short duration (less than two weeks) when compared to that of the anxiety disorder (greater than six months). To improve suicide prevention, our findings if confirmed should encourage clinicians to perform a close follow-up of adolescents with anxiety disorders for an early detection of sudden depressive breakdowns.

ObjectiveTo determine the postoperative attempted and completed suicide rates after subthalamic nucleus deep brain stimulation (STN-DBS) in a single-center cohort and to determine factors associated with attempted and completed suicide.MethodsWe retrospectively included all patients with Parkinson disease (PD) who underwent bilateral STN-DBS surgery at the Grenoble University Hospital between 1993 and 2016. For each patient who committed or attempted suicide, 2 patients with PD with STN-DBS without any suicidal behaviors were matched for age (±1 year), sex, and year of surgery (±2 years). Clinical data were collected from medical records. Detailed preoperative and postoperative neuropsychological evaluations, including frontal and Beck Depression Inventory (BDI) scores, were gathered.ResultsA total of 534 patients with PD were included. Completed and attempted suicide percentages were 0.75% (4 of 534) and 4.11% (22 of 534), respectively. The observed suicide rate in the first postoperative year (187.20 of 100,000 per year, 1 of 534) was higher than the expected National Observatory on Suicide Risks rate adjusted for age and sex (standardized mortality ratio 8.1). This rate remained similar over the second and third postoperative years. In a comparison of the 26 patients completing/attempting suicide and the 52 controls, the first group showed more frequent history of suicidal ideation/suicide attempts and psychotic symptoms, higher percentage of family psychiatric history, higher psychiatric medication use, and higher preoperative frontal and BDI scores on neuropsychological evaluations.ConclusionsSuicide behaviors can occur after STN-DBS, especially during the first 3 years. A careful multidisciplinary assessment and long-term follow-up are recommended to recognize and treat this potentially preventable risk for mortality.

AbstractSuicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year.Suicidal crisis:Acute intervention should start immediately in order to keep the patient alive.Diagnosis:An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential.Treatment:Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10–14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. Treatment with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. Treatment with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required.Treatment team:Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality.Family:The suicidal person independently of age should always be motivated to involve family in the treatment.Social support:Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks.Safety:A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks.Training of personnel:Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.

Background: Self-harm and suicide in children and adolescents are of serious consequence and increase during the adolescent years. Consequently, there is need for interventions that prevent such behaviour. The objective of this paper: to evaluate the effects of interventions preventing self-harm and suicide in children and adolescents in an overview of systematic reviews. Methods: We conducted a review of systematic reviews (OoO). We included reviews evaluating any preventive or therapeutic intervention. The quality of the included reviews was assessed independently, and data was extracted by two reviewers. We report the review findings descriptively. The certainty of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: Moderate certainty evidence suggests that school-based interventions prevent suicidal ideation and attempts short term, and possibly with long term effects on suicide attempts. The effects of community-based interventions following suicide clusters and local suicide plans are uncertain, as are the benefits and harms of screening young people for suicide risk. The effects of most interventions targeting children and adolescents with known self-harm are uncertain. However, low certainty evidence suggests that dialectical behavioural therapy and developmental group therapy are equally as effective on repetition of self-harm as enhanced treatment as usual. Conclusions: Research on several recommended practices, such as local suicide plans, prevention of suicide clusters and approaches to risk assessment, is lacking. When implemented, these interventions should be closely evaluated. There also is need for more research on treatment for repeated self-harm, including long term follow-up, and in general: possible harmful effects. Policy makers and health providers should consider evidence from population-based studies and adults in preventing self-harm and suicide in children and adolescents. Also, approaches showing promise in treatment of conditions associated with self-harm and/or suicidality, such as depression and psychosis, should be considered. PROSPERO registration: CRD42019117942 08/02/19.

Background: Self-harm and suicide in children and adolescents are of serious consequence and increase during the adolescent years. Consequently, there is need for interventions that prevent such behaviour. The objective of this paper: to evaluate the effects of interventions preventing self-harm and suicide in children and adolescents in an overview of systematic reviews. Methods: We conducted an overview of systematic reviews (OoO). We included reviews evaluating any preventive or therapeutic intervention. The methodological quality of the included reviews was assessed independently, and data was extracted by two reviewers. We report the review findings descriptively. The certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: Moderate certainty evidence suggests that school-based interventions prevent suicidal ideation and attempts short term, and possibly suicide attempts long term. The effects of community-based interventions following suicide clusters and local suicide plans are unknown, as are the benefits and harms of screening young people for suicide risk. The effects of most interventions targeting children and adolescents with known self-harm are unknown. However, low certainty evidence suggests that dialectical behavioural therapy and developmental group therapy are equally as effective on repetition of self-harm as enhanced treatment as usual. Conclusions: Research on several recommended practices, such as local suicide plans, prevention of suicide clusters and approaches to risk assessment, is lacking. When such interventions are implemented, the effects should be closely evaluated. There is also need for more research on treatment of repeated self-harm. Further research should include long term follow-up, and investigate possible adverse effects. In prevention of self-harm and suicide in children and adolescents, policy makers and health providers should consider evidence from population-based studies with mixed-age samples, adult samples, and studies on conditions associated with self-harm and/or suicidality, such as depression and psychosis. PROSPERO registration: CRD42019117942 08/02/19

Objective: Ketamine may reduce suicidal ideation in treatment-resistant depression. But it is not known how quickly this occurs and how long it persists. We undertook a systematic review and meta-analysis to determine the short- and long-term effectiveness of ketamine for suicidality. Method: CENTRAL, EMBASE, Medline, and PsycINFO were searched until 12 December 2018. Randomised controlled trials of ketamine or esketamine reporting data on suicidal ideation, self-harm, attempted or completed suicide in adults diagnosed with any psychiatric disorder were included. Two reviewers independently extracted data, and certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation tool. Standardised mean difference was used for continuous outcomes. Results: Twenty-five reports from 15 independent trials, with a total of 572 participants diagnosed with predominately affective disorders, were included. The evidence was rated moderate to low. In most trials, ketamine was administered at 0.5 mg/kg via a single intravenous infusion over a 30- to 45-minute period. Only a single trial of intranasal esketamine was identified. At 4 hours post-infusion, treatment with ketamine was associated with a significant reduction in suicidal ideation scores (standardised mean difference = −0.51, 95% confidence interval = [−1.00, −0.03]), which persisted until 72 hours post-infusion (time points between 12 and 24 hours: standardised mean difference = −0.63, 95% confidence interval = [−0.99, −0.26]; between 24 and 72 hours: standardised mean difference = −0.57, 95% confidence interval = [−0.99, −0.14]), but not thereafter. However, there was marked heterogeneity of results. In a single trial of esketamine, marginal effects on suicidal ideation were observed. In terms of actual suicidal behaviour, there were virtually no data on effects of ketamine or esketamine. Conclusion: A single infusion of ketamine may have a short-term (up to 72 hours) beneficial impact on suicidal thoughts. While confirmation of these results in further trials is needed, they suggest possible use of ketamine to treat acute suicidality. Means of sustaining any anti-suicidal effect need to be found.

Background and Objective: Suicide attempts are 10-20X more common than completed suicide and an important risk factor for death by suicide, yet most people who attempt suicide do not die by suicide. The process of recovering after a suicide attempt has not been well studied. The Reasons to go on Living (RTGOL) Project, a narrative web-based study, focuses on experiences of people who have attempted suicide and made the decision to go on living, a process not well studied. Narrative research is ideally suited to understanding personal experiences critical to recovery following a suicide attempt, including the transition to a state of hopefulness. Voices from people with lived experience can help us plan and conceptualize this work. This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. Material and Methods: A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery, a process which enabled participation from a large and diverse group of participants. The only direction given was “if you have made a suicide attempt or seriously considered suicide and now want to go on living, we want to hear from you.” The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Over 5 years, data analysis occurred in several phases over the course of the study, resulting in the identification of data that were inputted into an Excel file. This analysis used stories where participants described positive involvement with the mental health system (50 stories). Results: Several participants reflected on experiences many years previous, providing the privilege of learning how their life unfolded, what made a difference. Over a five-year period, 50 of 226 stories identified positive experiences with mental health care with sufficient details to allow analysis, and are the focus of this paper. There were a range of suicidal behaviours in these 50 stories, from suicidal ideation only to medically severe suicide attempts. Most described one or more suicide attempts. Three themes identified included: 1) trust and relationship with a health care professional, 2) the role of friends and family and friends, and 3) a wide range of services. Conclusion: Stories open a window into the experiences of the period after a suicide attempt. This study allowed for an understanding of how mental health professionals might help individuals who have attempted suicide write a different story, a life-affirming story. The stories that participants shared offer some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers, including immediately after a suicide attempt. Results of this study reinforce that just one caring professional can make a tremendous difference to a person who has survived a suicide attempt. Key Words: web-based; suicide; suicide attempt; mental health system; narrative research Word Count: 478 Introduction My Third (or fourth) Suicide AttemptI laid in the back of the ambulance, the snow of too many doses of ativan dissolving on my tongue.They hadn't even cared enough about meto put someone in the back with me,and so, frustrated,I'd swallowed all the pills I had with me— not enough to do what I wanted it to right then,but more than enough to knock me out for a good 14 hours.I remember very little after that;benzodiazepines like ativan commonly cause pre- and post-amnesia, says Google helpfullyI wake up in a locked rooma woman manically drawing on the windows with crayonsthe colors of light through the glassdiffused into rainbows of joy scattered about the roomas if she were coloring on us all,all of the tattered remnants of humanity in a psych wardmade into a brittle mosaic, a quilt of many hues, a Technicolor dreamcoatand I thoughtI am so glad to be able to see this. (Story 187)The nurse opening that door will have a lasting impact on how this story unfolds and on this person’s life. Each year, almost one million people die from suicide, approximately one death every 40 seconds. Suicide attempts are much more frequent, with up to an estimated 20 attempts for every death by suicide.1 Suicide-related behaviours range from suicidal ideation and self-injury to death by suicide. We are unable to directly study those who die by suicide, but effective intervention after a suicide attempt could reduce the risk of subsequent death by suicide. Near-fatal suicide attempts have been used to explore the boundary with completed suicides. Findings indicated that violent suicide attempters and serious attempters (seriousness of the medical consequences to define near-fatal attempts) were more likely to make repeated, and higher lethality suicide attempts.2 In a case-control study, the medically severe suicide attempts group (78 participants), epidemiologically very similar to those who complete suicide, had significantly higher communication difficulties; the risk for death by suicide multiplied if accompanied by feelings of isolation and alienation.3 Most research in suicidology has been quantitative, focusing almost exclusively on identifying factors that may be predictive of suicidal behaviours, and on explanation rather than understanding.4 Qualitative research, focusing on the lived experiences of individuals who have attempted suicide, may provide a better understanding of how to respond in empathic and helpful ways to prevent future attempts and death by suicide.4,5 Fitzpatrick6 advocates for narrative research as a valuable qualitative method in suicide research, enabling people to construct and make sense of the experiences and their world, and imbue it with meaning. A review of qualitative studies examining the experiences of recovering from or living with suicidal ideation identified 5 interconnected themes: suffering, struggle, connection, turning points, and coping.7 Several additional qualitative studies about attempted suicide have been reported in the literature. Participants have included patients hospitalized for attempting suicide8, and/or suicidal ideation,9 out-patients following a suicide attempt and their caregivers,10 veterans with serious mental illness and at least one hospitalization for a suicide attempt or imminent suicide plan.11 Relationships were a consistent theme in these studies. Interpersonal relationships and an empathic environment were perceived as therapeutic and protective, enabling the expression of thoughts and self-understanding.8 Given the connection to relationship issues, the authors suggested it may be helpful to provide support for the relatives of patients who have attempted suicide. A sheltered, friendly environment and support systems, which included caring by family and friends, and treatment by mental health professionals, helped the suicidal healing process.10 Receiving empathic care led to positive changes and an increased level of insight; just one caring professional could make a tremendous difference.11 Kraft and colleagues9 concluded with the importance of hearing directly from those who are suicidal in order to help them, that only when we understand, “why suicide”, can we help with an alternative, “why life?” In a grounded theory study about help-seeking for self-injury, Long and colleagues12 identified that self-injury was not the problem for their participants, but a panacea, even if temporary, to painful life experiences. Participant narratives reflected a complex journey for those who self-injured: their wish when help-seeking was identified by the theme “to be treated like a person”. There has also been a focus on the role and potential impact of psychiatric/mental health nursing. Through interviews with experienced in-patient nurses, Carlen and Bengtsson13 identified the need to see suicidal patients as subjective human beings with unique experiences. This mirrors research with patients, which concluded that the interaction with personnel who are devoted, hope-mediating and committed may be crucial to a patient’s desire to continue living.14 Interviews with individuals who received mental health care for a suicidal crisis following a serious attempt led to the development of a theory for psychiatric nurses with the central variable, reconnecting the person with humanity across 3 phases: reflecting an image of humanity, guiding the individual back to humanity, and learning to live.15 Other research has identified important roles for nurses working with patients who have attempted suicide by enabling the expression of thoughts and developing self-understanding8, helping to see things differently and reconnecting with others,10 assisting the person in finding meaning from their experience to turn their lives around, and maintain/and develop positive connections with others.16 However, one literature review identified that negative attitudes toward self-harm were common among nurses, with more positive attitudes among mental health nurses than general nurses. The authors concluded that education, both reflective and interactive, could have a positive impact.17 This paper is one part of a larger web-based narrative study, the Reasons to go on Living Project (RTGOL), that seeks to understand the transition from making a suicide attempt to choosing life. When invited to tell their stories anonymously online, what information would people share about their suicide attempts? This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. The focus on the positive impact reflects an appreciative inquiry approach which can promote better practice.18 Methods Design and Sample A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery. Participants were required to read and agree with a consent form before being able to submit their story through a text box or by uploading a file. No demographic information was requested. Text submissions were embedded into an email and sent to an account created for the Project without collecting information about the IP address or other identifying information. The content of the website was reviewed by legal counsel before posting, and the study was approved by the local Research Ethics Board. Stories were collected for 5 years (July 2008-June 2013). The RTGOL Project enabled participation by a large, diverse audience, at their own convenience of time and location, providing they had computer access. The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Of the 226 submissions to the website, 112 described involvement at some level with the mental health system, and 50 provided sufficient detail about positive experiences with mental health care to permit analysis. There were a range of suicidal behaviours in these 50 stories: 8 described suicidal ideation only; 9 met the criteria of medically severe suicide attempts3; 33 described one or more suicide attempts. For most participants, the last attempt had been some years in the past, even decades, prior to writing. Results Stories of positive experiences with mental health care described the idea of a door opening, a turning point, or helping the person to see their situation differently. Themes identified were: (1) relationship and trust with a Health Care Professional (HCP), (2) the role of family and friends (limited to in-hospital experiences), and (3) the opportunity to access a range of services. The many reflective submissions of experiences told many years after the suicide attempt(s) speaks to the lasting impact of the experience for that individual. Trust and Relationship with a Health Care Professional A trusting relationship with a health professional helped participants to see things in a different way, a more hopeful way and over time. “In that time of crisis, she never talked down to me, kept her promises, didn't panic, didn't give up, and she kept believing in me. I guess I essentially borrowed the hope that she had for me until I found hope for myself.” (Story# 35) My doctor has worked extensively with me. I now realize that this is what will keep me alive. To be able to feel in my heart that my doctor does care about me and truly wants to see me get better.” (Story 34). The writer in Story 150 was a nurse, an honours graduate. The 20 years following graduation included depression, hospitalizations and many suicide attempts. “One day after supper I took an entire bottle of prescription pills, then rode away on my bike. They found me late that night unconscious in a downtown park. My heart threatened to stop in the ICU.” Then later, “I finally found a person who was able to connect with me and help me climb out of the pit I was in. I asked her if anyone as sick as me could get better, and she said, “Yes”, she had seen it happen. Those were the words I had been waiting to hear! I quickly became very motivated to get better. I felt heard and like I had just found a big sister, a guide to help me figure out how to live in the world. This person was a nurse who worked as a trauma therapist.” At the time when the story was submitted, the writer was applying to a graduate program. Role of Family and Friends Several participants described being affected by their family’s response to their suicide attempt. Realizing the impact on their family and friends was, for some, a turning point. The writer in Story 20 told of experiences more than 30 years prior to the writing. She described her family of origin as “truly dysfunctional,” and she suffered from episodes of depression and hospitalization during her teen years. Following the birth of her second child, and many family difficulties, “It was at this point that I became suicidal.” She made a decision to kill herself by jumping off the balcony (6 stories). “At the very last second as I hung onto the railing of the balcony. I did not want to die but it was too late. I landed on the parking lot pavement.” She wrote that the pain was indescribable, due to many broken bones. “The physical pain can be unbearable. Then you get to see the pain and horror in the eyes of someone you love and who loves you. Many people suggested to my husband that he should leave me in the hospital, go on with life and forget about me. During the process of recovery in the hospital, my husband was with me every day…With the help of psychiatrists and a later hospitalization, I was actually diagnosed as bipolar…Since 1983, I have been taking lithium and have never had a recurrence of suicidal thoughts or for that matter any kind of depression.” The writer in Story 62 suffered childhood sexual abuse. When she came forward with it, she felt she was not heard. Self-harm on a regular basis was followed by “numerous overdoses trying to end my life.” Overdoses led to psychiatric hospitalizations that were unhelpful because she was unable to trust staff. “My way of thinking was that ending my life was the only answer. There had been numerous attempts, too many to count. My thoughts were that if I wasn’t alive I wouldn’t have to deal with my problems.” In her final attempt, she plunged over the side of a mountain, dropping 80 feet, resulting in several serious injuries. “I was so angry that I was still alive.” However, “During my hospitalization I began to realize that my family and friends were there by my side continuously, I began to realize that I wasn't only hurting myself. I was hurting all the important people in my life. It was then that I told myself I am going to do whatever it takes.” A turning point is not to say that the difficulties did not continue. The writer of Story 171 tells of a suicide attempt 7 years previous, and the ongoing anguish. She had been depressed for years and had thoughts of suicide on a daily basis. After a serious overdose, she woke up the next day in a hospital bed, her husband and 2 daughters at her bed. “Honestly, I was disappointed to wake up. But, then I saw how scared and hurt they were. Then I was sorry for what I had done to them. Since then I have thought of suicide but know that it is tragic for the family and is a hurt that can never be undone. Today I live with the thought that I am here for a reason and when it is God's time to take me then I will go. I do believe living is harder than dying. I do believe I was born for a purpose and when that is accomplished I will be released. …Until then I try to remind myself of how I am blessed and try to appreciate the wonders of the world and the people in it.” Range of Services The important role of mental health and recovery services was frequently mentioned, including dialectical behavioural therapy (DBT)/cognitive-behavioural therapy (CBT), recovery group, group therapy, Alcoholics Anonymous, accurate diagnosis, and medications. The writer in Story 30 was 83 years old when she submitted her story, reflecting on a life with both good and bad times. She first attempted suicide at age 10 or 12. A serious post-partum depression followed the birth of her second child, and over the years, she experienced periods of suicidal intent: “Consequently, a few years passed and I got to feeling suicidal again. I had pills in one pocket and a clipping for “The Recovery Group” in the other pocket. As I rode on the bus trying to make up my mind, I decided to go to the Recovery Group first. I could always take the pills later. I found the Recovery Group and yoga helpful; going to meetings sometimes twice a day until I got thinking more clearly and learned how to deal with my problems.” Several participants described the value of CBT or DBT in learning to challenge perceptions. “I have tools now to differentiate myself from the illness. I learned I'm not a bad person but bad things did happen to me and I survived.”(Story 3) “The fact is that we have thoughts that are helpful and thoughts that are destructive….. I knew it was up to me if I was to get better once and for all.” (Story 32): “In the hospital I was introduced to DBT. I saw a nurse (Tanya) every day and attended a group session twice a week, learning the techniques. I worked with the people who wanted to work with me this time. Tanya said the same thing my counselor did “there is no study that can prove whether or not suicide solves problems” and I felt as though I understood it then. If I am dead, then all the people that I kept pushing away and refusing their help would be devastated. If I killed myself with my own hand, my family would be so upset. DBT taught me how to ‘ride my emotional wave’. ……….. DBT has changed my life…….. My life is getting back in order now, thanks to DBT, and I have lots of reasons to go on living.”(Story 19) The writer of Story 67 described the importance of group therapy. “Group therapy was the most helpful for me. It gave me something besides myself to focus on. Empathy is such a powerful emotion and a pathway to love. And it was a huge relief to hear others felt the same and had developed tools of their own that I could try for myself! I think I needed to learn to communicate and recognize when I was piling everything up to build my despair. I don’t think I have found the best ways yet, but I am lifetimes away from that teenage girl.” (Story 67) The author of story 212 reflected on suicidal ideation beginning over 20 years earlier, at age 13. Her first attempt was at 28. “I thought everyone would be better off without me, especially my children, I felt like the worst mum ever, I felt like a burden to my family and I felt like I was a failure at life in general.” She had more suicide attempts, experienced the death of her father by suicide, and then finally found her doctor. “Now I’m on meds for a mood disorder and depression, my family watch me closely, and I see my doctor regularly. For the first time in 20 years, I love being a mum, a sister, a daughter, a friend, a cousin etc.” Discussion The 50 stories that describe positive experiences in the health care system constitute a larger group than most other similar studies, and most participants had made one or more suicide attempts. Several writers reflected back many years, telling stories of long ago, as with the 83-year old participant (Story 30) whose story provided the privilege of learning how the author’s life unfolded. In clinical practice, we often do not know – how did the story turn out? The stories that describe receiving health care speak to the impact of the experience, and the importance of the issues identified in the mental health system. We identified 3 themes, but it was often the combination that participants described in their stories that was powerful, as demonstrated in Story 20, the young new mother who had fallen from a balcony 30 years earlier. Voices from people with lived experience can help us plan and conceptualize our clinical work. Results are consistent with, and add to, the previous work on the importance of therapeutic relationships.8,10,11,14–16 It is from the stories in this study that we come to understand the powerful experience of seeing a family members’ reaction following a participant’s suicide attempt, and how that can be a potent turning point as identified by Lakeman and Fitzgerald.7 Ghio and colleagues8 and Lakeman16 identified the important role for staff/nurses in supporting families due to the connection to relationship issues. This research also calls for support for families to recognize the important role they have in helping the person understand how much they mean to them, and to promote the potential impact of a turning point. The importance of the range of services reflect Lakeman and Fitzgerald’s7 theme of coping, associating positive change by increasing the repertoire of coping strategies. These findings have implications for practice, research and education. Working with individuals who are suicidal can help them develop and tell a different story, help them move from a death-oriented to life-oriented position,15 from “why suicide” to “why life.”9 Hospitalization provides a person with the opportunity to reflect, to take time away from “the real world” to consider oneself, the suicide attempt, connections with family and friends and life goals, and to recover physically and emotionally. Hospitalization is also an opening to involve the family in the recovery process. The intensity of the immediate period following a suicide attempt provides a unique opportunity for nurses to support and coach families, to help both patients and family begin to see things differently and begin to create that different story. In this way, family and friends can be both a support to the person who has attempted suicide, and receive help in their own struggles with this experience. It is also important to recognize that this short period of opportunity is not specific to the nurses in psychiatric units, as the nurses caring for a person after a medically severe suicide attempt will frequently be the nurses in the ICU or Emergency departments. Education, both reflective and interactive, could have a positive impact.17 Helping staff develop the attitudes, skills and approach necessary to be helpful to a person post-suicide attempt is beginning to be reported in the literature.21 Further implications relate to nursing curriculum. Given the extent of suicidal ideation, suicide attempts and deaths by suicide, this merits an important focus. This could include specific scenarios, readings by people affected by suicide, both patients themselves and their families or survivors, and discussions with individuals who have made an attempt(s) and made a decision to go on living. All of this is, of course, not specific to nursing. All members of the interprofessional health care team can support the transition to recovery of a person after a suicide attempt using the strategies suggested in this paper, in addition to other evidence-based interventions and treatments. Findings from this study need to be considered in light of some specific limitations. First, the focus was on those who have made a decision to go on living, and we have only the information the participants included in their stories. No follow-up questions were possible. The nature of the research design meant that participants required access to a computer with Internet and the ability to communicate in English. This study does not provide a comprehensive view of in-patient care. However, it offers important inputs to enhance other aspects of care, such as assessing safety as a critical foundation to care. We consider these limitations were more than balanced by the richness of the many stories that a totally anonymous process allowed. Conclusion Stories open a window into the experiences of a person during the period after a suicide attempt. The RTGOL Project allowed for an understanding of how we might help suicidal individuals change the script, write a different story. The stories that participants shared give us some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers immediately after a suicide attempt. While we cannot know the experiences of those who did not survive a suicide attempt, results of this study reinforce that just one caring professional can make a crucial difference to a person who has survived a suicide attempt. We end with where we began. Who will open the door? References 1. World Health Organization. Suicide prevention and special programmes. http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/index.html Geneva: Author; 2013.2. Giner L, Jaussent I, Olie E, et al. Violent and serious suicide attempters: One step closer to suicide? J Clin Psychiatry 2014:73(3):3191–197.3. Levi-Belz Y, Gvion Y, Horesh N, et al. Mental pain, communication difficulties, and medically serious suicide attempts: A case-control study. Arch Suicide Res 2014:18:74–87.4. Hjelmeland H and Knizek BL. Why we need qualitative research in suicidology? Suicide Life Threat Behav 2010:40(1):74–80.5. Gunnell D. A population health perspective on suicide research and prevention: What we know, what we need to know, and policy priorities. Crisis 2015:36(3):155–60.6. Fitzpatrick S. Looking beyond the qualitative and quantitative divide: Narrative, ethics and representation in suicidology. Suicidol Online 2011:2:29–37.7. Lakeman R and FitzGerald M. How people live with or get over being suicidal: A review of qualitative studies. J Adv Nurs 2008:64(2):114–26.8. Ghio L, Zanelli E, Gotelli S, et al. Involving patients who attempt suicide in suicide prevention: A focus group study. J Psychiatr Ment Health Nurs 2011:18:510–18.9. Kraft TL, Jobes DA, Lineberry TW., Conrad, A., & Kung, S. Brief report: Why suicide? Perceptions of suicidal inpatients and reflections of clinical researchers. Arch Suicide Res 2010:14(4):375-382.10. Sun F, Long A, Tsao L, et al. The healing process following a suicide attempt: Context and intervening conditions. Arch Psychiatr Nurs 2014:28:66–61.11. Montross Thomas L, Palinkas L, et al. Yearning to be heard: What veterans teach us about suicide risk and effective interventions. Crisis 2014:35(3):161–67.12. Long M, Manktelow R, and Tracey A. The healing journey: Help seeking for self-injury among a community population. Qual Health Res 2015:25(7):932–44.13. Carlen P and Bengtsson A. Suicidal patients as experienced by psychiatric nurses in inpatient care. Int J Ment Health Nurs 2007:16:257–65.14. Samuelsson M, Wiklander M, Asberg M, et al. Psychiatric care as seen by the attempted suicide patient. J Adv Nurs 2000:32(3):635–43.15. Cutcliffe JR, Stevenson C, Jackson S, et al. A modified grounded theory study of how psychiatric nurses work with suicidal people. Int J Nurs Studies 2006:43(7):791–802.16. Lakeman, R. What can qualitative research tell us about helping a person who is suicidal? Nurs Times 2010:106(33):23–26.17. Karman P, Kool N, Poslawsky I, et al. Nurses’ attitudes toward self-harm: a literature review. J Psychiatr Ment Health Nurs 2015:22:65–75.18. Carter B. ‘One expertise among many’ – working appreciatively to make miracles instead of finding problems: Using appreciative inquiry as a way of reframing research. J Res Nurs 2006:11(1): 48–63.19. Lieblich A, Tuval-Mashiach R, Zilber T. Narrative research: Reading, analysis, and interpretation. Sage Publications; 1998.20. Braun V and Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006:3(2):77–101.21. Kishi Y, Otsuka K, Akiyama K, et al. Effects of a training workshop on suicide prevention among emergency room nurses. 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Purpose This study examined the prevalence of suicidal ideation and past suicide attempt in adult survivors of childhood cancer and investigated the relationship of suicidal symptoms to cancer treatment and current health. The hypothesis that poor physical health would be significantly associated with suicidality after adjusting for mental health variables was specifically tested. Methods Two hundred twenty-six adult survivors of childhood cancer (mean age, 28 years) seen in a survivor clinic completed the Short Form-36 and the Beck Depression Inventory (BDI), as well as suicide items from the Symptom Checklist-90 Revised, and Beck Scale for Suicide Ideation. Participants reporting current suicide ideation or any past suicide attempt were classified as suicidal. Results Twenty-nine participants (12.83%) reported suicidality, although only 11 of these were significantly depressed by BDI criteria. Univariate analyses found suicidality unrelated to age or sex but positively associated with younger age at diagnosis, longer time since diagnosis, cranial radiation treatment, leukemia diagnosis, depression, hopelessness, pain, and physical appearance concern. A hierarchical logistic regression showed that current physical functioning, including pain, was significantly associated with suicidality even after adjusting for treatment and depression variables. Conclusion Suicidal symptoms, which are reported by a significant minority of adult survivors of childhood cancer, are related to cancer treatments and post-treatment mental and physical health. Association of suicidal symptoms with physical health problems is important because these represent treatable conditions for which survivors may seek follow-up care. The relationship of physical well-being to suicidality underscores the need for a multidisciplinary approach to survivor care.

SynopsisThe World Health Organization's study on depressive disorders in different cultures began in 1972. Cohorts of depressed patients were identified in Basle, Montreal, Nagasaki, Teheran and Tokyo. The patients were assessed using standardized measures of social and clinical functioning. Ten-year follow-up data on clinical course, service contact, suicidal acts and social function outcomes were available for 439 (79%) patients. Over one-third (36%) were re-admitted at least once in the follow-up period, half of whom (18%) had very poor clinical outcome. Twenty-four per cent suffered severe social impairment for over half the follow-up period, and over one-fifth (21%) showed no full remissions. The best clinical course (one or two reasonably short episodes of depression with complete remission between episodes) was experienced twice as frequently in patients with a diagnosis of endogenous (65%) as in those diagnosed as suffering from psychogenic depression (29%). Among all patients, a fifth (22%) had at least one episode lasting for more than 1 year, and 10% had an episode lasting over 2 years during follow-up. Death by suicide occurred in 11% of patients, with a further 14% making unsuccessful suicide attempts.

Background/aims: Given high rates of depression and suicide among marginalized women, and increasing calls to integrate trauma-informed biomedical and community-led structural interventions, this study longitudinally examines the potential moderating effect of psychedelic use on the relationship between other illicit drug use and suicide risk. Methods: Data (2010–2017) were drawn from a community-based, prospective open cohort of marginalized women in Vancouver, Canada. Extended Cox regression analyses examined the moderating effect of psychedelic use on the association between other illicit drug use and incidence of suicidal ideation or attempt over follow-up. Results: Of 340 women without suicidal ideation or attempt at baseline, 16% ( n=53) reported a first suicidal episode during follow-up, with an incidence density of 4.63 per 100 person-years (95% confidence interval 3.53–6.07). In unadjusted analysis, psychedelic use moderated the relationship between prescription opioid use and suicide risk: among women who did not use psychedelics, prescription opioid use increased the hazard of suicide (hazard ratio 2.91; 95% confidence interval 1.40–6.03) whereas prescription opioid use was not associated with increased suicidal ideation or attempt among those who used psychedelics (hazard ratio 0.69; 95% confidence interval 0.27–1.73) (interaction term p-value: 0.016). The moderating effect of psychedelics remained significant when adjusted for confounders (interaction term p-value: 0.036). Conclusions: Psychedelic use had a protective moderating effect on the relationship between prescription opioid use and suicide risk. In the context of a severe public health crisis around prescription opioids and lack of addiction services tailored to marginalized women, this study supports calls for innovative, evidence-based and trauma-informed interventions, including further research on the potential benefits of psychedelics.

The number of deaths in a large series of suicide attempters followed up after their attempts was 3.3 times greater than expected. Suicide or probable suicide occurred in 2.8% by the end of the eighth year of follow-up, the rate of suicidal deaths being 26.9 times the expected rate. The highest risk of suicide was during the first 3 years, especially in the first 6 months, following an attempt. Factors identified at the time of the attempts which were associated with suicide risk included: being male, advancing age (females only), psychiatric disorder (especially schizophrenia), long-term use of hypnotics, poor physical health, and repeat attempts. Recent disruption of a relationship with a partner and major rows rarely preceded the attempts of those who later killed themselves. Factors predicting long-term risk of suicide also predicted short-term risk. There were more than double the expected number of deaths from natural causes, the excess being greatest in females. Markedly high death rates were found for endocrine, circulatory and respiratory diseases, and accidents.

IntroductionAlthough suicidal behavior is very common in bipolar disorder (BD), few long-term studies have investigated incidence and risk factors of suicide attempts (SAs) specifically related to illness phases of BD.ObjectivesWe examined incidence of SAs during different phases of BD in a long-term prospective cohort of bipolar I (BD-I) and II (BD-II) patients and risk factors specifically for SAs during major depressive episodes (MDEs).MethodsIn the Jorvi bipolar study (JoBS), 191 BD-I and BD-II patients were followed using life-chart methodology. Prospective information on SAs of 177 patients (92.7%) during different illness phases was available up to five years. Incidence of SAs and their predictors were investigated using logistic and Poisson regression models. Analyses of risk factors for SAs occurring during MDEs were conducted using two-level random-intercept logistic regression models.ResultsDuring the five-year follow-up, 90 SAs per 718 patient-years occurred. Compared with euthymia the incidence was highest, over 120-fold, during mixed states (765/1000 person-years [95% confidence interval (CI) 461–1269]) and also very high in MDEs, almost 60-fold (354/1000 [95%CI 277–451]). For risk of SAs during MDEs, the duration of MDEs, severity of depression and cluster C personality disorders were significant predictors.ConclusionsIn this long-term study, the highest incidences of SAs occurred in mixed phases and MDEs. The variations in incidence rates between euthymia and illness phases were remarkably large, suggesting that the question “when” rather than “who” may be more relevant for suicide risk in BD. However, risk during MDEs is likely also influenced by personality factors.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Cushing’s disease is an abnormal secretion of ACTH from the pituitary that causes an increase in cortisol production from the adrenal glands. Resultant manifestations from this excess in cortisol include multiple metabolic as well as psychiatric disturbances which can lead to significant morbidity and mortality. In this report, 23-year-old woman presented to mental health facility with history of severe depression and suicidal ideations. During evaluation, she found to have Cushing’s disease, which is unusual presentation. She had significant improvement in her symptoms with reduction of antidepressant medications after achieving eucortisolism. Cushing syndrome can present with wide range of neuropsychiatric manifestations including major depression. Although presentation with suicidal depression is unusual. Early diagnosis and prompt management of hypercortisolsim may aid in preventing or lessening of psychiatric symptoms The psychiatric and neurocognitive disorders improve after disease remission (the normalization of cortisol secretion), but some studies showed that these disorders can partially improve, persist, or exacerbate, even long-term after the resolution of hypercortisolism. The variable response of neuropsychiatric disorders after Cushing syndrome remission necessitate long term follow up.

Background Suicidal ideation is a major risk for a suicide attempt in younger people, such that reducing severity of ideation is an important target for suicide prevention. Smartphone applications present a new opportunity for managing ideation in young adults; however, confirmatory evidence for efficacy from randomized trials is lacking. The objective of this study was to assess whether a therapeutic smartphone application (“LifeBuoy”) was superior to an attention-matched control application at reducing the severity of suicidal ideation. Methods and findings In this 2-arm parallel, double-blind, randomized controlled trial, 455 young adults from Australia experiencing recent suicidal ideation and aged 18 to 25 years were randomly assigned in a 2:2 ratio to use a smartphone application for 6 weeks in May 2020, with the final follow-up in October 2020. The primary outcome was change in suicidal ideation symptom severity scores from baseline (T0) to postintervention (T1) and 3-month postintervention follow-up (T2), measured using the Suicidal Ideation Attributes Scale (SIDAS). Secondary outcomes were symptom changes in depression (Patient Health Questionnaire-9, PHQ-9), generalized anxiety (Generalized Anxiety Disorder-7, GAD-7), distress (Distress Questionnaire-5, DQ5), and well-being (Short Warwick–Edinburgh Mental Well-Being Scale, SWEMWBS). This trial was conducted online, using a targeted social media recruitment strategy. The intervention groups were provided with a self-guided smartphone application based on dialectical behavior therapy (DBT; “LifeBuoy”) to improve emotion regulation and distress tolerance. The control group were provided a smartphone application that looked like LifeBuoy (“LifeBuoy-C”), but delivered general (nontherapeutic) information on a range of health and lifestyle topics. Among 228 participants randomized to LifeBuoy, 110 did not complete the final survey; among 227 participants randomized to the control condition, 91 did not complete the final survey. All randomized participants were included in the intent-to-treat analysis for the primary and secondary outcomes. There was a significant time × condition effect for suicidal ideation scores in favor of LifeBuoy at T1 (p < 0.001, d = 0.45) and T2 (p = 0.007, d = 0.34). There were no superior intervention effects for LifeBuoy on any secondary mental health outcomes from baseline to T1 or T2 [p-values: 0.069 to 0.896]. No serious adverse events (suicide attempts requiring medical care) were reported. The main limitations of the study are the lack of sample size calculations supporting the study to be powered to detect changes in secondary outcomes and a high attrition rate at T2, which may lead efficacy to be overestimated. Conclusions LifeBuoy was associated with superior improvements in suicidal ideation severity, but not secondary mental health outcomes, compared to the control application, LifeBuoy-C. Digital therapeutics may need to be purposefully designed to target a specific health outcome to have efficacy. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12619001671156

BackgroundSuicides occur more often in the young and in the elderly. However, although several studies have been performed to evaluate the effect of suicide prevention in the young, no studies have explored this in the elderly. Somatic comorbidity is associated with elevated suicide risk, especially in case of pain, which occurs often in the elderly.ObjectiveTo explore if suicide prevention interventions might be applicable in the elderly and if somatic comorbidity might be relevant for their application.MethodEvidence synthesis of controlled studies evaluating suicide prevention interventions and of collaborative care trials for depressive disorder in patients with and without somatic comorbidity.ResultsElderly living alone and with multimorbidity are more prone to suicide risk. Hence interventions involving admission in a general hospital after a suicide attempt, short intervention and follow up might be well applicable in the elderly. In terms of outpatient interventions, and IPD analysis found that collaborative care for depressive disorder is effective in reducing suicidality, especially in the elderly. This effect is independent of somatic comorbidity.ConclusionThere is potential to develop and evaluate suicide prevention interventions for the elderly. Such interventions should address depression, multimorbidity and social isolation and may be provided at general hospital and at outpatient level.DisclosureNo significant relationships.

AbstractObjectives: To review the clinical presentation, and Accident and Emergency Department clinical response to 14-20 year olds in suicidal crisis in inner city Dublin and to carry out a six month follow up of these young people.Method: A retrospective review of the case notes of all 14-20 year olds who had attended the Mater Hospital A&E department between June 2001 and May 2002 with suicidal behaviour or ideation was carried out in order to establish socio-demographic information, type of suicidal or self-harming behaviour, intervention in the A&E department, and discharge plan. Active outreach attempts were made to trace, contact and interview these young peoples at least six months after the initial presentation. Quantitative measures of psychological functioning at follow-up included the General Health Questionnaire, The Beck Depression Inventory and The Scale for Suicidal Ideation. A qualitative interview covered their recall of the reasons for their deliberate self harm, their view of their current psychological functioning and personal relationships, reported repetition of deliberate self harm, and their views of what type of services would be useful for young people with suicidal ideation or behaviour.Results: A total of 89 young people aged 14-20 years (male: female ratio = 2:3) presented to the Mater A&E department between June 2001 and May 2002 with deliberate self-harm, deliberate self-poisoning and/or suicidal ideation, and accounted for 108 presentations. They showed high levels of psychosocial disadvantage. Almost half had a history of previous contact with mental health services, while the same proportion had a history of previous deliberate self-harm. Drug overdose using paracetamol was the most common method used. Psychiatric assessment was documented in 66% of cases, and documented follow up recommendations were made in 60% of cases. Two thirds of the 89 young people who formed the study population were traced. Half of those contacted agreed to be interviewed and half refused. The majority of those interviewed described themselves as functioning better psychologically than at the time of the index attendance at the A&E department The quantitative measures supported this. One third of those interviewed reported repeated deliberate self-harm since their index attendance, for which most did not seek medical intervention. Many of the young people had clear views about the importance of talking to someone when in crisis. They described a service, which was informal, accessible on a 24-hour basis, and staffed by people with experience of mental health, alcohol and drug related disorders.Conclusions: This is a particularly vulnerable group of patients from a socio-demographic and mental health perspective. Their attendance at the A&E department provides a unique opportunity for an in-depth psychosocial assessment, which should be recorded in a systematic way to assist clinical audit, facilitate strategic mental health planning and may confer some therapeutic clinical benefit to at risk young people. An easily accessible, active DSH team specifically tailored for young people in the A&E department could provide assessment and short-term follow-up. This is the approach recommended by young people in suicidal crisis, whose views need to be heard.

IntroductionTreatment resistant depression (TRD) affecting approximately 10–30% of all depressed patients often remains misdiagnosed and undertreated, leading to a higher risk of relapse and suicide. Electroconvulsive therapy (ECT) and sub-anesthetic ketamine have repeatedly shown to be effective in the TRD population. Administering ketamine as an anesthetic component to augment antidepressant efficacy of ECT has been proven inconclusive, while a combination of alternating ECT and ketamine has not been investigated yet.Case reportWe present a severely depressed and chronically suicidal female inpatient who failed multiple antidepressant treatment attempts, requiring frequent psychiatric admissions. Since available conventional as well as non-conventional antidepressant treatment strategies were nearly exhausted, we employed a combination of ECT (bilateral stimulation up to 150%) 2–3 times/week, while intravenous racemic ketamine (up to 75 mg per infusion) was administered on ECT free days 2–3 times/week. Consequently, robust anti-suicidal and antidepressant effects could be observed already during the first treatment week. The temporarily occurring subjective forgetfulness disappeared after the last ECT. Summarizing, we employed 9 ECT treatments and 7 ketamine infusions leading to a stable psychopathological state even after discharge from psychiatric inpatient care. In order to prevent relapse a maintenance-therapy comprising ECT once monthly and 2 ketamine infusions (up to 100 mg per infusion) administered on the day before and after ECT was established.ConclusionsIn our patient alternating ECT and intravenous racemic ketamine were proven safe and long-term effective after numerous failed antidepressant trials including ECT and ketamine alone. We may hence encourage clinicians to widen their therapeutic armamentarium in severe TRD.Disclosure of interestThe authors have not supplied their declaration of competing interest.

All studies of mortality in patients with a diagnosis of affective illness agree that the death rate is increased. The excess mortality appears primarily to result from suicide; any excess mortality from physical illness, most notably cardiovascular disease, now appears unlikely to be a simple consequence of affective illness. Historical comparisons suggest that acute treatment of affective disorder reduces the immediate risk of death. It is much more difficult to assess the impact of treatment upon the subsequent rates of suicide. This is true of all aspects of the acute and short-term continuation of treatment for an episode of illness, from the need for hospital admission to the choice of drug treatment. Adequate treatment of refractory depression and the possibility that some actions of drugs may increase the risks of suicide are emergent therapeutic issues that are still providing more questions than answers. Prophylaxis should also reduce the risk of suicide. However, although standardized mortality rates, reflecting relative risk, are very high, only ~2% of patients with affective disorder will commit suicide in a follow-up interval of 2 years. Comparison of mortality data for patients on lithium registers with that from lithium clinics shows important reductions in specialized clinics. Indeed, mortality from suicide may actually be lower than expected. It raises the question of whether long-term hospital follow-up by personnel with a specialist interest in drug treatment of major mental illness is safer than a potentially more erratic provision of care in the community. The future issues in the prevention of suicide include whether to treat patients by admission to a hospital in-patient unit or not, whether to treat for at least a year with adequate doses of tricyclic drugs or a selective 5-hydroxytryptamine (5-HT, serotonin) re-uptake inhibitor, and whether to maintain patients with a second episode of affective illness or a prolonged first illness indefinitely with lithium or antidepressants.

BackgroundConcerns have been expressed about the impact that screening for risk of suicide may have on a person's mental health.AimsTo examine whether screening for suicidal ideation among people who attend primary care services and have signs of depression increases the short-term incidence of feeling that life is not worth living.MethodIn a multicentre, single-blind, randomised controlled trial, 443 patients in four general practices were randomised to screening for suicidal ideation or control questions on health and lifestyle (trial registration: ISRCTN84692657). The primary outcome was thinking that life is not worth living measured 10–14 days after randomisation. Secondary outcome measures comprised other aspects of suicidal ideation and behaviour.ResultsA total of 443 participants were randomised to early (n = 230) or delayed screening (n = 213). Their mean age was 48.5 years (s.d. = 18.4, range 16–92) and 137 (30.9%) were male. The adjusted odds of experiencing thoughts that life was not worth living at follow-up among those randomised to early compared with delayed screening was 0.88 (95% CI 0.66–1.18). Differences in secondary outcomes between the two groups were not seen. Among those randomised to early screening, 37 people (22.3%) reported thinking about taking their life at baseline and 24 (14.6%) that they had this thought 2 weeks later.ConclusionsScreening for suicidal ideation in primary care among people who have signs of depression does not appear to induce feelings that life is not worth living.

ABSTRACTIntroduction: Because major depressive disorder (MDD) is often chronic and recurrent, even pediatric patients who are treated successfully during an acute episode may need longer-term treatment. Yet, data on long-term treatment with antidepressants in pediatric MDD are limited.Objective: To evaluate long-term effectiveness and safety of treatment with venlafaxine extended-release (ER) in children and adolescents with MDD.Methods: Subjects (n=86) 7–17 years of age with MDD entered a multicenter, open-label study of flexible-dose venlafaxine ER for 6 weeks of acute treatment, followed by continuation treatment for up to 6 months total treatment. The primary efficacy variable was the Children's Depression Rating Scale-Revised (CDRS-R) total score (intent-to-treat population).Results: Mean CDRS-R total score decreased from 60.1±10.0 at baseline to 36.3±13.1 at week 6, and to 33.8±15.0 at 6 months (last observation carried forward). Among completers (n=36), the mean CDRS-R total score was 24.3±7.6 at the end of 6 months of treatment. The most frequent treatment-emergent adverse events were headache (53%), nausea (26%), infection (24%), abdominal pain (22%), vomiting (21%), and pharyngitis (19%). Fifteen (17%) participants discontinued due to adverse events, 9 of whom did so within the first 6 weeks. Serious adverse events (suicide attempt [two], hostility [two], hallucinations, depression, and pharyngitis) occurred in seven patients. There were no suicides.Conclusion: Most improvement with venlafaxine ER occurs during the first 6 weeks of treatment. Prescribers should be alert to signs of suicidal ideation and hostility in pediatric patients.

Tianeptine is a new tricyclic compound whose principal action is to increase the reuptake of serotonin. In a multicentre trial in which 380 depressed patients were treated for one year, tianeptine produced a significant reduction in the MADRS scores from day 14, with a sustained reduction maintained for up to 12 months; other measures of efficacy (HRSA, HSCL, and CGI) also reflected the improvement. Only 11% of patients withdrew because of recurrence of depression and 2% because of side-effects, which were mainly drowsiness, irritability, and gastrointestinal disturbance. Apart from a minor reduction in heart rate, unaccompanied by any conduction changes, no clinically relevant changes in vital signs or laboratory tests were seen. Seven subjects who attempted suicide by tianeptine overdose had favourable outcomes, in spite of also taking other psychotropic drugs or alcohol. No evidence of tolerance or withdrawal symptoms was seen after treatment was stopped. These results suggest that tianeptine has the potential to provide safe antidepressant activity in both the acute and chronic phases of treatment.

BackgroundThere is inconsistent evidence regarding the influence of general cognitive abilities on the long-term course of depression.AimsTo investigate the association between general childhood cognitive abilities and adult depression outcomes.MethodWe conducted a cohort study using data from 633 participants in the New England Family Study with lifetime depression. Cognitive abilities at age 7 were measured using the Wechsler Intelligence Scale for Children. Depression outcomes were assessed using structured diagnostic interviews administered up to four times in adulthood between ages 17 and 49.ResultsIn analyses adjusting for demographic factors and parental psychiatric illness, low general cognitive ability (i.e. IQ<85 v. IQ>115) was associated with recurrent depressive episodes (odds ratio (OR) = 2.19, 95% CI 1.20–4.00), longer episode duration (rate ratio 4.21, 95% CI 2.24–7.94), admission to hospital for depression (OR = 3.65, 95% CI 1.34–9.93) and suicide ideation (OR = 3.79, 95% CI 1.79–8.02) and attempt (OR = 4.94, 95% CI 1.67–14.55).ConclusionsVariation in cognitive abilities, predominantly within the normal range and established early in childhood, may confer long-term vulnerability for prolonged and severe depression. The mechanisms underlying this vulnerability need to be established to improve the prognosis of depression among individuals with lower cognitive abilities.

ObjectivesTo evaluate the long-term safety and efficacy of belimumab in patients with systemic lupus erythematosus (SLE) in China.MethodsIn this phase 3, open-label extension period, eligible completers of study BEL113750 (NCT01345253) received intravenous belimumab 10 mg/kg monthly for ≤6 years. The primary endpoint was safety. Secondary endpoints included the SLE Responder Index (SRI)-4 response rate, severe SLE flares and changes in prednisone use. Analyses were based on observed data from the first dose of belimumab through to study end.ResultsOf the 424 patients who received belimumab, 215 (50.7%) completed the study, 208 (49.1%) withdrew and 1 patient died. Overall, 359/424 (84.7%) patients had adverse events (AEs), and 96/424 (22.6%) had serious AEs. 26/424 (6.1%) patients discontinued study treatment/withdrew from the study due to AEs. Postinfusion systemic reaction rate was 1.5 events/100 patient-years. Herpes zoster infection rate was 3.0 events/100 patient-years, of which 0.4 events/100 patient-years were serious events. One papillary thyroid cancer and one vaginal cancer were reported in year 0–1 and year 3–4, respectively. There were no completed suicides/suicide attempts and no reports of serious depression. The proportion of SRI-4 responders increased progressively (year 1, week 24: 190/346 (54.9%); year 5, week 48: 66/82 (80.5%)). Severe flares were experienced by 55/396 (13.9%) patients. For 335 patients with baseline prednisone-equivalent dose >7.5 mg/day, the number of patients with a dose reduction to ≤7.5 mg/day increased over time (year 1, week 24: 30/333 (9.0%); year 5, week 48: 36/67 (53.7%)).ConclusionsFavourable safety profile and disease control appeared to be maintained in patients with SLE in China for ≤6 years, consistent with previous belimumab studies.

Abstract Introduction Brexanolone demonstrates short-term efficacy for the treatment of postpartum depression (PPD). Postpartum depression is linked to infanticide and maternal suicide, and current treatment often fails to adequately control depressive symptoms. The purpose of this analysis is to further understand the experience(s) of women who have received brexanolone for the treatment of PPD. Methods Semistructured interviews modeled after the theory of planned behavior (TPB) were conducted to assess women's perceptions of treatment for PPD with brexanolone. Women who received treatment with brexanolone at this inpatient facility were eligible to participate in this study. The TPB is often used to predict intention to perform health-related behaviors. Semistructured interviews were recorded and transcribed, and thematic analysis was conducted to identify common ideas across all interviews. Follow-up assessment of depressive and anxious symptoms was also conducted using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), respectively. Results Five of the 10 women who received treatment with brexanolone at this facility were interviewed, and common themes related to the TPB were analyzed. Attitudes toward brexanolone were favorable, and having a strong support system was a motivating factor in receiving treatment for PPD. Insurance approval, need for childcare, and poor understanding of symptoms of PPD were barriers to receiving treatment with brexanolone. Symptoms of depression and anxiety were rated as low at the time of the follow-up interview as measured by the PHQ-9 (mean 1.6, range 1 to 3) and GAD-7 (mean 2.8, range 2 to 4), respectively. Discussion Brexanolone rapidly and sustainably reduced symptoms of PPD and was well-received by patients. Despite significant barriers to use, women who received treatment with brexanolone advocated for its availability as well as increased awareness of PPD.

Suicide was the third leading cause of death in adolescents in the world in 2016 with a mortality rate of about 136,000 cases. Reasons teenagers commit suicide include family financial problems, psychological distress, low self-esteem, lack of confidence, and depression. In addition, the difficulty of professional help and social support from the surrounding environment also opens up opportunities for adolescents to commit suicide. Suicidal behavior is often associated with nonsuicidal self-injury (NSSI). NSSI is an act of self-injury with no intention to commit suicide, but according to the Interpersonal Theory for Suicide by Joiner (2005), NSSI’s actions are considered to be one of the factors increasing the ability to commit suicide attempts (acquired capability). This study is aimed at exploring the relationship between NSSI and acquired capability for suicide by meta-analysis study. Eight studies from 119 articles involving the term NSSI and acquired capability were studied using the random-effects model. A total of 3398 samples were included in the study. The results showed that the effect size between NSSI and acquired capability was (r = .208), which means that NSSI is positively correlated with acquired capability and has a weak relationship. The results of this study also show that this study has a high heterogeneity value (I2 = 91,48) and there is no publication bias. Bunuh diri adalah penyebab kematian nomor tiga pada remaja di dunia pada tahun 2016 dengan angka kematian sekitar 136.000 kasus. Alasan remaja melakukan bunuh diri antara lain adalah masalah-masalah keuangan keluarga, distres psikologis, rendahnya harga diri, kurang percaya diri, dan depresi. Selain itu, sulitnya pertolongan tenaga profesional dan dukungan sosial dari lingkungan sekitarnya juga membuka peluang para remaja untuk melakukan percobaan bunuh diri. Perilaku bunuh diri sering dihubungkan dengan Nonsuicidal Self-Injury (NSSI). NSSI merupakan tindakan perusakan diri dengan tanpa adanya keinginan untuk bunuh diri, namun menurut teori Interpersonal Theory for Suicide oleh Joiner (2005), tindakan NSSI dianggap menjadi salah satu faktor meningkatnya kemampuan seseorang untuk melakukan percobaan bunuh diri (acquired capability). Penelitian ini bertujuan untuk mengeksplorasi hubungan antara NSSI dan acquired capability dengan studi meta-analisis. Delapan artikel korelasional dari 119 artikel yang melibatkan istilah NSSI dan acquired capability dipelajari menggunakan random-effect models. Sebanyak 3398 sampel dilibatkan dalam penelitian ini. Hasil penelitian menunjukkan nilai effect size antara NSSI dan acquired capability adalah sebesar (r = .208), yang berarti NSSI berkorelasi positif dengan acquired capability dan memiliki hubungan yang lemah. Hasil penelitian ini juga menunjukkan bahwa studi ini memiliki nilai heterogenitas yang tinggi(I2 = 91,48) dan tidak terdapat bias publikasi.

IntroductionVagus nerve stimulation (VNS) is a neuromodulation technique approved for Treatment-Resistant Depression (TRD). Evidence regarding its long-term efficacy and safety is still scarce.ObjectivesTo descriptively report a case series of 3 patients undergoing adjunctive VNS for TRD with an over 10-year follow-up.MethodsWe investigated outcomes of clinical interest in patients with ongoing VNS for at least 10 years after the device implantation. They had participated in a larger single-arm interventional study conducted at the University Hospital of Padua. They were diagnosed with chronic unipolar (1), recurrent unipolar (1), and bipolar (1) TRD.ResultsOur 3 cases had an average 14-year history of psychiatric disease before surgery. Afterward, all subjects achieved clinical remission within two years. 2 patients experienced relapses within the first 4 years of treatment (respectively, 1 and 2 episodes). The other case showed a recurrent trend of brief relapses every two years. Only 1 individual needed to be admitted to the psychiatric unit once. None of them committed suicidal attempts. Prescription of antidepressants remained almost unchanged after the first two years. 2 individuals improved and 1 maintained their working position. Common adverse events were voice alteration (3/3), neck pain (2/3), and cough (2/3).ConclusionsVery few cases of 10-year VNS for TRD have been reported so far. For our subjects, VNS was most likely to have a major impact on the clinical course of the disease. This treatment can be a safe and effective adjunctive intervention in a subgroup of patients with TRD.

Data obtained included the total number of ED presentations, and the number presenting with deliberate self-harm, suicidal intent, lacerations, anxiety, depression, psychosis and overdose. Data collected was statistically analyzed using the two-proportion z-test. Data from ICU showed a 15.7% increase in specified mental health presentations from 2019 to 2020, compared to a 0.65% decrease from 2018 to 2019. The MHLT report revealed no statistical difference in the number of referrals made between 2019 and 2020. ED data showed mental health issues made up 2.06% of all presentations in 2020, a statistically significant increase compared to 1.53% in 2019 due to the large sample size. Despite fewer overall admissions to ICU and presentations to ED at Salisbury District Hospital in 2020, the percentage of these due to self-harm, overdose and suicidal attempts have increased compared to the same period in 2019 and 2018. Similar patterns are emerging in studies, both in the UK and internationally, and long-term consequences on the mental health of the population are to be expected.

Abstract Purpose Honest, Open, Proud (HOP; formerly “Coming Out Proud”/COP) is a peer-led group program to support people with mental illness in their disclosure decisions and in their coping with stigma. The aims of this study were to provide (i) a conceptual review of HOP, including versions for different target groups and issues related to outcome measurement and implementation; and (ii) a meta-analysis of program efficacy. Methods Conceptual and empirical literature on disclosure and the HOP program was reviewed. Controlled trials of HOP/COP were searched in literature databases. A meta-analysis of HOP efficacy in terms of key outcomes was conducted. Results HOP program adaptations for different target groups (e.g. parents of children with mental illness; veterans or active soldiers with mental illness) exist and await evaluation. Recruitment for trials and program implementation may be challenging. A meta-analysis of five HOP RCTs for adults or adolescents with mental illness or adult survivors of suicide attempts found significant positive effects on stigma stress (smd = − 0.50) as well as smaller, statistically non-significant effects on self-stigma (smd = − 0.17) and depression (smd = − 0.11) at the end of the HOP program. At 3- to 4-week follow-up, there was a modest, not statistically significant effect on stigma stress (smd = − 0.40, 95%-CI -0.83 to 0.04), while effects for self-stigma were small and significant (smd = − 0.24). Long-term effects of the HOP program are unknown. Conclusion There is initial evidence that HOP effectively supports people with mental illness in their disclosure decisions and in their coping with stigma. Implementation issues, future developments and public health implications are discussed.

Abstract Recently two CD19-targeted CAR-T cell products were approved by the FDA for treatment of relapsed/refractory (R/R) acute lymphoblastic leukemia (ALL) and non-Hodgkin lymphoma (NHL). Excellent anti-tumor activity has been observed in patients with B cell malignancies. However, data regarding long-term effects of this therapy are very limited. Here we report long-term effects in 59 patients (pts) with R/R NHL and chronic lymphocytic leukemia (CLL) who received a total of 85 CD19-targeted CAR-T cell infusions on a clinical trial in our institution (NCT01865617), survived more than a year, and had at least one year follow-up data after their first CAR-T cell infusion. One patient who survived more than a year was excluded from this report due to incomplete data. Median follow-up was 23 months (range, 13-57) after the first CAR-T cell infusion. We report adverse events that occurred or persisted beyond 90 days after the last CAR-T cell infusion, excluding events related to disease progression. Median age at CAR-T cell infusion was 60 years (range, 34-73). There were 42 (71%) pts with NHL and 17 (29%) with CLL. The median number of prior lines of treatment was 4 (range, 1-8). 23 (39%) pts had received prior autologous (auto) hematopoietic cell transplantation (HCT), and 9 (15%) pts had received prior allogeneic (allo) HCT. 35 (59%) pts received one CAR-T cell infusion, 22 (37%) pts received 2 infusions, and 2 (3%) pts received 3 infusions. 3 (5%) pts received a maximum cell dose of 2x10(5)/kg, 40 (68%) pts received a maximum cell dose of 2x10(6)/kg, and 16 (27%) pts received a maximum cell dose of 2x10(7)/kg. 65 (76%) infusions were preceded by cyclophosphamide and fludarabine. CRS grade I/II occurred in 38 (64%) pts, and grade III in 4 (7%) pts (graded per Lee et al. Blood, 2014). No grade IV CRS was reported in this cohort. Acute neurotoxicity occurred in 20 (34%) pts. At 2 months after CAR-T cell infusion complete response (CR) was documented in 34 (58%) pts, partial response (PR) in 12 (20%) pts, and disease progression (PD) in 13 (22%) pts. During the follow-up period, another 15 (25%) pts developed PD. 29 (49%) pts received salvage therapy after CAR-T cell infusion, 8 (14%) of them received allo HCT. 5 (8%) pts received allo HCT as consolidation after CAR-T cell. 5 of 25 (20%) pts who did not receive additional therapy after last CAR-T cell infusion experienced ongoing cytopenias requiring G-CSF support, or RBC or platelet transfusions, beyond 90 days after last CAR-T cells infusion. 8 (14%) pts were diagnosed with subsequent malignancies, including 3 (5%) myelodysplasia, 4 (7%) non-melanoma skin cancer, and 1 non-invasive bladder cancer. All, but 1 patient with skin cancer, had auto or allo HCT before CAR-T cell therapy. Neuropsychiatric disorders were documented in 5 (8%) pts; including major depression, suicidal attempt, myoclonic seizures, and TIA. 5 (8%) pts experienced cardiovascular events. 4 (7%) pts developed renal dysfunction. 3 (5%) pts developed respiratory disorders. One pt had gastrointestinal bleeding. Of the 9 pts who had undergone allo HCT before CAR-T cell therapy, 1 pt (11%) developed GVHD flare. Severe hypogammaglobulinemia (IgG &lt; 400 mg/dL) or IgG replacement beyond day 90 after last CAR-T cell infusion (and before HCT if was done) were documented in 24 (41%) pts. 54 pts were included in the infection analysis. 178 suspected infection events beyond day 90 after last CAR-T cell infusion were documented in 40 (74%) pts. Antimicrobial treatments were documented for 124 infection events. 44 (25%) of the events were microbiologically proven. The most common infections were upper (92) and lower (29) respiratory tract infections. 25 (46%) pts required hospital admission due to infections, of them 8 (15%) were admitted to the ICU. When excluding infections that occurred after salvage therapy following CAR-T cell, we identified 117 infections in 28 (52%) pts. 3 pts died of non-relapse causes (2 due to infection after allo HCT, and 1 due to duodenal ulcer and gut perforation). In conclusion, our data suggest that long-term effects of CD19-targeted CAR-T cell therapy are acceptable. Most effects identified in our cohort were not severe, and many may have been related to prior or subsequent therapies (e.g. HCT before or after CAR-T cell therapy, or subsequent salvage treatments). Our data is consistent with recent published data demonstrating excellent long-term disease outcome for this heavily pre-treated population. Disclosures Turtle: Juno/Celgene: Membership on an entity's Board of Directors or advisory committees, Patents & Royalties, Research Funding; Nektar Therapeutics: Membership on an entity's Board of Directors or advisory committees, Research Funding; Precision Biosciences: Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Eureka Therapeutics: Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Caribu Biosciences: Membership on an entity's Board of Directors or advisory committees. Maloney:Juno Therapeutics: Research Funding; GlaxoSmithKline: Research Funding; Janssen Scientific Affairs: Honoraria; Roche/Genentech: Honoraria; Seattle Genetics: Honoraria.

The pandemic of COVID-19 has afflicted every individual and has initiated a cascade of directly or indirectly involved events in precipitating mental health issues. The human species is a wanderer and hunter-gatherer by nature, and physical social distancing and nationwide lockdown have confined an individual to physical isolation. The present review article was conceived to address psychosocial and other issues and their aetiology related to the current pandemic of COVID-19. The elderly age group has most suffered the wrath of SARS-CoV-2, and social isolation as a preventive measure may further induce mental health issues. Animal model studies have demonstrated an inappropriate interacting endogenous neurotransmitter milieu of dopamine, serotonin, glutamate, and opioids, induced by social isolation that could probably lead to observable phenomena of deviant psychosocial behavior. Conflicting and manipulated information related to COVID-19 on social media has also been recognized as a global threat. Psychological stress during the current pandemic in frontline health care workers, migrant workers, children, and adolescents is also a serious concern. Mental health issues in the current situation could also be induced by being quarantined, uncertainty in business, jobs, economy, hampered academic activities, increased screen time on social media, and domestic violence incidences. The gravity of mental health issues associated with the pandemic of COVID-19 should be identified at the earliest. Mental health organization dedicated to current and future pandemics should be established along with Government policies addressing psychological issues to prevent and treat mental health issues need to be developed. References World Health Organization (WHO) Coronavirus Disease (COVID-19) Dashboard. 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Abstract Background Depression is one of the most common and serious diseases worldwide: According to WHO, more than 300 million people worldwide were affected by depression in 2015. In this group, the suicide rate is about 20 times higher than the population average. In Germany, around 10,000 people take their lives each year, many of them suffering from depression. The Institute for Quality and Efficiency in Health Care commissioned the Department of Health Care Management at the Berlin University of Technology to conduct a Health Technology Assessment on whether non-drug interventions influence coping with suicidal crises in unipolar depression. Methods A systematic search of primary studies and systematic reviews (e.g., in MEDLINE, PSYCINFO) was performed to assess the benefit of ambulatory crisis intervention programmes or psychosocial interventions compared to another non-drug treatment, drug treatment, inpatient treatment or no treatment/waiting list in adult suicidal patients with unipolar depression regarding patient-relevant outcomes (e.g., suicide attempts, suicidal ideation, depression). Results The search yielded a total of 4,159 hits. After two rounds of screening for relevance and removing duplicates, 4 studies remained for inclusion in the qualitative and quantitative analysis. The studies present RCTs assessing the effects of cognitive behavioural therapy (CBT) of the 2. and 3. wave - all short-term programmes focussing on suicidality. Results indicate a benefit of CBT compared to standard treatment, depending on the outcome, on the “wave” and on the time of follow up assessment. Conclusions There is some evidence on benefits of CBT for adult patients with suicidal crises in unipolar depression. However, the quality of the included RCTs is weak and evidence on benefits of other non-drug interventions in outpatient care is missing. Further research is needed to identify effective interventions, especially for the vulnerable weeks immediately after suicide attempt. Key messages Short term cognitive behavioural therapy with suicidal prevention elements may influence coping with suicidal crises in unipolar depression positively. Further research is needed to identify effective interventions for the vulnerable weeks immediately after suicide attempt.

The purpose of this study was to explore the pattern of alcohol use, mode of suicide and extent of depression among 200 female commercial sex workers (CSWs) in Bengaluru, India and use Karma yoga principles of Shrimad Bhagavad Gita as a tool for Cognitive Behaviour therapy (CBT) for a period of 6 weeks to maintain abstinence after a short detoxification programme of 2 weeks and lower their depression. A 3 month follow up indicated they had maintained abstinence for that period and had not attempted suicide also.

The authors present the results from a 3-year follow-up among 170 patients who had participated in the original randomized study, which consisted of three treatment conditions: (a) 3-month abandonment psychotherapy (AP) delivered by certified psychotherapists, (b) AP delivered by nurses, and (c) treatment as usual in a psychiatric crisis center. All subjects were recruited at the emergency room after a suicide attempt and met diagnostic criteria for borderline personality disorder and major depression. Psychotic symptoms, bipolar disorder, and mental retardation were exclusion criteria. At 3-year follow-up, 134 (78.8%) subjects had blind, reliable assessment by clinical psychologists. The intent-to-treat analysis indicated that those patients who had received AP during acute treatment had better global functioning, improved work adjustment, and less unemployment/disability at 3-year follow-up. No differences were found as a function of type of therapist delivering AP. The data confirm that short-term AP gains in psychosocial functioning are sustained over the longer term.

Perinatal depression includes major and minor depression occurring in pregnancy and one year postpartum. Affecting one in seven women, it is one of the most common pregnancy complications; however, it is often under recognized and undertreated. A personal history of perinatal or non-perinatal depression significantly increases risk. Screening using a validated instrument is recommended in the context of systems to ensure effective diagnosis, treatment, and follow-up. Evidence-based treatment includes psychotherapy and pharmacotherapy. Selective serotonin reuptake inhibitors are well-studied in pregnancy, are associated with low overall absolute risk, and are differentially secreted into breast milk. If left untreated, perinatal depression is associated with significant short- and long-term negative maternal-child consequences including, among many others things, poor bonding. Of note, maternal suicide exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality. It is critical to recognize that one in five women who screen positive for perinatal depression will have bipolar disorder and are at highest risk for postpartum psychosis, suicide, and infanticide, especially if prescribed unopposed anti-depressant monotherapy. Women who screen positive for having bipolar disorder should be referred for psychiatric evaluation. This review contains 6 figures, 13 tables and 54 references Keywords: Pregnancy, Postpartum, Perinatal, depression, Mood disorder, Baby blues, Bipolar disorder, Psychosis, Psychotherapy, Psychopharmacology

Perinatal depression includes major and minor depression occurring in pregnancy and one year postpartum. Affecting one in seven women, it is one of the most common pregnancy complications; however, it is often under recognized and undertreated. A personal history of perinatal or non-perinatal depression significantly increases risk. Screening using a validated instrument is recommended in the context of systems to ensure effective diagnosis, treatment, and follow-up. Evidence-based treatment includes psychotherapy and pharmacotherapy. Selective serotonin reuptake inhibitors are well-studied in pregnancy, are associated with low overall absolute risk, and are differentially secreted into breast milk. If left untreated, perinatal depression is associated with significant short- and long-term negative maternal-child consequences including, among many others things, poor bonding. Of note, maternal suicide exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality. It is critical to recognize that one in five women who screen positive for perinatal depression will have bipolar disorder and are at highest risk for postpartum psychosis, suicide, and infanticide, especially if prescribed unopposed anti-depressant monotherapy. Women who screen positive for having bipolar disorder should be referred for psychiatric evaluation. This review contains 6 figures, 13 tables and 54 references Keywords: Pregnancy, Postpartum, Perinatal, depression, Mood disorder, Baby blues, Bipolar disorder, Psychosis, Psychotherapy, Psychopharmacology

Perinatal depression includes major and minor depression occurring in pregnancy and one year postpartum. Affecting one in seven women, it is one of the most common pregnancy complications; however, it is often under recognized and undertreated. A personal history of perinatal or non-perinatal depression significantly increases risk. Screening using a validated instrument is recommended in the context of systems to ensure effective diagnosis, treatment, and follow-up. Evidence-based treatment includes psychotherapy and pharmacotherapy. Selective serotonin reuptake inhibitors are well-studied in pregnancy, are associated with low overall absolute risk, and are differentially secreted into breast milk. If left untreated, perinatal depression is associated with significant short- and long-term negative maternal-child consequences including, among many others things, poor bonding. Of note, maternal suicide exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality. It is critical to recognize that one in five women who screen positive for perinatal depression will have bipolar disorder and are at highest risk for postpartum psychosis, suicide, and infanticide, especially if prescribed unopposed anti-depressant monotherapy. Women who screen positive for having bipolar disorder should be referred for psychiatric evaluation. This review contains 6 figures, 13 tables and 54 references Keywords: Pregnancy, Postpartum, Perinatal, depression, Mood disorder, Baby blues, Bipolar disorder, Psychosis, Psychotherapy, Psychopharmacology

BackgroundAlthough previous studies demonstrated no association between depression and tamoxifen in patients with breast cancer, there is still a limited amount of long-term follow-up data. This study aimed to evaluate the relationship between endocrine treatment and the risk of depression.MethodsThis nationwide population-based cohort study used data obtained over a 14-year period (January 2007 to December 2021) from the Korean National Health Insurance claims database. All female patients with breast cancer were included. We examined the incidence of depression in patients who underwent endocrine treatment, and those who did not undergo endocrine treatment constituted the control group.ResultsThe data from 11,109 patients who underwent endocrine treatment and 6,615 control patients between 2009 and 2010 were analyzed. After performing matching for comorbidities and age, both groups comprised 6,532 patients. The median follow-up were 119.71 months. Before and after matching was performed, the endocrine treatment was not a significant risk factor for developing depression (p=0.7295 and p=0.2668, respectively), nor was it a significant factor for an increased risk for suicide attempt (p=0.6381 and p=0.8366, respectively).ConclusionsUsing a real-world population-based cohort, this study demonstrated that there is no evidence that the endocrine treatment increases the risk of depression.

AbstractThis study of a cohort of 1-year treatment-compliant survivors of a suicide attempt examined for the first time whether a high CYP2D6-CYP2C19 metabolic capacity (pharmacogenes related to psychopathology, suicide, and attempt severity) and/or polypharmacy treatments predicted repeat suicide attempts, adjusting for sociodemographic and clinical factors as confounders. Of the 461 (63% women) consecutively hospitalized patients who attempted suicide and were evaluated and treated after an index attempt, 191 (67.5% women) attended their 6- and 12-month follow-up sessions. Clinicians were blinded to the activity scores (AS) of their genotypes, which were calculated as the sum of the values assigned to each allele (CYP2C19 *2, *17; CYP2D6 *3, *4, *4xN, *5, *6, *10, wtxN). No differences were found in polypharmacy prescription patterns and the variability of CYP2D6 and CYP2C19 genotypes between adherents and dropouts, but the formers were older, with a higher frequency of anxiety and bipolar disorders and fewer alcohol and substance use disorders. The risk of reattempts was higher for CYP2D6 ultrarapid (AS > 2) metabolizers (β = 0.561, p = 0.005) and violent suicide survivors (β = −0.219, p = 0.042) if the attempt occurred during the first 6-month period, individuals with an increased number of MINI DSM-IV Axis I mental disorders (β = 0.092, p = 0.032) during the second 6-month period and individuals with a combined high CYP2D6-CYP2C19 metabolic capacity (AS > 4) (β = 0.345, p = 0.024) and an increased use of drugs other than antidepressants, anxiolytics-depressants and antipsychotics-lithium (β = 0.088, p = 0.005) in multiple repeaters during both periods. CYP2D6 and CYP2C19 rapid metabolism and polypharmacy treatment for somatic comorbidities must be considered to prevent the severe side effects of short-term multiple suicide reattempts after a previous attempt.

Background: Although fluoxetine and, in the USA, escitalopram are approved for depression in adolescence, substantial concern surrounds antidepressant use in youth. Major controversies regarding efficacy and safety (increased suicidality). Introduction: The cathegory of depression is very broad and overinclusive, in terms of etiology, role of psychosocial adversities severity, episodicity, presentation, relationship with bipolarity. This heterogeneity, not fully controlled considered in Randomized Controlled Trials (RCTs), may account for the disappointing results on both efficacy and safety. Method: Based on the available literature, we will address the following topics: a) controversies regarding the definition of depression as a unique homogeneous condition with a unique type of pharmacological treatment; b) controversies about the interpretation of data from Randomized Controlled Trials (RCTs) on the efficacy of pharmacological treatments in adolescent depression; c) the interpretation of data regarding the safety of antidepressant treatment in adolescent depression, particularly in terms of increased suicidal risk. Results: According to RCTs, antidepressants are minimally to moderately more effective than placebo, principally based on very high placebo responses, and only fluoxetine showed more evidence of efficacy. These differences in meta-analyses are sometimes statistically, but not clinically significant. Depression is a heterogeneous condition in terms of etiology, role of psychosocial adversities severity, episodicity, presentation, relationship with bipolarity. This heterogeneity may partly explain the low drug-placebo difference and the high placebo response (possibly related to a high level of natural recovery of the adolescent depression). In the National Institute of Mental Health (NIMH)-funded studies, including a lower number of study sites and more reliable enrollment procedures, lower placebo response rates and greater group differences between medication and placebo were found. Robust evidence supports an increased risk of emergent suicidality after starting antidepressants. A clear age effect on suicidal risk after antidepressants is supported by a comprehensive meta-analysis, showing that suicidal risk increased with decreasing age, being markedly greater in subjects aged between 18 and 25 years. However, the term suicidality is too broad, as it includes suicidal ideation, suicidal attempts, and completed suicide, with a hugely wide range of severity and pervasiveness. If emergent suicidality should be actively and carefully explored, empirical evidence, albeit weak, suggests that combined pharmacotherapy (antidepressant and/or lithium) associated with psychotherapy may be helpful in reducing pretreatment suicidal ideation and suicidal risk. Discussion: Moderate to severe depression should be treated with psychotherapy and/or fluoxetine, the best-supported medication, and treatment-resistant adolescents should always receive combined treatment with psychotherapy. Suicidal ideation, particularly with a plan, should be actively explored before starting an antidepressant, as a reason for the closest monitoring. Emergent suicidality after starting antidepressants, as well as antidepressant-related activation, should also be closely monitored and may lead to antidepressant discontinuation. Although no response to pharmacotherapy and psychotherapy may occur in up to 40% of depressed adolescents, possible predictors or mediators of poorer response in adolescents are uncertain, and only a few studies support possible treatment strategies. Finally, studies exploring the efficacy of antidepressants in specific depression subtypes, i.e., based on prevalent psychopathological dimensions (apathy, withdrawal, impulsivity), are warranted.

Introduction Discourses of queer youth suicide regularly represent non-heterosexual young men as vulnerable and as victims who are inherently without strategies for coping with adversity (qv. Rasmussen; Marshall; Driver 3). Alternatively, queer youth are sometimes marked as fundamentally resilient, as avid users of tools of resilience and community such as the internet (Smith & Gray 74; Wexler et al. 566; Hillier & Harrison; Bryson & McIntosh). In the latter approach, protective factors are typically presented as specific to queer youth (e.g., Russell 10), therefore also minoritising and essentialising resilience. Both approaches ignore the diversity of queer young lives and the capacity for a subject to be both vulnerable and resilient—concepts which need to be unpacked if we are to further our understanding of minority lives. Significantly, both approaches also ignore the fact that growing up occurs in a series of transitions, cultural encounters and circumstantial changes. Queer (LGBT) youth are neither all victims and vulnerable, nor are they all self-reliant and resilient. Recent research has indicated that non-heterosexual youth continue to have a higher rate of suicide and self-harm (Cover, Queer Youth Suicide), although this is by no means indicative that vast numbers of LGBTI require support, intervention or preventative measures throughout all aspects of the transition into adult life. This article has two objectives, both of which are best addressed together in order to come at an understanding as how best to frame approaches to queer youth suicide as an ongoing social concern. Firstly, to ask what human, psychological and subjective ‘resilience’ might be said to mean in the context of public discourses of queer youth suicidality, and secondly to ask what a concept of ‘resilience’ does for queer youth identity in terms of relationality. Neither objective, of course, can be met alone in a short article—the purpose here is to open thinking on the topic in ways that question normative assumptions about the conditions of queer youth in the context of liveable lives and the positioning of resilience as reliant on normative accounts of identity. The article begins with a brief overview of the different uses of resilience in the context of broad social representations of queer youth. It goes on to discuss the It Gets Better video site which aimed to produce resilience among predominantly bullied queer youth by ‘imparting hope’. Some remarks on the relationship between identity, sexuality, sociality and resilience will conclude. Resilience and the Queer Youth Subject Developed by Crawford Holling in the 1970s, the concept of resilience was used to describe the capacity of a system to “absorb change and disturbance and still maintain the same relationships between populations or state variables” (Holling 14). In terms of ecology and the physical sciences, the notion of resilience operates within an assumption that future events will not be known but will be unexpected, thereby requiring a capacity to accommodate those events whatever form they take (21). When later used in the psychological sciences, the term resilience likewise assumes disruption and uncertainty in lived experience, requiring a resilient subject to be capable in both learning and adaptation. In the context of queer youth, resilience, then, can be applied to mean an adaptation to new situations which exacerbate vulnerability to suicidality for those who are positioned to seek escape from intolerable emotional pain or the perception of life as unliveable (Cover, Queer Youth Suicide 10, 148). Resilience in this use presumes that, for example, bullying has a detrimental causal relationship with suicidality when it newly occurs if the subject does not have the capacity to adapt and incorporate it into everyday life. Bullying, however, is generally related to suicide only by virtue of its ongoingness rather than it being a sudden shift in social relations. Striking about much of the discourse of resilience in the psychological sciences is that the concept of resilience presumes a unitary subject who is a subject prior to relationality and sociality (e.g. Leipold & Greve; Singh et al.; Smith & Gray). Resilience is thus seen as a capacity to cope with adversity as if adversity arises prior to the subject rather than being a form of relationality that conditions the subject. In that context, the queer youth subject is understood in essentialist terms, whereby sexual subjectivity is represented simultaneously as both a norm and abnormal, and is a factor of subjectivity that is understood to pre-exist sociality. That is, the queer youth subject is queer before relationality with others, thereby before the kinds of relationalities that might demand resilience. An alternative is to understand queer youth not as vulnerable because they are queer, but as subjects constituted in the (inequitably distributed) precarity of corporeal life in sociality, and thereby already formed in (inequitably distributed) resilience to the sorts of shifts, changes and adversities that shift one from an experience of vulnerability to an experience of a life that is unliveable (Butler, Precarious Life; Frames of War). Approaching queer youth suicide from a perspective not of risk but through the simultaneous fostering and critique of resilience opens the possibility of providing solutions that aid younger persons to resist suicidality as a flight from intolerable pain without articulating the self as inviolable and thereby losing the ethical value of the recognition of vulnerability. The question, then, is whether such critique can be found in sites of resilience discourse in relation to queer youth. Queer Youth and It Gets Better The video blogging site It Gets Better (http://www.itgetsbetter.org) was begun by columnist Dan Savage in response to a spate of reported queer student suicides in September/October 2010 in the United States. The site hosts more than a thousand video contributions, many from queer adults who seek to provide hope for younger persons by showing that queer adulthood is markedly different from the experiences of harassment, bullying, loneliness or surveillance experienced by queer youth in school and family environments. This is among the first widely-available communicative media form to address directly queer youth on issues related to suicide, and the first to draw on lived experiences as a means by which to provide resources for queer youth resilience. The fact that these experiences are related through video-logs (vlogs) provides the texts with a greater sense of authenticity and a framework which often addresses youth directly on the topic of suicidality (Cover, Queer Youth Suicide). Savage’s intention was to produce resilience in queer youth by imparting ‘hope for young people facing harassment’ and to create ‘a personal way for supporters everywhere to tell LGBT youth that … it does indeed get better’ (http://www.itgetsbetter.org/pages/about-it-gets-better-project/). Hope, in this context, is represented as the core attribute of queer youth resilience. The tag-line of the site is: Many LGBT youth can’t picture what their lives might be like as openly gay adults. They can’t imagine a future for themselves. So let’s show them what our lives are like, let’s show them what the future may hold in store for them (http://www.itgetsbetter.org/). Hope for the future is frequently presented as hope for an end to school days. In the primary video of the site, Dan Savage’s partner Terry describes his school experiences: My school was pretty miserable … I was picked on mercilessly in school. People were really cruel to me. I was bullied a lot. Beat up, thrown against walls and lockers and windows; stuffed into bathroom stalls. . . . Honestly, things got better the day I left highschool. I didn’t see the bullies every day, I didn’t see the people who harassed me every day, I didn’t have to see the school administrators who would do nothing about it every day. Life instantly got better (http://www.itgetsbetter.org/pages/about-it-gets-better-project/) Such comments present a picture of school life in which the institutional norms of secondary schools that depend so heavily on surveillance, discriminative norms, economies of secrecy and disclosure permit bullying and ostracisation to flourish and become, then, the site of hopelessness in what to many appears at the time as a period of never-ending permanency. Indeed, teen-aged life has often been figured in geographic terms as a kind of hopeless banishment from the realities that are yet to come: Eve Sedgwick referred to that period as ‘that long Babylonian exile known as queer childhood’ (4). The emphatic focus on the institutional environment of highschool rather than family, rural towns, closetedness, religious discourse or feelings of isolation is remarkably important in changing the contemporary way in which the social situation of queer youth suicide has been depicted. The discourse of the It Gets Better project and contributions makes ‘school’ its object—a site that demands resilience of its queer students as the remedy to the detrimental effects of bullying. Here, however, resilience is not depicted as adaptability but the strength to tolerate and, effectively, ‘wait out’, a bullying environment. The focus on bullying that frames the dialogue on queer youth suicide and youth resilience in the It Gets Better videos is the product of a mid-2000s shift in focus to the effects of bullying on LGBT youth in place of critiques of heterosexism, sexual identity, coming out and physical violence (Fodero), regularly depicting bullying as directly causal of suicide (Kim & Leventhal 151; Espelage & Swearer 157; Hegna & Wichstrøm 35). Bullying, in these representations, is articulated as that which is, on the one hand, preventable through punitive institutional policies and, on the other, as an ineradicable fact of living through school years. It is, in the latter depiction, that experience for which younger LGBT persons must manage their own resistance. In depicting school as the site of anti-queer bullying, the It Gets Better project represents queer youth as losing hope of escape from the intolerable pain of bullying in its persistence and repetition. However, the site’s purpose is to show that escape from the school environment to what is regularly depicted as a neoliberal, white and affluent representation of queer adulthood, founded on conservative coupledom (Cover, “Object(ives) of Desire”), careers, urban living, and relative wealth—depictions somewhat different from the reality of diverse queer lives. The shift from the school-bullying in queer youth to the liberal stability of queer adulthood is figured in the It Gets Better discourse as not only possible but as that which should be anticipated. It is in that anticipation that resilience is articulated in a way which calls upon queer youth to manage their own resiliency by having or performing hopefulness. Representing hope as the performative element in queer youth resilience has precedence as a suicide prevention strategy. Hopelessness is a key factor in much of the contemporary academic discussion of suicide risk in general and is often used as a predictor for recognising suicidal behaviour (Battin 13), although it is also particularly associated with suicidality and queer teenagers. Hopelessness is usually understood as despair or desperateness, the lack of expectation of a situation or goal one desires or feels one should desire. For Holden and colleagues, hopelessness is counter to social desirability, which is understood as the capacity to describe oneself in terms by which society judges a person as legitimate or desirable (Holden, Mendonca & Serin 500). Psychological and psychiatric measurement techniques frequently rely on Aaron T. Beck’s Hopelessness Scale, which utilises a twenty-question true/false survey designed to measure feelings about the future, expectation and self-motivation in adults over the age of seventeen years as a predictor of suicidal behaviour. Beck and colleagues attempted to provide an objective measurement for hopelessness rather than leave it treated as a diffuse and vague state of feeling in patients with depression. The tool asks a series of questions, most about the future, presenting a score on whether or not the answers given were true or false. Questions include: ‘I might as well give up because I can’t make things better for myself’; ‘I can’t imagine what my life would be like in ten years’; ‘My future seems dark to me’; and ‘All I can see ahead of me is unpleasantness rather than pleasantness’. Responding true to these indicates hopelessness. Responding false to some of the following also indicates hopelessness: ‘I can look forward to more good times than bad times’; and ‘When things are going badly, I am helped by knowing they can’t stay that way forever’ (Beck). While these questions and the scale are not used uncritically, the relationship between the discursive construction through the questions of what constitutes hopelessness and the aims of the It Gets Better videos are notably comparable. The objective, then, of the videos is to provide evidence and, perhaps, instil hope that would allow such questions to be answered differently, particularly to be able to give a true response to the last question above. Hallway Allies liaison support group, which operates across university campuses and high schools to prevent bullying, stated in this representative way in the introduction to their video contribution: ‘Remember to keep your head up, highschool doesn’t last forever’ (http://www.itgetsbetter.org/video /entry/5wwozgwyruy/). Or, as Rebecca in the introductory statement of another video contribution put it: You may be feeling like this pain will last forever, like you have no control, it’s dark, oppressive and feels like there is no end. I know – I get it. but I promise … hang in there and you’ll find it … Wait – you’ll see – it gets better! (http://www.itgetsbetter.org/video/entry/wxymqzw3oqy/). As can be seen, such video examples respond to a discourse of hopelessness aligned with the framework exemplified by Beck’s scale, prompting queer youth audiences of these videos to imagine a future for themselves, to understand hope in temporal terms of future wellbeing, and to know that the future does not necessarily hold the same kinds of unpleasantness as experienced in the everyday high school environment. Sexual Identity, Resilience and the Normative Lifecycle In the It Gets Better framework, resilience is produced in the knowledge of a queer life that is linear and patterned through stages in relation to institutional forms of belonging (and non-belonging). That is, a queer life is represented as one which undergoes the hardship of being bullied in school, of leaving that institutional environment for a queer adulthood that is built on a myth of safety, pleasure, success and a distinctive break from the environment of the past (as if the psyche or the self is re-produced anew in a phase of a queer lifecycle). Working within a queer theoretical and cultural understanding of identity, sexual subjectivity can be understood as constituted in social and cultural formations. Overturning the previously-held liberal notion of power as the power which represses sex and sexualities, Foucault’s History of Sexuality provided queer theory with an argument in which power, as deployed through discourse and discursive formations, produces the coherent sexual subject. This occurs historically and only in specific periods. In Foucault’s analysis, homosexual identities become conceivable in the Nineteenth Century as a result of specific juridical, medical and criminal discourses (85). From a Foucauldian perspective, there is no subject driven by an inner psyche or a pre-determined desire (as in psychoanalysis). Instead, such subjectivity occurs in and through the power/knowledge network of discourse as it writes or scripts the subject into subjectivity. Canonical queer theorist Judith Butler has been central in extending Foucault’s analysis in ways which are pragmatic for understanding queer youth in the context of growing up and transitioning into adulthood. Her theory of performativity has usefully complexified the ways in which we can understand sexual identity and allowed us to overcome the core assumption in much queer youth research that heterosexual and homosexual identities are natural, mutually-exclusive and innate; instead, allowing us to focus on how the process of subject formation for youth is implicated in the tensions and pressures of a range of cultural, social, organisational and communicative encounters and engagements. Butler projects the most useful post-structuralist discussion of subjectivity by suggesting that the subject is constituted by repetitive performances in terms of the structure of signification that produces retroactively the illusion of an inner subjective core (Butler, Gender Trouble 143). Queer identity becomes a normative ideal rather than a descriptive feature of experience, and is the resultant effect of regimentary discursive practices (16, 18). The non-heterosexual subject, then, is performatively constituted by the very ‘expressions’ that are formed as recognisable identity performances in the context, here, of a set of lifecycle expectations built through a vulnerable queer childhood, being bullied, attaining hope, leaving school and fruition in queer adulthood. Resilience, in the It Gets Better discourse, then, is seen to be produced in understanding the stages of a normative queer life. An issue emerges for how queer youth suicide is understood within this particular formation that posits non-heterosexuality as the problematic source of suicidality emerges in the assumption that the vulnerability to suicidal behaviours for queer youth is the result singularly of sexuality, rather than looking to the fact that sexuality is one facet of identity – an important and sometimes fraught one for adolescents in general – located within a complex of other formations of identity and selfhood. This is part of what Diana Fuss has identified as the “synecdochical tendency to see only one part of a subject’s identity (usually the most visible part) and to make that part stand for the whole” (116). This ignores the opportunity to think through the conditions of queer youth in terms of the interaction between different facets of identity (such as gender and ethnicity, but also personal experience), different contexts in which identity is performed and different institutional settings that vary in response and valuation of non-normative aspects of subjectivity, thereby allowing a vulnerability not to be an attribute of being a queer youth, but to be understood as produced across a nuanced and complex array of factors. While the very concept of resilience invokes both an individualisation of the subject and a disciplinary regime of pastoral care (Foucault, Abnormal), queer youth in the It Gets Better discourse of hope are depicted multiply as: Inherently vulnerable and lacking resilience as a result of an essentialist notion of sexual orientation.Constituted in a relationality within a schooling environment that is conditioned by bullying as the primary expression of diverse socialityFinding resilience only through a self-managed and self-articulated expression of ‘hope’ that is to be produced in the knowledge that there is an ‘escape’ from a school environment. What the discourse of that which we might refer to as “resilient hopefulness” does is represent queer youth reductively as inherently non-resilient. It ignores the multiple expressions of sexual identity, the capacity to respond to suicidality through a critique of normative sexual subjectivity, and the capabilities of queer youth to develop meaningful relationships across all sexual possibilities that are, themselves, forms of resilience or at least mitigations of vulnerability. At the same time, “resilient hopefulness” is produced within a context in which a normative sociality of bullying culture is expressed as timeless and unchangeable (rather than historical and institutional), thereby requiring queer younger persons to undertake the task of managing vulnerability, risk, resilience and identity as an individualised responsibility outside of communities of care. Whether the presentation of a normative lifecycle is genuinely a preventative measure for queer youth suicidality is that which suicidologists and practitioners must test, although one might argue at this stage that resilience is better produced through a broader appeal to social diversity rather than the regimentation of a queer life that must ‘wait in hope’ for a liveability that may never come. References Battin, Margaret Pabst. Ethical Issues in Suicide. Englewood Cliffs, N.J.: Prentice-Hall, 1995. Beck, Aaron T., Arlene Weissman, Larry Trexler, and David Lester. “The Measurement of Pessimism: The Hopelessness Scale” Journal of Consulting and Clinical Psychology, 42.6 (1974): 861–865. Bryson, Mary K., and Lori B. MacIntosh. “Can We Play ‘Fun Gay’?: Disjuncture and Difference, and the Precarious Mobilities of Millennial Queer Youth Narratives.” International Journal of Qualitative Studies in Education 23.1 (2010): 101-124. Butler, Judith. Gender Trouble: Feminism and the Subversion of Identity. London & New York: Routledge, 1990. Butler, Judith. Precarious Life. London: Verso, 2004. Butler, Judith. Frames of War: When Is Life Grievable? London and New York: Verso, 2009. Cover, Rob. “Object(ives) of Desire: Romantic Coupledom versus Promiscuity, Subjectivity and Sexual Identity.”Continuum: Journal of Media & Cultural Studies 24.2 (2010): 251-263. Cover, Rob. Queer Youth Suicide, Culture and Identity: Unliveable Lives? London: Ashgate, 2012. Driver, Susan. “Introducing Queer Youth Cultures.” Queer Youth Cultures. Ed. Susan Driver. Albany, NY: SUNY Press (2008). 1-18. Espelage, Dorothy L., and Susan M. Swearer. “Addressing Research Gaps in the Intersection between Homophobia and Bullying.” School Psychology Review 37.2 (2008): 155–159. Fodero, Lisa. “Teen Violinist Dies after Student Internet Lark.” The Age, 1 Oct. 2010. 1 Oct. 2010 ‹http://www.theage.com.au/world/>. Foucault, Michel. The History of Sexuality: An Introduction. Trans. Robert Hurley. London: Penguin, 1990. Foucault, Michel. Abnormal: Lectures at the Collège de France, 1974–1975. Eds. Valerio Marchetti and Antonella Salmoni. Trans. Graham Burchell. New York: Picador, 2004. Fuss, Diana. Essentially Speaking: Feminism, Nature & Difference. New York and London: Routledge, 1989. Hegna, Kristinn, and Lars Wichstrøm. “Suicide Attempts among Norwegian Gay, Lesbian and Bisexual Youths: General and Specific Risk Factors.” Acta Sociologica 50.1 (2007): 21–37. Hillier, Lynne, and Lyn Harrison. “Building Realities Less Limited than Their Own: Young People Practising Same-Sex Attraction on the Internet.” Sexualities 10.1 (2007): 82-100. Holden, Ronald R., James C. Mendonca and Ralph C. Serin. “Suicide, Hopelessness, and social desirability: A Test of an Interactive Model.” Journal of Consulting and Clinical Psychology 57.4 (1989): 500–504. Holling, C. S. “Resilience and Stabity of Ecological Systems.” Annual Review of Ecology and Systematics 4 (1973): 1-23. Kim, Young Shin, and Bennett Leventhal. “Bullying and Suicide. A Review.” International Journal of Adolescent Medical Health 20.2 (2008): 133–154. Leipold, Bernhard, and Werner Greve. “Resilience: A Conceptual Bridge between Coping and Development.” European Psychologist 14.1 (2009): 40-50. Marshall, Daniel. “Popular Culture, the ‘Victim’ Trope and Queer Youth Analytics.” International Journal of Qualitative Studies in Education 23.1 (2010): 65-86. Rasmussen, Mary Lou. Becoming Subjects: Sexualities and Secondary Schooling. New York: Routledge, 2006. Russell, Stephen T. “Beyond Risk: Resilience in the Lives of Sexual Minority Youth.” Journal of Gay & Lesbian Issues in Education 2.3 (2005): 5-18. Sedgwick, Eve Kosofsky. “Queer Performativity: Henry James’s The Art of the Novel.” GLQ 1.1 (1993): 1–14. Singh, Anneliese A., Danica G. Hays, and Larel S. Watson. “Strength in the Face of Adversity: Resilience Strategies of Transgender Individuals.” Journal of Counseling & Development 89.1 (2011): 20-27. Smith, Mark. S., and Susan W. Gray. “The Courage to Challenge: A New Measure of Hardiness in LGBT Adults.” Journal of Gay & Lesbian Social Services 21.1 (2009): 73-89. Wexler, Lisa Marin, Gloria DiFluvio, and Tracey K. Burke. “Resilience and Marginalized Youth: Making a Case for Personal and Collective Meaning-Making as Part of Resilience Research in Public Health.” Social Science & Medicine 69.4 (2009): 565-570.

Abstract Background Sanitary, societal and economic effects due to the COVID-19 pandemic could lead to an impact on population's mental health. Santé publique France (SpF), the French public health agency set up a specific monitoring based on emergency department (ED) and GP's associations (GPs) SOS Médecins (SOSMed) data to early assess the impact of COVID-19 pandemic on mental health. Methods Since 2004, SpF daily collects data from ED participating to the OSCOUR® network (93% of French emergency attendances) and from SOSMed network. For both data sources, visits for several mental health disorders were analyzed for different age groups in 2020 and 2021 (until Week 16) and compared to years 2018 and 2019 (mean) with a focus on the two lockdown periods (resp W11 to W19-2020 and W45 to W51-2020) Results During the first lockdown period, while a major decrease of all-cause activity was observed in both networks, the number of SOSMed visits for anxiety increased in adults with a peak of + 115% in W13-2020 compared to 2018-19 and remained higher than the 2 previous years until W12-2021. An increase in ED visits for mood disorders (including depression) for children (especially 11-17yo) were also observed from W36 (back to school) and reinforced at the beginning of the 2nd lockdown period to reach +111% in W12-2021 compared to 2018-19. 11-17yo children were also concerned by an increase in ED visits for suicide ideation since W36 (peak of + 170% in W12-2021) and suicide attempt from W04-2021 to W12-2021 (peaks of + 45% and +41% in W05 and W10-2021). Discussion ED and SOSMed visits are the most reactive data sources to assess the impact of COVID-19 pandemic on the mental health of French population. These results confirm that the impact concerns all age groups. For children, the condition seems to worsen in 2021 and highlight the need of a close follow-up of the situation and the reinforcement of preventive measures in order to prevent long-term impacts. Key messages Results confirm an impact of COVID-19 pandemic on populations mental health. Impact of COVID-19 on mental health: a long-term issue for children?

Adjustment disorder is a condition of subjective emotional distress triggered as a consequence of a meaningful change in life. The diagnosis of adjustment disorder is hindered by the difficult operational definition of stress and of its related concept of “vulnerability,” by the problem of disentangling symptoms of adjustment disorder from those attributable to comorbid anxiety and mood disorders, and by the poor boundaries of the disorder with other stress-related conditions on the one hand and with common adaptation to life events on the other. Despite the high frequency of its diagnosis in clinical settings, there has been relatively little research on the adjustment disorder and, consequently, very few hints about its treatments. Several psychotherapies have been developed to deal with patients diagnosed with adjustment disorder, with inconclusive evidence on their effectiveness. Antidepressants may abate the symptoms and help patients reacquire occupational and social functioning. The medium-term outcome of adjustment disorder is good, with 70 to 80% of those diagnosed with it showing no evidence of psychopathology when reassessed 5 years from the episode. However, when comorbid with a personality disorder or a substance use disorder, the short-term risk of suicide may be increased. The long-term outcome of adjustment disorder seems to be worse in children and adolescents than in adults. In particular, adolescents diagnosed with adjustment disorder were more likely than adults to have received a diagnosis of a severe mental disorder at the 5-year follow-up, including schizophrenia, schizoaffective disorder, and bipolar disorder. This review contains 1 figure, 6 tables, and 52 references. Key words: adaptation, adjustment disorder, anxiety, depression, stress, trauma, treatment, vulnerability