Ivan W. Miller

Increases in Manic Symptoms After Life Events Involving Goal Attainment

Bipolar disorder has been conceptualized as an outcome of dysregulation in the behavioral activation system (BAS), a brain system that regulates goal-directed activity. On the basis of the BAS model, the authors hypothesized that life events involving goal attainment would promote manic symptoms in bipolar individuals. The authors followed 43 bipolar I individuals monthly with standardized symptom severity assessments (the Modified Hamilton Rating Scale for Depression and the Bech-Rafaelsen Mania Rating Scale). Life events were assessed using the Goal Attainment and Positivity scales of the Life Events and Difficulties Schedule. As hypothesized, manic symptoms increased in the 2 months following goal-attainment events, but depressed symptoms were not changed following goal-attainment events. These results are congruent with a series of recent polarity-specific findings.

Serotonin transporter genetic variation and biased attention for emotional word stimuli among psychiatric inpatients.

The short allele in a variable repeat sequence of the promoter region of the serotonin transporter gene (5-HTTLPR) has been associated with stronger activation in brain regions critical for processing emotional stimuli. The authors examined whether variants of the 5-HTTLPR promoter polymorphism were also associated with individual differences in attentional biases for emotional stimuli. Words related to anxious and dysphoric emotional states were presented to psychiatric inpatients in a standard dot-probe reaction time task. Compared with participants with two long alleles, carriers of the short 5-HTTLPR allele exhibited a stronger attentional bias for anxious word stimuli. No genetic group difference was observed for dysphoric word stimuli. Findings from this preliminary study highlight the potential for integrating genetic and cognitive models of psychopathology.

Trends in US emergency department visits for attempted suicide and self-inflicted injury, 1993–2008

OBJECTIVEnThe objective was to describe the epidemiology of emergency department (ED) visits for attempted suicide and self-inflicted injury over a 16-year period.nnnMETHODnData were obtained from the National Hospital Ambulatory Medical Care Survey including all visits for attempted suicide and self-inflicted injury (E950-E959) during 1993-2008.nnnRESULTSnOver the 16-year period, there was an average of 420,000 annual ED visits for attempted suicide and self-inflicted injury [1.50 (95% confidence interval, 1.33-1.67) visits per 1000 US population], and the average annual number for these ED visits more than doubled from 244,000 in 1993-1996 to 538,000 in 2005-2008. During the same time frame, ED visits for these injuries per 1000 US population almost doubled for males (0.84 to 1.62), females (1.04 to 1.96), whites (0.94 to 1.82) and blacks (1.14 to 2.10). Visits were most common among ages 15-19, and the number of visits coded as urgent/emergent decreased from 0.95 in 1993-1996 to 0.70 in 2005-2008.nnnCONCLUSIONSnED visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. Awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. In addition, this information may be used to inform current suicide and self-injury related ED interventions and treatment programs.

Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures

Objective: There have been few treatment trials for psychogenic nonepileptic seizures (PNES). Some psychotherapies have been shown to improve PNES and comorbid symptom outcomes. We evaluated a pharmacologic intervention to test the hypothesis that sertraline would reduce PNES. Methods: We conducted a pilot, double-blind, randomized, placebo-controlled trial in an academic medical hospital with epilepsy center outpatients. Subjects aged 18 to 65 years diagnosed with video-EEG–confirmed PNES were treated with flexible-dose sertraline or placebo over 12 weeks. Seizure calendars and symptom scales were charted prospectively. Secondary outcome measures included psychiatric symptom scales and psychosocial variables. Results: Thirty-eight subjects enrolled, and 26 (68%) completed the trial. Thirty-three subjects with nonzero nonepileptic seizure rates at baseline were included in intent-to-treat analysis of the primary outcome. Subjects assigned to the sertraline arm experienced a 45% reduction in seizure rates from baseline to final visit (p = 0.03) vs an 8% increase in placebo (p = 0.78). Secondary outcome scales revealed no significant between-group differences in change scores from baseline to final visit, after adjustment for differences at baseline. Conclusions: PNES were reduced in patients treated with a serotonin selective reuptake inhibitor, whereas those treated with placebo slightly increased. This study provides feasibility data for a larger-scale study. Level of evidence: This study provides Class II evidence that flexible-dose sertraline up to a maximum dose of 200 mg is associated with a nonsignificant reduction in PNES rate compared with a placebo control arm (risk ratio 0.51, 95% confidence interval 0.25–1.05, p = 0.29), adjusting for differences at baseline.

The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE): method and design considerations.

BACKGROUNDnDue to the concentration of individuals at-risk for suicide, an emergency department visit represents an opportune time for suicide risk screening and intervention.nnnPURPOSEnThe Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) uses a quasi-experimental, interrupted time series design to evaluate whether (1) a practical approach to universally screening ED patients for suicide risk leads to improved detection of suicide risk and (2) a multi-component intervention delivered during and after the ED visit improves suicide-related outcomes.nnnMETHODSnThis paper summarizes the ED-SAFEs study design and methods within the context of considerations relevant to effectiveness research in suicide prevention and pertinent human participants concerns. 1440 suicidal individuals, from 8 general EDs nationally will be enrolled during three sequential phases of data collection (480 individuals/phase): (1) Treatment as Usual; (2) Universal Screening; and (3) Intervention. Data from the three phases will inform two separate evaluations: Screening Outcome (Phases 1 and 2) and Intervention (Phases 2 and 3). Individuals will be followed for 12 months. The primary study outcome is a composite reflecting completed suicide, attempted suicide, aborted or interrupted attempts, and implementation of rescue procedures during an outcome assessment.nnnCONCLUSIONSnWhile classic randomized control trials (RCT) are typically selected over quasi-experimental designs, ethical and methodological issues may make an RCT a poor fit for complex interventions in an applied setting, such as the ED. ED-SAFE represents an innovative approach to examining the complex public health issue of suicide prevention through a multi-phase, quasi-experimental design embedded in real world clinical settings.

LETHAL MEANS ACCESS AND ASSESSMENT AMONG SUICIDAL EMERGENCY DEPARTMENT PATIENTS.

Reducing access to lethal means (especially firearms) might prevent suicide, but counseling of at‐risk individuals about this strategy may not be routine. Among emergency department (ED) patients with suicidal ideation or attempts (SI/SA), we sought to describe home firearm access and examine ED provider assessment of access to lethal means.

Using structured telephone follow-up assessments to improve suicide-related adverse event detection.

Adverse event (AE) detection and reporting practices were compared during the first phase of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE), a suicide intervention study. Data were collected using a combination of chart reviews and structured telephone follow-up assessments postenrollment. Beyond chart reviews, structured telephone follow-up assessments identified 45% of the total AEs in our study. Notably, detection of suicide attempts significantly varied by approach with 53 (18%) detected by chart review, 173 (59%) by structured telephone follow-up assessments, and 69 (23%) marked as duplicates. Findings provide support for utilizing multiple methods for more robust AE detection in suicide research.