Vikas Menon

Suicide risk assessment and formulation: An update

There continues to be a lack of clarity on how to assess individual cases for suicidal risk. Though a surfeit of information regarding patient risk factors for suicide is available, clinicians and mental health professionals face difficulties in integrating and applying this information to individuals, in order to come up with an assessment report that is at once comprehensive, operational and easily communicable. This article outlines the basic steps involved in risk assessment with a focus on applying and integrating them. Illustrative questions and examples are used to aid understanding where appropriate. The three major domains emphasized across all contemporary models of risk assessment are specific suicidal thoughts, risk factors and protective factors. Evidence based warning signs associated with near term risk of suicide are reviewed and various approaches proposed for risk formulation are discussed with the aim of providing usable and practical information regarding assessment and formulation of suicide risk. The importance of following a structured, systematic approach is highlighted.

Stressful life events, hopelessness, and coping strategies among impulsive suicide attempters

Background: Suicides are among the most important causes of death in the economically productive population. Characteristics of impulsive and nonimpulsive suicide attempters may differ which would have a bearing on planning preventive measures. Aims: This study aimed to characterize the clinical and psychological profile of impulsive and nonimpulsive suicide attempters. Settings and Design: This retrospective comprehensive chart-based study was conducted at a tertiary care hospital in South India. Methods: The study utilized records of patients over a period of 3 years. An attempt was considered impulsive if the time between suicidal idea and the attempt was <30 min. Stressful life events were assessed using presumptive stressful life events scale; hopelessness was evaluated using Beck Hopelessness Scale (BHS) and coping was measured using Coping Strategies Inventory Short Form. Statistical Analysis Used: Impulsive and nonimpulsive suicide attempters were compared using appropriate inferential statistical tests. Results: Of 316 patients, 151 were classified as having an impulsive suicidal attempt (47.8% of the sample). The impulsive and nonimpulsive suicide attempters did not differ on demographic characteristics. Use of natural plant products was more common in impulsive attempters (27.2% vs. 12.7%), while physical methods like hanging was less common (0.7% vs. 7.3%). Those with an impulsive attempt were more likely to have a recent contact with a health professional (24.5% vs. 4.5%). Impulsive suicide attempters had higher scores on BHS (Mann–Whitney U = 7680.5, P < 0.001), and had recollected greater number of stressors. Conclusion: Impulsive suicide attempters differ from nonimpulsive suicide attempters in clinical features like methods of attempt, presence of hopelessness, and stressors.

Psychotherapeutic applications of mobile phone-based technologies: A systematic review of current research and trends

There is a growing interest in using mobile phone technology to offer real-time psychological interventions and support. However, questions remain on the clinical effectiveness and feasibility of such approaches in psychiatric populations. Our aim was to systematically review the published literature on mobile phone apps and other mobile phone-based technology for psychotherapy in mental health disorders. To achieve this, electronic searches of PubMed, ScienceDirect, and Google Scholar were carried out in January 2016. Generated abstracts were systematically screened for eligibility to be included in the review. Studies employing psychotherapy in any form, being delivered through mobile-based technology and reporting core mental health outcomes in mental illness were included in the study. We also included trials in progress with published protocols reporting at least some outcome measures of such interventions. From a total of 1563 search results, 24 eligible articles were identified and reviewed. These included trials in anxiety disorders (8), substance use disorders (5), depression (4), bipolar disorders (3), schizophrenia and psychotic disorders (3), and attempted suicide (1). Of these, eight studies involved the use of smartphone apps and others involved personalized text messages, automated programs, or delivered empirically supported treatments. Trial lengths varied from 6 weeks to 1 year. Good overall retention rates indicated that the treatments were feasible and largely acceptable. Benefits were reported on core outcomes in mental health illness indicating efficacy of such approaches though sample sizes were small. To conclude, mobile phone-based psychotherapies are a feasible and acceptable treatment option for patients with mental disorders. However, there remains a paucity of data on their effectiveness in real-world settings, especially from low- and middle-income countries.

Assessment of DNA damage and repair efficiency in drug naïve schizophrenia using comet assay

The etiology of schizophrenia continues to be confounding and elusive. Some knowledge gaps exist in the neurodegenerative theory of schizophrenia. Oxidative DNA damage and repair deficits are relevant to the mechanisms of neurodegeneration but have not been studied in drug naïve schizophrenia. The present study used the comet assay technique to study the extent of DNA damage in circulating peripheral lymphocytes of patients with drug naïve schizophrenia (n = 40) along with an age and gender matched control group (n = 40). We also assessed the DNA repair efficiency in cases following incubation in a nutrient medium. All the assayed comet parameters demonstrated significantly greater baseline DNA damage in cases in comparison to the controls except for head diameter (p < 0.001 for all significant results, p = 0.32 for head diameter). Gender, age and duration of illness (p = 0.21, 0.69 and 0.12 respectively for tail length) did not influence any of the parameters significantly. Significant decrease was noted in the comet tail length and percentage of DNA in comet tail (p < 0.001 for both) in cases following incubation suggesting that the DNA repair machinery was preserved. No difference in DNA repair efficiency was noted between the genders (p = 0.23 for tail length). Our findings confirm the presence of significant baseline DNA damage in schizophrenia even prior to the initiation of anti-psychotic treatment. Additionally, intact genomic repair efficiency was noted in this group as a whole. These results provide some evidence for oxidative DNA damage as molecular link underpinning neurodegeneration in drug naïve schizophrenia.

Do personality traits such as impulsivity and hostility-aggressiveness predict severity of intent in attempted suicide? Findings from a record based study in South India

Background: Little is known about the association of personality traits with intent in attempted suicide. Aims: Our objectives were to assess the levels of selected personality factors among suicide attempters and to examine their association with suicide intent. Materials and Methods: A chart review of 156 consecutive suicide attempters was carried out. All participants were administered the Beck Suicide Intent Scale, Barratt Impulsivity Scale-11, Buss-Perry Aggression Questionnaire, and Past Feelings and Acts of Violence Scale to assess suicide intent, trait impulsivity, hostility-aggression, and violence, respectively. Pearsons product moment correlation was the used as the test of association. Stepwise linear regression was used to identify predictors of suicide intent. Results: Suicide intent was significantly correlated with verbal aggression (Pearson r = 0.90, P = 0.030), hostility (Pearson r = 0.316, P < 0.001), and nonplanning impulsivity (r = -0.174, P = 0.049). High hostility and low motor impulsivity emerged as significant predictors of suicide intent. Conclusion: Personality traits such as hostility and to an extent, impulsivity are accurate predictors of intentionality in attempted suicide. Clinicians should focus on these personality attributes during a routine evaluation of suicide attempters. They can also be considered as potential targets for suicide prevention programs.

Clinical and Socio-Demographic Correlates of Suicidal Intent Among Young Adults: A Study From South India

BACKGROUND Intent in attempted suicide is considered an indicator of subsequent suicide. Few studies in developing countries have examined correlates of suicidal intent among young adults. AIMS This study aimed to assess the intent score among a sample of young suicide attempters from South India and to identify the factors associated with suicide intent among them. METHOD The clinical charts of 64 consecutive subjects aged 15-24 years attending emergency services for attempted suicide were reviewed. All participants completed a semistructured proforma, the Presumptive Stressful Life Events Scale, the Beck Hopelessness Scale, the Pierce Suicide Intent Scale, and the Global Assessment of Functioning Scale. Psychiatric diagnoses were made according to the ICD-10 clinical descriptions and diagnostic guidelines. RESULTS The intent scores were in the moderate-to-high range for most subjects. Suicide intent score significantly varied depending on the presence or absence of psychiatric morbidity. In bivariate analysis, psychiatric morbidity and hopelessness correlated positively with suicide intent, and in linear regression, hopelessness emerged as a predictor of suicide intent. CONCLUSION A high intent of suicide in young is associated with psychiatric morbidity and presence of hopelessness. Hopelessness may be a key predictor of suicidal intent. Assessment of suicidal intent and hopelessness among young attempters is important and may help identify high-risk individuals who need intensive interventions.

An exploratory study of immune markers in acute and transient psychosis

The aim of this study was to look into the balance of pro-inflammatory (TNF-α, IL-6) and anti-inflammatory (TGF-β) cytokines and their association with stress, alterations in HPA axis activity and the disease severity in acute psychosis. Socio-demographic and clinical details were collected from 41 in-patients with a diagnosis of Acute and Transient Psychotic Disorder. Holmes and Rahe Stress Scale for stress in the preceding year, and Brief Psychiatric Rating Scale at baseline and follow up (4-12 weeks) for psychopathology were applied. IL-6, TNF-α (pro-inflammatory), TGF-β (anti-inflammatory) and Cortisol (morning and afternoon values) were measured at baseline and follow up. A total of 30 out of 41 cases recruited had follow up data available. The levels of IL-6 (p<0.001), TNF-α (p<0.001) and TGF-β (p<0.001) at baseline were all found to be significantly elevated compared to 42 age and gender matched healthy controls. There was a significant increase in the levels of TNF-α (p=0.020) and morning levels of cortisol (p=0.009) and a significant decrease in the levels of TGF-β (p=0.004) and afternoon levels of cortisol (p=0.043) from baseline to follow up. This study showed that there was an increased level of both pro and anti-inflammatory cytokines at baseline and a prolonged pro - inflammatory compared to anti - inflammatory response which warrants larger prospective studies and comparative studies to patients with schizophrenia and bipolar disorders.

Is Depression an Inflammatory Disease? Findings from a Cross-Sectional Study at a Tertiary Care Center.

Background: Evidence linking inflammation and depression is marred by several methodological inconsistencies. Further, varying information is present on the role of gender as a potential confounder in this association. Aims: To assess systemic inflammation in drug naοve depression by measuring selected pro-inflammatory (tumor necrosis factor-alpha [TNF-α], interleukin-6 [IL-6]) and anti-inflammatory cytokines (transforming growth factor-beta [TGF-β]) and comparing them with a matched control group. We also aimed at exploring the differences in these markers between genders. Setting and Design: The study was a cross-sectional one carried out a teaching cum Tertiary Care Hospital. Materials and Methods: We recruited 55 drug naοve cases diagnosed with major depression and compared them for inflammatory markers with a matched apparently healthy control group (n = 42) at baseline. The inflammatory markers were also compared between the genders. Baseline depression and stress levels were assessed using standard measures. Statistical Analysis Used: Mann-Whitney U-test. Results: In comparison with healthy controls, drug naοve depressed individuals demonstrated significantly raised baseline levels of TNF-α and IL-6 (P < 0.001 for both) but no difference in levels of TGF-β (P = 0.433). Neither the baseline depression nor the stress scores correlated with any of the inflammatory markers (P = 0.955 and 0.816 for TNF-α respectively). Males and females were comparable on the levels of markers studied (P = 0.986, 0.415, and 0.430 for TNF-α, IL-6 and TGF-β respectively). Conclusion: There is evidence for higher baseline inflammation in depression prior to starting anti-depressant therapy. Gender does not mediate this observed link between inflammation and depression.

Barriers to healthcare seeking among medical students: a cross sectional study from South India

Objective To determine the barriers to seeking help from healthcare services reported by medical students at an Indian medical school, and to compare the barriers for using physical health services with those for using mental health services. Methods In 2014, we invited all medical students across the nine semesters of training at a government medical college in Puducherry, India, to complete a 28 item questionnaire about perceived barriers to seeking healthcare services. The questionnaire enquired about barriers to using physical and mental healthcare services separately. Results Completed responses were available from 461 of 509 students (response rate 90.6%). Stigma, confidentiality issues, lack of awareness about where to seek help and fear of unwanted intervention were more commonly reported for mental healthcare seeking (OR 4.21, 4.01, 3.19 and 2.43, respectively), while issues relating to cost, lack of time and fear of side effects were observed less frequently (OR 0.45, 0.46 and 0.57, respectively) compared with physical healthcare seeking. In comparison with physical health, students were more indifferent to their mental health issues and preferred self-diagnosis and informal consultations over formal documented care. Conclusions Barriers to seeking healthcare services differ for mental and physical health issues. Many system based barriers such as stigma, confidentiality issues and poor awareness of service location were reported by students. Institutional programmes should use this information for improving the usage, satisfaction and effectiveness of healthcare delivery systems for medical students.

Cognitive behavior therapy for medically unexplained symptoms: A systematic review and meta-analysis of published controlled trials

Medically unexplained symptoms (MUS) commonly present across the board in medical specialties and are often challenging to treat. Our objective was to assess the efficacy for cognitive-behavior therapy (CBT) in MUS. Electronic search of databases was carried out for published controlled trials in English language peer-reviewed journals from inception till August 2016. Effect sizes for the trials were computed using standardized mean difference, and I2 test was used to assess sample heterogeneity. Pooled mean effect sizes were derived using a random-effects model. Critical appraisal of studies was done using the Cochrane risk of bias assessment tool. A total of 11 trials involving 1235 subjects were included in the study. Ten trials used standard CBT techniques while one studied the efficacy of mindfulness-based CBT technique. The control arms were treatment as usual in five trials, augmented care in four and waitlisted controls in two trials. The pooled mean effect size for CBT was 0.388 (range 0.055–0.806, 95% confidence intervals 0.316–0.461). The I2 value was 0 using a random effects model indicating low heterogeneity among studies. Risk of bias was noted in many included studies. Egger plot intercept indicated potential publication bias. CBT was superior to the waiting list, treatment as usual or enhanced usual care with moderate effect sizes in the treatment of MUS. These findings are impacted by the limited number of studies in this area and questionable methodological rigor of included studies.