Opioid use disorder (OUD) is a devastating condition with frequent suicidality, contributing to overdose deaths. Theta burst stimulation (TBS) to the dorsolateral prefrontal cortex (DLPFC) is used to treat major depressive disorder (MDD) and is effective in treating suicidal ideation. We piloted a randomized, double-blind, sham-controlled trial of bilateral rTMS for patients with OUD and MDD experiencing suicidality.

Sequential bilateral TBS was delivered guided by structural neuroimaging: continuous TBS to the right then intermittent TBS to the left DLPFC, daily (20 treatments). The primary objective was to determine the feasibility of this population. The primary clinical outcome was the scale for suicidal ideation (SSI), secondary outcomes included depressive symptoms and opioid cue-induced craving. ClinicalTrials.gov: NCT04785456.

Eighty-seven individuals were pre-screened. The most common reasons for ineligibility included being unreachable by the study team, difficulty with scheduling/travel requirements, and medical/psychiatric instability. Six participants (5:1 M:F) were enrolled (3/arm), four had a fentanyl use history; two completed per protocol (1/arm). Of the participants with follow-up data, SSI scores decreased in 2/3 in the sham arm and 2/2 in the active arm; depression and opioid craving scores decreased in all participants.

We present the first data piloting a structural neuroimaging-guided, multi-session rTMS treatment course in outpatients with suicidality and OUD in the current North American context. Recruitment and retention were the main challenges given the highly unstable medical and psychosocial context of this patient population. Future trials should consider a suitable environment to improve the feasibility of delivering this treatment.

Adolescents with psychiatric disorders are at increased risk of suicide, with insomnia, depression, and social-personal factors playing pivotal roles. This study investigates the interplay between these factors in a sample of adolescent psychiatric inpatients in Italy, with a particular focus on their association with suicide attempts.

We conducted a cross-sectional study on 95 adolescent inpatients (54 suicide attempters, 41 non-attempters) to explore their sociodemographic and clinical variables, including insomnia, depression, and social-personal factors as history of bullying. Logistic regression analyses and Pearson’s correlations were used to identify significant predictors of suicide attempts and their interrelations.

Suicide attempters were predominantly female (90% vs. 75%, p = 0.04) and more likely to have a family psychiatric history (83% vs. 63%, p = 0.04), a history of bullying (26% vs. 9%, p = 0.01), and insomnia (79% vs. 53%, p = 0.01). Depression was strongly associated with suicide attempts (96% vs. 70%, p = 0.01), while physically active adolescents were significantly less likely to attempt suicide (27% vs. 53%, p = 0.01). Insomnia and depression were highly correlated (r = 0.94, p = 0.02), emphasizing the critical role of the former in emotional dysregulation. Behavioral factors, such as physical inactivity and bullying, emerged as additional key contributors to suicidal behavior.

This study highlights the multifaceted nature of suicide risk in adolescent psychiatric inpatients, with sleep disturbances, depression, and behavioral factors playing central roles. These findings underscore the need for integrated interventions targeting sleep, emotional regulation, and behavioral vulnerabilities to mitigate suicide risk.

Despite uncertain benefits, antidepressants are used in the management of personality disorders (PDs). We investigated the association between antidepressants and two adverse outcomes - suicidal behaviour and violent crimes - in individuals with PDs.

We used nationwide Danish healthcare registries to identify all individuals with a diagnosed PD aged 18–64 years from 2007 to 2016. Antidepressant use was identified using dispensed prescriptions. Individuals were followed up for healthcare presentations of suicidal behaviour and separately for police-recorded charges of violent crimes. We applied a within-individual design comparing rates of suicidal behaviour and violent crimes during time periods of antidepressant treatment with periods without treatment. Subgroup analyses were performed according to PD clusters, individual antidepressants, specific PDs, psychiatric comorbidities, and history of suicidal behaviour and violent crime.

The cohort included 167,319 individuals with a diagnosed PD, 19,519 (12%) of whom were prescribed antidepressants and presented at least one outcome event during follow-up, making them eligible for within-individual analyses. Overall, we found an association with lower rates of suicidal behavior during periods of antidepressant treatment, compared with periods when individuals were not on antidepressants (incidence rate ratio 0.86, 95% CI 0.84–0.89). However, this association was modified by specific PDs, individual antidepressants, comorbidities, and past history. For violent crimes, we did not observe consistent associations in any direction.

Antidepressants were associated with lower rates of suicidal behaviour, but less clearly in violent crimes. Types of PDs, individual antidepressants, and comorbidities modified these associations.

Many psychiatric and somatic comorbidities increase the risk of suicidal behavior, but the effect of co-existing comorbidities is sparsely elucidated. We described co-existence of psychiatric and somatic comorbidities and the influence of the combined comorbidity burden on the risk of suicidal behavior.

We defined two case populations above 10 years in the Danish health registries: those who 1) died by suicide (2010–2020) and 2) had an incident suicide attempt (2010–2021). Co-existing somatic and psychiatric comorbidities and relative odds of suicidal behavior at increasing comorbidity burden were assessed.

Among 5.9 million Danish citizens (2021), 6,257 individuals died by suicide whereas 30,570 had an incident suicide attempt. More than half had ≥2 co-existing psychiatric and/or somatic comorbidities. Of those who died by suicide, 18% had co-existing mood disorders and stress disorders, while 5% had both mood disorders and cancer. An 88-fold increase of odds for attempting suicide and a 35-fold increase of odds for suicide were observed among those with the highest combined burden of somatic and psychiatric comorbidities relative to those without. The presence of somatic comorbidities seemed to protect against suicide in older individuals.

Psychiatric and somatic comorbidities commonly co-exist in individuals with suicidal behavior. Higher combined burden of psychiatric and somatic comorbidities increased the odds of suicidal behavior, though the presence of somatic diseases had a potential protective effect on the risk of suicide in older individuals. This warrants collaboration and enhanced awareness of suicidal behavior risks across somatic and psychiatric departments.

One of the most relevant risk factors for suicide is the presence of previous attempts. The symptomatic profile of people who reattempt suicide deserves attention. Network analysis is a promising tool to study this field.

To analyze the symptomatic network of patients who have attempted suicide recently and compare networks of people with several attempts and people with just one at baseline.

1043 adult participants from the Spanish cohort “SURVIVE” were part of this study. Participants were classified into two groups: single attempt group (n = 390) and reattempt group (n = 653). Different network analyses were carried out to study the relationships between suicidal ideation, behavior, psychiatric symptoms, diagnoses, childhood trauma, and impulsivity. A general network and one for each subgroup were estimated.

People with several suicide attempts at baseline scored significantly higher across all clinical scales. The symptomatic networks were equivalent in both groups of patients (p > .05). Although there were no overall differences between the networks, some nodes were more relevant according to group belonging.

People with a history of previous attempts have greater psychiatric symptom severity but the relationships between risk factors show the same structure when compared with the single attempt group. All risk factors deserve attention regardless of the number of attempts, but assessments can be adjusted to better monitor the occurrence of reattempts.

Suicidal behavior constitutes a multi-cause phenomenon that may also be present in people without a mental disorder. This study aims to analyze suicidal behavior outcomes in a sample of attempters, from a symptom-based approach.

The sample comprised 673 patients (72% female; M = 40.9 years) who attended a hospital emergency department due to a suicide attempt. A wide range of clinical factors (e.g., psychopathology symptoms, psychiatric diagnoses, impulsivity, acquired capability), was administered within 15 days after the index attempt. Nine psychopathology domains were explored to identify the profile of symptoms, using latent profile analysis. The relationship between the profile membership and suicide outcome (i.e., intensity of suicidal ideation, number of suicide behaviors, and medical injury derived from index attempt) was also studied, using linear and logistic regression.

Three psychopathology profiles were identified: high-symptom profile (45.02% of participants), moderate-symptom profile (42.50%), and low-symptom profile (12.48%). High-symptom profile members were more likely to show higher risk of non-suicidal self-injury, acquired capability for suicide, and more severe suicide behavior and ideation. On the other hand, a more severe physical injury was associated with low-symptom profile membership in comparison to membership from the other profiles (OR < 0.45, p < .05).

A symptom-based approach may be useful to monitor patients and determine the risk of attempt repetition in the future and potential medical injury, and to optimize prevention and intervention strategies.

An association between sensationalized media reporting and subsequent increase in suicidal behavior has been documented, and adolescents are especially vulnerable to imitative influences. The aims of this study were to examine the characteristics of the articles reporting adult and adolescent (under age 18) suicides in the Italian press and to assess adherence to the World Health Organization (WHO) guidelines for responsible reporting. Methods: The print versions of the three newspapers with the widest national distribution in Italy were searched for all the articles on incident suicides printed over a 7-month period (July 2022 to February 2023). Articles were examined for adherence to the WHO guidelines. Results: Overall, 213 articles were identified, reporting on 122 individual suicide cases (88.5% adults and 11.5% adolescents). Of the articles, 78.9% were on adults and 21.1% on adolescents, with a ratio articles/suicide cases of 1.6 for adults and 3.2 for adolescents (p < 0.0001). Adolescent suicide articles had more words (mean 612.5 ± SD 275.6) than adult ones (462.1 ± 267.7, p = 0.001). Potentially harmful reporting features were present in both the adult and adolescent articles (12–82%). Few articles (0–15%) included protective features. Articles on adolescents were more adherent to the WHO guidelines for omitting specific information of suicide method and location. Conclusions: Significant differences were found in the press reporting of adolescent versus adult suicides, with adolescent suicides receiving more attention in terms of the number of articles and article length. Suicide press reporting can be improved. A close collaboration between journalists and suicide prevention experts may be beneficial.

Neuropsychiatric symptoms in major neurocognitive disorders have been strongly associated with suicidality.

The objectives were to explore suicide rates in degenerative neurocognitive disorders (DNDs), alcohol-related neurocognitive disorders (ARNDs), and traumatic brain injuries (TBIs). Patients who received these diagnoses between 1998 and 2015 (N = 231,817) were identified from nationwide registers, and their mortality was followed up until December 31, 2018. We calculated incidences of suicides per 100,000 person-years, types of suicides, and suicide rates compared with the general population (standardized mortality ratio [SMR]).

During the follow-up, 0.3% (95% confidence interval [95% CI]: 0.2–0.5) of patients with DNDs, 1.1% (0.7–1.8) with ARNDs, and 1.0% (0.7–1.3) with TBIs committed suicide. Suicide mortality rate was higher in men (58.9, 51.3, to 67.4 per 100,000) than in women (9.8, 7.5, to 12.5 per 100,000). The highest suicide rate was in ARNDs (98.8, 65.1, to 143.8 per 100,000), followed by TBIs (82.0, 62.4, to 105.8 per 100,000), and DNDs (21.2, 18.3, to 24.5 per 100,000). The SMRs (95% CI) were 3.69 (2.53–5.38), 2.99 (2.31–3.86), and 1.31 (1.13–1.51), respectively, and no sex difference emerged. The most common cause of death was self-inflicted injury by hanging or drowning (12.4, 10.3, to 14.8 per 100,000).

Suicide rates were higher in all three patient groups than the general population. Suicide risk remained elevated for more than 10 years after diagnosis. The suicide methods were mostly violent.

Inflammatory biomarkers are reportedly increased in depressed patients. Several studies have been conducted using neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and monocyte/lymphocyte ratio (MLR). The objective of this systematic review was to study the relationship between these peripheral biomarkers and suicidality in depressed patients with/without suicidal behavior, including suicide attempts and ideation, and healthy controls.

We searched the following relevant terms in the PubMed, Web of Science, and Scopus databases published in the last 5 years. We assessed the methodological quality of included studies using the Oxford criteria and reviewed the evidence following PRISMA guidelines.

Eleven studies were retained for the data synthesis, with a total sample of 1,701 participants, of which the majority (819) were patients with depression and suicidal behavior, 494 were depressed patients without suicidal behavior, and only 388 were healthy participants. Our results reinforce the idea that NLR could be an attractive, convenient, and cost-effective trait marker of suicidal vulnerability in patients with major depressive disorder (MDD).

Future large-scale replication studies are needed to examine the apparently understudied role of PLR and MLR in depressed patients in greater depth.

There is a concern that the COVID-19 pandemic will lead to an increase in suicides. Several reports from the first months of the pandemic showed no increase in suicide rates while studies with longer observation times report contrasting results. In this study, we explore the suicide rates in Norway during the first year of the pandemic for the total population as well as for relevant subgroups such as sex, age, geographical areas, and pandemic phases.

This is a cohort study covering the entire Norwegian population between 2010 and 2020. The main outcome was age-standardized suicide rates (per 100,000 inhabitants) in 2020 according to the Norwegian Cause of Death Registry. This was compared with 95% prediction intervals (95% PI) based on the suicide rates between 2010 and 2019.

In 2020, there were 639 suicides in Norway corresponding to a rate of 12.1 per 100,000 (95% PI 10.2–14.4). There were no significant deviations from the predicted values for suicides in 2020 when analyzing age, sex, pandemic phase, or geographical area separately. We observed a trend toward a lower than predicted suicide rate among females (6.5, 95% PI 6.0–9.2), and during the two COVID-19 outbreak phases in 2020 (2.8, 95% PI 2.3–4.3 and 2.8, 95% CI 2.3–4.3).

There is no indication that the COVID-19 pandemic led to an increase in suicide rates in Norway in 2020.

Suicidal ideation (SI) is an important risk factor of death by suicide. Recent data suggest that suicidal depression (i.e., moderate to severe depression with SI) could be a specific depression subtype with worse clinical outcomes than nonsuicidal depression (i.e., without SI).

Among 898 French adult inpatients (67% women, mean age: 41.23 [SD: 14.33]) with unipolar depression, 71.94% had moderate to severe depression (defined using the cut-offs of validated scales: beck depression inventory, clinician-rated 30-item inventory depression symptomatology, and quick inventory of depressive symptomatology) and among them, 63.6% had SI according to the suicidal item (score ≥ 2) of the depression scale they filled in. Clinical features (anxiety, psychological pain, and hopelessness) were assessed at baseline. The occurrence of a suicide attempt (SA) or a suicide event (SE) (i.e., actual, aborted or interrupted SA, or hospitalization for SI) was recorded during the 1-year follow-up. The risk of actual SA and SE was compared between groups with adjusted Cox regression models.

The risk of actual SA and SE during the follow-up was 2- and 1.8-fold higher, respectively, in patients with suicidal depression, independently of potential cofounders such as history of lifetime SA, age, sex, and baseline depression severity.

Suicidal depression is associated with poorer prognosis in terms of actual SA/SE, despite optimal care (i.e., care in a hospital department specialized in the management of suicidal crisis). Specific therapeutic strategies might be needed for these patients.

Suicide is one of the main preventable causes of death. Artificial intelligence (AI) could improve methods for assessing suicide risk. The objective of this review is to assess the potential of AI in identifying patients who are at risk of attempting suicide.

A systematic review of the literature was conducted on PubMed, EMBASE, and SCOPUS databases, using relevant keywords.

Thanks to this research, 296 studies were identified. Seventeen studies, published between 2014 and 2020 and matching inclusion criteria, were selected as relevant. Included studies aimed at predicting individual suicide risk or identifying at-risk individuals in a specific population. The AI performance was overall good, although variable across different algorithms and application settings.

AI appears to have a high potential for identifying patients at risk of suicide. The precise use of these algorithms in clinical situations, as well as the ethical issues it raises, remain to be clarified.

Guidance in England recommends psychosocial assessment when presenting to hospital following self-harm but adherence is variable. There is some evidence suggesting that psychosocial assessment is associated with lower risk of subsequent presentation to hospital for self-harm, but the potential cost-effectiveness of psychosocial assessment for hospital-presenting self-harm is unknown.

A three-state four-cycle Markov model was used to assess cost-effectiveness of psychosocial assessment after self-harm compared with no assessment over 2 years. Data on risk of subsequent self-harm and hospital costs of treating self-harm were drawn from the Multicentre Study of Self-Harm in England, while estimates of effectiveness of psychosocial assessment on risk of self-harm, quality of life, and other costs were drawn from literature. Incremental cost-effectiveness ratios (ICERs) for cost per Quality Adjusted Life Year (QALY) gained were estimated. Parameter uncertainty was addressed in univariate and probabilistic sensitivity analyses.

Cost per QALY gained from psychosocial assessment was £10,962 (95% uncertainty interval [UI] £15,538–£9,219) from the National Health Service (NHS) perspective and £9,980 (95% UI £14,538–£6,938) from the societal perspective. Results were generally robust to changes in model assumptions. The probability of the ICER being below £20,000 per QALY gained was 78%, rising to 91% with a £30,000 threshold.

Psychosocial assessment as implemented in the English NHS is likely to be cost-effective. This evidence could support adherence to NICE guidelines. However, further evidence is needed about the precise impacts of psychosocial assessment on self-harm repetition and costs to individuals and their families beyond immediate hospital stay.

Psychiatric comorbidities and suicide attempts are highly prevalent in Bipolar Disorders (BD). We examined the associations between childhood maltreatment, psychiatric comorbidities, and suicide attempts, in terms of lifetime prevalence, sequence of onset, and current symptoms.

We assessed 3,047 individuals with BD for suicide attempts, anxiety disorders, substance use disorders, and eating disorders. Participants completed a self-report for the assessment of childhood maltreatment. Associations between childhood maltreatment and characteristics of comorbidities (lifetime prevalence, current symptoms, and age at onset) were examined using logistic regressions and network analyses.

Psychiatric comorbidities were frequent with a mean number per individual of 1.23 (SD = 1.4). Most comorbidities occurred prior to the onset of BD. Participants who reported higher levels of childhood maltreatment had more frequent and multiple comorbidities, which were also more currently active at inclusion. Childhood maltreatment did not decrease the age of onset of comorbidities, but was associated with a faster accumulation of comorbidities prior to the onset of BD. Logistic regression and network analyses showed that emotional abuse and sexual abuse might play a prominent role in the lifetime prevalence of psychiatric comorbidities and suicide attempts.

Childhood maltreatment was associated with suicide attempts, and with frequent, multiple, and persistent psychiatric comorbidities that accumulated more rapidly prior to the onset of BD. Hence, childhood maltreatment should be systematically assessed in individuals with BD, in particular when the course of the disorder is characterized by a high comorbid profile or by a high suicidality.

Long-acting injectable (LAI) antipsychotics improve medication adherence in patients with schizophrenia and extend the duration of therapeutic drug levels but with administration of an increased dose. Real-world mortality data in patients prescribed LAIs are lacking. We conducted a population-based cohort study to estimate and compare the incidence rates of all-cause death and completed suicide in patients with schizophrenia/schizoaffective disorder exposed to LAIs and oral antipsychotics.

Patients with a diagnosis of schizophrenia/schizoaffective disorder between January 1, 2015 and November 30, 2019 were enrolled from the Taiwan National Health Insurance Research Database and linked to Death Registry records. Eligible patients were new antipsychotic users. Relative risks of death for each antipsychotic compared with oral paliperidone were evaluated using a Cox proportional hazard model adjusted for age, sex, Charlson Comorbidity Index, index year, bipolar or major depressive or other mood disorders, mental disorders due to drug use, and baseline hospitalization frequency.

There were 228,791.08 person-years of follow-up (mean 2.48 years). The incidence rates of all-cause death in users of LAI paliperidone administered monthly (PP1M) and every 3 months (PP3M) were 7.40/1,000 person-years (95% confidence interval 5.94–9.11) and 9.93 (5.88–15.79), respectively. The incidences of completed suicide were 2.03/1,000 person-years (1.32–2.99) and 3.10 (1.14–6.88), respectively. No significant associations were observed between PP1M and PP3M compared to oral paliperidone in incidences of all-cause death or for completed suicide.

No increased risk of all-cause death or completed suicide was observed in users of antipsychotic LAIs, including PP1M and PP3M.

Suicide risk in patients is markedly elevated during psychiatric inpatient care, as well as after discharge. However, it is unclear whether, and to what extent, this increased suicide risk varies between sex. Thus, the aim of this study was to analyze sex differences for suicides during and after psychiatric hospitalization in various countries.

National suicide mortality rates and inpatient-related suicide rates (three intervals: during psychiatric inpatient treatment, 1 month, and 1 year after discharge) from 12 countries for 2000–2016 were analyzed, and a logistic model was used to quantify the effect of sex.

Persons admitted to or discharged from psychiatric inpatient care exhibited significantly increased rates of suicide compared to those in the general population. Furthermore, increase of suicide risk was significantly higher for females than for males for all investigated time intervals (inpatient suicide odds ratio [OR] 1.85; suicide within 1 month after discharge—OR 1.94; suicide within 1 year after discharge—OR 2.04).

Analysis confirmed the time during and after psychiatric inpatient care to be significantly associated with an elevated risk for suicide. Further, a significant sex effect was observed, with females in this population being at a proportionally higher risk for suicide during psychiatric inpatient treatment as well as the year following discharge. Our study implicates that more effective suicide preventive measures during inpatient stay, focusing on female patients, are needed.

The relationship between population density and suicide risk remains unclear. While urbanization is associated with greater risk for psychopathology, higher suicide rates have been reported in rural areas. We examined population density and suicide in the Italian population in the last 30 years.

The Italian National Institute of Statistics databases of the Italian population aged 15 years and older (52.4 million in 2016) were used to compute age-adjusted annual total mortality and suicide rates for the years 1985–2016. According to the European Union statistical office (EUROSTAT) criteria, municipalities were classified into densely populated areas, intermediate density areas, or thinly populated areas. Rate ratios (RRs) were computed by sex, age, and geographical area, using densely populated areas as reference.

Total mortality was not associated with population density. In males, suicide rate increased with decreasing population density (RR = 1.17, 95% confidence interval [CI]:1.08–1.28, in intermediate population areas, and RR = 1.32, 95% CI: 1.20–1.45, in thinly populated areas, in 2016). This inverse relationship was found across age, geographical areas, and consecutively over 22 years (1994–2016). In females, no significant difference was detected (RR = 0.96, 95% CI: 0.82–1.13 in intermediate density areas and RR = 1.02, 95% CI: 0.85–1.22 in thinly populated areas). Hanging was the most common suicide method among males, more frequent in thinly (58.8%) than intermediate (53.2%) or densely (41.4%) populated areas.

A consistent and temporally stable inverse relationship between population density and suicide was found in the male, but not female, population. Men may be more vulnerable to adverse social and economic factors associated with lower population density.