Proximal psychiatric risk factors for suicidality in youth: the Great Smoky Mountains Study

CONTEXT: Psychiatric disorder is a major risk factor for suicidality but has poor positive predictive value. OBJECTIVES: To characterize proximal risks for suicidality associated with anxiety, depressive, disruptive behavior, and substance use disorders, and to test whether there are critical combinations of disorders that discriminate at-risk youth independent of severity of psychopathology. DESIGN: The Great Smoky Mountains Study, a representative sample of children and adolescents aged 9 to 16 years from the southeastern United States. Subjects and their parents were interviewed on multiple occasions from 1993 to 2000 about the subjects' recent psychiatric and suicidal history. SETTING: An epidemiological sample of youth. PARTICIPANTS: The sample included 1420 individual subjects with 6676 records across 8 waves of data collection. MAIN OUTCOME MEASURES: Wanting to die, suicidal ideation, suicide plans, or suicide attempt during the past 3 months. RESULTS: Eleven broad psychiatric profiles discriminated suicidal youth. Risk was greatest in association with current depression plus anxiety (specifically GAD [generalized anxiety disorder]) (odds ratio, 468.53) or depression plus a disruptive disorder (primarily ODD [oppositional-defiant disorder]) (odds ratio, 222.94). Unless comorbid, anxiety and substance use disorders were not proximally associated with suicidality. The severity of symptom-related impairment and, in some cases, total symptom load explained risk associated with all psychiatric profiles except depression plus anxiety, specifically GAD (adjusted odds ratio, 50.16). Severity of impairment and poverty defined by federal guidelines for families were both independent risk factors, irrespective of psychiatric profile. Suicidal youth without diagnosable disorders had subthreshold (mostly disruptive) disorders, disabling relationship difficulties, or psychiatric symptoms without associated impairment. CONCLUSIONS: Severity of symptom-related impairment and total symptom load explained most of the risk for suicidality associated with current psychiatric disorders. Only depression plus GAD discriminated at-risk youth independent of severity of psychopathology.     

Models, metaphors and psychopathology: commentary on Javanbakht's "bugs and bowls"

The theory of bugs and bowls," as outlined by Javanbakht (2005), is, in essence a psychobiological metaphor for understanding psychotic processes. It attempts to bridge psychological and biological explanations for psychotic phenomena by using the metaphor of "bugs and bowls." In this metaphor, the bowl represents the organism's capacity to contain its own inner experience. The bowl is described psychologically, in analytic terms, vis-à-vis traditional ego function and its action of repression. Interestingly, the superego is left out in this discussion. Inner experience, in this regard, corresponds to the wishes and fears of the unconscious. Repressed pathological memories are included in this explanation as well. On the biological side, neuroanatomic, neurochemical, and cortical-subcortical circuits and neural networks are reviewed and folded into the metaphor. The author cites a variety of different literatures to beef up his proposal that "bugs and bowls" is a utilitarian model for the modern clinician. Although we are quite fond of the analogy, there are a few things about it that "bug" us.     

Empirical studies of defense style: relationships with psychopathology and change

The Defense Style Questionnaire (DSQ) is a widely used self-report measure of empirically derived groupings of defense mechanisms ranked on an adaptive hierarchy. A review of published studies indicates strong evidence that adaptiveness of defense style correlates with mental health and that some diagnoses are correlated with specific defense patterns-for example, borderline personality disorder with greater use of both maladaptive and image-distorting defenses and less use of adaptive defenses. For other diagnoses, the pattern of defenses is less clear but often reinforces theoretical formulations.Defense styles become more adaptive with improvement in symptoms, but intermediate defenses tend to be stable (traitlike) over time. Defenses are sometimes predictive of the quality of the therapeutic alliance. Although one might speculate that assessment of defenses can be useful in planning treatment, there are no studies supporting this hypothesis.     

Twin studies of psychopathology: why do the concordance rates vary?

Many current discussions of hereditary factors in psychopathology focus on twin studies as the primary source of evidence supporting the importance of genetic determinants. In summarizing the results of these studies, authors often derive estimates of concordance rates by collapsing across studies and presenting mean or median rates. This practice implicitly assumes that the concordance rates yielded by different studies represent equally reliable estimates of the population mean. The present study evaluates the validity of this assumption. Reports of twin studies of schizophrenia and affective disorder were reviewed. A meta-analysis was conducted to examine the influence of methodological factors on concordance rates. Analyses indicated that both sample-selection and zygosity-determination procedure are systematically associated with concordance rates. For schizophrenia, MZ concordance rates are significantly lower when samples are selected from a twin register as opposed to a psychiatric facility. Lower MZ concordance rates are also yielded by studies that employ laboratory procedures to determine zygosity. Implications of the findings for future research are discussed.     

Early parental loss and development of adult psychopathology

We assessed the effect of parental loss during childhood on the development of psychopathology in 90 adults. The subjects with a history of adult psychopathology (PATH group), in comparison with subjects with no history of a psychiatric disorder (NO PATH group), had poorer quality of childhood home life and personal adaptation subsequent to parental loss as assessed by the Home Life and Personal Adaptation (HAPA) scale developed by us. Total HAPA scale scores were the single most powerful predictor of adult psychopathology, accounting for correct prediction of adult psychopathology in 80% (72/90) of the subjects. The PATH subjects had significantly increased plasma levels of cortisol and beta-endorphin immunoreactivity. Moreover, cortisol and adrenocorticotropic hormone levels significantly correlated with total HAPA scores. First-degree family history of psychiatric disorders, age at loss, and parental vs maternal loss were not significantly different between PATH and NO PATH subjects. We conclude that the quality of home life subsequent to early parental loss is critically related to the development of adult psychopathology. The hypothesis that early trauma results in enduring neuroendocrine alterations in hypothalamic-pituitary-adrenal axis function is examined.     

Prenatal maternal infections and children’s socioemotional development: findings from the UK Millennium Cohort Study

Previous research suggests that prenatal maternal infections may be associated with increased odds of children having a neurodevelopmental disorder. However, little evidence exists on associations with broader child outcomes, especially subclinical symptoms. Participants were the N = 14,021 members of the population-representative UK Millennium Cohort Study. We examined associations between prenatal maternal infections, both maternal-reported and hospital-recorded, and children’s socioemotional development, using the Strengths and Difficulties Questionnaire (SDQ) at age three. Maternal-reported prenatal infections were associated with increased emotional symptoms, after adjusting for several potential confounds and covariates. Hospital-recorded prenatal infections were not associated with children’s socioemotional outcomes, after adjusting for potential confounding and covarying factors. Findings suggest that prenatal maternal infections, particularly those which the mothers remember months later, may be associated with increased emotional problems in early childhood. This emphasises the need for screening for and preventing infections during pregnancy. Further, the occurrence of prenatal infection indicates the potential need for early intervention for children’s emotional difficulties.

     

Genetic and early environmental influences on the serotonin system: consequences for brain development and risk for psychopathology

Background

Despite more than 60 years of research in the role of serotonin (5-HT) in psychopathology, many questions still remain. From a developmental perspective, studies have provided more insight into how 5-HT dysfunctions acquired in utero or early in life may modulate brain development. This paper discusses the relevance of the developmental role of 5-HT for the understanding of psychopathology. We review developmental milestones of the 5-HT system, how genetic and environmental 5-HT disturbances could affect brain development and the potential role of DNA methylation in 5-HT genes for brain development.

Methods

Studies were identified using common databases (e.g., PubMed, Google Scholar) and reference lists.

Results

Despite the widely supported view that the 5-HT system matures in early life, different 5-HT receptors, proteins and enzymes have different developmental patterns, and development is brain region–specific. A disruption in 5-HT homeostasis during development may lead to structural and functional changes in brain circuits that modulate emotional stress responses, including subcortical limbic and (pre)frontal areas. This may result in a predisposition to psychopathology. DNA methylation might be one of the underlying physiologic mechanisms.

Limitations

There is a need for prospective studies. The impact of stressors during adolescence on the 5-HT system is understudied. Questions regarding efficacy of drugs acting on 5-HT still remain.

Conclusion

A multidisciplinary and longitudinal approach in designing studies on the role of 5-HT in psychopathology might help to bring us closer to the understanding of the role of 5-HT in psychopathology.