Psychiatric outcomes amongst adult survivors of childhood burns

Background

Research on the adult psychiatric outcomes of childhood burns is limited.

Aims

To examine the rates of DSM-IV psychiatric disorder amongst adult survivors of paediatric burns, and to explore factors likely to contribute to variation in outcomes. In line with Meyer and colleagues [1], it was expected that high levels of psychopathology would be found.

Method

Participants were 272 adults hospitalised for burns during childhood between the years 1980 and 1990. Structured interviews and self-report questionnaires were used to assess psychiatric symptoms.

Results

Lifetime prevalence of any DSM-IV disorder was 42%, 30% for depressive disorders, and 28% for anxiety disorders. Eleven percent had made a suicide attempt. Female gender, single relationship status, higher level of disfigurement, longer hospital stays and higher number of burn-related surgeries were associated with adverse psychiatric outcomes.

Conclusions

High rates of suicidality and depression were concerning in adults with a history of childhood burns. Factors found to predict psychiatric outcomes could be used to direct interventions and further research is needed to establish how this could best be done.     

Suicidalité chez les adolescents appartenant au spectre de l’autisme

Suicidal behaviors are clinically mentioned in children and adolescents with autism spectrum disorder (ASD). But clinical research in this field is very limited and the diagnosis is not considered in emergency units. In clinical populations of adolescents with an ASD, suicidality was found with a frequency of 11–20%. One of the major individual risk factors to look for is the depressive disorder. However, the diagnosis is quite difficult to make because of the common features between ASD and depression. Self-assessment of suicidality and depression or anxiety remains unreliable, suggesting the need of external observers. The bullying and social integration problems are some important concerns in this population, because they are considered as predisposing factors pushing to commit suicide. Further clinical research in suicidal behaviors in adolescent with ASD will lead to develop targeted therapeutic interventions.     

抑郁症患者自杀相关问题的研究

目的探讨抑郁症患者自杀的相关问题。方法调查80例门诊及住院治疗的抑郁症患者,记录自杀相关问题及相应临床资料。结果抑郁症患者出现自杀意念、自杀意图、自杀行为的比例分别为78.7%、52.5%和27.5%。女性患者自杀行为明显多于男性。精神疾病家族史、自杀家族史均与自杀行为关系密切。结论抑郁症患者存在较多的自杀问题,特别对病程长、多次住院、具有精神疾病或自杀家族史者,更是自杀预防的重点人群。     

Cerebrospinal fluid GABA concentration: relationship with impulsivity and history of suicidal behavior, but not aggression, in human subjects

The objective of this study was to assess the relationship between cerebrospinal fluid concentrations of the neurotransmitter gamma-aminobutyric acid (GABA) and measures of impulsivity and related behaviors (aggression and suicidality) in healthy volunteer and personality disordered subjects. CSF GABA levels, and measures of impulsivity, aggression, and history of suicidal behavior were obtained by morning lumbar puncture in 57 healthy volunteer subjects and in subjects with personality disorder. CSF GABA levels were not found to correlate with measures of aggression but were found to correlate directly with measures of impulsivity; e.g., a composite measure of impulsivity in all subjects (r = 0.35, df = 46, P = 0.015) and in personality disordered subjects examined separately (r = 0.39, df = 30, P = 0.029). In the personality disorder group, CSF GABA levels were higher among subjects with a history of suicidal behavior compared with those without this history. These data suggest that central GABAergic function correlates directly with impulsiveness and history of suicidal behavior, but not aggressiveness, in personality disordered subjects. This may be consistent with observations that high doses of benzodiazepines can lead to “behavioral disinhibition” in human subjects. Further work assessing this and other aspects of the central GABA system in personality disordered subjects are warranted.     

“There are always two sides to these things”: Managing the dilemma of serious adverse effects from SSRIs

Over the past two decades, evidence and regulatory responses have surfaced regarding associations between selective serotonin reuptake inhibitors (SSRIs) and serious adverse effects, especially akathisia, aggression and suicidality. Given increasing concern about depression prevalence and harm, the dominance of biomedical approaches, and the normalisation of antidepressant use, reports about the potential for serious adverse effects from SSRIs present a dilemma for people working in depression intervention: the drugs are linked to “two conflicting claims” that they may either decrease or increase harm. We present data from in-depth semi-structured interviews with nine professionals in New Zealand working in fields relating to depression and supportive of SSRIs, to investigate the negotiation of this dilemma. We analysed participants’ talk about akathisia, aggression and suicidality associated with SSRIs, and found the use of rhetorical strategies that minimised the significance of risks, countered risks with notions of benefit and/or questioned the validity of risks. These discursive resources provided ways of mitigating the dilemma otherwise posed by evidence of adverse drug effects. However in doing so they referenced notions of SSRI benefit that relied upon assumptions about the efficacy of the drugs, risks of untreated depression, and the impact of adverse effects. Overall, our analysis highlights ways in which evidence of serious adverse effects from SSRIs can be rhetorically contained and undermined.     

Differential pattern of response in mood symptoms and suicide risk measures in severely ill depressed patients assigned to citalopram with placebo or citalopram combined with lithium: role of lithium levels

The assumption that antidepressants may reduce suicide risk by reducing depressive symptoms is not based on data. Further, it is unclear if the retrospectively based anti-suicidal effects of lithium can be prospectively evaluated using lithium as an augmenting agent to antidepressants.To verify our hypothesis, we designed and conducted an exploratory proof of concept trial of four weeks duration using a randomized, double-blind, parallel group method. Forty patients were assigned to citalopram + lithium and 40 were assigned to citalopram + placebo. The primary dependent measures were the Sheehan-Suicidality Tracking Scale (S-STS) and the Montgomery-Asberg Depression Rating Scale (MADRS).The reduction of S-STS scores was large (43%) and twice that seen in MADRS scores (25%) among the eighty patients included in the trial. Both response (χ² = 8.8, p < 0.01) and remission (χ² = 4.6, p = 0.03) rates showed similar patterns.There were no significant differences in mean total S-STS change scores among patients assigned to citalopram with placebo (4.8 ± 5.1) and patients assigned to citalopram with lithium (5.1 ± 5.2). When explored further, a subgroup of the patients assigned to citalopram and lithium achieved therapeutic serum levels and had significantly higher S-STS remission rates (45% compared to 19%, p < 0.05).There were no deaths by suicide or other causes indicating that trials enrolling acutely suicidal patients are feasible. These results suggest that citalopram may have a direct therapeutic effect on suicidal thoughts and behaviors. Further, lithium when used in therapeutic doses may augment such effects. These data warrant further exploration of lithium and an antidepressant combination for anti-suicidal effects.     

The associations of insomnia symptoms and chronotype with daytime sleepiness,mood symptoms and suicide risk in adolescents

ObjectivesTo investigate the association of insomnia and chronotype preference with daytime impairment and psychopathology in a community sample of adolescents in Hong Kong.MethodsThis was a cross-sectional study that included seven local secondary schools in Hong Kong. A total of 1667 adolescents (mean age: 14.8 ± 1.6 years old; boys: 56.5%) returned a battery of self-report questionnaires including Insomnia Severity Index (ISI) and reduced Horne and Östberg Morningness and Eveningness Questionnaire (rMEQ) for assessing insomnia symptoms and chronotype preference, respectively. A subset of adolescent samples (n = 768) were additionally assessed for suicidal ideation. Potential confounders including age, gender and sleep duration were controlled for in the analyses.ResultsThe prevalence of insomnia symptoms and eveningness chronotype was 37% and 25.6%, respectively. Regression models indicated that insomnia and eveningness were independently associated with excessive daytime sleepiness (insomnia: adjusted OR [AdjOR] = 3.8; 95% confidence interval [C.I.] = 2.9–5.0; eveningness: AdjOR = 2.6; 95% C.I. = 1.9–3.7), and an increased risk of depression (insomnia: AdjOR = 3.5, 95% C.I. = 2.5–5.0; eveningness: AdjOR = 2.0, 95% C.I. = 1.3–3.2). The odds ratio increased to 8.7 (95% C.I. = 6.1–12.3, p < 0.001) for excessive daytime sleepiness and 4.8 (95% C.I. = 3.2–7.2, p < 0.001) for depression among adolescents with both insomnia and eveningness. Insomnia symptoms, but not eveningness, were associated with anxiety symptoms (AdjOR = 5.8; 95% C.I. = 3.6–9.4) and suicidal ideation (AdjOR = 2.1, 95% C.I. = 1.4–3.2).ConclusionsThe present study provided further evidence that insomnia and eveningness uniquely contributed to poor daytime functioning and mood related outcomes, while the co-existence of these two conditions could confer a greater risk in adolescents. However, insomnia, but not eveningness, was significantly linked to suicidality after controlling for mood symptoms. Our findings highlighted the necessity of timely management of sleep and circadian issues in adolescents.