JAMA Psychiatry最新文献

Importance: In the Netherlands, a growing group of young people request medical assistance in dying based on psychiatric suffering (MAID-PS). Little is known about this group, their characteristics, and outcomes.

Objective: To assess the proportion of requests for and deaths by MAID-PS among young patients, outcomes of their application and assessment procedures, and characteristics of those patients who died by either MAID or suicide.

Design, setting, and participants: This retrospective cohort study included Dutch individuals younger than 24 years requesting MAID-PS between January 1, 2012, and June 30, 2021, whose patient file had been closed by December 1, 2022, at the Expertisecentrum Euthanasie, a specialized health care facility providing MAID consultation and care.

Main outcomes and measures: Outcomes of the MAID-PS assessment procedure (discontinued, rejected, or MAID-PS) and clinical characteristics of patients who died by MAID or suicide.

Results: The study included 397 processed applications submitted by 353 individuals (73.4% female; mean [SD] age, 20.84 [1.90] years). Between 2012 and the first half of 2021, the number of MAID-PS applications by young patients increased from 10 to 39. The most likely outcome was application retracted by the patient (188 [47.3%]) followed by application rejected (178 [44.8%]). For 12 applications (3.0%), patients died by MAID. Seventeen applications (4.3%) were stopped because the patient died by suicide during the application process and 2 (0.5%) because the patient died after they voluntarily stopped eating and drinking. All patients who died by suicide or MAID (n = 29) had multiple psychiatric diagnoses (most frequently major depression, autism spectrum disorder, personality disorders, eating disorder, and/or trauma-related disorder) and extensive treatment histories. Twenty-eight of these patients (96.5%) had a history of suicidality that included multiple suicide attempts prior to the MAID application. Among 17 patients who died by suicide, 13 of 14 (92.9%) had a history of crisis-related hospital admission, and 9 of 12 patients who died by MAID (75.0%) had a history of self-harm.

Conclusions and relevance: This cohort study found that the number of young psychiatric patients in the Netherlands who requested MAID-PS increased between 2012 and 2021 and that applications were retracted or rejected for most. Those who died by MAID or suicide were mostly female and had long treatment histories and prominent suicidality. These findings suggest that there is an urgent need for more knowledge about persistent death wishes and effective suicide prevention strategies for this high-risk group.

Importance: Preventing suicide is one of the top priorities in public health policy. Identifying key social determinants of health (SDOH) in suicide risk is critical for informing clinical practices, future research, and policy solutions to prevent suicide.

Objective: To examine the associations of SDOH with suicide-related outcomes.

Data sources: Studies published before July 2023 were searched through PubMed, PsycINFO, Embase, and Web of Science. The date of the search was August 4, 2023.

Study selection: We included the most up-to-date meta-analyses reporting associations between SDOH and suicide-related outcomes.

Data extraction and synthesis: Three independent reviewers extracted data and conducted quality assessment using the Joanna Briggs Institute Checklist for Systematic Reviews and Research Syntheses.

Main outcomes and measures: The main outcomes of interest were suicide mortality, suicide attempt, and suicidal ideation.

Results: A total of 46 meta-analyses met inclusion criteria. For suicide mortality, justice system-involved individuals in the community, exposure to others' and parental suicide, firearm accessibility, divorce, experience in foster care, release from incarceration, and midlife (age 35-65 years) unemployment were the SDOH with consistently strong effects. Individuals released from incarceration demonstrated a high prevalence of suicide mortality (114.5 per 100 000 persons). With regard to suicide attempt, experience of childhood abuse and maltreatment and sexual assault, gender and sexual minority status, and parental suicide mortality were the strongest risk factors. The prevalence of suicide attempt among homeless individuals (28.9%; 95% CI, 21.7%-37.2%) and incarcerated female youths (27%; 95% CI, 20%-34%) and adults (12.2%; 95% CI, 7.1%-17.2%) was high. For suicidal ideation, identification as bisexual and intimate partner violence in women were the strongest risk factors. The prevalence of lifetime suicidal ideation in homeless individuals was 41.6% (95% CI, 28.6%-56.0%). Protective factors associated with reduced risk of suicide mortality were religious affiliation and being married. School connectedness showed protective associations against suicide attempt and suicidal ideation.

Conclusions and relevance: Tailoring interventions and future research for identified priority subpopulations, such as justice system-involved individuals in the community, and implementing policy measures addressing the SDOH that showed strong associations with suicide mortality, attempts, and ideation, such as gun licensing requirements, are critical to counteracting social and environmental forces that increase suicide risk.

Importance: Older adults with major depressive disorder (MDD) or mild cognitive impairment (MCI) are at high risk for cognitive decline.

Objective: To assess the efficacy of cognitive remediation (CR) plus transcranial direct current stimulation (tDCS) targeting the prefrontal cortex in slowing cognitive decline, acutely improving cognition, and reducing progression to MCI or dementia in older adults with remitted MDD (rMDD), MCI, or both.

Design, setting, and participants: This randomized clinical trial was conducted at 5 academic hospitals in Toronto, Ontario, Canada. Participants were older adults who had rMDD (with or without MCI, age ≥65 y) or MCI without rMDD (age ≥60 y). Assessments were made at baseline, month 2, and yearly from baseline for 3 to 7 years.

Interventions: CR plus tDCS (hereafter, active) or sham plus sham 5 days a week for 8 weeks followed by twice-a-year 5-day boosters and daily at-home CR or sham CR.

Main outcomes and measures: The primary outcome was change in global composite cognitive score. Secondary outcomes included changes in 6 cognitive domains, moderating effect of the diagnosis, moderating effect of APOE ε4 status, change in composite score at month 2, and progression to MCI or dementia over time.

Results: Of 486 older adults who provided consent, 375 (with rMDD, MCI, or both) received at least 1 intervention session (mean [SD] age, 72.2 [6.4] years; 232 women [62%] and 143 men [38%]). Over a median follow-up of 48.3 months (range, 2.1-85.9), CR and tDCS slowed cognitive decline in older adults with rMDD or MCI (adjusted z score difference [active - sham] at month 60, 0.21; 95% CI, 0.07 to 0.35; likelihood ratio test [LRT] P = .006). In the preplanned primary analysis, CR and tDCS did not improve cognition acutely (adjusted z score difference [active - sham] at month 2, 0.06, 95% CI, -0.006 to 0.12). Similarly, the effect of CR and tDCS on delaying progression from normal cognition to MCI or MCI to dementia was weak and not significant (hazard ratio, 0.66; 95% CI, 0.40 to 1.08; P = .10). Preplanned analyses showed treatment effects for executive function (LRT P = .04) and verbal memory (LRT P = .02) and interactions with diagnosis (P = .01) and APOE ε4 (P < .001) demonstrating a larger effect among those with rMDD and in noncarriers of APOE ε4.

Conclusions and relevance: The study showed that CR and tDCS, both targeting the prefrontal cortex, is efficacious in slowing cognitive decline in older adults at risk of cognitive decline, particularly those with rMDD (with or without MCI) and in those at low genetic risk for Alzheimer disease.

Trial registration: ClinicalTrials.gov Identifier: NCT02386670.