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: Previous reports regarding comparative suicide incidence among US physicians vs nonphysicians have been inconclusive.

Objective: To estimate the national incidence of male and female physician suicide and analyze associated factors, comparing findings to the general population.

Design, setting, and participants: This retrospective cohort study investigated suicides among physicians and nonphysicians aged 25 years and older in the US from January 2017 to December 2021. The analysis took place from November 2023 to September 2024. National Violent Death Reporting System data from 30 US states and Washington, DC, were used. Decedents with missing age or sex were excluded for incidence, and missing race, ethnicity, or marital status for further analyses.

Exposure: Physician occupation.

Main outcome and measures: Suicide incidence rate ratios (IRRs) and odds ratios (aORs) adjusted by age, sex, race, ethnicity, and marital status were used to compare preceding circumstances, primary method, and substances.

Results: A total of 448 physician (354 [79%] male and 94 [21%] female; mean [SD] age, 60 [16] years) and 97 467 general population (76 697 [79%] male and 20 770 [21%] female; mean [SD] age, 51 [17] years) suicides were identified. Female physicians had higher rates of suicide than female nonphysicians in 2017 (IRR, 1.88; 95% CI, 1.19-2.83) and 2019 (IRR, 1.75; 95% CI, 1.09-2.65), with overall higher 2017 to 2021 suicide risk (IRR, 1.53; 95% CI, 1.23-1.87). Male physicians had lower 2017 to 2021 suicide risk than male nonphysicians (IRR, 0.84; 95% CI, 0.75-0.93). Compared to the general population and including all available jurisdiction data, physicians had higher odds of depressed mood (aOR, 1.35; 95% CI, 1.14-1.61; P < .001) as well as mental health (aOR, 1.66; 95% CI, 1.39-1.97; P < .001), job (aOR, 2.66; 95% CI, 2.11-3.35; P < .001), and legal (aOR, 1.40, 95% CI, 1.06-1.84; P = .02) problems preceding suicide as well as use of poisoning (aOR, 1.85; 95% CI, 1.50-2.30; P < .001) and sharp instruments (aOR, 4.58; 95% CI, 3.47-6.06; P < .001). Physicians also had higher odds of positive toxicology for caffeine; poison; cardiovascular agents; benzodiazepines; anxiolytics, nonbenzodiazepines, or hypnotics; and drugs not prescribed for home use.

Conclusion and relevance: These findings show a higher incidence of suicide for US female physicians compared to female nonphysicians. Comprehensive and multimodal suicide prevention strategies remain warranted.

Importance: Treatment-resistant depression (TRD) is a major challenge in mental health, affecting a significant number of patients and leading to considerable burdens. The etiological factors contributing to TRD are complex and not fully understood.

Objective: To investigate the genetic factors associated with TRD using polygenic scores (PGS) across various traits and explore their potential role in the etiology of TRD using large-scale genomic data from the All of Us (AoU) Research Program.

Design, setting, and participants: This study was a cohort design with observational data from participants in the AoU Research Program who have both electronic health records and genomic data. Data analysis was performed from March 27 to October 24, 2024.

Exposures: PGS for 61 unique traits from 7 domains.

Main outcomes and measures: Logistic regressions to test if PGS was associated with treatment-resistant depression (TRD) compared with treatment-responsive major depressive disorder (trMDD). Cox proportional hazard model was used to determine if the progressions from MDD to TRD were associated with PGS.

Results: A total of 292 663 participants (median [IQR] age, 57 (41-69) years; 175 981 female [60.1%]) from the AoU Research Program were included in this analysis. In the discovery set (124 945 participants), 11 of the selected PGS were found to have stronger associations with TRD than with trMDD, encompassing PGS from domains in education, cognition, personality, sleep, and temperament. Genetic predisposition for insomnia (odds ratio [OR], 1.11; 95% CI, 1.07-1.15) and specific neuroticism (OR, 1.11; 95% CI, 1.07-1.16) traits were associated with increased TRD risk, whereas higher education (OR, 0.88; 95% CI, 0.85-0.91) and intelligence (OR, 0.91; 95% CI, 0.88-0.94) scores were protective. The associations held across different TRD definitions (meta-analytic R2 >83%) and were consistent across 2 other independent sets within AoU (the whole-genome sequencing Diversity dataset, 104 388, and Microarray dataset, 63 330). Among 28 964 individuals followed up over time, 3854 developed TRD within a mean of 944 days (95% CI, 883-992 days). All 11 previously identified and replicated PGS were found to be modulating the conversion rate from MDD to TRD.

Conclusions and relevance: Results of this cohort study suggest that genetic predisposition related to neuroticism, cognitive function, and sleep patterns had a significant association with the development of TRD. These findings underscore the importance of considering psychosocial factors in managing and treating TRD. Future research should focus on integrating genetic data with clinical outcomes to enhance understanding of pathways leading to treatment resistance.