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Exploration-Exploitation and Suicidal Behavior in Borderline Personality Disorder and Depression. 边缘型人格障碍和抑郁症患者的探索-剥削和自杀行为。
IF 22.5 1区 医学 Q1 PSYCHIATRY Pub Date : 2024-10-01 DOI: 10.1001/jamapsychiatry.2024.1796
Aliona Tsypes, Michael N Hallquist, Angela Ianni, Aleksandra Kaurin, Aidan G C Wright, Alexandre Y Dombrovski
<p><strong>Importance: </strong>Clinical theory and behavioral studies suggest that people experiencing suicidal crisis are often unable to find constructive solutions or incorporate useful information into their decisions, resulting in premature convergence on suicide and neglect of better alternatives. However, prior studies of suicidal behavior have not formally examined how individuals resolve the tradeoffs between exploiting familiar options and exploring potentially superior alternatives.</p><p><strong>Objective: </strong>To investigate exploration and exploitation in suicidal behavior from the formal perspective of reinforcement learning.</p><p><strong>Design, setting, and participants: </strong>Two case-control behavioral studies of exploration-exploitation of a large 1-dimensional continuous space and a 21-day prospective ambulatory study of suicidal ideation were conducted between April 2016 and March 2022. Participants were recruited from inpatient psychiatric units, outpatient clinics, and the community in Pittsburgh, Pennsylvania, and underwent laboratory and ambulatory assessments. Adults diagnosed with borderline personality disorder (BPD) and midlife and late-life major depressive disorder (MDD) were included, with each sample including demographically equated groups with a history of high-lethality suicide attempts, low-lethality suicide attempts, individuals with BPD or MDD but no suicide attempts, and control individuals without psychiatric disorders. The MDD sample also included a subgroup with serious suicidal ideation.</p><p><strong>Main outcomes and measures: </strong>Behavioral (model-free and model-derived) indices of exploration and exploitation, suicide attempt lethality (Beck Lethality Scale), and prospectively assessed suicidal ideation.</p><p><strong>Results: </strong>The BPD group included 171 adults (mean [SD] age, 30.55 [9.13] years; 135 [79%] female). The MDD group included 143 adults (mean [SD] age, 62.03 [6.82] years; 81 [57%] female). Across the BPD (χ23 = 50.68; P < .001) and MDD (χ24 = 36.34; P < .001) samples, individuals with high-lethality suicide attempts discovered fewer options than other groups as they were unable to shift away from unrewarded options. In contrast, those with low-lethality attempts were prone to excessive behavioral shifts after rewarded and unrewarded actions. No differences were seen in strategic early exploration or in exploitation. Among 84 participants with BPD in the ambulatory study, 56 reported suicidal ideation. Underexploration also predicted incident suicidal ideation (χ21 = 30.16; P < .001), validating the case-control results prospectively. The findings were robust to confounds, including medication exposure, affective state, and behavioral heterogeneity.</p><p><strong>Conclusions and relevance: </strong>The findings suggest that narrow exploration and inability to abandon inferior options are associated with serious suicidal behavior and chronic suicidal thoughts. By con
重要性:临床理论和行为学研究表明,经历自杀危机的人往往无法找到建设性的解决方案,也无法将有用的信息纳入决策中,从而导致过早地趋向于自杀,而忽视了更好的选择。然而,之前对自杀行为的研究并未正式考察个体如何在利用熟悉的选择和探索潜在的更好选择之间进行权衡:从强化学习的正式角度研究自杀行为中的探索和利用:在2016年4月至2022年3月期间,对一个大型一维连续空间的探索-利用进行了两项病例对照行为研究,并对自杀意念进行了为期21天的前瞻性流动研究。参与者从宾夕法尼亚州匹兹堡市的精神病住院部、门诊部和社区招募,并接受了实验室和门诊评估。研究对象包括被诊断为边缘型人格障碍(BPD)以及中年和晚年重度抑郁障碍(MDD)的成年人,每个样本都包括在人口统计学上等同的有高致死率自杀未遂史、低致死率自杀未遂史、有BPD或MDD但无自杀未遂史的人,以及无精神障碍的对照组。MDD 样本还包括一个有严重自杀意念的亚组:主要结果和测量指标:行为(无模型和模型衍生)探索和利用指数、自杀未遂致死率(贝克致死率量表)以及前瞻性评估的自杀意念:BPD组包括171名成年人(平均[标码]年龄为30.55[9.13]岁;女性135人[79%])。MDD 组包括 143 名成年人(平均 [SD] 年龄为 62.03 [6.82] 岁;81 [57%] 为女性)。在 BPD 组中(χ23 = 50.68; P 结论和相关性:研究结果表明,狭隘的探索和无法放弃劣质选择与严重的自杀行为和长期自杀想法有关。相比之下,本研究中从事低致死率自杀行为的个体对采取可能不利的行动表现出较低的阈值。
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引用次数: 0
Population-Based Risk of Psychiatric Disorders Associated With Recurrent Copy Number Variants. 基于人群的与复发性拷贝数变异相关的精神疾病风险。
IF 22.5 1区 医学 Q1 PSYCHIATRY Pub Date : 2024-10-01 DOI: 10.1001/jamapsychiatry.2024.1453
Morteza Vaez, Simone Montalbano, Xabier Calle Sánchez, Kajsa-Lotta Georgii Hellberg, Saeid Rasekhi Dehkordi, Morten Dybdahl Krebs, Joeri Meijsen, John Shorter, Jonas Bybjerg-Grauholm, Preben B Mortensen, Anders D Børglum, David M Hougaard, Merete Nordentoft, Daniel H Geschwind, Alfonso Buil, Andrew J Schork, Dorte Helenius, Armin Raznahan, Wesley K Thompson, Thomas Werge, Andrés Ingason
<p><strong>Importance: </strong>Recurrent copy number variants (rCNVs) have been associated with increased risk of psychiatric disorders in case-control studies, but their population-level impact is unknown.</p><p><strong>Objective: </strong>To provide unbiased population-based estimates of prevalence and risk associated with psychiatric disorders for rCNVs and to compare risks across outcomes, rCNV dosage type (deletions or duplications), and locus features.</p><p><strong>Design, setting, and participants: </strong>This genetic association study is an analysis of data from the Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH) case-cohort sample of individuals born in Denmark in 1981-2008 and followed up until 2015, including (1) all individuals (n = 92 531) with a hospital discharge diagnosis of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), bipolar disorder, major depressive disorder (MDD), or schizophrenia spectrum disorder (SSD) and (2) a subcohort (n = 50 625) randomly drawn from the source population. Data were analyzed from January 2021 to August 2023.</p><p><strong>Exposures: </strong>Carrier status of deletions and duplications at 27 autosomal rCNV loci was determined from neonatal blood samples genotyped on single-nucleotide variant microarrays.</p><p><strong>Main outcomes and measures: </strong>Population-based rCNV prevalence was estimated with a survey model using finite population correction to account for oversampling of cases. Hazard ratio (HR) estimates and 95% CIs for psychiatric disorders were derived using weighted Cox proportional hazard models. Risks were compared across outcomes, dosage type, and locus features using generalized estimating equation models.</p><p><strong>Results: </strong>A total of 3547 rCNVs were identified in 64 735 individuals assigned male at birth (53.8%) and 55 512 individuals assigned female at birth (46.2%) whose age at the end of follow-up ranged from 7.0 to 34.7 years (mean, 21.8 years). Most observed increases in rCNV-associated risk for ADHD, ASD, or SSD were moderate, and risk estimates were highly correlated across these disorders. Notable exceptions included high ASD-associated risk observed for Prader-Willi/Angelman syndrome duplications (HR, 20.8; 95% CI, 7.9-55). No rCNV was associated with increased MDD risk. Also, rCNV-associated risk was positively correlated with locus size and gene constraint but not with dosage type. Comparison with published case-control and community-based studies revealed a higher prevalence of deletions and lower associated increase in risk for several rCNVs in iPSYCH2015.</p><p><strong>Conclusions and relevance: </strong>This study found that several rCNVs were more prevalent and conferred less risk of psychiatric disorders than estimated previously. Most case-control studies overestimate rCNV-associated risk of psychiatric disorders, likely because of selection bias. In an era where genetics is increa
重要性:在病例对照研究中,复发性拷贝数变异(rCNVs)与精神疾病风险的增加有关,但其对人群的影响尚不清楚:目的:提供基于人群的rCNVs患病率和与精神障碍相关风险的无偏估计值,并比较不同结果、rCNV剂量类型(缺失或重复)和位点特征的风险:这项遗传关联研究分析了灵北基金会综合精神病学研究计划(iPSYCH)的病例队列样本数据,这些样本于 1981-2008 年间在丹麦出生,并随访至 2015 年、其中包括:(1)出院诊断为注意力缺陷/多动障碍(ADHD)、自闭症谱系障碍(ASD)、双相情感障碍、重度抑郁障碍(MDD)或精神分裂症谱系障碍(SSD)的所有患者(n = 92 531);(2)从源人群中随机抽取的子队列(n = 50 625)。数据分析时间为 2021 年 1 月至 2023 年 8 月:通过单核苷酸变异微阵列对新生儿血液样本进行基因分型,确定27个常染色体rCNV位点缺失和重复的携带者状态:采用调查模型估算基于人群的rCNV患病率,并使用有限人群校正以考虑病例的过度采样。使用加权 Cox 比例危险模型得出了精神疾病的危险比 (HR) 估计值和 95% CI。使用广义估计方程模型对不同结果、剂量类型和病位特征的风险进行了比较:在 64 735 名出生时被分配为男性(占 53.8%)和 55 512 名出生时被分配为女性(占 46.2%)的个体中,共发现了 3547 个 rCNV,这些个体在随访结束时的年龄在 7.0 岁到 34.7 岁之间(平均 21.8 岁)。大多数观察到的与rCNV相关的ADHD、ASD或SSD风险的增加是适度的,并且这些疾病的风险估计值高度相关。值得注意的例外情况包括观察到普拉德-威利/安杰尔曼综合征重复基因与 ASD 相关的高风险(HR,20.8;95% CI,7.9-55)。没有 rCNV 与 MDD 风险增加相关。此外,rCNV 相关风险与基因座大小和基因限制呈正相关,但与剂量类型无关。与已发表的病例对照研究和基于社区的研究相比,iPSYCH2015 中几种 rCNV 的缺失发生率较高,相关风险增加较低:本研究发现,与之前的估计相比,几种 rCNVs 的流行率更高,所带来的精神障碍风险更低。大多数病例对照研究都高估了与 rCNV 相关的精神疾病风险,这很可能是由于选择偏差造成的。在遗传学越来越多地被应用于临床的今天,这些结果凸显了基于人群的风险估计对于遗传学预测的重要性。
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引用次数: 0
Consistency of Delusion Themes Across First and Subsequent Episodes of Psychosis. 妄想主题在首次和随后的精神病发作中的一致性。
IF 22.5 1区 医学 Q1 PSYCHIATRY Pub Date : 2024-10-01 DOI: 10.1001/jamapsychiatry.2024.2040
Gil Grunfeld, Ann-Catherine Lemonde, Ian Gold, Vincent Paquin, Srividya N Iyer, Martin Lepage, Ridha Joober, Ashok Malla, Jai L Shah
<p><strong>Importance: </strong>Despite growing interest in the phenomenology of delusions in psychosis, at present little is known about their content and evolution over time, including whether delusion themes are consistent across episodes.</p><p><strong>Objective: </strong>To examine the course of delusions and thematic delusion content across relapse episodes in patients presenting to an early intervention service for psychosis.</p><p><strong>Design, setting, and participants: </strong>This longitudinal, observational study used clinical data systematically collected from January 2003 to March 2018 from a cohort of consenting patients with affective or nonaffective first-episode psychosis, followed up naturalistically for up to 2 years in an early intervention service for psychosis in Montréal, Quebec, Canada. Data included the thematic content and severity of delusions (scores ≥3 using the Scale for the Assessment of Positive Symptoms) and associated psychotic and nonpsychotic symptoms, both across an initial episode and, in the event of remission, a potential relapse. Data were analyzed from September 2021 to February 2023.</p><p><strong>Exposure: </strong>An early intervention service for psychosis, organized around intensive case management and a multidisciplinary team approach, which observed each patient for up to 2 years of care.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was positive symptom relapse and remission, including the presence and content of delusions, which was coded per the Scale for the Assessment of Positive Symptoms and accepted definitions. The main statistical measures included repeated paired-sample t tests and binary logistic regression analyses.</p><p><strong>Results: </strong>Of 636 consenting patients, mean (SD) age was 23.8 (4.75) years; 191 patients were female, 444 were male, and 1 patient was nonbinary. Remission rates were high, and relapse rates were relatively low: 591 individuals had baseline delusions, of which 558 (94.4%) achieved remission. Of these 558 patients, only 182 (32.6%) had a subsequent relapse to a second or later episode of psychosis. Of the 182 patients who did relapse, however, a large proportion (115 [63.2%]) reported threshold-level delusions. Of these 115, 104 patients (90.4%) had thematic delusion content consistent with that reported during the index (first) episode. Those who relapsed with delusions had fewer delusion themes present during subsequent episodes of psychosis compared with the index episode and lower levels of other psychotic and nonpsychotic symptoms.</p><p><strong>Conclusions and relevance: </strong>Specialized early intervention services for psychosis can achieve high rates of sustained remission. However, in this study, the minority of individuals with delusions who later relapsed experienced similar delusion themes during subsequent episodes. These findings raise important considerations for the conceptualization of delusions and have cl
重要性:尽管人们对精神病妄想现象学的兴趣与日俱增,但目前对妄想的内容及其随时间的演变却知之甚少,包括妄想的主题在不同发作期是否一致:目的:研究向精神病早期干预服务机构求诊的患者在复发过程中的妄想过程和妄想主题内容:这项纵向观察性研究使用了 2003 年 1 月至 2018 年 3 月期间系统收集的临床数据,这些数据来自于加拿大魁北克省蒙特利尔市一家精神病早期干预服务机构对自愿接受的情感性或非情感性首发精神病患者进行的长达 2 年的自然随访。数据包括妄想的主题内容和严重程度(使用阳性症状评估量表评分≥3分)以及相关的精神病性和非精神病性症状,既包括首次发作,也包括缓解后的潜在复发。数据分析时间为2021年9月至2023年2月:精神病早期干预服务以强化个案管理和多学科团队方法为基础,对每位患者进行长达两年的护理观察:主要结果是阳性症状的复发和缓解,包括妄想的存在和内容,根据阳性症状评估量表和公认的定义进行编码。主要统计量包括重复配对样本 t 检验和二元逻辑回归分析:在 636 名同意接受治疗的患者中,平均(标清)年龄为 23.8(4.75)岁;191 名女性患者,444 名男性患者,1 名患者为非二元患者。缓解率很高,复发率相对较低:591 人有基线妄想,其中 558 人(94.4%)获得缓解。在这 558 名患者中,只有 182 人(32.6%)随后复发,进入第二次或以后的精神病发作期。然而,在复发的 182 名患者中,有很大一部分(115 人 [63.2%])报告出现了阈值水平的妄想。在这 115 名患者中,有 104 名患者(90.4%)的妄想内容与指数(第一次)发作时的妄想内容一致。妄想复发的患者在随后的精神病发作中出现的妄想主题少于指数发作,其他精神病和非精神病症状的程度也较低:针对精神病的专门早期干预服务可以实现较高的持续缓解率。然而,在这项研究中,少数妄想症患者后来复发了,他们在随后的发作中出现了类似的妄想主题。这些发现对妄想症的概念化提出了重要的思考,并对疾病轨迹和护理具有临床意义。
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引用次数: 0
Social Vulnerability and Prevalence and Treatment for Mental Health and Substance Use Disorders. 社会脆弱性与精神健康和药物使用障碍的流行和治疗。
IF 22.5 1区 医学 Q1 PSYCHIATRY Pub Date : 2024-10-01 DOI: 10.1001/jamapsychiatry.2024.1870
Robert D Gibbons, Mark Olfson, Loren Saulsberry, Mark J Edlund, Sahar Zangeneh, Natalie Bareis, Lydia Chwastiak, Jason B Gibbons, Ronald C Kessler
<p><strong>Importance: </strong>Community-level social vulnerability (SV) is associated with physical illness and premature mortality. Its association with mental health (MH) and substance use disorders (SUDs) needs further study.</p><p><strong>Objective: </strong>To study associations of SV with clinical diagnoses of MH disorders, SUDs, and related treatments in the US noninstitutionalized population of adults aged 18 years and older.</p><p><strong>Design, setting, and participants: </strong>A survey of adults in a national sample of US households between October 2020 and October 2022. Participants drawn from a multistage, clustered, and stratified area probability sample of US households were included, excluding adults older than 65 years because of the difficulty of differentiating mental disorders from symptoms of dementia. The sample also included adults living in prisons, state psychiatric hospitals, and homeless shelters who were excluded from the sample of US households used in these analyses. Each sample household was sent a letter explaining the study and offering the option to complete the household roster online, by phone, or by email. Of the 12 906 adults selected for clinical interviewing in the household sample, 4674 completed clinical interviews.</p><p><strong>Main outcomes and measures: </strong>Main outcomes were Structured Clinical Interview for DSM-5 past-year diagnoses of MH disorders and SUDs and responses to survey questions regarding treatment received. The Social Vulnerability Metric (SVM) and the Area Deprivation Index (ADI) were used to determine SV at the residential zip code level.</p><p><strong>Results: </strong>The analysis involved 4674 participants (2904 [62.13%] female and 1770 [37.87%] male; mean [SD] age, 41.51 [13.41] years). Controlling for measured confounders, the SVM was significantly associated with diagnoses of schizophrenia spectrum disorder (SSD; adjusted odds ratio [aOR], 17.22; 95% CI, 3.05-97.29), opioid use disorder (OUD; aOR, 9.47; 95% CI, 2.30-39.02), stimulant use disorder (aOR, 6.60; 95% CI, 2.01-21.67), bipolar I disorder (aOR, 2.39; 95% CI, 1.19-4.80), posttraumatic stress disorder (aOR, 1.63; 95% CI, 1.06-2.50), and any MH disorder (aOR, 1.44; 95% CI, 1.14-1.83), but not major depressive disorder (MDD), generalized anxiety disorder (GAD), or any SUD. Results were similar for the ADI but generally of lower magnitude (SSD aOR, 11.38; 95% CI, 1.61-80.58; OUD aOR, 2.05; 95% CI, 0.30-14.10; stimulant use disorder aOR, 2.18; 95% CI, 0.52-9.18). Among participants with SSDs, SV was associated with reduced MH treatment (aOR, 0.001; 95% CI, 0.00-0.18) and reduced SUD treatment in participants with OUD or stimulant use disorder (aOR, 0.24; 95% CI, 0.02-2.80).</p><p><strong>Conclusions and relevance: </strong>In contrast to previous studies using nonclinical symptom-based survey data, we found no association between SV and GAD or MDD. By contrast, there were associations of SV with prevalence of SSD, s
重要性:社区层面的社会脆弱性(SV)与身体疾病和过早死亡有关。其与心理健康(MH)和药物使用障碍(SUDs)的关系需要进一步研究:研究美国 18 岁及以上非住院成年人群中 SV 与 MH 疾病、SUDs 临床诊断及相关治疗的关系:在 2020 年 10 月至 2022 年 10 月期间对美国全国家庭样本中的成年人进行调查。调查对象来自美国家庭的多级、聚类和分层地区概率样本,但不包括 65 岁以上的成年人,因为很难区分精神障碍和痴呆症状。样本中还包括住在监狱、州立精神病院和无家可归者收容所的成年人,这些人不包括在这些分析所用的美国家庭样本中。每个样本家庭都收到了一封信,信中解释了这项研究,并提供了在线、电话或电子邮件填写家庭名册的选择。在家庭样本中被选中进行临床访谈的 12 906 名成年人中,有 4674 人完成了临床访谈:主要结果为DSM-5结构化临床访谈过去一年的精神障碍和药物滥用诊断,以及对有关所接受治疗的调查问题的回答。社会脆弱性指标(SVM)和地区贫困指数(ADI)用于确定居住地邮编级别的社会脆弱性:分析涉及 4674 名参与者(女性 2904 人 [62.13%] ,男性 1770 人 [37.87%];平均 [SD] 年龄 41.51 [13.41] 岁)。在控制测量的混杂因素后,SVM 与精神分裂症谱系障碍(SSD;调整赔率比 [aOR],17.22;95% CI,3.05-97.29)、阿片类药物使用障碍(OUD;aOR,9.47;95% CI,2.30-39.02)、兴奋剂使用障碍(aOR,6.60;95% CI,2.01-21.67)、双相 I 型障碍(aOR,2.39;95% CI,1.19-4.80)、创伤后应激障碍(aOR,1.63;95% CI,1.06-2.50)和任何 MH 障碍(aOR,1.44;95% CI,1.14-1.83),但不包括重度抑郁障碍(MDD)、广泛性焦虑障碍(GAD)或任何 SUD。ADI 的结果与之相似,但程度普遍较低(SSD aOR,11.38;95% CI,1.61-80.58;OUD aOR,2.05;95% CI,0.30-14.10;兴奋剂使用障碍 aOR,2.18;95% CI,0.52-9.18)。在患有 SSD 的参与者中,SV 与 MH 治疗的减少有关(aOR,0.001;95% CI,0.00-0.18),与 OUD 或兴奋剂使用障碍参与者 SUD 治疗的减少有关(aOR,0.24;95% CI,0.02-2.80):与以往使用非临床症状调查数据进行的研究不同,我们发现 SV 与 GAD 或 MDD 之间没有关联。与此相反,SV 与 SSD、兴奋剂使用障碍和 OUD 的患病率存在关联,且治疗率相应下降。这些结果表明,SVM 可能有助于开发更全面的护理模式,将针对 MH 疾病和 SUD 的医疗和社会护理结合起来。
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引用次数: 0
Suicidal Ideation and Suicide Attempts After Direct or Indirect Psychotherapy: A Systematic Review and Meta-Analysis. 直接或间接心理治疗后的自杀意念和自杀企图:系统回顾与元分析》。
IF 25.8 1区 医学 Q1 PSYCHIATRY Pub Date : 2024-09-25 DOI: 10.1001/jamapsychiatry.2024.2854
Wouter van Ballegooijen,Josine Rawee,Christina Palantza,Clara Miguel,Mathias Harrer,Ioana Cristea,Remco de Winter,Renske Gilissen,Merijn Eikelenboom,Aartjan Beekman,Pim Cuijpers
ImportanceSuicidal ideation and suicide attempts are debilitating mental health problems that are often treated with indirect psychotherapy (ie, psychotherapy that focuses on other mental health problems, such as depression or personality disorders). The effects of direct and indirect psychotherapy on suicidal ideation have not yet been examined in a meta-analysis, and several trials have been published since a previous meta-analysis examined the effect size of direct and indirect psychotherapy on suicide attempts.ObjectiveTo investigate the effect sizes of direct and indirect psychotherapy on suicidal ideation and the incidence of suicide attempts.Data SourcesPubMed, Embase, PsycInfo, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials were searched for articles published up until April 1, 2023.Study SelectionRandomized clinical trials of psychotherapy for any mental health problem, delivered in any setting, compared with any control group, and reporting suicidal ideation or suicide attempts were included. Studies measuring suicidal ideation with 1 item were excluded.Data Extraction and SynthesisPRISMA guidelines were followed. Summary data were extracted by 2 independent researchers and pooled using 3-level meta-analyses.Main Outcomes and MeasuresHedges g was pooled for suicidal ideation and relative risk (RR) was pooled for suicide attempts.ResultsOf 15 006 studies identified, 147 comprising 193 comparisons and 11 001 participants were included. Direct and indirect psychotherapy conditions were associated with reduced suicidal ideation (direct: g, -0.39; 95% CI, -0.53 to -0.24; I2, 83.2; indirect: g, -0.30; 95% CI, -0.42 to -0.18; I2, 52.2). Direct and indirect psychotherapy conditions were also associated with reduced suicide attempts (direct: RR, 0.72; 95% CI, 0.62 to 0.84; I2, 40.5; indirect: RR, 0.68; 95% CI, 0.48 to 0.95; I2, 0). Sensitivity analyses largely confirmed these results.Conclusions and RelevanceDirect and indirect interventions had similar effect sizes for reducing suicidal ideation and suicide attempts. Suicide prevention strategies could make greater use of indirect treatments to provide effective interventions for people who would not likely seek treatment for suicidal ideation or self-harm.
重要性自杀意念和自杀未遂是使人衰弱的心理健康问题,通常采用间接心理疗法(即针对抑郁症或人格障碍等其他心理健康问题的心理疗法)进行治疗。直接和间接心理疗法对自杀意念的影响尚未在一项荟萃分析中进行过研究,而且自从之前的一项荟萃分析研究了直接和间接心理疗法对自杀未遂的影响后,又发表了几项试验。目的 研究直接和间接心理疗法对自杀意念和自杀未遂发生率的影响大小。数据来源检索了PubMed、Embase、PsycInfo、Web of Science、Scopus和Cochrane Central Register of Controlled Trials中截至2023年4月1日发表的文章。研究筛选纳入了针对任何心理健康问题、在任何环境下进行、与任何对照组进行比较、报告有自杀意念或自杀企图的心理治疗随机临床试验。数据提取与综合研究遵循PRISMA指南。由两名独立研究人员提取摘要数据,并采用3级元分析法进行汇总。主要结果和测量方法对自杀意念的Hedges g进行汇总,对自杀未遂的相对风险(RR)进行汇总。结果在确定的15 006项研究中,纳入了147项,包括193项比较和11 001名参与者。直接和间接心理治疗条件与自杀意念的减少有关(直接:g,-0.39;95% CI,-0.53 至 -0.24;I2,83.2;间接:g,-0.30;95% CI,-0.42 至 -0.18;I2,52.2)。直接和间接心理治疗条件也与自杀企图的减少有关(直接:RR,0.72;95% CI,-0.42 至-0.18;I2,52.2):RR,0.72;95% CI,0.62 至 0.84;I2,40.5;间接:RR,0.68;95% CI,0.48 至 0.95;I2,0)。结论与相关性直接和间接干预对减少自杀意念和自杀企图的效果大小相似。自杀预防策略可以更多地利用间接治疗,为那些不可能因自杀意念或自残而寻求治疗的人提供有效的干预。
{"title":"Suicidal Ideation and Suicide Attempts After Direct or Indirect Psychotherapy: A Systematic Review and Meta-Analysis.","authors":"Wouter van Ballegooijen,Josine Rawee,Christina Palantza,Clara Miguel,Mathias Harrer,Ioana Cristea,Remco de Winter,Renske Gilissen,Merijn Eikelenboom,Aartjan Beekman,Pim Cuijpers","doi":"10.1001/jamapsychiatry.2024.2854","DOIUrl":"https://doi.org/10.1001/jamapsychiatry.2024.2854","url":null,"abstract":"ImportanceSuicidal ideation and suicide attempts are debilitating mental health problems that are often treated with indirect psychotherapy (ie, psychotherapy that focuses on other mental health problems, such as depression or personality disorders). The effects of direct and indirect psychotherapy on suicidal ideation have not yet been examined in a meta-analysis, and several trials have been published since a previous meta-analysis examined the effect size of direct and indirect psychotherapy on suicide attempts.ObjectiveTo investigate the effect sizes of direct and indirect psychotherapy on suicidal ideation and the incidence of suicide attempts.Data SourcesPubMed, Embase, PsycInfo, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials were searched for articles published up until April 1, 2023.Study SelectionRandomized clinical trials of psychotherapy for any mental health problem, delivered in any setting, compared with any control group, and reporting suicidal ideation or suicide attempts were included. Studies measuring suicidal ideation with 1 item were excluded.Data Extraction and SynthesisPRISMA guidelines were followed. Summary data were extracted by 2 independent researchers and pooled using 3-level meta-analyses.Main Outcomes and MeasuresHedges g was pooled for suicidal ideation and relative risk (RR) was pooled for suicide attempts.ResultsOf 15 006 studies identified, 147 comprising 193 comparisons and 11 001 participants were included. Direct and indirect psychotherapy conditions were associated with reduced suicidal ideation (direct: g, -0.39; 95% CI, -0.53 to -0.24; I2, 83.2; indirect: g, -0.30; 95% CI, -0.42 to -0.18; I2, 52.2). Direct and indirect psychotherapy conditions were also associated with reduced suicide attempts (direct: RR, 0.72; 95% CI, 0.62 to 0.84; I2, 40.5; indirect: RR, 0.68; 95% CI, 0.48 to 0.95; I2, 0). Sensitivity analyses largely confirmed these results.Conclusions and RelevanceDirect and indirect interventions had similar effect sizes for reducing suicidal ideation and suicide attempts. Suicide prevention strategies could make greater use of indirect treatments to provide effective interventions for people who would not likely seek treatment for suicidal ideation or self-harm.","PeriodicalId":14800,"journal":{"name":"JAMA Psychiatry","volume":null,"pages":null},"PeriodicalIF":25.8,"publicationDate":"2024-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142321184","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Predicting Suicides Among US Army Soldiers After Leaving Active Service. 预测美军士兵退出现役后的自杀率。
IF 25.8 1区 医学 Q1 PSYCHIATRY Pub Date : 2024-09-25 DOI: 10.1001/jamapsychiatry.2024.2744
Chris J Kennedy,Jaclyn C Kearns,Joseph C Geraci,Sarah M Gildea,Irving H Hwang,Andrew J King,Howard Liu,Alex Luedtke,Brian P Marx,Santiago Papini,Maria V Petukhova,Nancy A Sampson,Jordan W Smoller,Charles J Wolock,Nur Hani Zainal,Murray B Stein,Robert J Ursano,James R Wagner,Ronald C Kessler
ImportanceThe suicide rate of military servicemembers increases sharply after returning to civilian life. Identifying high-risk servicemembers before they leave service could help target preventive interventions.ObjectiveTo develop a model based on administrative data for regular US Army soldiers that can predict suicides 1 to 120 months after leaving active service.Design, Setting, and ParticipantsIn this prognostic study, a consolidated administrative database was created for all regular US Army soldiers who left service from 2010 through 2019. Machine learning models were trained to predict suicides over the next 1 to 120 months in a random 70% training sample. Validation was implemented in the remaining 30%. Data were analyzed from March 2023 through March 2024.Main outcome and measuresThe outcome was suicide in the National Death Index. Predictors came from administrative records available before leaving service on sociodemographics, Army career characteristics, psychopathologic risk factors, indicators of physical health, social networks and supports, and stressors.ResultsOf the 800 579 soldiers in the cohort (84.9% male; median [IQR] age at discharge, 26 [23-33] years), 2084 suicides had occurred as of December 31, 2019 (51.6 per 100 000 person-years). A lasso model assuming consistent slopes over time discriminated as well over all but the shortest risk horizons as more complex stacked generalization ensemble machine learning models. Test sample area under the receiver operating characteristic curve ranged from 0.87 (SE = 0.06) for suicides in the first month after leaving service to 0.72 (SE = 0.003) for suicides over 120 months. The 10% of soldiers with highest predicted risk accounted for between 30.7% (SE = 1.8) and 46.6% (SE = 6.6) of all suicides across horizons. Calibration was for the most part better for the lasso model than the super learner model (both estimated over 120-month horizons.) Net benefit of a model-informed prevention strategy was positive compared with intervene-with-all or intervene-with-none strategies over a range of plausible intervention thresholds. Sociodemographics, Army career characteristics, and psychopathologic risk factors were the most important classes of predictors.Conclusions and relevanceThese results demonstrated that a model based on administrative variables available at the time of leaving active Army service can predict suicides with meaningful accuracy over the subsequent decade. However, final determination of cost-effectiveness would require information beyond the scope of this report about intervention content, costs, and effects over relevant horizons in relation to the monetary value placed on preventing suicides.
重要性军人回归平民生活后自杀率急剧上升。设计、设置和参与者在这项预后研究中,我们为 2010 年至 2019 年期间退役的所有正规美国陆军士兵创建了一个综合行政数据库。在70%的随机训练样本中,对机器学习模型进行了训练,以预测未来1至120个月内的自杀事件。在其余 30% 的样本中进行验证。主要结果和测量指标结果是国家死亡指数中的自杀。预测因素来自退役前的行政记录,包括社会人口统计学、军队职业特征、精神病理学风险因素、身体健康状况指标、社会网络和支持以及压力因素。结果在队列中的 800 579 名士兵(84.9% 为男性;退役时的中位数 [IQR] 年龄为 26 [23-33] 岁)中,截至 2019 年 12 月 31 日发生了 2084 起自杀事件(每 10 万人年 51.6 起)。假设斜率随时间变化一致的套索模型与更复杂的堆叠泛化集合机器学习模型相比,在除最短风险范围外的所有风险范围内都具有良好的判别能力。接受者操作特征曲线下的测试样本面积从退役后第一个月内自杀的 0.87(SE = 0.06)到 120 个月内自杀的 0.72(SE = 0.003)不等。预测风险最高的 10%的士兵占整个范围内所有自杀人数的 30.7%(SE = 1.8)到 46.6%(SE = 6.6)。与 "全部干预 "或 "不干预 "策略相比,在一系列合理的干预阈值范围内,以模型为依据的预防策略的净收益为正。社会人口学、军队职业特征和精神病理学风险因素是最重要的几类预测因素。这些结果表明,基于离开现役军队时可用的管理变量的模型可以准确预测随后十年的自杀事件。然而,最终确定成本效益需要本报告范围之外的信息,即干预内容、成本和相关时间段内的效果与预防自杀的货币价值之间的关系。
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引用次数: 0
Actualizing Military Suicide Prevention Through Digital Health Modernization. 通过数字健康现代化实现军队自杀预防。
IF 25.8 1区 医学 Q1 PSYCHIATRY Pub Date : 2024-09-25 DOI: 10.1001/jamapsychiatry.2024.2679
Ian H Stanley,Ellen P Embrey,Vikhyat S Bebarta
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引用次数: 0
Suicidality Calls to a National Helpline After a Terror Attack and War. 恐怖袭击和战争后全国求助热线接到的自杀电话。
IF 25.8 1区 医学 Q1 PSYCHIATRY Pub Date : 2024-09-18 DOI: 10.1001/jamapsychiatry.2024.2034
Joy Benatov,Liat Itzhaky,Shiri Daniels,Gil Zalsman
ImportanceChanges in suicide rates after a nationwide trauma may be different from changes in psychiatric symptoms or general distress after such events. However, very few studies have examined short-term suicide-related reactions after such an event.ObjectiveTo evaluate the short-term outcome of the events in Israel on October 7, 2023, a large-scale terror attack and unfolding war, on changes in suicidality as reflected in percentages of suicide-related calls in relation to all calls to a national mental health first aid helpline, the Israeli Association for Emotional First Aid (ERAN).Design, Setting and ParticipantsThe data included all interactions via the various ERAN helpline services between January 1, 2022, and December 31, 2023.ExposuresThe October 7, 2023, terror attack on Israel.Mean Outcomes and MeasuresChanges in the numbers of overall calls and suicide-related calls to the ERAN helpline using an interrupted time-series analysis.ResultsA total of 602 323 calls were received by the ERAN helpline. The number of calls reflecting psychological distress in the 3 months before October 7, 2023, was 67 555 compared with 89 445 calls in the 3 months after. Analysis indicated that overall calls increased significantly on October 7 (β = 2089.16; 95% CI, 1918.97-2259.35). In addition, the daily trajectory of all calls changed significantly after October 7 (β = -22.77; 95% CI, -33.37 to -12.16), such that there was a decrease in the number of calls per day (β = -11.34; SE = 1.213; t = -9.35; P < .001). The number of suicide-related calls in the 3 months before October 7 was 1887, whereas 1663 suicide-related calls were registered in the 3 months after. Analysis showed that there were no changes in the daily number of suicide-related calls from before October 7 (β = -0.001; 95% CI, -0.005 to 0.03) or on October 7 (β = -0.22; 95% CI, -3.69 to 3.25). Therefore, the percentage of suicide-related calls decreased significantly on October 7 (β = -1.42; 95% CI, -1.92 to -0.92) and gradually increased in the following period (β = 0.016; 95% CI, 0.006-0.026).Conclusions and RelevanceThe findings of this cohort study suggest that although short-term emotional distress increased after national trauma, the percentage of suicide-related calls decreased. These results support previous studies suggesting that suicidality is not one of the immediate reactions to such traumas.
重要性全国性创伤后自杀率的变化可能不同于此类事件后精神症状或一般痛苦的变化。目标评估 2023 年 10 月 7 日在以色列发生的大规模恐怖袭击和正在进行的战争事件对自杀率变化的短期影响,自杀相关电话占全国心理健康急救求助热线以色列情感急救协会(ERAN)所有电话的百分比反映了自杀率的变化。设计、环境和参与者数据包括2022年1月1日至2023年12月31日期间通过ERAN求助热线各种服务进行的所有互动。暴露2023年10月7日对以色列的恐怖袭击。平均结果和测量采用间断时间序列分析法对ERAN求助热线的总来电数量和自杀相关来电数量进行分析。在 2023 年 10 月 7 日之前的 3 个月中,反映心理困扰的电话数量为 67 555 个,而在之后的 3 个月中则为 89 445 个。分析表明,10 月 7 日当天的总来电数明显增加(β = 2089.16;95% CI,1918.97-2259.35)。此外,在 10 月 7 日之后,所有呼叫的日轨迹发生了显著变化(β = -22.77; 95% CI, -33.37 to -12.16),每天的呼叫数量有所减少(β = -11.34; SE = 1.213; t = -9.35; P < .001)。在 10 月 7 日之前的 3 个月中,与自杀有关的电话数量为 1887 个,而在 10 月 7 日之后的 3 个月中,与自杀有关的电话数量为 1663 个。分析表明,与 10 月 7 日之前(β = -0.001;95% CI,-0.005 至 0.03)或 10 月 7 日当天(β = -0.22;95% CI,-3.69 至 3.25)相比,每天的自杀相关电话数量没有变化。因此,自杀相关电话的百分比在 10 月 7 日显著下降(β = -1.42; 95% CI, -1.92 to -0.92),并在接下来的时间里逐渐上升(β = 0.016; 95% CI, 0.006-0.026)。这些结果支持了之前的研究,即自杀并不是此类创伤的直接反应之一。
{"title":"Suicidality Calls to a National Helpline After a Terror Attack and War.","authors":"Joy Benatov,Liat Itzhaky,Shiri Daniels,Gil Zalsman","doi":"10.1001/jamapsychiatry.2024.2034","DOIUrl":"https://doi.org/10.1001/jamapsychiatry.2024.2034","url":null,"abstract":"ImportanceChanges in suicide rates after a nationwide trauma may be different from changes in psychiatric symptoms or general distress after such events. However, very few studies have examined short-term suicide-related reactions after such an event.ObjectiveTo evaluate the short-term outcome of the events in Israel on October 7, 2023, a large-scale terror attack and unfolding war, on changes in suicidality as reflected in percentages of suicide-related calls in relation to all calls to a national mental health first aid helpline, the Israeli Association for Emotional First Aid (ERAN).Design, Setting and ParticipantsThe data included all interactions via the various ERAN helpline services between January 1, 2022, and December 31, 2023.ExposuresThe October 7, 2023, terror attack on Israel.Mean Outcomes and MeasuresChanges in the numbers of overall calls and suicide-related calls to the ERAN helpline using an interrupted time-series analysis.ResultsA total of 602 323 calls were received by the ERAN helpline. The number of calls reflecting psychological distress in the 3 months before October 7, 2023, was 67 555 compared with 89 445 calls in the 3 months after. Analysis indicated that overall calls increased significantly on October 7 (β = 2089.16; 95% CI, 1918.97-2259.35). In addition, the daily trajectory of all calls changed significantly after October 7 (β = -22.77; 95% CI, -33.37 to -12.16), such that there was a decrease in the number of calls per day (β = -11.34; SE = 1.213; t = -9.35; P < .001). The number of suicide-related calls in the 3 months before October 7 was 1887, whereas 1663 suicide-related calls were registered in the 3 months after. Analysis showed that there were no changes in the daily number of suicide-related calls from before October 7 (β = -0.001; 95% CI, -0.005 to 0.03) or on October 7 (β = -0.22; 95% CI, -3.69 to 3.25). Therefore, the percentage of suicide-related calls decreased significantly on October 7 (β = -1.42; 95% CI, -1.92 to -0.92) and gradually increased in the following period (β = 0.016; 95% CI, 0.006-0.026).Conclusions and RelevanceThe findings of this cohort study suggest that although short-term emotional distress increased after national trauma, the percentage of suicide-related calls decreased. These results support previous studies suggesting that suicidality is not one of the immediate reactions to such traumas.","PeriodicalId":14800,"journal":{"name":"JAMA Psychiatry","volume":null,"pages":null},"PeriodicalIF":25.8,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142245171","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Are Psychiatric Nosologies Limiting the Success of Clinical Prediction Models? 精神病学命名是否限制了临床预测模型的成功?
IF 25.8 1区 医学 Q1 PSYCHIATRY Pub Date : 2024-09-18 DOI: 10.1001/jamapsychiatry.2024.2662
Isabelle Scott,Barnaby Nelson
{"title":"Are Psychiatric Nosologies Limiting the Success of Clinical Prediction Models?","authors":"Isabelle Scott,Barnaby Nelson","doi":"10.1001/jamapsychiatry.2024.2662","DOIUrl":"https://doi.org/10.1001/jamapsychiatry.2024.2662","url":null,"abstract":"","PeriodicalId":14800,"journal":{"name":"JAMA Psychiatry","volume":null,"pages":null},"PeriodicalIF":25.8,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142245409","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Clinical Outcomes of Continuation and Maintenance Electroconvulsive Therapy 持续和维持电休克疗法的临床效果
IF 25.8 1区 医学 Q1 PSYCHIATRY Pub Date : 2024-09-18 DOI: 10.1001/jamapsychiatry.2024.2360
Anders Jørgensen, Frederikke Hoerdam Gronemann, Maarten P. Rozing, Martin B. Jørgensen, Merete Osler
ImportanceLarge-scale evidence for the efficacy of continuation and maintenance electroconvulsive therapy (c/mECT) is lacking.ObjectiveTo provide an exhaustive and naturalistic insight into the real-world outcomes and the cost-effectiveness of c/mECT in a large dataset.Design, Setting, and ParticipantsThis cohort study included all patients in the Danish National Patient Registry who initiated treatment with ECT from 2003 through 2022. The data were analyzed from October 2023 to February 2024.ExposuresECT. An algorithm to identify c/mECTs in the dataset was developed: (&amp;gt;3 treatments with ≥7 and &amp;lt;90 days between adjacent treatments, occurring within a time frame of 180 days [cECT] or more [mECT] after an acute [aECT] series).Main Outcomes and MeasuresThe association of c/mECT with subsequent 6- to 12-month risk of hospitalization or suicidal behavior using Cox proportional hazard regression with multiple adjustments and aECT only as a reference, propensity score matching, and self-controlled case series analysis using a Poisson regression model. A cost-effectiveness analysis based on hospitalization and ECT expenses was made.ResultsA total of 19 944 individuals were treated with ECT (12 157 women [61%], 7787 men [39%]; median [IQR] age, 55 [41-70] years). Of these, 1533 individuals (7.7%) received c/mECT at any time point (1017 [5.1%] cECT only and 516 [2.6%] mECT). Compared with patients receiving aECT only, c/mECT patients more frequently experienced schizophrenia (odds ratio [OR], 2.14; 95% CI, 1.86-2.46) and schizoaffective disorder (OR, 2.42; 95% CI, 1.90-3.09) and less frequently unipolar depression (OR, 0.56; 95% CI, 0.51-0.62). In all models, c/mECT was associated with a lower rate of hospitalization after finishing aECT (eg, 6-month adjusted hazard ratio, 0.68; 95% CI, 0.60-0.78 [Cox regression]; 6-month incidence rate ratio, 0.51; 95% CI, 0.41-0.62 [Poisson regression]). There was no significant difference in the risk of suicidal behavior. Compared with the periods before the end of aECT, c/mECT was associated with a substantial reduction in total treatment costs.Conclusions and RelevanceIn a nationwide and naturalistic setting, c/mECT after aECT was infrequently used but associated with a lower risk of readmission than aECT alone. The totality of the evidence indicates that c/mECT should be considered more often to prevent relapse after successful aECT in patients whose condition does not respond sufficiently to other interventions.
重要性目前尚缺乏有关持续和维持电休克疗法(c/mECT)疗效的大规模证据。目的通过一个大型数据集,对 c/mECT 的实际疗效和成本效益进行详尽的自然分析。数据分析时间为 2023 年 10 月至 2024 年 2 月。开发了一种算法来识别数据集中的c/mECTs:(相邻治疗之间相隔≥7和&amp;lt;90天的3次治疗,在急性[aECT]系列治疗后180天[cECT]或更长时间[mECT]内发生)。主要结果和测量采用经多重调整的 Cox 比例危险回归、仅以 aECT 为参照、倾向得分匹配以及使用泊松回归模型的自控病例系列分析,得出 c/mECT 与随后 6 至 12 个月的住院或自杀行为风险之间的关系。结果 共有 19 944 人接受了 ECT 治疗(女性 12 157 人 [61%],男性 7 787 人 [39%];中位数 [IQR] 年龄 55 [41-70] 岁)。其中,1533 人(7.7%)在任何时间点接受了 c/mECT 治疗(1017 人 [5.1%] 仅接受了 cECT,516 人 [2.6%] 接受了 mECT)。与仅接受 aECT 的患者相比,c/mECT 患者更常出现精神分裂症(几率比 [OR],2.14;95% CI,1.86-2.46)和分裂情感障碍(OR,2.42;95% CI,1.90-3.09),而单相抑郁症(OR,0.56;95% CI,0.51-0.62)则较少出现。在所有模型中,c/mECT 与完成 aECT 后较低的住院率相关(例如,6 个月调整后危险比为 0.68;95% CI 为 0.60-0.78 [Cox回归];6 个月发病率比为 0.51;95% CI 为 0.41-0.62 [泊松回归])。自杀行为的风险没有明显差异。结论与意义在全国范围内的自然环境中,aECT 后使用 c/mECT 的情况并不常见,但与单独使用 aECT 相比,c/mECT 的再入院风险更低。所有证据表明,对于病情对其他干预措施反应不佳的患者,应更多地考虑使用 c/mECT 来预防 aECT 成功后的复发。
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JAMA Psychiatry
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