ALGOS: the development of a randomized controlled trial testing a case management algorithm designed to reduce suicide risk among suicide attempters.
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ABSTRACT:
SUBMITTER: Vaiva G
PROVIDER: S-EPMC3023738 | biostudies-literature | 2011 Jan
REPOSITORIES: biostudies-literature
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ALGOS: the development of a randomized controlled trial testing a case management algorithm designed to reduce suicide risk among suicide attempters.
Vaiva Guillaume G Walter Michel M Al Arab Abeer S AS Courtet Philippe P Bellivier Frank F Demarty Anne Laure AL Duhem Stephane S Ducrocq Francois F Goldstein Patrick P Libersa Christian C
BMC psychiatry 20110102
<h4>Background</h4>Suicide attempts (SA) constitute a serious clinical problem. People who attempt suicide are at high risk of further repetition. However, no interventions have been shown to be effective in reducing repetition in this group of patients.<h4>Methods/design</h4>Multicentre randomized controlled trial. We examine the effectiveness of "ALGOS algorithm": an intervention based in a decisional tree of contact type which aims at reducing the incidence of repeated suicide attempt during ...[more]
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Project description:BACKGROUND:Few studies have examined white matter abnormalities in suicide attempters using diffusion tensor imaging (DTI). This study sought to identify white matter regions altered in individuals with a prior suicide attempt. METHODS:DTI scans were acquired in 13 suicide attempters with major depressive disorder (MDD), 39 non-attempters with MDD, and 46 healthy participants (HP). Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were determined in the brain using two methods: region of interest (ROI) and tract-based spatial statistics (TBSS). ROIs were limited a priori to white matter adjacent to the caudal anterior cingulate cortex, rostral anterior cingulate cortex, dorsomedial prefrontal cortex, and medial orbitofrontal cortex. RESULTS:Using the ROI approach, suicide attempters had lower FA than MDD non-attempters and HP in the dorsomedial prefrontal cortex. Uncorrected TBSS results confirmed a significant cluster within the right dorsomedial prefrontal cortex indicating lower FA in suicide attempters compared to non-attempters. There were no differences in ADC when comparing suicide attempters, non-attempters and HP groups using ROI or TBSS methods. CONCLUSIONS:Low FA in the dorsomedial prefrontal cortex was associated with a suicide attempt history. Converging findings from other imaging modalities support this finding, making this region of potential interest in determining the diathesis for suicidal behavior.
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Project description:Suicide rates are high in old age, and the contribution of cognitive risk factors remains poorly understood. Suicide may be viewed as an outcome of an altered decision process. The authors hypothesized that impairment in reward/punishment-based learning, a component of affective decision making, is associated with attempted suicide in late-life depression. They expected that suicide attempters would discount past reward/punishment history, focusing excessively on the most recent rewards and punishments. The authors further hypothesized that this impairment could be dissociated from executive abilities, such as forward planning.The authors assessed reward/punishment-based learning using the probabilistic reversal learning task in 65 individuals age 60 and older: suicide attempters, suicide ideators, nonsuicidal depressed elderly, and nondepressed comparison subjects. The authors used a reinforcement learning computational model to decompose reward/punishment processing over time. The Stockings of Cambridge test served as a control measure of executive function.Suicide attempters but not suicide ideators showed impaired probabilistic reversal learning compared to both nonsuicidal depressed elderly and nondepressed comparison subjects, after controlling for effects of education, global cognitive function, and substance use. Model-based analyses revealed that suicide attempters discounted previous history to a higher degree relative to comparison subjects, basing their choice largely on reward/punishment received on the last trial. Groups did not differ in their performance on the Stockings of Cambridge test.Older suicide attempters display impaired reward/punishment-based learning. The authors propose a hypothesis that older suicide attempters make overly present-focused decisions, ignoring past experiences. Modification of this "myopia for the past" may have therapeutic potential.
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Project description:BackgroundBrief contact interventions (BCIs) might be reliable suicide prevention strategies. BCI efficacy trials, however, gave equivocal results. AlgoS trial is a composite BCI that yielded inconclusive results when analyzed with Intention-To-Treat strategy. In order to elicit intervention strengths and weaknesses, post-hoc analyses of AlgoS data were performed.MethodsAlgoS was a randomized controlled trial conducted in 23 French hospitals. Suicide attempters were randomly assigned to either the intervention group (AlgoS) or the control group (Treatment as usual TAU). In the AlgoS arm, first-time suicide attempters received crisis cards; non first-time suicide attempters received a phone call, and post-cards if the call could not be completed, or if the participant was in crisis and/or non-compliant with the post-discharge treatment. An As Treated strategy, accounting for the actual intervention received, was combined with subgroup analyses.Results1,040 patients were recruited and randomized into two groups of N = 520, from which 53 withdrew participation; 15 were excluded after inclusion/exclusion criteria reassessment. AlgoS first attempters were less likely to reiterate suicide attempt (SA) than their TAU counterparts at 6 and 13-14 months (RR [95% CI]: 0.46 [0.25-0.85] and 0.50 [0.31-0.81] respectively). AlgoS non-first attempters had similar SA rates as their TAU counterparts at 6 and 13-14 months (RR [95% CI]: 0.84 [0.57-1.25] and 1.00 [0.73-1.37] respectively). SA rates were dissimilar within the AlgoS non-first attempter group.ConclusionsThis new set of analysis suggests that crisis cards could be efficacious to prevent new SA attempts among first-time attempters, while phone calls were probably not significantly efficacious among multi-attempters. Importantly, phone calls were informative of new SA risk, thus a key component of future interventions.
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Project description:BackgroundFrequent emergency department (ED) users account for a disproportionately high number of ED visits. Studies on case management (CM) interventions to reduce frequent ED use have shown mixed results, and few studies have been conducted within a universal health coverage system.ObjectiveTo determine whether a CM intervention-compared to standard emergency care-reduces ED attendance.DesignRandomized controlled trial.ParticipantsTwo hundred fifty frequent ED users (5 or more visits in the prior 12 months) who visited a public urban ED at the Lausanne University Hospital between May 2012 and July 2013 were allocated to either an intervention (n = 125) or control (n = 125) group, and monitored for 12 months.InterventionsAn individualized CM intervention consisting of concrete assistance in obtaining income entitlements, referral to primary or specialty medical care, access to mental health care or substance abuse treatment, and counseling on at-risk behaviors and health care utilization (in addition to standard care) at baseline and 1, 3, and 5 months.Main measuresWe used a generalized linear model for count data (negative binomial distribution) to compare the number of ED visits during the 12-month follow-up between CM and usual care, from an intention-to-treat perspective.Key resultsAt 12 months, there were 2.71 (±0.23) ED visits in the intervention group versus 3.35 (±0.32) visits among controls (ratio = 0.81, 95 % CI = 0.63; 1.02). In the multivariate model, the effect of the CM intervention on the number of ED visits approached statistical significance (b = -0.219, p = 0.075). The presence of poor social determinants of health was a significant predictor of ED use in the multivariate model (b = 0.280, p = 0.048).ConclusionsCM may reduce ED use by frequent users through an improved orientation to the health care system. Poor social determinants of health significantly increase use of the ED by frequent users.
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Project description:BACKGROUND: Suicidal and violent behaviours are interlinked and share common biological underpinnings. In the present study we analysed the association between violent behaviour as a child, childhood trauma, adult psychiatric illness, and substance abuse in relation to interpersonal violence as an adult in suicide attempters with mood disorders. METHODS: A total of 161 suicide attempters were diagnosed with Structured Clinical Interviews and assessed with the Karolinska Interpersonal Violence Scale (KIVS) measuring exposure to violence and expressed violent behaviour in childhood (between 6-14 years of age) and during adult life (15 years or older). Ninety five healthy volunteers were used as a comparison group. A logistic regression analysis was conducted with the two KIVS subscales, expressed violent behaviour as a child and exposure to violence in childhood together with substance abuse, personality disorder diagnoses and age as possible predictors of adult interpersonal violence in suicide attempters. RESULTS: Violent behaviour as a child, age and substance abuse were significant predictors of adult interpersonal violence. ROC analysis for the prediction model for adult violence with the KIVS subscale expressed violence as a child gave an AUC of 0.79. Using two predictors: violent behaviour as a child and substance abuse diagnosis gave an AUC of 0.84. The optimal cut-off for the KIVS subscale expressed violence as a child was higher for male suicide attempters. CONCLUSIONS: Violent behaviour in childhood and substance abuse are important risk factors for adult interpersonal violent behaviour in suicide attempters.
| S-EPMC4227101 | biostudies-literature
Project description:OBJECTIVES:While suicidal behavior often manifests in adolescence and early adulthood, some people first attempt suicide in late life, often with remarkable lethal intent and determination. Given these individuals' more adaptive functioning earlier in life, they may possess traits that hinder adjustment to aging, such as high conscientiousness, rather than impulsive-aggressive traits associated with suicidal behavior in younger adults. METHODS:A cross-sectional case-control study was conducted in older adults aged ≥50 (mean: 65), divided into early- and late-onset attempters (age at first attempt ≤ or >50, mean: 31 vs 61), suicide ideators as well as non-suicidal depressed and healthy controls. Personality was assessed in terms of the five-factor model (FFM, n = 200) and five DSM personality disorders analyzed on the trait level as continuous scores (PDs, n = 160). Given our starting hypothesis about late-onset attempters, the FFM dimension conscientiousness was further tested on the subcomponent level. RESULTS:All clinical groups displayed more maladaptive profiles than healthy subjects. Compared to depressed controls, higher neuroticism, and borderline traits characterized both suicide ideators and early-onset attempters, while only early-onset attempters further displayed lower extraversion and higher antisocial traits. Late-onset attempters were similar to depressed controls on most measures, but scored higher than them on orderliness, a conscientiousness subcomponent. CONCLUSIONS:While neuroticism, introversion, and cluster B traits are prominent in early-onset suicidal behavior, late-onset cases generally lack these features. In contrast, higher levels of orderliness in late-onset suicidal behavior are compatible with the age-selective maladjustment hypothesis. Key points Personality of elderly attempters differed between those with early- and late-onset first attempts. Early-onset attempters possessed personality traits generally found in younger suicidal populations (high neuroticism, low extraversion, antisocial, and borderline PD traits), supporting that constitutional suicide risk factors persist into late life in some individuals. Late-onset suicide attempters had higher levels of orderliness than non-suicidal depressed participants, suggesting that this generally adaptive trait may facilitate suicidal behavior in a subset of depressed elderly.
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Project description:A previous suicide attempt is a potent risk factor for suicide later on. Crisis intervention, psychiatric and psychosocial evaluation at emergency medical facilities, and follow-up care for suicide attempters are considered important components for suicide prevention. The Japanese Multimodal Intervention Trials for Suicide Prevention (J-MISP) includes a randomized, controlled, multicenter trial of post-suicide attempt case management for the prevention of further attempts (ACTION-J) to address the continuing increase in suicides in Japan. The primary aim of ACTION-J is to examine the effectiveness of an extensive intervention for suicide attempters in prevention of recurrent suicidal behavior, as compared with standard intervention. This paper describes the rationale and protocol of the ACTION-J trial.In this clinical trial, case management intervention will be provided at 19 emergency medical facilities in Japan. After crisis intervention including psychiatric evaluation, psychosocial assessment, and psychological education, subjects will be randomly assigned to either a group receiving continuous case management or a control group receiving standard care. Suicidal ideation, depressive symptoms, and general health condition will be evaluated as secondary measures. The intervention was initiated in July 2006. By December, 2009, 842 subjects will be randomized. Subject follow-up will continue for 1.5 to 5 years.Suicide is a complex phenomenon that encompasses multiple factors. Case management by multi-sector collaboration is needed. ACTION-J may provide valuable information on suicide attempters and may develop effective case management to reduce future risk for suicide attempters.UMIN Clinical Trials Registry number, UMIN000000444. ClinicalTrials.gov number, NCT00736918.
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Project description:FKBP5 is a critical component of the Hypothalamic-Pituitary-Adrenal (HPA) axis, a system which regulates our response to stress. It forms part of a complex of chaperones, which inhibits binding of cortisol and glucocorticoid receptor translocation to the nucleus. Variations in both the HPA axis and FKBP5 have been associated with suicidal behavior. We developed a systematic, targeted sequencing approach to investigate coding and regulatory regions in or near FKBP5 in 476 bipolar disorder suicide attempters and 473 bipolar disorder non-attempters. Following stringent quality control checks, we performed single-variant, gene-level and haplotype tests on the resulting 481 variants. Secondary analyses investigated whether sex-specific variations in FKBP5 increased the risk of attempted suicide. One variant, rs141713011, showed an excess of minor alleles in suicide attempters that was statistically significant following correction for multiple testing (Odds Ratio = 6.65, P-value = 7.5 x 10-4, Permuted P-value = 0.038). However, this result could not be replicated in an independent cohort (Odds Ratio = 0.90, P-value = 0.78). Three female-specific and four male-specific variants of nominal significance were also identified (P-value < 0.05). The gene-level and haplotype association tests did not produce any significant results. This comprehensive study of common and rare variants in FKBP5 focused on both regulatory and coding regions in relation to attempted suicide. One rare variant remained significant following correction for multiple testing but could not be replicated. Further investigation is required in larger sample sets to fully elucidate the association of this variant with suicidal behavior.
| S-EPMC5193409 | biostudies-literature
Project description:BackgroundInvestigators conducting studies that include potentially suicidal individuals are obligated to develop a suicide risk management (SRM) protocol. There is little available in the literature to guide researchers in SRM protocol development.ObjectivesThe aim of the study was to describe an SRM protocol developed for a randomized controlled trial (RCT) currently enrolling cardiac patients who report moderate to severe levels of hopelessness.MethodsThe SRM protocol identifies suicidal ideation and measures ideation severity through use of the Columbia-Suicide Severity Rating Scale risk factor questions. Based on responses, study participants are deemed safe or at low, moderate, or high risk for suicide. The SRM protocol guides research staff through a plan of action based on risk level. The protocol further guides staff through a plan over the course of this prospective study-from hospital enrollment to home-based visits.ResultsResearch staff are well trained to identify suicidal ideation risk factors, initiate specific questioning about suicidal intent, determine level of risk, identify protective factors and a safe environment, and make referrals if needed. Of the 51 patients hospitalized with cardiac disease who reported moderate to severe hopelessness, 43 scored at a safe suicide risk level and 8 scored at low risk. Thirty-five of the 51 patients enrolled in the RCT. Of the 35 participants who received home visits to date, there have been three instances of low and one instance of moderate suicide risk. The SRM protocol has been consistently and accurately used by research personnel in both hospital and home settings. One modification has been made to the protocol since study activation, namely, the addition of an assessment of counseling history and encouragement of continued counseling. Booster training sessions of research staff will continue throughout the course of the RCT.DiscussionUse of the SRM protocol identifies study participants who are safe or at risk for suicide in both hospital and home settings, and research staff can refer participants accordingly.ConclusionThe SRM protocol developed for this RCT can serve as a model in the development of SRM protocols for future research in acute care, community, or home-based settings.
| S-EPMC7736508 | biostudies-literature
Project description:Relatively little research attention has been paid to sex issues in late life suicidal behaviour. The aim was to compare clinical characteristics of women and men aged 70+ who were hospitalized after a suicide attempt. We hypothesized higher depression and anxiety scores in women, and we expected to find that men would more often attribute the attempt to health problems and compromised autonomy. Participants (56 women and 47 men, mean age 80) were interviewed by a psychologist. In addition to psychiatric and somatic health assessments, participants responded to an open-ended question concerning attributions of the attempt. There were no sex differences in depression and anxiety. Forty-five percent of the men and 14% of the women had a history of substance use disorder (p = 0.02). At least one serious physical disability was noted in 60.7% of the women and 53.2% of the men (p = 0.55). Proportions attributing their attempt to somatic illness did not differ (women, 14.5% vs. men 17.4%, p = 0.79), and similar proportions attributed the attempt to reduced autonomy (women, 21.8% vs. men, 26.1%, p = 0.64). We found strikingly similar figures for depression scores, functional disability and attributions for attempting suicide in older men and women. Larger studies are needed in diverse settings as sex differences might be influenced by cultural context.
| S-EPMC5800240 | biostudies-literature